Weekend update

Weekend update

Congress is back at work on Capitol Hill this week. The FEHBlog did find an easy to read list of upcoming Congressional hearings on Congress.gov. The FEHBlog did not find any hearing relevant to the FEHBP coming up.

The FEHBlog is following news about the COVID-19 epidemic. The Wall Street Journal reports that the number of cases outside China is growing particularly in South Korea (602 cases) and Italy (155 cases). There are 34 cases in the U.S. In a Centers for Disease Control conference with the press last Friday, Dr. Nancy Messonnier explained that

We are making our case counts in two tables.  One only tracks people who were repatriated by the state department, and the second tracks all other cases picked up through U.S. public health network.  CDC will continue to update these numbers every Monday, Wednesday, and Friday.  We are keeping track of cases resulting from repatriation efforts separately because we don’t believe those numbers accurately represent the picture of what is happening in the community in the united states at this time.  As of this morning, when you break things up this way, we have 13 U.S. cases versus 21 cases among people who were repatriated [here].  The repatriated cases include 18 passengers from the “diamond princess” and three from the Wuhan [China] repatriation flights

The Wall Street Journal confirms the growing trend of large health insurers to offer their own primary care delivery services to their health plan members [previously documented by the FEHBlog].

“It’s very worrisome for hospitals,” said Chas Roades, a health-care consultant. “Suddenly, the plan you’re relying on for payment is also competing with you at the front end of the delivery system.”

Hospitals’ biggest concern may be the power that primary-care doctors have over where their patients go for care such as imaging scans and specialist procedures. Hospitals rely on doctors to direct patients to them for such services—one reason they have bought up physician practices. Insurer-owned clinics might refer patients away from certain hospital systems, cutting off important revenue. 

The FEHBlog in contrast is delighted with this trend which will hold down costs while improving health care quality. Competition itself is healthy. “’Health care has got to be more seamless and more integrated,” said Rob Falkenberg, chief executive of UnitedHealthcare’s California operation.” Agreed.

Fierce Healthcare reports that Oscar Health has creating a $3 per prescription formulary of about 100 popular prescription drugs and insulin. The formulary went into effect on January 1, 2020 for about half of Oscar’s health plan members. The other half if covered by Medicare or live in certain states like New York which have not approved the formulary. The article explains that

Oscar was able to price the drugs so low through plan design.“The price we pay to acquire the drug for our members has not changed,” [Oscar spokesperson Jackie] Kahn said. “Instead, we chose to have our members pay $3 and we are covering the rest.”

Thursday Miscellany

Fedweek noticed another tidbit in the agency’s FY 2021 budget that’s worth noting :

OPM is seeking authority from Congress to offer federal employees what it calls “voluntary benefits” such as short-term disability insurance, prepaid legal plans, emergency short-term childcare, and personal accident insurance.

The purchasing employee or annuitant would be responsible for paying 100% of the premiums for these coverages. What’s more the FEHBlog knows that prepaid legal plans cannot be offered on a pretax basis like FEDVIP can.

In other news,

  • Milliman posted an interesting infographic on various aspects of organ transplantation in the U.S. Average wait times are up and survival rates are down. That’s puzzling.
  • Healthcare Dive reports that “The [federal] Health Information Technology Advisory Committee on Wednesday unanimously approved its second annual report to Congress on the state of health IT landscape, recommending fixes to improve the electronic access, exchange and use of medical information.”
  • The Centers for Disease Control announced today that this year’s flu vaccine is having an efficacy rate of 45%.
  • Health Affairs offers an interesting study on the impact of administrative costs on U.S. healthcare spending.

Monday Musings

Federal News Network offers a useful report on the President’s Fiscal Year 2021 budget priorities for the federal workforce. Particularly in an election year, the President’s budget proposal is principally a political document. Now let Congress do its job.

Coordinating benefits when group health plan members have coverage under more than one plan is complicated. Nothing is more complicated than coordinating group health plan benefits with Medicare, and FEHB plans have to do a lot of this work due to the large number of Medicare eligible annuitant members, some of whom remain employed while most are retired. The FEHBlog could go on and on. See Section 9 of your plan brochure.

