Monday Roundup

CMS

Monday Roundup

David Ermer–CDC, CMS, COVID-19, OPM, U.S. Healthcare–
Photo by Sven Read on Unsplash

The Office of Personnel Management reminds us that this is Public Service Recognition Week. “Celebrated annually during the first week of May since 1985, Public Service Recognition Week (PSRW) (external link) is time set aside to honor the men and women who serve our nation as federal, state, county and local government employees.”

From the COVID-19 front:

The Food and Drug Administration is preparing to authorize use of the Pfizer-BioNTech Covid-19 vaccine in adolescents 12 to 15 years old by early next week, according to federal officials familiar with the agency’s plans, opening up the nation’s vaccination campaign to millions more Americans.

The news is highly anticipated: Eager parents have been counting down the weeks since Pfizer announced results from its trial in adolescents, showing the vaccine is at least as effective in that age group as it is in adults. Vaccinating children is also key to raising the level of immunity in the population and bringing down the numbers of hospitalizations and deaths.

The authorization could come as early as late this week, according to the federal officials, who did not give their names because they weren’t authorized to speak publicly. If it is granted, the Centers for Disease Control and Prevention’s vaccine advisory panel will likely meet the following day to review the clinical trial data and make recommendations for the vaccine’s use in adolescents.

  •  The Wall Street Journal informs us

Everyone who was desperate for a vaccine has gotten a shot, said Alexandra Simon, the California director of vaccines for Curative, a Covid-19 testing and health-services company administering vaccines across the country. The company is now seeing people with access issues, including questions about insurance or identification, and fears about being unable to take care of children because of side effects. Many people, she said, simply can’t take time off. Others only want an appointment on Thursday or Friday, or prefer a site with the vaccine from Pfizer Inc. and BioNTech SE, said Curative’s chief information officer, Isaac Turner.

But the fact that supply now exceeds immediate demand means getting vaccinated is a much easier process. That message may be getting across because over 3.3 million doses of COVID-19 vaccine were administered Sunday per the CDC.

  • The Wall Street Journal also hopefully reports that “The next generation of Covid-19 vaccines in development could come as a pill or a nasal spray and be easier to store and transport than the current handful of shots that form the backbone of the world-wide vaccination effort.”

Good advice from the American Medical Association (“AMA”)

  • The AMA offers six lifestyle changes that can prevent heart disease.
  • The AMA also recommends eight keys to ending the drug overdose crisis.

In healthcare business news, the Wall Street Journal reports that

The Blue Cross Blue Shield Association said it dropped a rule that limited competition among its member insurers, moving to implement a key aspect of an antitrust settlement the companies reached last year with customers. * * *

Previously, the rule was that two-thirds of a Blue licensee’s national net revenue from health plans and related services must stem from Blue-branded business.

The Blue Cross Blue Shield Association includes 35 insurers, each of which typically hold exclusive rights to the Blue Cross and Blue Shield brands within a certain territory, a setup that would remain intact under the antitrust settlement.

However, lifting the revenue cap could allow the Blue insurers to compete more against one another by expanding their non-Blue businesses, experts said. Dropping the limit “certainly should increase competition,” said Tim Greaney, a professor at the University of California Hastings College of the Law, though he said it isn’t clear how quickly it would have an effect.

Following up on a couple of items from Friday’s post:

  • The FEHBlog mentioned that a company called ClosedLoop.ai had won a million dollar healthcare artificial intelligence prize from the federal government. The FEHBlog couldn’t figure out what the prize winning invention did. STAT News tells us that ClosedLoop.ai “bested 300 rivals with a system capable of forecasting adverse health events by crunching an array of data on patients.” Nifty.
  • The FEHBlog also pulled the key tidbit from the 457 page long HHS second notice of 2022 benefit and payment parameters. Katie Keith in the Health Affairs blog provides much more detail for all those interested.

Friday Stats and More

David Ermer–ACA, CMS, COVID-19, U.S. Healthcare–

Based on the Centers for Disease Control’s COVID-19 Data Tracker website, here is the FEHBlog’s chart of new weekly COVID-19 cases and deaths over the 14th week of 2020 through 17th week of this year (beginning April 2, 2020, and ending April 28, 2021; using Thursday as the first day of the week in order to facilitate this weekly update):

and here is the CDC’s latest overall weekly hospitalization rate chart for COVID-19:

The FEHBlog has noticed that the new cases and deaths chart shows a flat line for new weekly deaths  because new cases greatly exceed new deaths. Accordingly here is a chart of new COVID-19 deaths over the period (April 2, 2020, through April 28, 2021):

Finally here is a COVID-19 vaccinations chart over the period December 17, 2020, through April 28, 2021 which also uses Thursday as the first day of the week:

As of yesterday, 39% of the U.S. population over age 18 and 68.8% of those over age 65 have been fully vaccinated. The Centers for Medicare & Medicaid Services Office of Minority Health will host a May 13 webinar on building COVID-19 vaccine confidence. Register for the 12 p.m. ET webinar here. The FEHBlog already has done so.

