Thursday Miscellany

Thursday Miscellany

Earlier this month, the National Center for Health Statistics released a report on 2019 births in our country. Here are some notable snippets from that report:

  • The provisional number of births for the United States in 2019 was 3,745,540, down 1% from the number in 2018 (3,791,712). This is the fifth year that the number of births has declined after the increase in 2014, down an average of 1% per year, and the lowest number of births since 1985.
  • The birth rate for teenagers in 2019 was 16.6 births per 1,000 females aged 15–19, down 5% from 2018 (17.4), reaching another record low for this age group. The rate has declined by 60% since 2007 (41.5), the most recent period of continued decline, and 73% since 1991, the most recent peak.
  • The low-risk cesarean delivery rate, or cesarean delivery among nulliparous (first birth), term (37 or more completed weeks based on the obstetric estimate), singleton (one fetus), vertex (head-first) births, also decreased to 25.6% of births in 2019 from 25.9% in 2018.
  • The percentage of infants born preterm (births at less than 37 completed weeks of gestation) fell 8% from 2007 (the most recent year for which national data are available based on the obstetric estimate of gestation) to 2014, but has risen 7% from 2014 (9.57%) to 2019.

Healthcare Dive reports that

The number of Medicare beneficiaries using telehealth skyrocketed in the early weeks of the pandemic as the Trump administration relaxed regulations to virtual care.

The looser regulations are only in place for the extent of the national public health emergency, but myriad groups have called on HHS to permanently relax the barriers. Top administration health officials have said they’re exploring the possibility.

Here’s hoping.

Health IT Security informs us about Verizon’s latest data breach investigations report.

For healthcare, there were 798 security incidents and 521 confirmed data breaches in 2019, compared to 304 incidents in the previous year. While miscellaneous insider errors, privilege misuse, and web applications were the leading causes 2018 healthcare data breaches, external threats outpaced insiders in this year’s report.

In fact, 51 percent of healthcare data breaches were caused by external actors, and insider-related breaches fell to 48 percent. Despite the slight increase in external-related breaches, healthcare does remain the leading industry for internal bad actors.

It’s not always a good thing to be in first place.

Let’s wrap it up with a story about responsible corporate citizenship. Becker’s Hospital CFO Report informs us that

CMS automatically sent out the first slice of federal funding under the Coronavirus Aid, Relief and Economic Security Act based on historical Medicare fee-for-service reimbursement. Now, several companies are returning the relief aid.

[Healthcare companies] Cigna, CVS Health, DaVita, Encompass and Walmart are among the companies sending back federal grants they received under the CARES Act, which are meant to reimburse healthcare providers for expenses or lost revenues tied to the COVID-19 pandemic, according to Business Insider. The companies are returning a total of nearly $574 million.

The common reason for returning these large amounts of money was aptly stated by CVS Health:

“We have made the decision to return the funds and forgo participation in subsequent disbursements,” CVS Health President and CEO Larry Merlo wrote in a May 19 letter to HHS Secretary Alex Azar. “In doing so, we hope to help HHS provide additional support to other providers who are facing significant financial challenges as a result of the pandemic.”

Bravo.

Tuesday Tidbits

While the FEHBlog has been discussing the progress of convalescent plasma to treat COVID-19, its time to turn to the Gilead drug remdesivir Fierce Pharma discusses today a recently released peer reviewed study that shows that the drug works well with patients suffering from moderate severity COVID-19.

The 1,063-patient study showed remdesivir’s benefits appear greatest for hospitalized patients in the middle of the disease-severity spectrum. For those who required oxygen supplementation but were not mechanically ventilated, remdesivir cut the time to recovery by 47% compared with placebo. But remdesivir didn’t much help patients with mild or moderate disease, and outcomes for patients on invasive ventilation or extracorporeal membrane oxygenation were nearly the same in both arms of the study.

According to the article, studies are continuing on the efficacy of the drug for patients with mild severity COVID-19.

The Wall Street Journal reports today that physicians are concerned over fact that anti-anxiety and anti-depression prescriptions have spiked during the great hunkering down. “Many physicians have a low threshold for prescribing them. It’s very problematic,” says Bruce J. Schwartz, deputy chair and professor of psychiatry and behavioral sciences at Montefiore Medical Center in New York. “Many people do develop a dependency on these medications.” The article offers alternate approaches, and FEHB plans now usually offer coaching services to help with the problems.

