Friday Factoids

Medicare

Friday Factoids

David Ermer–CMS, FDA, Federal employment benefits, Generative AI, Medicare, SDOH, U.S. Healthcare–
Photo by Sincerely Media on Unsplash

From the FDA front —

  • MedPage Today tells us
    • “Lecanemab (Leqembi) showed clinical benefit in early Alzheimer’s disease in its confirmatory trial, paving the way for traditional approval of the drug, an FDA advisory committee said Friday.
    • “In a 6-0 vote, the agency’s Peripheral and Central Nervous System Drugs Advisory Committee fully backed the evidence supporting the anti-amyloid monoclonal antibody. * * *
    • “The agency is expected to make its final decision about lecanemab by July 6.
  • KFF provides a cost perspective in anticipation of FDA approval of this drug, which action is expected to trigger CMS approval for Medicare Part B coverage.

From the FEHB front, Tammy Flanagan writing in Govexec delves into FEHB and Medicare Part B coverage.

From the litigation front —

  • The Wall Street Journal reports
    • “Pharmaceutical industry giants completed a deal to pay $19 billion to states that accused them of fueling the opioid crisis, infusing more money into communities still struggling with how to address the scourge of drug use.”
    • “Most states agreed to the deal to settle agreements with manufacturers Teva and Allergan as well as pharmacy chains CVS and Walgreens. The agreement is in addition to a $26 billion so-called global settlement with drug distributors McKesson, Cardinal Health and AmerisourceBergen and manufacturer Johnson & Johnson. The latest settlements close lawsuits against most of the major players and brings the total income from opioid litigation that states will have to spend to about $50 billion. 
    • “The legal fight stretches back nearly a decade, when more than 3,000 lawsuits from states, Native American tribes and counties alleged the drugmakers, pharmacies and distributors played down the risk of painkillers and didn’t stem their flow. Misuse of prescription painkillers sparked a health crisis that was supercharged as fentanyl infiltrated the illicit drug supply and now claims more than 100,000 lives in the U.S. each year. 
    • “Money from the recent settlements will begin to flow to states this year. More than $3 billion from the global settlementhas already been dispersed. The funds are distributed to states based on population adjusted to account for the burden of the opioid epidemic based on deaths and people using drugs. The agreements require most of the money to be spent on abating the opioid crisis, but the parameters are broad and officials are using different strategies to spend it.”
  • KFF has created a tracker to follow the distribution of the opioid litigation settlement funds.

From the CMS front —

  • Healthcare Dive informs us,
    • “CMS is exploring programs that would pay social or community health workers to address patients’ social needs in a bid to invest more heavily in food, housing, transportation and other social determinants of health, according to agency officials.
    • “We are looking at that. For example, in maternal health, thinking about the role of doula and community health workers,” Liz Fowler, director of the Center for Medicare and Medicaid Innovation, said on Thursday during the CMS’ inaugural health equity conference.”
  • and
    • “CMS announced a new model that aims to strengthen and improve primary care, including by ensuring small and rural organizations are able to enter into value-based care arrangements. 
    • “The Making Care Primary Model will run for more than 10 years in eight states — in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina and Washington.
    • “Research shows primary care is key to improving health outcomes and lowering costs. The CMS noted Medicare and Medicaid patients are often diagnosed with multiple chronic conditions, and primary care providers are charged with prevention, screening and management. But, because many patients will see multiple specialists, coordinating care can be challenging.”
  • Fierce Healthcare relates,
    • “The Department of Health and Human Services (HHS) has released a 43-drug list of the Medicare Part B prescription treatments that must repay the program for raising prices above the rate of inflation.
    • “The second quarterly list takes effect in July and is an expansion over the 20 price-capped drugs from April through June. According to HHS, the rebates could save Medicare beneficiaries taking the treatments anywhere from $1 to $449 per average dose in out-of-pocket costs.
    • “The Medicare Prescription Drug Inflation Rebate Program is a critical way to address long-term price increases by drug companies, and [the Centers for Medicare and Medicaid Services (CMS)] is continuing our work to make prescription drugs more affordable for people with Medicare,” CMS Administrator Chiquita Brooks-LaSure said in a release.
    • “The full list of prescription drugs and biological products with adjusted coinsurance amounts for July 1 to Sept. 30 is available here (PDF).
    • “Of note, CMS said the list could be adjusted before or after July 1 based on public feedback notifying the agency of any potential discrepancies, as was the case during the program’s inaugural quarter when a highly publicized list of 27 drugs was later trimmed down to 20.”

