Weekend update

Congress

Weekend update

David Ermer–CDC, Congress–

The FEHBlog is back inside the Capitol Beltway following a weekend trip. Congress remains in session on Capitol Hill this coming week. Fierce Healthcare reports that “Leaders of the Senate Finance Committee demanded Cigna and Optum produce critical documents over the pricing of insulin, with a subpoena threat looming.”

Here are links for the Centers for Disease Controls’ U.S. situation summaries for influenza and the COVID-19 viruses. Yesterday, Leap Day, the CDC reported regrettably about

three hospitalized patients [in the State of Washington] who have tested presumptive-positive for the virus that causes COVID-19, including one patient who died.

Two of the patients are from a long-term care facility (LTCF) where one is a health care worker. Additional residents and staff of the LTCF who have not yet been tested for COVID-19 are reportedly either ill with respiratory symptoms or hospitalized with pneumonia of unknown cause.

The patient who died, a male in his 50s, was being treated at the same hospital. He was not a resident of the LTCF.

This is the first reported death in the United States from COVID-19, as well as the first reported case in a health care worker and the first possible outbreak in a LTCF. These reports from Washington follow others of community spread in Oregon and two places in California earlier this week. While there is still much to learn about the unfolding situations in California, Oregon and Washington, preliminary information raises the level of concern about the immediate threat for COVID-19 for certain communities in the United States. Most people in the United States will have little immediate risk of exposure to this virus, but some people will be at increased risk depending on their exposures. The greatest risk is to those who have been in close contact with people with COVID-19. People with suspected or confirmed exposure should reach out to their state or local public health department.

ABC News adds today that

Two new cases of coronavirus have been confirmed in Washington state, according to health officials.

The cases include a male in his 60s, who has underlying health conditions but is stable, and another man in 60s with underlying health conditions but is in critical condition.

Both cases are in King County, bringing the total number of confirmed cases in the county to six. One of those cases is a U.S. postal worker, county’s health administration stated.

It appears that this unfortunate Postal worker is the first FEHB member afflicted by the disease. Good luck to all of the COVID-19 and influenza patients. We are lucky to live in a country with excellent healthcare.

Midweek update

David Ermer–CDC, Congress, Rx coverage–

The Wall Street Journal recently published a story titled “How the Drug Lobby Lost its Mojo in Washington.” The story also is available on the Journal’s listener friendly podcast. The upshot of the story is that the bipartisan effort to enact a drug pricing law may have legs as they say on Capitol Hill.

“In the past PhRMA had a reputation for rolling the tanks against every proposal irrespective of industry impact,” says PhRMA Chief Executive Officer Stephen Ubl. “We are now taking a more proactive approach of coming to the table to offer policy makers solutions that would address patient affordability challenges.”

PhRMA’s Mr. Ubl says the drug industry could be open to a deal that combines elements of bills from Mr. Grassley, Mrs. Pelosi and House Republicans, saying there “are provisions in all three bills that have bipartisan support and could meaningfully improve affordability for patients without including price controls.” 

In the no good deed goes unpunished department, the Pharmacy Times reports that

Four FDA-approved products that face no competition may increase health care spending by as much as $20.25 billion, according to a new analysis by Vizient Inc.1

The report focused on the Unapproved Drug Initiative (UDI) and its unintended effects on the market. The UDI was an FDA mandate enacted in 2006 that required unapproved drugs in use prior to FDA review of safety and efficacy to be either approved or removed from the market. Once a previously unapproved drug receives FDA approval, the manufacturers of other unapproved versions are asked to remove their products from the market.1

Although the goal of the UDI was to remove potentially dangerous medications from the market, the report authors noted that most of the products are chemically well-defined, reuqire no research and development, and are widely used in health care settings.1

The researchers used the wholesale acquisition cost (WAC) for all calculations and then estimated and used IQVIA data for all US health care product units purchased.1

According to the authors, the UDI has resulted in $2.66 billion in increased costs already incurred, $8.75 billion in estimated cossts awaiting the UDI decision, and $17.59 billion in remaining exclusivity estimated costs.1

Hokey smokes, that’s a big bowl of wrong.

The FEHBlog who is not much of a world traveler was aware of the State Department’s international travel advisories. Today he learned about the Center for Disease Control’s travel health notices. It’s important to check both lists if you plan to travel internationally.