The American Hospital Association reports that “The Centers for Medicare & Medicaid Services today released a second final notice of benefit and payment parameters to implement standards governing health insurance issuers and marketplaces for 2022 that were not finalized in the Jan. 19 final rule. CMS chose not to finalize the proposed premium adjustment percentage and instead finalized a lower percentage, resulting in lower maximum out-of-pocket costs for consumers ($8,700 for individuals and $17,400 for families) than originally proposed.” These are the 2022 out of pocket maximums on in-network cost sharing that apply to FEHB plans. Here’s a link to the HHS press release which promises even more guidance down the road.

The Centers for Medicare and Medicaid Services announced the winner and runner-up in its healthcare artificial intelligence competition today. “Out of more than 300 initial entries, ClosedLoop.ai was chosen as the grand prize winner and will receive up to $1 million in prize money. Based in Austin, Texas, the company is a leader in developing healthcare data science solutions. Challenge Runner-Up Geisinger, a non-profit healthcare system based in Danville, Pennsylvania [and the carrier of an FEHB plan], will receive up to $230,000 in prize money.” Congratulations.


Thursday Miscellany

David Ermer–CMS, COVID-19, COVID-19 vaccine, Federal employment benefits, OPM, Patient safety, Telehealth, U.S. Healthcare–
Photo by Mel on Unsplash

Today the U.S. Office of Personnel Management released guidance to federal agencies on American Rescue Plan Act “provisions authorizing emergency paid leave (EPL) for covered Federal employees in specified qualifying circumstances through special funds.” The Federal News Network offers information on how federal employees can apply for EPL.

From the COVID-19 front, the Wall Street Journal reports that Astra-Zeneca now expects to file an emergency use application for its COVID-19 vaccine with the Food and Drug Administration in the middle of next month.

“One especially time-consuming task has been compiling British data from almost four months of vaccinations in the U.K., including efficacy, virus-transmission and safety statistics, people close to the process say. That has added to the complexity of AstraZeneca’s submission and is expected to lengthen any FDA review. Other shots that the FDA has authorized had large-scale human trial data but little or none from real-world rollouts outside of controlled studies.”

No good deed, etc.

From the patients safety front, the Leapfrog Group released its Spring 2021 hospital safety grades yesterday. The two hospitals closest in proximity to the FEHBlog’s residence are graded A and B. Beckers Hospital Review helpfully points out the 27 hospitals with straight A scores and F scores. Meanwhile, Healthcare Finance reports that

The Centers for Medicare and Medicaid Services on Wednesday released the overall hospital quality star ratings that now include new methodology in five measure groups.

CMS rated over 4,500 hospitals from one to five stars, with five representing the highest quality rating.

Of 4,586 hospitals, 13.5%, or 455 hospitals, received five stars; 988 received four stars; 1,018 received three stars; 690 received two stars; and 204 received one star.

For more than a quarter of hospitals, 1,181, no information was available.

This compares to January 2020 data, when of the 5,340 hospitals listed, 396 received five stars; 1,132 received four stars; 1,108 got three stars; 710 received two stars; and 226 got one star. Another 1,761 had no rating information available.

Furthermore, the Centers for Disease Control released a new study setting a “Baseline to Measure Quality of Antibiotic Prescribing in U.S. Hospitals.”

Since 2015, when the prescribing data were collected, CDC has been working diligently with partners like the American Hospital Association and others to implement stewardship efforts and programs in acute care.

CDC will continue building on this progress and important work in the coming years as a part of the newly released Combating Antibiotic-Resistant Bacteria National Action Plan. Good luck with that effort.

In healthcare business news:

  • Healthcare Dive informs us that ” Virtual care powerhouse Teladoc reported a wider-than-expected net loss in the first quarter, but beat Wall Street estimates on revenue with a topline of $454 million, up 151% year over year, driven by growth in specialty offerings and multi-product contracts. * * * CEO Jason Gorevic contended he is unworried about mounting competition in the lucrative telehealth space, banking the company’s heft and variety of clinical services will fend off entrenched rivals and new entrants like Amazon.”
  • Fierce Healthcare advises “Do not expect the Biden administration to pull away from price transparency even though the administration wants to pull a requirement for hospitals to post Medicare Advantage rates, experts say. The proposal included in a hospital inpatient payment rule released late Tuesday is more aimed at easing administrative burdens for hospitals still struggling due to the pandemic, several experts said. “The repeal of this requirement more falls into the bucket of easing hospitals’ burden as opposed to the agency’s stance on hospital price transparency,” said Caitlin Sheetz, head of analytics and a director for the consulting firm ADVI, in an interview with Fierce Healthcare.
  • Fierce Healthcare also reports that “Anthem has completed its acquisition of home health benefits manager MyNEXUS, the insurer announced Thursday morning. MyNEXUS offers comprehensive home-based nursing management to health insurers, providing integrated clinical services to some 1.7 million Medicare Advantage beneficiaries in 20 states. The company’s platforms largely automate the visit and authorization, which allows members to access care more quickly, according to the announcement. MyNEXUS will be folded into Anthem’s Diversified business group.”

