Monday Musings

Medicare

Monday Musings

Posted By David Ermer–Categorized In 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.

Weekend update

Posted By David Ermer–Categorized In 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.

Midweek update

Posted By David Ermer–Categorized In 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.

Monday musings

Posted By David Ermer–Categorized In Medicare–

Healthcare Dive reports that people finally are using patient portals and apps in substantial numbers.

Nearly 60% of patients report their provider or insurer offered them online access to their medical record in 2019, and nearly 40% viewed their record electronically at least once in the past year. Both are significantly up from 2018, analysts said.

Happy day. People taking more interest in their health will help control healthcare spending over time, in the FEHBlog’s view.

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

Over the last several years, CMS has been actively monitoring the rapid innovation of [Next Generation Sequencing] NGS [genetic] tests and the evolution of cancer diagnostic tools. NGS tests provide the most comprehensive genetic analysis of a patient’s cancer because they enable simultaneous detection of multiple types of genetic alterations. Medicare first began covering laboratory diagnostic tests using NGS in March 2018 for Medicare patients with advanced cancer that met specific criteria. As a result of today’s decision, more Medicare patients will have access to NGS in managing other types of inherited cancers to reduce mortality and improve health outcomes.

Health Payer Intelligence provides more background on today’s CMS decision.

Last Friday, the FEHBlog called attention to a Fedweek article discussing a new OPM Inspector General report on FEHBP dependent eligibility issues. The FEHBlog could not readily track down the report discussed in the article. A friend of the FEHBlog discovered that the Fedweek article is referencing 2019 Top Management Challenge No. 9 (pp 21-22) which was released early last November. Mystery solved!

Midweek update

Posted By David Ermer–Categorized In Federal employment benefits, Medicare–

CVS announced the following six health trends for 2020

  1. Continued evolution in kidney care 
  2. Greater consumer scrutiny on wellness products 
  3. The need for data stewardship as digital health rolls on 
  4. Pharmacies as a tool to reach underserved populations 
  5. Efforts to mitigate loneliness 
  6. Increased transparency around drug pricing 

The Centers for Medicare and Medicaid Services has decided to extend Medicare coverage to acupuncture for chronic low back pain as an alternative to opioid based pain killers. The CMS decision ” will cover up to 12 sessions in 90 days with an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement.” Previously Medicare excluded acupuncture from coverage.

Retired OPM official Reg Jones discusses survivor benefits related to federal employment in Fedweek. FEHBP survivor benefits are generous if the prerequisites are met:

If your spouse receives an annuity in any amount and was covered under either the self plus one or self and family option of your FEHB plan, he or she and all eligible children may continue coverage. If the annuity amount is less than the premiums required, your spouse will be able to directly make payments to cover the rest of the cost.