In the healthcare provider competition department, Fierce Healthcare reports that

The Urgent Care Association released its 2019 benchmarking report that showed the total number of centers had reached 9,616 as of November 2019, a 9.6% jump from the previous year.

The number of centers has increased steadily each year from 2013, when the total number of urgent care centers was 6,100. Both urgent care centers and retail clinics have continued to grow across the U.S. as patients look for convenience and affordability, creating competition with traditional hospital and physician practice services.

In the FEHBlog’s view, convenient access to care is great as long as the primary care provider is kept in the loop.

In the good public health news department, the Department of Health and Human Services announced today that

The Health Resources and Services Administration (HRSA) [has] awarded approximately $117 million to expand access to HIV care, treatment, medication, and prevention services. This investment is a critical component of the Administration’s Ending the HIV Epidemic: A Plan for America (EHE) initiative, which aims to reduce the number of new HIV infections in the United States by 90 percent by 2030.

The EHE initiative and today’s awards focus on 48 counties, Washington, D.C., and San Juan, Puerto Rico, geographic areas where more than 50 percent of new HIV diagnoses occurred in 2016 and 2017, as well as the seven states with a substantial rural HIV burden.

Finally, as she is the most influential healthcare policymaker in the U.S. per Modern Healthcare, take a gander at CMS Administrator Seema Verma’s speech to the annual CMS quality conference.

Monday Musings

David Ermer–CDC, Congress, Medicare, Uncategorized–

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

David Ermer–CDC, Congress–

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.

Midweek update

David Ermer–Congress, Uncategorized–

Today the House Ways and Means Committee passed its surprise billing proposal (H.R. 5826) by voice vote. This bipartisan bill is strongly by hospital and other healthcare provider organizations. Enough said.

The Hill reports on the state of efforts in the Senate to lower prescription drug prices. The efforts currently are up in the air according to the Majority Leader Mitch McConnell.

Speaking of prescription drugs, Bioworld informs us that a

New analysis from Clarivate Analytics’ Cortellis Forecast Team predicts 11 medicines set to enter the market in 2020 will reach more than $1 billion in sales by 2024. Drugs for central nervous system indications and cancer dominate the list, almost universally accelerated in their development by orphan drug status or other designation intended to speed their path to market. Most medicines are for indications in markets already crowded with competitors, meaning they’ll face substantial pressures to differentiate from existing products.

The Office of National Coordinator of Health Information Technology discusses last week’s 10th annual ONC conference in a blog post.

We heard about standards for clinical data and financial transactions, technology for matching you with your (snail) mail, and how leading innovators are using application programming interfaces and the HL7® FHIR® standard to advance access. And yet, these technologies are not always working in sync. Several new and proposed policies from HHS – including ONC’s and CMS’s proposed interoperability rules and the Trusted Exchange Framework and Common Agreement – are set to move the nation one step closer to making these technologies work for the patient.

It can’t happen too soon, in the FEHBlog’s view.

Also this week Healthgrades issued its best U.S. hospitals list. Healthgrades explains that its ratings are “based solely on clinical quality outcomes for 32 conditions and procedures. This premier distinction rewards hospitals that consistently exhibit exceptional, comprehensive quality care.” Although none of the D.C. located hospitals are included on the list, there are several in the D.C. suburbs of Maryland and Virginia.

Tuesday Tidbits

David Ermer–ACA, Congress, Uncategorized–

Earlier today, the House Education and Labor Committee advanced its bipartisan surprise billing proposal (H.R. 5800) today by a 32-13 vote. As the FEHBlog mentioned last Friday, the House Ways and Means Committee has released the legislative text of its bipartisan surprise billing proposal (H.R. 5826). While these proposals seek to protect consumers, which is a good thing, they also will impose new administrative burdens on the health system but won’t encourage out-of-network providers to go in-network. The FEHBlog anticipates that if bipartisanship on this issue continues in the House, then it’s likely that the House bill will wind up in the Senate’s bill to lower healthcare costs (S. 1895) and eventually become law.

The Association of Community Health Plans has proposed

a certification framework for digital health care pricing tools that makes quality and pricing information accessible, understandable and actionable for consumers. Outlined in a new issue brief, ACHP offers a core set of standards for meaningful price transparency and lays out a roadmap for independent certification of these tools.