In benefit design news, Health Payer Intelligence offers a thoughtful article describing key considerations for implementing diabetes management programs.

Friday Stats and More

David Ermer–CMS, Congress, COVID-19, COVID-19 vaccine, Telehealth, U.S. Healthcare–

Based on the Centers for Disease Control’s COVID-19 Data Tracker website, here is the FEHBlog’s chart of new weekly COVID-19 cases and deaths over the 14th week of 2020 through 16th week of this year (beginning April 2, 2020, and ending April 21, 2021; using Thursday as the first day of the week in order to facilitate this weekly update):

and here is the CDC’s latest overall weekly hospitalization rate chart for COVID-19:

The FEHBlog has noticed that the new cases and deaths chart shows a flat line for new weekly deaths  because new cases greatly exceed new deaths. Accordingly here is a chart of new COVID-19 deaths over the period (April 2, 2020, through April 21, 2021):

Finally here is a COVID-19 vaccinations chart over the period December 17, 2020, through April 21, 2021 which also uses Thursday as the first day of the week:

The Hill reports this evening that

Johnson & Johnson coronavirus vaccinations should resume immediately, federal regulators said Friday.

The approval follows a recommendation from a federal advisory panel that the shot’s benefits outweigh its risks. 

States could start administering the shots in hours, if not days. There are about 9.5 million doses of the vaccine sitting on shelves across the country that could be deployed immediately.

The Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC), which had jointly recommended a nationwide pause 10 days ago, accepted the recommendation from CDC’s Advisory Committee on Immunization Practices.

The panel wants the FDA to add a warning label intended to make providers aware of the risk of a rare complication involving blood clots in women under the age of 50. 

Johnson & Johnson has already negotiated warning label language with FDA, a company official told the panel.

Medscape adds that “The recommended pause on April 13 in the rollout of the Janssen/Johnson and Johnson vaccine has not substantially deflated confidence in COVID-19 immunization, a new poll reveals.” Let’s go.

From Capitol Hill, Healthcare Dive reports that “The Senate Finance Committee split upon party lines in a Thursday vote on the nomination of Chiquita Brooks-LaSure, President Joe Biden’s pick to head the powerful agency overseeing Medicare and Medicaid, voting 14-14 to move to a full Senate vote without a recommendation for confirmation.” The FEHBlog expects that Ms. Brooks-LaSure will be confirmed next week.

Speaking of health equity, Econtalk currently features a fascinating discussion between host Russ Roberts, who recently became President of Jerusalem’s Shalem College, and Washington University Sociology Professor Mark Rank  “on the nature of poverty and the challenge of ending or reducing it.”

Fierce Healthcare offers interviews with healthcare experts on telehealth regulation and health equity.

Beckers points out how UnitedHealthcare plans to make Optum a $100 billion business and how Anthem’s IngenioRx PBM business keeps growing.

Midweek update

David Ermer–CMS, COVID-19, COVID-19 vaccine, OPM, Rx coverage, U.S. Healthcare–

Today was the second day of the OPM AHIP FEHB Carrier Conference. One of the sessions concerned COVID-19 vaccination outreach to socially disadvantaged communities. The FEHBlog learned that Kaiser Permanente, which is the third largest FEHB plan carrier, has released a COVID-19 vaccination equity tookit and that Geisinger, a Pennsylanvia based FEHB plan carrier, has produced a Neighborly website chock full of community resources. A speaker referenced this New York Times article on the following topic: “Half of American adults have received at least one shot of the coronavirus vaccine. Now comes the hard part: persuading the other half to get it.”