About ten years ago, Congress passed a law colloquially known as Section 111 which requires group health plans, among others, to report demographic information to the Centers for Medicare and Medicaid Services (“CMS”) in order to facilitate coordination of benefits. Now in its infinite wisdom CMS has decided to move forward with a proposed rule to impose civil monetary penalties on Section 111 reporting entities, including FEHB plans, for certain Section 111 errors. More details are available in this CMS fact sheet.

Bear in mind that larger FEHB plans in particular are under OPM Inspector General scrutiny for the accuracy of their Medicare coordination of benefits efforts. Moreover, the carriers, not the federal government, are on the risk for the FEHBP coverage. In short, Medicare coordination of benefits creates enough headaches for FEHBP carriers without the added risk of civil monetary penalties. How about a little comity between CMS and OPM? (E.g. Because OPM does not seek to penalize CMS for its COB goofs, CMS should not penalize FEHBP for their COB goofs.) The public comment deadline on the proposed CMS rule is April 20.

In a bit of hopeful news, Health Payer Intelligence discusses a successful Horizon New Jersey Blue Cross initiative to apply value based pricing to pediatricians. “If value-based care in pediatric healthcare truly is the future of value-based care, payers need to leverage strong provider relationships to establish effective pediatric quality measures in order to improve their pediatric value-based care performance, Horizon’s executive vice president for healthcare management and transformation Allen Karp illuminated.” Yes indeed.

Finally, on the disease front, HHS reports that

U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis [an extremely dangerous infection] over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion according to an unprecedented study by researchers from the U.S. Department of Health and Human Services.

Researchers determined that the increase in sepsis was not due to the growing number of American seniors enrolling in Medicare. From 2012 through 2018, the U.S. saw a 22 percent increase in the Medicare enrollment rates but a 40 percent increase in the rate of sepsis-related hospital admissions among beneficiaries.

Most patients with sepsis arrived at the hospital with the condition, rather than developing sepsis in the hospital, a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis. However, two-thirds of these sepsis patients had a medical encounter in the week prior to hospitalization. This finding represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.

Let’s get going with those efforts.

Also the FEHBlog learned that the Centers for Disease Control has issued interim guidance on COVID-19 for businesses and employers which also is probably good advice for controlling the flu. The FEHBlog appreciates the CDC’s work as should we all.

Thursday Miscellany

The FEHBlog visited a large radiology practice in Washington DC today for a routine test. The desk attendant asked the FEHBlog to fill out a brief novel coronavirus questionnaire, e.g., have you travelled to China recently etc. The FEHBlog wondered why they weren’t asking about the flu. It occurred to the FEHBlog that the practice’s employees are vaccinated against the flu but not the coronavirus. In any event, Stat News, a Boston Globe service offers an interview with the Centers for Disease Control and Prevention about efforts to avoid the novel coronavirus spreading in the U.S.

Healthcare Dive offers a simple side by side analysis of the three bipartisan surprise billing proposals under House of Representatives consideration. Thanks.

Health Payer Intelligence discusses four Social Determinant of Health barriers that health plans are seeking to remove in order to improve access to care. The publications deems those barriers to be

the lack of behavioral and mental healthcare, difficulty in obtaining transportation to healthcare appointments, cost barriers to medication adherence, and access to medical care sites—both physical and virtual.

In a bit of related good news, the CDC reports that

The percentage of all persons who were in families having problems paying medical bills in the past 12 months decreased 4.5 percentage points from 19.7% in 2011 to 15.2% in 2015 and then decreased 1.0 percentage point from 2015 through 2018 (14.2%).

Govexec.com discusses the bipartisan effort underway in Congress to correct some oversights in the new paid family leave law for federal employees. The bill is HR 5885. That program takes effect October 1, 2020.

Weekend update

Congress remains in session this coming week on Capitol Hill. Tomorrow the President will deliver his proposed FY 2021 budget to Congress. The Wall Street Journal reports that the

$4.8 trillion budget [proposal] charts a path for the start of a potential second term, proposing steep reductions in social-safety-net programs and foreign aid and higher outlays for defense and veterans.

[The safety net program savings include] $130 billion from changes to Medicare prescription-drug pricing.

Federal News Network advises that

Signs indicate the Trump administration is still pursuing the merger of the Office of Personnel Management with the General Services Administration, despite recent congressional language prohibiting the transfer of OPM statutory functions to other agencies.