Smart move given the federal government’s push for price transparency tools.

The Wuhan or novel coronavirus has an official name. Forbes reports that

Today, the World Health Organization (WHO) announced the official new name of nCoV2019 (2019 novel coronavirus), the strain of coronavirus that has infected over 43,000 people worldwide, resulting in 1017 deaths.

COVID-19, as the virus will now be known, was decided on by the WHO, with the organization giving a number of reasons as to why it was chosen.

Evidently the FEHBlog was violating WHO guidelines by referring to this disease as the Wuhan virus. Lo siento.

Healthcare Dive reports on Change Healthcare survey of healthcare provider and payer executives. The article describes differences of opinion between payer and provider executives. Here’s one —

Their positions on social determinants of health seem to reflect one of the widest splits. Providers appear to have the edge in terms of gathering information on substance abuse among patients (71.4% of provider executives versus 52.5% of payers). However, payers are much more effective at pinning down the income data of their enrollees (45.9% versus 26.5%). They also had a 10-point advantage in focusing on health literacy (39.3% vs. 29.6%), although the numbers suggest both factions did not consider it a major issue.

Big Monday

David Ermer–Congress, Federal employment benefits, Uncategorized–

The U.S. Office of Personnel Management (“OPM”) released its call letter for 2021 FEHBP benefit and rate proposals today. The carrier proposals are due on Sunday May 31, 2020. To prepare the proposals carriers also need OPM’s technical guidance, which is a separate Carrier letter, and to submit their proposals, carriers also must complete OPM’s extensive “ADC” information request. OPM expects a lot from its FEHBP carriers.

The President did transmit his FY 2021 budget proposal to Congress today. The Administration intends to propose to statutory change to the FEHBP government contribution formula (5 USC Sec. 8906):

to base it on a plan’s score from the FEHB Plan Performance Assessment would improve healthcare quality and affordability within the program. The enactment of the proposals in 2021 will not begin to impact program financials until 2023. [Page 1168]✦

This appears to be a retread from the last budget cycle. However, the FEHBlog does not recall reviewing the proposed legislative language for the 2019 proposal. This proposal assuming its the same one didn’t get very far then, and it’s unlikely to get further this year in the FEHBlog’s view. Federal News Network discusses other federal employee compensation found issues in the budget proposal.

Russ Roberts the host of the Econtalk podcast held a fascinating conversation with “physician and author Marty Makary of Johns Hopkins University talks about his book The Price We Pay.” The book concerns fixing our healthcare system. Dr. Makary made a lot of sense to the FEHBlog. He encourages readers to listen to this podcast or read the transcript.

Weekend update

David Ermer–CDC, Congress, Medicare, Rx coverage–

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.

TGIF

David Ermer–Congress–

The American Hospital Association reports today that

House Ways and Means Committee Chairman Richard Neal, D-Mass., and Ranking Member Kevin Brady, R-Texas, this morning released legislative text of the Consumer Protections Against Surprise Medical Bills Act of 2020, the committee’s proposal to address surprise medical bills. The legislation prohibits providers from balance billing patients for emergency services or medical care the patient reasonably could have expected to be in-network, and does not allow patients to be charged more than the in-network cost-sharing amount. The proposal does not rely on a benchmark payment rate to determine out-of-network reimbursement, but instead includes a period for health plans and providers to negotiate reimbursement, to be followed by a mediated dispute resolution process should it be necessary. The proposal also includes several other consumer protection and transparency provisions. The committee is expected to mark up the legislation on Wednesday, Feb. 12. 

In addition, House Committee on Education and Labor Chairman Robert “Bobby” Scott, D-Va., and Ranking Member Virginia Foxx, R-N.C., this morning unveiled the Ban Surprise Billing Act. The legislation is similar to the bills passed last year by the House Energy and Commerce Committee and Senate Health, Education, Labor and Pensions Committee in that it relies on a median in-network rate to resolve out-of-network payments. For amounts paid above $750 (or $25,000 for air ambulance services), the legislation allows for an independent dispute resolution process to determine the final payment. A summary of the legislation is here, and legislative text was released late this afternoon. The committee is scheduled to mark up the legislation on Tuesday, Feb. 11.