In COVID-19 vaccine news from outside the carrier conference

  • The Society for Human Resource Management reports that “To encourage more widespread vaccinations, President Joe Biden has announced a paid leave tax credit to employers that provide full pay for any employee who takes time off to get a COVID-19 vaccination. The tax credit is available to organizations with fewer than 500 employees, and it also provides full pay for employees who take time to recover from the vaccination. The credit covers up to $511 per day for each vaccinated employee, and is funded by the American Rescue Plan.” The FEHBlog will post the implementing IRS notice tomorrow.
  • Fierce Pharma reports that “AstraZeneca is still planning to apply for emergency use authorization of its shot in the U.S., a company spokesman confirmed. * * * If going down that road yields an endorsement from the U.S., it could help boost the damaged reputation of the shot. Much of the world, especially poorer nations, are in dire need of vaccines and global demand is expected to extend into the next few years at least. In addition, the shot has a key advantage over its mRNA rivals––its lower price, which makes it particularly attractive to developing nations.”
  • Govexec reports that “State Department Spokesperson Ned Price said on Tuesday that the department had delivered vaccines to all of its posts abroad, as of Sunday.“ and “The Defense Department said on Tuesday it expects to start receiving 390,000 vaccine doses weekly, which is up from an average of 155,500 per week. “[Eighty-three] percent of vaccines received by the Defense Department have been administered, exceeding the U.S. average of 78%, and more than 28% of our total force is now vaccinated,” Pentagon Press Secretary John Kirby said during a briefing on Monday. 

There was a lot of carrier conference discussion about expensive yet curative cell and gene therapies. The FEHBlog ran across this recent MIT report on that topic.

Also the FEHBlog was overjoyed to hear from an OPM speaker that with any luck laterthis decade OPM will begin providing carriers with HIPAA 820 standard transactions that will allow them to reconcile premiums to headcount. The FEHBlog has been advocating this logical step for quite a while.

In other healthcare news —

  • Healthcare Dive informs us about Elizabeth Fowler’s first public address since taking the reins of the CMS Center for Medicare and Medicaid Innovation earlier this year. “‘In my view, we’re at a really critical juncture in the path to value-based care,’ Fowler said at the National Association of Accountable Care Organizations’ spring conference on Tuesday, asking stakeholders for patience as CMMI reviews paused models and outlines a path forward.”
  • Saturday is the Drug Enforcement Administration’s spring edition of National Prescription Drug Take Back Day. “National Prescription Drug Take Back Day is a safe, convenient, and responsible way to dispose of unused or expired prescription drugs at locations in communities throughout the country. The October 2020 Take Back Day brought in 985,392 pounds (492.7 tons) of medication. This is the largest amount ever collected in the program’s ten years!” You can find your nearest collection site here.

Friday Stats and More

David Ermer–CMS, COVID-19, COVID-19 vaccine, Medicare–

Based on the Centers for Disease Control’s COVID-19 Data Tracker website, here is the FEHBlog’s chart of new weekly COVID-19 cases and deaths over the 14th week of 2020 through 9th week of this year (beginning April 2, 2020, and ending April 7, 2021; using Thursday as the first day of the week in order to facilitate this weekly update):

and here is the CDC’s latest overall weekly hospitalization rate chart for COVID-19:

The FEHBlog has noticed that the new cases and deaths chart shows a flat line for new weekly deaths  because new cases greatly exceed new deaths. Accordingly here is a chart of new COVID-19 deaths over the period (April 2, 2020, through April 7, 2021):

Finally here is a COVID-19 vaccinations chart over the period December 17, 2020, through April 7, 2021 which also uses Thursday as the first day of the week:

That is quite a sharp increase in distributed doses of the COVID-19 vaccine.

Bloomberg reports that

The U.S. recorded 4 million vaccine doses on Friday, returning the pace of inoculations almost to the level before a post holiday lull, according to the Bloomberg Vaccine Tracker. It was the third straight day of increases, with the seven-day average now at 3.03 million doses a day. So far, 179 million doses have been administered. At this pace, it’s estimated to take another 3 months to cover 75% of the population.

Pfizer and BioNTech announced today that they have “requested amendments to the U.S. Emergency Use Authorization (EUA) of the Pfizer-BioNTech [2 dose mRNA] Vaccine (BNT162b2) to expand the use in adolescents 12 to 15 years of age.” That’s a good sign for an in-person teaching in high schools next year.

Bloomberg also reports this evening that

The U.S. Centers for Disease Control is working with health departments in four states to evaluate symptoms experienced after Johnson & Johnson vaccinations but has “not found any reason for concern,” a spokeswoman said in a statement.

“Many people don’t have any side effects after Covid-19 vaccines, but some people will have pain or swelling at the injection site or fever, chills, or a headache,” spokeswoman Kristen Nordlund said. “These typically don’t last long and are signs that your body is building protection.”

She said the states are Colorado, North Carolina, Georgia and Iowa. The symptoms include “dizziness, light headedness, feeling faint, rapid breathing, and sweating.” She said the CDC “is aware of other instances of these symptoms occurring with the other Covid-19 vaccines.”