The administration will, for example, issue a joint budget request for OPM and GSA for 2021 [just like the FY 2020 budget], Federal News Network has learned

Of course, rather than prohibiting the transfer, Congress more accurately put the merger on hold pending an independent study of the transfer by the National Academy for Public Administration. The report on the study is expected to be submitted in June 2020.

OPM released additional guidance on the Wuhan or novel coronavirus to Chief Human Capitol Officers on Friday February 7. Here’s a link to the Centers for Disease Control’s website about reports of the disease in our country.

Healthcare Dive reports that

Telehealth and remote monitoring are becoming significant forces in healthcare delivery, according to a new survey of 1,300 primary care and specialty physicians released Thursday by the American Medical Association.

The number of physicians who use telehealth for visiting with patients has doubled between 2016 and 2019, although the overall number remains relatively low with 28% of surveyed physicians reporting they have adopted telehealth technology. Remote patient monitoring has also grown, from just 13% of physicians using it in 2016 to 22% in 2019.

That’s encouraging news.

Tuesday Tidbits

The Affordable Care Act (“ACA”) regulators issued a new ACA frequently asked questions (number 41) yesterday. Number 41 discusses the 2019 revised summary of benefits and coverage template and related documents intended for use in the 2021 plan year.

OPM Director Dale Cabaniss sent a letter yesterday to the federal government’s Chief Human Capital Officers about the Wuhan or novel coronavirus.

Although the risk of contracting 2019-nCoV remains very low, agencies should remind employees to use good health habits such as hand washing and encourage sick employees to seek medical treatment and use sick leave or other appropriate workplace flexibilities.  Where necessary, agencies should consider implementing social distancing, including the use of telework. 

That strikes the FEHBlog as good advice for the flu too.

The FEHBlog ran across today this Healio article which takes a deeper dive into last week’s CDC findings that drug overdose deaths dropped by 4% when comparing 2017 and 2018 statistics.

Other data published in Morbidity and Mortality Weekly Report show that opioid prescribing rates dropped in 11 states — California, Delaware, Florida, Idaho, Kentucky, Louisiana, Maine, Ohio, Texas, Virginia and West Virginia — during 2010 to 2016. These states represent about 38% of the U.S. population, according to researchers.

Finally Beckers Hospital Review discusses a disturbing study published in the Annals of Internal Medicine finding that

Visits to primary care physicians fell by 24.2 percent over the study period [2008-2016]. The proportion of adults who did not visit a primary care physician in a given year increased from 38.1 percent in 2008 to 46.4 percent in 2016.

Young adults, people without a chronic disease and individuals living in low-income areas demonstrated the largest drop in primary care visits, although the trend was visible across all age groups and income levels, according to NPR.

The study blames the unfortunate situation on rising out of pocket costs. However, the Affordable Care Act made in-network preventive care visits free. So that’s at best a partial answer. Health plans should strive to encourage strong relationships between members and their primary care physicians. The FEHBlog certainly appreciates his

Monday Musings

The Wall Street Journal reports today that

There have been at least 19 million U.S. cases of the flu this season, 180,000 hospitalizations, and 10,000 deaths, according to preliminary estimates from the CDC. There were 61,000 flu-related deaths in 2017-18 and 34,200 deaths in 2018-19. Public health experts say the levels of hospitalization are similar to recent seasons, but deaths are lower than usual and outpatient reports of influenza-like illness remain elevated.

The article adds that

More than half of the positive influenza test results from public health laboratories this flu season have been in children and adults under the age of 25, according to the Centers for Disease Control and Prevention’s most recent weekly influenza report. That’s a higher portion than in the past few years, when less than half the cases were in kids and young adults. 

The reason: The predominant strain circulating early this season was influenza B, which causes more significant illness in children than in adults. 

It makes one wonder why the Wuhan or novel coronavirus was named as a public health emergency but evidently not the flu. The FEHBlog realizes that the public health emergency declaration was intended to free up funding for an unexpected illness but even more government and press focus should be placed on the flu in the FEHBlog’s opinion.

Recently the FEHBlog mentioned a U.S. District Court for the District of Columbia decision holding that the government mandated “patient rates” applicable to individual requests for their own medical records cannot be applied to requests that direct the records to third parties. HHS’s Office for Civil Rights issued an important notice last week advising compliance with the court’s order. The FEHBlog would not be surprised to see an appellate challenge to the decision.