From the U.S. healthcare business front —

  • Beckers Hospital Review reports
    • “In the first quarter of 2023, 17 healthcare companies with more than $10 million in liabilities filed for Chapter 11 bankruptcy, a sharp rise compared to seven bankruptcies in the first quarter of 2022, Bloomberg Law reported June 9.
    • “High-profile bankruptcies from Envision, Invacare Corp. and Sorrento Therapeutics contributed to the numbers. The first three months of 2023 saw a slight slump in bankruptcies but remain higher than the same period a year ago.
    • “Despite the year-over-year increase, the first quarter of 2023 still had fewer healthcare bankruptcies than the fourth quarter of 2022.
    • “Once the government money ran out, once all the stimulus dollars around healthcare ran out, there was essentially going to be this backwash,” Timothy Dragelin, a healthcare director at FTI Consulting, told Bloomberg. “The fact that labor costs increased substantially—you also had the issues with supply chain and supply chain caused some disruptions.”
  • Fierce Healthcare tells us
    • “Walgreens Boots Alliance sold its remaining stake in post-acute care and infusion services company Option Care Health for $330 million.
    • “The drugstore chain announced Thursday it sold 10.8 million shares of Option Care Health and plans to use the proceeds primarily for debt paydown, continued support of the company’s strategic priorities and to help fund its healthcare-focused business initiatives, according to a press release.
    • “The transaction is another decisive action WBA is taking to unlock value and further simplify the company’s portfolio,” the company said.
    • “Back in March, Walgreens cut its stake in Option Care Health when it sold 15.5 million shares at $30.75 per share. The transaction reduced Walgreen’s ownership in the company, formerly known as Walgreens Infusion Services, from 14% to 6%, according to a Walgreens news release. “

From the generative AI front —

  • Beckers Hospital CFO Report points out the steps the Google and Microsoft are taking to integrate generative AI in healthcare systems.
  • HR Dive discusses the impact of generative AI on employers and the workplace.

Thursday Miscellany

David Ermer–CMS, Congress, COVID-19 vaccine, FDA, HSA, Medical / Rx research, Medicare, Rx coverage, Telehealth–
Photo by Josh Mills on Unsplash