The Wall Street Journal cautions that “Deliveries of Johnson & Johnson’s JNJ -1.06% Covid-19 vaccine doses throughout the U.S. are expected to plunge by more than 80% next week, according to state officials and federal data, as J&J grapples with manufacturing challenges.”

Whither the emergency use application for the other adenovirus based COVID-19 from AstraZeneca/Oxford University?

Under the and More subheading —

  • Yesterday the CDC Director Rochelle Walensky issued a statement on her “Commitment to Addressing Racism as an Obstacle to Health Equity.” “To build a healthier America for all, we must confront the systems and policies that have resulted in the generational injustice that has given rise to racial and ethnic health inequities. We at CDC want to lead in this effort—both in the work we do on behalf of the nation’s health and the work we do internally as an organization.” Well said.
  • The Biden Administration released an abbreviated version of its Fiscal Year 2022 federal budget today.

The Office of Management and Budget (OMB) today submitted to Congress President Biden’s discretionary funding request for Fiscal Year 2022. As Congress prepares to begin the annual appropriations process, the request lays out the President’s discretionary funding recommendations across a wide range of policy areas and outlines a strategy for reinvesting in the foundations of our country’s resilience and strength. The request — which represents only one element of the Administration’s broader agenda — includes key investments in K-12 education, medical research, housing, civil rights, and other priorities that are vital to our future. Later this spring, the Administration will release the President’s Budget, which will present a unified, comprehensive plan to address the overlapping challenges we face in a fiscally and economically responsible way.

The Wall Street Journal adds that “The preliminary plan released Friday by the White House would raise discretionary spending by 8.4%, or $118 billion, from the $1.4 trillion authorized last year, excluding emergency measures to combat the Covid-19 pandemic. Discretionary spending is the part of the budget that Congress shapes through the appropriations process.”

  • Yesterday, the FEHBlog discussed the Center for Medicare and Medicaid Service’s proposal rule for the Fiscal Year 2022 Medicare prospective payment and quality system for psychiatric hospitals. Becker’s Hospital CFO Report informs us that in addition CMS issued three other pricing rules for rehabilitation hospitals, hospices, and skilled nursing facilities.
  • Finally, Fierce Healthcare reports that

While hospitals post a mixed record on complying with a major price transparency rule [that took effect on January 1, 2021],the Biden administration has not announced how they are going to keep facilities in line.

Several studies and analyses have shown that larger health systems have not done a good job fully complying with the rule to post payer-negotiated rates online. The results come as the Centers for Medicare & Medicaid Services (CMS) has not announced major enforcement actions against hospitals not meeting the controversial rule’s requirements.

“So far with the current administration, we haven’t seen the agency put out any information on the auditing process or changes to the reporting requirements or changes to the penalties for noncompliance,” said Caitlin Sheetz, director and head of analytics for consulting firm ADVI, in an interview with Fierce Healthcare. “Unless that changes, I don’t think we are going to see large shifts in hospital behavior.”

Thursday Miscellany

David Ermer–CMS, COVID-19, COVID-19 vaccine, OPM, Rx coverage, U.S. Healthcare–
Photo by Juliane Liebermann on Unsplash

Yesterday, the Office of Personnel Management issued its technical guidance supporting the call letter for 2022 benefit and rate proposals which are due by May 31, 2021. The guidance provides insight into the call letter’s priorities.

The FEHBlog’s priority is supporting the COVID-19 vaccination effort. STAT News reports that

Useful Covid-19 information isn’t reaching the Instagram generation [Z]. There’s almost no messaging specifically tailored to them from federal or state public health officials. There’s hardly anything official on Tik Tok. And even the limited efforts to reach them where they are — like Instagram’s links to its “Covid-19 information center”— aren’t working. * * * Numerous public health officials told STAT that the issue of growing vaccine reluctance among young people can be solved with a coordinated campaign of reliable, useful information that makes it both easy and enticing for young people to get vaccinated, even if they may not personally benefit much. Those same officials acknowledged, however, that much of the groundwork for messaging to young people is yet to be done.

Recognizing a problem is the first step toward solving it.

Govexec.com informs us that

FEMA has sent about 3,000 employees to vaccination sites and is fully running 30 mass vaccination centers. It declined to say how many volunteers it was seeking from other agencies. The emergency response agency is standing up community vaccination centers fully run and staffed by federal employees, providing funding and staffing to state-run sites and deploying mobile vaccination centers.

Thanks Feds.

The Centers for Medicare and Medicaid Services announced yesterday a proposed rule “that would update Medicare payment policies and rates for the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) for Fiscal Year (FY) 2022 and propose changes to the IPF Quality Reporting (IPFQR) Program. * * * Total estimated payments to IPFs are estimated to increase by 2.3% or $90 million in FY 2022 relative to IPF payments in FY 2021.  For FY 2022, CMS is proposing to update the IPF PPS payment rates by 2.1% based on the proposed IPF market basket update of 2.3%, less a 0.2 percentage point productivity adjustment.”