Last week, the Trump Administration made available to State governments a new Medicaid Healthy Adult Opportunity block grant program. The program reminds the FEHBlog of the block grant approach in the Republican’s 2017 bill to repeal and replace the Affordable Care Act. Healthcare Dive reports

Analysts with Cantor Fitzgerald said they maintain a positive view on the manged care sector following the block grant news last week. “It remains to be seen if/when/how many states will opt into the initiative,” the analysts said in a recent note. “We continue to view Medicaid as a compelling growth area.”

The nation’s health insurance lobby didn’t take a position on the measure, but stressed the importance of having flexibility in the program and the need to cover everyone​.

“We support offering state policymakers flexibility to design their Medicaid programs to best meet the needs of their citizens. At the same time, funding mechanisms for Medicaid should not undermine Americans’ access to the care they need and deserve,” America’s Health Insurance Plans said in a statement Friday.

Even if states were interested in implementing the policy, legal experts told Healthcare Dive the demonstration is unlikely to get off the ground — as a fight in the courts is all but certain.

That’s unfortunate, in the FEHBlog’s opinion.

Thursday Miscellany

Today the Centers for Disease Control released final U.S. life expectancy data for the U.S.

  • Life expectancy for the U.S. population in 2018 was 78.7 years, an increase of 0.1 year from 2017.
  • The age-adjusted death rate decreased by 1.1% from 731.9 deaths per 100,000 standard population in 2017 to 723.6 in 2018.

These improvements, while slight, are the first improvements in four years. The Wall Street Journal observes that

Lower mortality from cancer, accidents and unintentional injuries were the main reasons life expectancy ticked up in 2018. The {CDC] also said that drug overdose deaths among U.S. residents fell 4% that year, the first such decline in 28 years.

Good news indeed but, of course, room for improvement remains.

The Washington Post discusses a Health Care Cost Institute (“HHCI”) report finding that the Trump Administration’s final rule requiring hospital to disclose their negotiated prices for 300 common services may reduce prices. From the HCCI report,

  • If the highest market prices – for each service – declined such that they were equivalent to the 60th percentile price today, spending would decrease even if the lowest-priced claims within all services were raised to the 59th percentile price;
  • If the lowest 33% of prices – for each service – increased to the 33rd percentile, spending would increase even if the highest 10% of prices – for each service – were lowered to the 90th percentile; ​
  • If within each service, the highest-priced claims were lowered to the 75th percentile market price and the lowest-priced claims increased to the 25th percentile market price, spending would decline by 6.4%, and; ​
  • Spending would increase overall if the lowest half of prices all increased to their service’s median market price and the uppermost quarter of every service’s prices declined to the 75th percentile.

Hope springs eternal. The hospital transparency rule, which, is under legal challenge is set to take effect January 1, 2021. Today was the comment deadline for proposed HHS price transparency rule for health plans.

The Robert Wood Johnson Foundation reviews food label changes that became applicable to most foods on grocery shelves on January 1, 2020. Check it out.

Tuesday Tidbits

Johns Hopkins University provides us with a Wuhan coronavirus dashboard that constantly updates the spread of the virus. AJMC.com offers coverage of HHS’s Secretary Alex Azar’s press conference on the topic held earlier today.

“Americans should know that this is a potentially very serious public health threat, but, at this point, Americans should not worry for their own safety,” Azar said. Of the 4500 cases confirmed in China, the country has reported more than 100 deaths. However, “the cases that have been identified skew severe, including patients who are older or have other illnesses. The mortality rate may drop over time as we identify a broader set of cases.”

The CDC recently announced it would begin screening travelers for the virus at 20 airports, up from an initial number of 5. “We are constantly preparing for the possibility that the situation could worsen, and your health and safety has been and will be our top priority,” Azar said.

AHRQ released a chart book on employer sponsored health coverage in our country in 2018.

Between 2017 and 2018, there was no significant change in the overall percentage of private-sector employees (47.8 percent in 2018) enrolled in a health insurance plan offered by their employers (“enrollment rate”). There was also no significant change in the enrollment rate in any firm-size category.

In 2018, average annual health insurance premiums per enrolled employee with private-sector employer coverage were $6,715 for single coverage, $13,425 for employee-plus-one coverage, and $19,565 for family coverage. These amounts represent increases of 5.4 percent for single coverage, 5.0 percent for employee-plus-one coverage, and 4.7 percent for family coverage over 2017 levels

In 2018, enrolled employees paid 21.3 percent of total premiums for single coverage, 27.1 percent for employee-plus-one coverage, and 27.8 percent for family coverage (Exhibit ES.14). The employee share of total premiums in 2018 for single coverage decreased by 0.9 percentage points from its 2017 level, while the employee shares for the other two coverage types were not significantly different from their 2017 levels.