If the arbitration approach becomes law, you can be sure that health plans will restrict out of network coverage as far as they can unless Congress repeals that option. In other words, it appears that the out-of-network providers are looking to squeeze the last golden egg out of the strangled goose. The FEHBlog appreciates in-network providers for helping to control health care spending.

Bloomberg News reports that

AHIP President and CEO Matt Eyles said health insurers should be allowed to classify efforts to address social determinants of health as quality improvements or patient care instead of as administrative costs. Health insurers are uniquely positioned to tackle SDOH, according to Eyles, who said changing how the initiatives are classified “would allow for greater measurement over time to understand how we might we might be impacting cost trends.”

Good recommendation. OPM should take this approach with all FEHB plans.

Modern Healthcare informs us

The novel [or Wuhan] coronavirus that threatens to hobble the global economy, causing travel restrictions and the closure of some U.S. retail stores in China, is expected to stabilize in April, according to a projection from S&P Global Ratings. 

S&P’s analysts said a worst-case scenario would involve the virus spreading into late May, with an optimistic prediction calling for an end to transmissions in March. The firm said the impact on economic activity in Asia could peak around the middle of the year before an economic rebound in 2021.

Hope springs eternal.

Midweek update

David Ermer–ACA, Congress, Medicare, SCOTUS–

OPM and AHIP which co-sponsor the annual FEHBP Carrier Conference have posted the Conference agenda. The FEHBlog welcomes the half day of break out sessions has been added to the agenda. The conference which is held in Arlington Virginia will run from early Wednesday afternoon April 1 through late Friday morning April 3.

Earlier today, the House of Representatives, as expected, passed a bill to repeal the 2006 law obligating the Postal Service to pre-fund healthcare coverage for their annuitants. Businesses generally have to account for this type of cost as a liability, but don’t have to put the money aside as the Postal Service must (although the Postal Service has not been able to fund the cost since 2012).

The FEHBlog expects the Senate to adopt this bill which reflects reality. The FEHBlog wonders whether this action will deflate the long running effort to create a lower cost Postal Service program within the FEHBP. The next edition of a general postal reform bill will be telling on this point.

The Centers for Medicare and Medicaid Services today proposed changes to the Medicare Advantage and Part D prescription drug programs. Health Payer Intelligence explains that the proposals

will increase plans’ revenues by 0.93 percent. The proposed rule would extend Medicare Advantage eligibility to those diagnosed with end-stage renal disease (ESRD), lower cost-sharing on prescription drugs, and enforce greater transparency and comparability of out-of-pocket healthcare spending for different drugs. CMS also introduced measures to promote using generics and biosimilar

CMS explains that the agency “will accept comments on all proposals in the Advance Notice through Friday, March 6, 2020, before publishing the final Rate Announcement by April 6, 2020.”

Speaking of Medicare, Healthcare Dive discusses an intriguing Humana initiative to develop primary care centers for their Medicare Advantage members. “The new venture is likely to double the number of centers [Humana subsidiary} Partners in Primary Care operates. It currently runs 47 locations throughout Kansas, Missouri, North Carolina, South Carolina, Texas and Florida.”

The FEHBlog has been tracking the course of the Texas v. U.S. case through the U.S. Supreme Court (Consolidated Nos. 19-840, 19-841). A group of States and the House of Representatives have petitioned the Supreme Court to review a December 2019 Fifth Circuit opinion holding the ACA’s individual mandate unconstitutional and directing the lower court to reconsider the extent to which the remainder of this massive law is severable from the unconstitutional part.

The parties’ and amici (friends of the Court) briefing on the petition for review will be competed on February 12, 2020. The Court’s docket sheet revealed today that the briefs will be distributed to the Court for the February 21, 2020 conference.

The Court needs four votes to take the case for review. If the Court decides to grant review (or certiorari), the decision would be announced late afternoon on February 12. Otherwise, a decision to decline review would be announced the following Monday February 15. The Court may punt the case to later conference in which event the cases will not be referenced in the February 15 order. All of the briefs are available by searching the Court’s docket for one of the case numbers — 19-840 or 19-841.

Medcity News provides a useful list of prescription drugs that are going off patent in 2020. The list also projects the availability of generic competitors.