Fierce Healthcare alerts us that “Drugs for inflammatory autoimmune conditions account for a growing chunk of pharmacy spend, according to new data from Prime Therapeutics. The pharmacy benefit manager studied (PDF) data on its 15 million commercially insured members in 2019 and 2020 and found that fewer than 1% of members had an inflammatory autoimmune condition such as psoriasis, rheumatoid arthritis, ulcerative colitis or Crohn’s disease. However, drugs treating these conditions accounted for nearly 20% of drug spend in the medical and pharmacy benefit, Prime Therapeutics found.” Wow.

Healthcare Dive reports that

  • While urgent care centers do keep some lower-acuity patients from visiting costly emergency departments, their presence is not associated with a drop in total healthcare costs, according to a report in Health Affairs.
  • Using commercial claims and enrollment data from 2008 to 2019, researchers found an increase of 1,000 lower-acuity urgent care visits resulted in 27 fewer lower-acuity ER visits. The entry of a high-volume urgent care center into a ZIP code was associated with a 31% drop in emergency visits.
  • However, while ER trips were far more costly ($1,716 vs. $178), each $1,646 ER visit was offset by $6,327 more in urgent care costs because the number of urgent care visits per enrollee required to reduce one ER visit was 37.

Hmmm.

Health Payer Intelligence discusses a three ways for employers to fund their employee health benefit plans — insured, self-funded and an approach (with which the FEHBlog was not familiar) level funding.

In the level-funded model, the employer pays the insurer each month to cover expected healthcare expenditures, the Society for Human Resource Management (SHRM) website explains. The funds go towards claim payments, stop-loss insurance premiums, and administrative costs.

If this sounds familiar that is because this model borrows from both the fully-insured and self-insured models.

However, the distinction is that in a level-funded health plan, the insurer will return to the employer any funds that remain at the end of the year, if the volume of medical claims is not as high as anticipated. Alternatively, if the volume of medical claims exceeds the projected cost, employers will face a higher stop-loss insurance premium.

Although this is the general template for a level-funded plan, contracts may include various specifications, the SHRM site says. For example, some insurers may require that their company retain a certain percentage of the savings or that these funds roll over to be spent on medical claims in the subsequent year.

In this model, insurers—specifically larger insurers—may have cemented their level-funded plan offerings or they may work with employers to tailor the funding plan to fit the business’s needs.

Level-funded plans cater to smaller firms that want a self-insured health plan but may not be able to afford the high cost of medical claims and stop-loss insurance.

You do learn something new everyday.

Midweek Update

David Ermer–ACA, CDC, CMS, COVID-19, Federal employment benefits, U.S. Healthcare–
Photo by Manasvita S on Unsplash

Bloomberg reports today that

The B.1.1.7 variant of the coronavirus, first found in the U.K., has overtaken the initial form of the virus in the U.S. and is now the country’s most common strain, the head of the Centers for Disease Control and Prevention said Wednesday. CDC Director Rochelle Walensky said at a briefing that the version had overtaken other mutations that have emerged, as well as the initial version of the virus in the U.S.

The Centers for Disease control has identified the B.1.1.7 variant as a “variant of concern” which means

A variant for which there is evidence of an increase in transmissibility, more severe disease (increased hospitalizations or deaths), significant reduction in neutralization by antibodies generated during previous infection or vaccination, reduced effectiveness of treatments or vaccines, or diagnostic detection failures.

Here is the CDC’s breakdown on the B.1.1.7. variant:

Name
(Pango lineage)		Spike Protein SubstitutionsName
(Nextstraina)		First DetectedBEI Reference IsolatebKnown Attributes
B.1.1.7Δ69/70
Δ144Y
(E484K*)
(S494P*)
N501Y
A570D
D614G
P681H		20I/501Y.V1United KingdomNR-54000external icon~50% increased transmission 5

Likely increased severity based on hospitalizations and case fatality rates 6
Minimal impact on neutralization by EUA monoclonal antibody therapeutics 7, 14
Minimal impact on neutralization by convalescent and post-vaccination sera 8,9,10,11,12,13,19

WebMD adds that “Of the three “variants of concern” recognized by the World Health Organization and the CDC, studies have shown that the mRNA vaccines created by Pfizer/BioNTech and Moderna, as well as the Novavax vaccine, remain highly effective against the B.1.1.7 variant, which was first recognized in the United Kingdom. * * * Johnson & Johnson, Moderna, and Pfizer are all exploring options to make their vaccines more effective against the variants [of concern].”