Speaking of healthcare coaching programs, CNBC reports that the great hunkering down has been good for companies that provide coaching or telehealth / digital health programs.

The Centers for Medicare and Medicaid Services announced that their 2021 pilot program to lower insulin costs for Medicare beneficiaries is bearing fruit.

Based on CMS’s estimates, beneficiaries who use insulin and join a plan participating in the model could see average out-of-pocket savings of $446, or 66 percent, for their insulins, funded in part by manufacturers paying an estimated additional $250 million of discounts over the five years of the model. With a robust voluntary response from Part D sponsors, CMS anticipates beneficiaries will have Part D plan options in all 50 states, the District of Columbia, and Puerto Rico, through either a standalone prescription drug plan (PDP) or a Medicare Advantage plan with prescription drug coverage. Beneficiaries will be able to enroll during Medicare open enrollment, which is from October 15, 2020 through December 7, 2020, for Part D coverage that begins on January 1, 2021.

Well done. Hopefully the Medicare approach will be translatable to employer sponsored coverage like the FEHBP.

Friday Stats and More

The CDC’s COVID-19 cases in the U.S. website, which the FEHBlog tracks, added age demographic information this week. The basic infection mortality rate stabilized then dropped slightly then stabilized again over the past two weeks. That has to be good news. The CDC’s weekly COVIDview supports the FEHBlog’s layman analysis.

MedPage Today offers an interesting story about the downswing of the illness from the perspective of New York City clinicians who have been on the front line.

The Centers for Medicare and Medicaid Services finalized today a subset of proposed Medicare Advantage and Part D changes that the agency proposed earlier this year. CMS is releasing the final rule in two installments so that Medicare Advantage and Part D plans are not overwhelmed. That’s considerate.

OPM released additional COVID-19 guidance for federal agencies today. The guidance concerns the Families First Coronavirus Response Act’s paid leave program for employees affected by COVID-19.

Monday Mishmash

Today, the Centers for Medicare and Medicare Services released its proposed rule describing changes to its Medicare Part A prospective payment system (“PPS”) changes for the federal fiscal year beginning October 1, 2020. This PPS applies to acute and long term inpatient care. Fierce Healthcare explains that the changes represent “an approximately 1.6% increase to inpatient hospital stay payments” that will add about $2.1 billion to Medicare spending next fiscal year.

A friend of the FEHBlog recommended a book called “Together: The Healing Power of Connection in a Sometimes Lonely World” written by former U.S. Surgeon General Vivek Murthy. It seems like a perfect read for the great hunkering down. The FEHBlog will let you know.

In other news:

  • Fierce Healthcare also discusses how CVS Health has adapted its specialty pharmacy to the COVID-19 emergency. According to the article, CVS Specialty is making greater use of digital tools, e.g., “a 30% increase in March alone in encounter volume through CVS Specialty’s secure messaging tool, which allows [their] pharmacists to text members directly to discuss their medications.”
  • The Wall Street Journal reports that “Atul Gawande is in advanced discussions to step down as chief executive and take on a less operational role as chairman of Haven, the health-care venture backed by Amazon.com Inc., Berkshire Hathaway Inc., and JPMorgan Chase JPM , according to people with knowledge of the matter.” Haven was the big new thing is 2018 when Dr. Gawande came aboard.
  • The HHS Office of Inspector General announced the availability of two “toolkits and the accompanying code can be used to analyze claims data for prescription drugs and identify patients who may be misusing or abusing prescription opioids and may be in need of additional case management or other followup. These toolkits and accompanying code can also be used to answer research questions about opioid utilization.”

Tuesday Tidbits

Theme for Cinco de Mayo — Ball of confusion that’s what the world is today. The Temptations (1970)

The American Hospital Association reported today that hospitals are losing $50.7 billion monthly from March through June due of course to the COVID-19 emergency. That’s a lot more than the $175 billion that Congress has appropriated so far for grants to hospitals and other healthcare providers. The FEHBlog doubts that most hospitals have strong balance sheets. No wonder health plans are stepping up to offer support as noted on Sunday.

Healthcare Dive discusses a study that reminds us about the large extent to which private payers including FEHB plans subsidize hospitals and other providers due to the insufficient payments from Medicare. “It’s unlikely Washington would take concrete measures to shrink hospitals’ toplines during the pandemic.”