The statutory minimum employee contribution for FEHB coverage is 25% (5 U.S.C. Sec. 8906).

Finally here’s a shocking Justice Department press release concerning an electronic health records vendor Practice Fusion Inc. which agreed to pay the Government $145 million to settle criminal and civil complaints.

The resolution announced today addresses allegations that Practice Fusion extracted unlawful kickbacks from pharmaceutical companies in exchange for implementing clinical decision support (CDS) alerts in its EHR software designed to increase prescriptions for their drug products.  Specifically, in exchange for “sponsorship” payments from pharmaceutical companies, Practice Fusion allowed the companies to influence the development and implementation of the CDS alerts in ways aimed at increasing sales of the companies’ products.  Practice Fusion allegedly permitted pharmaceutical companies to participate in designing the CDS alert, including selecting the guidelines used to develop the alerts, setting the criteria that would determine when a healthcare provider received an alert, and in some cases, even drafting the language used in the alert itself.  The CDS alerts that Practice Fusion agreed to implement did not always reflect accepted medical standards.  In discussions with pharmaceutical companies, Practice Fusion touted the anticipated financial benefit to the pharmaceutical companies from increased sales of pharmaceutical products that would result from the CDS alerts.  Between 2014 and 2019, health care providers using Practice Fusion’s EHR software wrote numerous prescriptions after receiving CDS alerts that pharmaceutical companies participated in designing

Weekend update

Both Houses of Congress are in session this week on Capitol Hill. The FEHBlog has signed up for Congress.gov alerts for S. 1895, Senator Lamar Alexander’s bipartisan bill to lower health care cost. The FEHBlog received his first alert this morning — the addition of a summary of key bill provisions:

Among other things, the bill

applies in-network cost-sharing requirements to certain emergency and related nonemergency services that are provided out-of-network, and prohibits health care facilities and practitioners from billing above the applicable in-network cost-sharing rate for such services; 

revises certain requirements in order to expedite the approval of generics and biosimilars, including requirements relating to citizen petitions, application effective dates, and labeling; 

requires health care facilities and practitioners to give patients a list of provided services upon discharge and to bill for such services within 45 days; 

limits prices that pharmacy benefit managers (PBMs) may charge health insurers or enrollees for prescription drugs, based on prices paid by PBMs to pharmacies; 

establishes grant programs to support vaccinations and data modernization; and 

requires health insurers to make certain information, including estimated out-of-pocket costs, accessible to enrollees through specified technology (e.g., mobile applications).

The Hill reports that the Centers for Disease Control will begin to publish Wuhan coronavirus updates on Mondays, Wednesdays and Fridays. There are now five confirmed cases in the U.S., all of whom are hospitalized. One hundred other people under being watched for the virus.

Chicago’s Crain Business informs us about the merger for four southside Chicago hospitals.

The combination [Advocate Trinity Hospital, Mercy Hospital & Medical Center, South Shore Hospital and St. Bernard Hospital] aims to bolster the precarious finances of the safety-net hospitals that treat large numbers of low-income patients on Medicaid, which pays less than Medicare and commercial insurance.

With an estimated $1.1 billion investment—including private donations and government dollars intended for hospital transformation—the plan is to build at least one new hospital and open up to six new community health centers that would expand access to preventive services and address social determinants of health, such as food insecurity, the four hospital leaders said today.

That’s a hopeful twist on such deals.

The Wall Street Journal reports today that

Hundreds of regional grocery stores in cities from Minneapolis to Seattle are closing or selling pharmacy counters, which have been struggling as consumers make fewer trips to fill prescriptions and big drugstore chains tighten their grip on the U.S. market. * * *

Grocery pharmacies are the latest casualty of industry consolidation that has for years been forcing mom-and-pop drugstores to close. Even some big players have rethought the market. Target Corp. sold off its pharmacy business to CVS Health Corp. five years ago. * * *

The tougher conditions come as the entire drugstore industry copes with a shift to online shopping and shrinking profits in prescription medicines, which often disproportionately affect smaller players.

And so it goes.