The Wall Street Journal offers a helpful tip — “Pharmacies and health officials are making a plea to Americans who received their Covid-19 vaccines: Cancel the other shots you booked.” That is sensible advice.

The Department of Health and Human Service reports today that “more than half a million consumers have already signed up for health insurance through HealthCare.gov as a result of the Biden Administration’s Special Enrollment Period (SEP) for the COVID-19 Public Health Emergency. * * * Today’s report from the Centers for Medicare & Medicaid Services (CMS), which covers plan selections from February 15 to March 31, also shows gains in enrollment among historically uninsured communities, including Black consumers and Americans near the poverty level. Of applicants who identified a race, 17% identified as Black – compared to about 11% in both 2020 and 2019 during the same time period. Among consumers requesting financial assistance, 41% report being at or slightly above the federal poverty level, compared to 38% in 2020 and 33% in 2019.” The SEP continues until August 15, 2021. Will / can HHS make the open enrollment permanent?

In other heathcare / healthcare business news:

  • Healthcare Dive reports “UnitedHealth Group has named longtime executive Brian Thompson as the new chief executive officer of its health benefits business, UnitedHealthcare, the biggest private payer in the U.S.”
  • The CDC discusses the “Surprising Link Between Chronic Kidney Disease, Diabetes, and Heart Disease.”

Risk factors for each condition are similar and include high blood sugar, high blood pressure, family history, obesity, unhealthy diet, and physical inactivity.

High blood sugar can slowly damage the kidneys, and, over time, they can stop filtering blood as well as they should, leading to CKD. Approximately 1 in 3 adults with diabetes has CKD.

When the kidneys don’t work well, more stress is put on the heart. When someone has CKD, their heart needs to pump harder to get blood to the kidneys. This can lead to heart disease, the leading cause of death in the United States. Change in blood pressure is also a CKD complication that can lead to heart disease. Luckily, preventing or managing one condition can help you prevent and manage the others and lower the risk for more complications [as explained in the article].

  • The Labor Department today issued FAQs and model forms to help ERISA governed plans implement the free COBRA continuation coverage available from April 1 through September 30, 2021, for COBRA-eligible folks who lost their ERISA coverage due to an involuntary termination or reduction in hours. This offer does not extend to FEHB enrollees who are covered under a different continuation of coverage program colloquially known as TCC>
  • Fedweek offers Reg Jone’s column on benefits available on the death of a current federal employee. These are very valuable rights that protect the employee’s family.

Thursday Miscellany

David Ermer–CMS, Congress, COVID-19, OPM, U.S. Healthcare–
Photo by Juliane Liebermann on Unsplash

From Capitol Hill, the American Hospital Association gleefully reports that “The Senate today passed by 90-2 vote a bill that, among other health care provisions, would eliminate the 2% across-the-board cut to all Medicare payments, known as sequestration, until the end of 2021. To pay for the change, the bill, which was introduced by Sens. Jeanne Shaheen, D-N.H., and Susan Collins, R-Maine, would increase the fiscal year 2030 sequester cuts. The House is expected to take up the Senate-passed bill when it the week of April 13 when it returns to Washington D.C.”

The U.S. Office of Personnel Management announced six political appointments to the agency which do not require Senate confirmation. Good luck to them.

From the COVID-19 front, the Wall Street Journal observes

In many ways, AstraZeneca, which developed the vaccine in partnership with the University of Oxford, is delivering on its main promises. More than 70 countries, including the U.K. and much of the rest of Europe, have found the shot safe and effective. Although it isn’t a big player in vaccines, AstraZeneca helped make an experimental shot ready for mass use in less than a year. The company has built a manufacturing and distribution network that is delivering doses to the world’s poorest. Unlike most of its big competitors with vaccines or vaccine candidates, it has promised to do all this at no profit. The vaccine has been crucial to the U.K. drive that boasts one of the world’s best per-capita vaccination rates.

But at crucial moments, company executives have fumbled communications with governments, regulators and the public. That has left a reputational cloud over the vaccine effort—an effort that Dr. Soriot has said reflects the company’s desire to play a leading role in battling the pandemic.

The reverse — good public relations by a bad actor — would be a much worse situation. The FEHBlog hopes that the Food and Drug Administration does not delay emergency use authorization for the AstraZeneca vaccine.

Also from the COVID-19 front today, the Centers for Medicare and Medicaid Services issued a fact sheet on the value of monoclonal antibodies (mAb) treatment for high risk Covid-19 positive patients.

mAb treatment for COVID-19 is different from a COVID-19 vaccine. A vaccine triggers your body’s natural immune response, but can take weeks to develop enough antibodies and prevent some kinds of infection. Some vaccines for COVID-19 require two shots, so your body can develop its own immune response to the disease. But if you already have the virus, mAb treatment gives your body the antibodies it needs to protect itself.