Fierce Healthcare informs us that after reaching out to 500,000 Medicare Advantage members Humana has decided to waive Medicare Advantage member cost sharing for primary and behavioral healthcare this year whether the care is delivered in office or virtually. “William Shrank, M.D., chief medical officer at Humana, told FierceHealthcare that the insurer is tracking member behavior in this area and has gathered plenty of anecdotal evidence that patients are deferring potentially necessary care due to the pandemic.”

Catalyst for Health Reform has created a new state by state report card on healthcare price transparency laws. “Sixteen states [including the FEHBlog’s home state of Maryland] received passing grades this year, up from only seven when CPR last graded states in 2017.”

Person using a laptop

Thursday Miscellany

The Centers for Medicare and Medicaid Services today announced wide ranging Medicare changes to make healthcare more accessible during the COVID-19 emergency. For example,

For the duration of the COVID-19 emergency, CMS is waiving limitations on the types of clinical practitioners that can furnish Medicare telehealth services. Prior to this change, only doctors, nurse practitioners, physician assistants, and certain others could deliver telehealth services. Now, other practitioners are able to provide telehealth services, including physical therapists, occupational therapists, and speech language pathologists.

CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is broadening that list to include many behavioral health and patient education services. CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.

It will be interesting to see whether commercial plans adopt these changes (perhaps they already have). Check out the lengthy list. Hopefully many of these changes will be made permanent following the COVID-19 emergency.

As the FEHBlog has listed major COVID-19 testing locations. It occurred that he should also link to the COVID-19 sites for the major actuarial consulting firms, all of which provide useful information for health plans:

These sites are a valuable public service in the FEHBlog’s view.

HHS’s Office for Civil Rights today provided a helpful COVID-19 cyber threat resources. While the FEHBlog could not find a link to the list, he was able to upload the email to Dropbox.

It’s World Health Day

The World Health Organization has declared today World Health Day appropriately honoring nurses and midwives. U.S. HHS Secretary Alex Azar commented

“This year’s theme for World Health Day, ‘Celebrating Nurses and Midwives,’ is also an important reminder of the work being done by frontline healthcare workers every day, around the world, to save lives. Preparing for and responding to outbreaks that can cross borders is one of the most important contributions we can make to support our healthcare workers, and we applaud the heroic work they have been doing to battle the global pandemic

The FEHBlog heartily agrees. Now, how about some Tuesday Tidbits?

  • Yesterday, as Health Payer Intelligence reports, the Centers for Medicare and Medicaid Services “finalized its Medicare Advantage and Part D rates, including finalizing the disputed Medicare Advantage end-stage renal disease (ESRD) payment rule without changes.” HPI adds that CMS anticipates a slight uptick (1.66 percent) in revenue as a result of the new rate announcement, based on its changes to the reimbursement methodologies for Medicare Advantage organizations, PACE organizations, and Part D sponsors. The uptick does not account for the adjustments related to the underlying coding trend, which CMS anticipates will bump most risk scores by around 3.56 percent.” In the FEHBlog’s view, the extension of Medicare Advantage coverage to beneficiaries under age 65 with end stage renal disease could be disruptive to Medicare Advantage rates.
  • The Centers for Disease Control released yesterday a report on “Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020.” Here’s the summary

What is already known about this topic?

Data from China suggest that pediatric coronavirus disease 2019 (COVID-19) cases might be less severe than cases in adults and that children (persons aged <18 years) might experience different symptoms than adults.

What is added by this report?

In this preliminary description of pediatric U.S. COVID-19 cases, relatively few children with COVID-19 are hospitalized, and fewer children than adults experience fever, cough, or shortness of breath. Severe outcomes have been reported in children, including three deaths.

What are the implications for public health practice?

Pediatric COVID-19 patients might not have fever or cough. Social distancing and everyday preventive behaviors remain important for all age groups because patients with less serious illness and those without symptoms likely play an important role in disease transmission.

  • TechCrunch brings us up to date another potential COVID-19 vaccine is entering phase 1 human trials with Food and Drug Administration approval. This vaccine is being developed by Inovio Pharmaceuticals with financial backing from the Bill and Melinda Gates Foundation. Best of luck to Inovio and the other developers.
  • A friend of the FEHBlog found this online edited transcript of NYC pulmonologist David Price’s chat and Q&A on COVID-19 discussed in yesterday’s FEHBlog. Check it out.