That is positive news.

In miscellaneous healthcare news —

Anthem is planning to acquire myNEXUS, a company that manages home-based nursing services for insurers.

According to the announcement, myNEXUS provides support to 1.7 million Medicare Advantage members across 20 states. The company’s platform largely automates the visit and authorization, getting care to the member faster, they said.

MyNEXUS uses a digital analytics tool in tandem with a team of more than 250 clinicians to plan and optimize home care, the companies said. In addition, it works with a nationwide network of providers and nursing agencies for local care.

  • Healio reports that at “the Renal Physicians Association annual meeting, representatives from three companies [led by CVS Health] shared their approach to the changing paradigm of kidney care and emphasized the shift to value-based models that center on the patient.”
  • America’s Health Insurance Plans announced that

Electronic prior authorization (ePA) can significantly reduce the time between a request for prior authorization and a decision and the time to a patient receiving care.  These were two of the top findings from an initiative launched by America’s Health Insurance Plans (AHIP) to better understand the impact of ePA on the prior authorization process.

“Prior authorization is an important tool in helping patients receive safe, effective, clinically appropriate care,” said Kate Berry, Senior Vice President of Clinical Affairs at AHIP.  “We are always looking for ways to enhance the patient and provider experience, and electronic prior authorization is an example.  Today’s analysis provides a blueprint for how to leverage electronic tools to improve prior authorization.”

AHIP launched the Fast Prior Authorization Technology Highway—or Fast PATH—to better understand how electronic prior authorization could impact the process for patients and providers. Six health insurance providers—Blue Shield of California, Cambia Health Solutions, Cigna, Florida Blue, Humana, and WellCare (now Centene)—that collectively cover over 50 million Americans participated in the project, with Availity and Surescripts serving as the technology partners.

Bravo.

  • Health Payer Intelligence informs us that “Payers should prepare for the payer price transparency rule to go into effect by building clear communication paths with members, reassessing their contracting processes, and asking themselves a couple of key questions, according to a report from PricewaterhouseCoopers’s Health Research Institute (HRI).” Check it out.

Monday Roundup

David Ermer–AHRQ, CMS, COVID-19, COVID-19 vaccine–
Photo by Sven Read on Unsplash

“The ides of March are come.
Soothsayer: Ay, Caesar; but not gone.” Wm. Shakespeare

From the COVID-19 vaccine front —

The Centers for Medicare and Medicaid Services (“CMS”) announced today that

Effective for COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies and many other immunizers will be $40 to administer each dose of a COVID-19 vaccine. This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines, and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses. The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.  

CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing during the public health emergency (PHE). Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates.

Medscape reports that “AstraZeneca Plc is preparing to file for U.S. emergency use authorization (EUA) for its COVID-19 vaccine later this month or early April after accumulating enough data to judge the inoculation’s efficacy, sources with knowledge of the ongoing clinical trial told Reuters on Friday.” STAT News in its article titled the “Curious Case of the AstraZeneca’s COVID-19 vaccine” concludes

The U.S. study, started last September and including 30,000 patients, is, like the studies for the Moderna and Johnson & Johnson vaccines, being run with the U.S. National Institutes of Health. It’s the best hope for settling any questions or concerns about the AstraZeneca vaccine once and for all.

STAT News also informs us that Biden Administration is about to embark on a $1.5 billion public relations campaign to convince Americans to receive the COVID-19 vaccine. “Much of the project’s funding comes from the sweeping $1.9 trillion Covid-19 relief bill Biden signed last week. The administration has also already pledged over $500 million in additional funds to address vaccine uptake, health literacy, and equity in the vaccine distribution, including $250 million to fund local health literacy projects and another $255 million for the CDC to fund local government efforts to focus on equity and confidence in underserved communities.”

The Federal Times reports that “Washington, D.C. Mayor Muriel Bowser released an updated vaccination timeline March 15 that outlines when, among other essential professions, federal government and Postal Service employees can expect to become eligible for a COVID-19 vaccine. * * * Just under seven percent of federal employees are located in Washington, D.C.”

Also, Fierce Healthcare offers UnitedHealthcare scientist and Healthcare Dive offers hospital executive reflections on the first anniversary of the great hunkering down.

The HHS Office of Inspector General has unveiled a new website about the agency’s oversight of COVID-19 response and recovery. The website calls attention to the agency’s updated list of COVID-19 scams.

During this Patient Safety Awareness Week, HHS’s Agency for Healthcare Research and Quality calls attention to its Chartbook on Patient Safety. “This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (QDR). The QDR includes annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety.”