Thursday Miscellany

The Centers for Medicare Services plans to start a new pilot program known as ET3 that allows certain ambulance companies to take traditional Medicare patients who call 911 to less acuity health care facilities than the usual hospital emergency room.

Under the ET3 Model, Medicare will pay participating ambulance suppliers and providers to: 

Transport a beneficiary to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or

Initiate and facilitate treatment in place by a qualified health care practitioner, either in-person on the scene or via telehealth. 

Upon arriving on the scene of a 911 call, participating ambulance suppliers and providers may triage Medicare beneficiaries to one of these Model’s interventions. 

The ET3 program will begin later this year for a two year period.

One of OPM’s heaviest weighted HEDIS measures turns on whether a pregnant woman visits her obstetrician in the first trimester of her pregnancy. Interestingly, Health Affairs Blog explains that

Prenatal care has been largely left out of the growing national conversation about the rise in maternal morbidity and mortality and the stark racial disparities in maternal health outcomes. This notable absence may be a consequence of how little is understood about the content and quality of prenatal care services and their relationship to maternal and infant health. Increased understanding of what happens during labor, delivery, and the postpartum period is essential to improving outcomes: the Centers for Disease Control and Prevention (CDC) estimates that roughly two-thirds of maternal deaths occur during childbirth and the first year thereafter. The remaining third of deaths occur during pregnancy. Prenatal care—spanning most of a year and consuming substantial time and resources from patients and providers alike—may represent an important opportunity to prevent these deaths, as well as to identify and mitigate risks of subsequent mortality or morbidity. 

There are three primary impediments to rigorous research in this area:

Reliance on blunt quality metrics that do not reflect important dimensions of care;

Limited access to data on what occurs during prenatal care; and

Empirical challenges to evaluating the impact of prenatal care on maternal and infant outcomes.

In other words, it’s complicated.

Fierce Healthcare reports on a survey about the extent to which patients lie to their physician and offers tips to doctors on how to encourage their patients to be truthful. If patients lie to their doctors, then members may well lie to their health plan too so the tips in the article should be generally helpful.

Midweek update

On the COVID-19 front —

  • The Senate this afternoon approved H.R. 6021, the Families First Coronavirus Response bill. HR Dive explains the paid leave revisions that the House made to the bill first passed last Saturday before sending the bill to the Senate. Three attempts in the Senate to further amend the bill were rejected. The President has indicated that he will sign the bill.
  • H.R 6021 will mandate all types of health plans, including FEHB plans, cover FDA approved COVID-19 testing without cost sharing or medical management by the health plan. OPM already has required this for FEHB plans. However, the no cost sharing aspect of this coverage does not extend to treatment of the COVID-19 disease. A recent survey “of nearly 600 individual and family health insurance enrollees released today by eHealth, Inc. more than two thirds (69%) feel they lack a basic understanding of how testing and treatment of coronavirus (COVID-19) would be covered by their health insurance plan.” A word to the wise, etc.
  • Federal News Network reports “Federal agencies have 48 hours [until tomorrow] to review, modify and start implementing policies and procedures that will realign critical resources to slow the spread of the coronavirus. This includes offering “maximum telework flexibilities” for the federal workforce and may even include mandatory telework orders, the Office of Management and Budget said Tuesday night.”
  • The Wall Street Journal’s Journal podcast offers an interesting 20 minute long take on the race for a cure to the COVID-19 disease. One of the drugs discussed on the podcast is a Regeneron arthritis drug Kevazara that acts to calm the body’s immune system. Severe cases of COVID-19 cause lung inflammation. The FEHBlog read in the Great Influenza that the flu pandemic caused a spike in the death rate for healthy young adults. This flu struck deep in the lungs where the alveoli tissues transfer oxygen to the blood stream. The body’s immune system took great umbrage with this type of attack and threw everything at the disease. The body’s immune system attack often was the cause of death in young adults who have the strongest immune systems. The modern treatment is to try to calm the immune system and use a ventilator, options that didn’t exist in 1918.
  • Verily Health, the Google / Alphabet affiliate, issued an update on its development of a COVID-19 testing platform for patients. The Washington Post reports on COVID-19 testing sites in the DC metropolitan area.
  • Medicare has expanded the availability of telehealth for traditional Medicare beneficiaries during the COVID-19 emergency. HHS has issued guidance to health care providers on how to maintain HIPAA Privacy and Security rule compliance in the brave new world of telehealth.

In other news–

  • The Labor Department’s Employee Benefits Security Administration has released its latest report to Congress on improving health plan compliance with the federal mental health parity law and its report and an appendix on EBSA enforcement of that law in 2019.
  • Healthcare Dive reports that “The Trump administration is considering pushing back the timeline for payers, providers and health IT vendors to come into compliance with its two sweeping rules to promote interoperability as the healthcare system struggles with the novel coronavirus outbreak.” It would make sense to slow down the effort to ensure that it is done correctly, in the FEHBlog’s opinion.
  • AHRQ wisely points out the need to rethink the role of primary care in reducing hospital readmissions. Check it out.
  • Fierce Healthcare reports that

Aetna is linking Unite Us, a social care coordination platform, with its Guardian Angel program for members who have suffered an opioid overdose. The insurer, owned by CVS Health, will roll out the joint effort first in North Carolina, it announced this week. Using the Unite Us platform, care managers will be able to more effectively link members with social supports and other nonclinical options to aid in recovery, such as housing and healthy food.

Bravo.

Thursday Thoughts

Fedweek reports that

The largest FEHB carrier, Blue Cross-Blue Shield, has loosened several policies, for those diagnosed with COVID-19, the respiratory condition caused by the COVID-19 virus including waiving:

prior authorization requirements for diagnostic tests and for covered services that are “medically necessary and consistent with CDC guidance”;

any copays or deductibles for diagnostic tests or treatment under that same standard;

early medication refill limits on 30-day prescription maintenance medications and cost sharing for prescriptions for up to a 14-day supply; and

copays for telehealth services related to COVID-19.

The FEHBlog was pleased to see that FEP is waiving telehealth cost sharing related to COVID-19. OPM’s carrier letter mentioned in yesterday’s post overlooked telehealth which is an important tool to mitigate the spread of COVID-19. If your plan offers a telehealth benefit, it is important to pre-register for that benefit before you need to use it. The FEHBlog found his plan’s pre-registration program to be quite efficient.

You will find that FEHBP plans prominently have links to their special COVID-19 coverage features on their websites.

The Wall Street Journal has put its helpful COVID-19 update website outside its general website paywall.

In other news,

  • The Centers for Medicare and Medicaid Services announced earlier this week “the Part D Senior Savings Model, a voluntary model that enables participating Part D enhanced plans to lower Medicare beneficiaries’ out-of-pocket costs for insulin to a maximum $35 copay per thirty-day supply throughout the benefit year. Beneficiaries who take insulin and enroll in a plan participating in the model should save an average of $446 in annual out-of-pocket costs for insulin, or over 66 percent, relative to their average cost-sharing for insulin today.” This program will launch next year. Time will tell whether the prescription benefit plan can extend this discount to FEHBP and other commercial health plans.
  • The National Cancer Institute released the Annual Report to the Nation on the Status of Cancer. The report presents good news
    • Overall cancer incidence rates are leveling off among males and increasing slightly among females.These trends reflect population changes in cancer risk factors, screening test use, diagnostic practices, and treatment advances. 
    • This year’s Special Section focused on progress toward select Healthy People 2020 objectives related to four common cancers (lung, colorectal, female breast, and prostate). The Healthy People 2020 target death rate (161.4 deaths per 100,000 persons) for all cancers combined was met overall and in most sociodemographic groups.
    • During 2007-2017, cancer death rates decreased 15% overall, and the percent improvement target (-10%) was met in many sociodemographic groups.
    • Many of the Healthy People 2020 objectives for death rates, cancer screening, and major risk factors related to lung, colorectal, female breast, and prostate cancer were met.
  • Becker’s Hospital Review provides an overview of seven key dates of the HHS interoperability rule released earlier this week.
  • Healthcare Dive discusses the five additional healthcare apps that CVS/caremark has added to its curated app “formulary” for the benefit of plan sponsors. “Livongo Health, Hinge Health, Hello Heart, Torchlight and Whil are now available for CVS’ PBM clients to use, in addition to Sleepio, a personalized digital sleep program and the first participating program when the service launched in 2019.”
Our firm is closely monitoring the impacts of COVID-19. Effective 3/16/20, Ermer & Suter has implemented telework for all of our staff to encourage social distancing and help contain the virus. We remain fully operational and are readily available from our telework locations with no change in telephone numbers or email addresses.