From Washington, DC —

  • The Senate Finance Committee held a hearing today about “Consolidation and Corporate Ownership in Health Care: Trends and Impacts on Access, Quality, and Costs.”
  • Mercer Consulting informs us
    • “Two key House committees voted this week to send a series of health care bills to the House floor, including legislation to make permanent the ability of health savings account-qualifying high-deductible health plans (HSA-qualifying HDHPs) to cover telehealth and other remote care services on a predeductible basis. Originally enacted as part of the 2020 Coronavirus Aid, Relief and Economic Security (CARES) Act, this flexibility was most recently extended as part of the 2023 Consolidated Appropriations Act, and now is set to expire on Dec. 31, 2024, for calendar-year plans (later for noncalendar-year plans).”
  • “The U.S. Department of Health and Human Services (HHS) released the STI Federal Implementation Plan to detail how various agencies and departments across the federal government are taking a comprehensive approach to making meaningful and substantive progress in improving public health. This new plan builds on other key HHS actions to protect the public’s health by addressing the growing threat of sexually transmitted infections (STIs) in America.”
    • Roll Call identifies potential obstacles to implementing this plan.
  • Govexec reports
    • “As smoke from Canadian wildfires moves into the Northeast and Mid-Atlantic regions of the United States, triggering air quality warnings in several cities, the Office of Personnel Management on Thursday reminded agencies to protect the health of federal workers who ordinarily may work or commute to work amid the hazardous haze.”
      • Healthcare Dive discusses health system reactions to this problem.
        • “Hospitals in the northeastern U.S. are keeping an eye on air quality as smoke from Canadian wildfires envelops the region. Most health systems contacted by Healthcare Dive did not report significant spikes in patient volumes yet, but they said they’re continuing to monitor the situation.
        • “Millions of people live in areas currently under air quality alerts, and meteorologists say conditions may not significantly improve for a few more days.
        • “Health systems in the region are urging residents to stay indoors and use masks — particularly snug-fitting N95s — when traveling outside. Though everyone should limit their time outdoors, it’s especially important for older people, children and pregnant women as well as those with conditions like heart or lung disease or asthma, according to Kristin Fless, a pulmonologist at RWJBarnabas Health Medical Group.”
  • The Wall Street Journal relates
    • “Ashish Jha, the White House Covid-19 czar, will be leaving his post next week in the latest sign the Biden administration is confident the country is on stronger footing in its fight against the virus.
    • “Jha plans to leave June 15 and return July 1 to his previous position as dean of Brown University’s School of Public Health. He will be the last of the administration’s rotating Covid-19 czars. Instead, the director of the White House’s nascent Office of Pandemic Preparedness and Response Policy, who hasn’t been named, will advise the president and coordinate federal responses to various biological and pandemic threats.”

From the  public health front —

  • Mercer Consulting tells us
    • Our research over the past few years has tracked the ways employers are working to align employee benefit programs with their organizations’ overarching DEI goals. For Pride month, here’s a round-up of survey results relating to health and well-being benefits of particular importance to the LGBTQ+ community.
    • Here’s a link to the article.
  • The American Hospital Association reports
    • “The first data on the safety of a third mRNA COVID-19 vaccine dose among young children show that a third dose is safe for children ages 6 months to 5 years old, similar to findings for doses one and two, the Centers for Disease Control and Prevention reportedtoday, based on reports to the Vaccine Adverse Event Reporting System and v-safe voluntary smartphone health checker for use after vaccination.
    • “This study’s findings can reassure health care professionals, parents, and caregivers that a third dose of COVID-19 vaccine is safe for children ages 6 months to 5 years and can protect them from severe illness,” CDC said.
    • “While CDC recommends that all children ages 6 months through 5 years old receive at least 1 bivalent mRNA COVID-19 vaccine dose, vaccination rates among this age group have been low.”
  • Health Payer Intelligence informs us
    • “Group health insurance plan members with high healthcare spending often have one or more of the same five chronic diseases, according to a fast facts sheet from the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI).
    • “The study covered healthcare claims from 8.6 million group insurance health plan members using 2021 data from the Merative MarketScan Commercial Database. Members were 65 years of age or younger and the health plans covered a variety of types.
    • “Five conditions were very common among the group health insurance plan members with the highest healthcare spending: heart disease, respiratory conditions, musculoskeletal conditions, nervous system conditions, and skin disorders. A couple of these are among the most expensive chronic diseases in the US. They are also some of the most common comorbidities.”

From the Rx coverage front —

  • BioPharma Dive notes that tomorrow a Food and Drug Administration advisory committee will consider recommending that the FDA give full marketing approval to the Alzheimer’s drug Leqembi.
    • “A closely watched Alzheimer’s disease medicine appears to be heading toward broader approval, as documents released Wednesday show the Food and Drug Administration appears to have few concerns with it.”
  • BioPharm Dive also tells us that “After years of disappointment, cancer vaccines show new promise. Moderna presented new data at ASCO for its melanoma shot, highlighting progress with a personalized approach that’s also being pursued by BioNTech and Gritstone.”
    • “Moderna is testing its shot, mRNA-4157, together with Merck’s immunotherapy Keytruda in people with melanoma who have had their primary tumors removed. The goal of such “adjuvant” treatment is to prevent cancer from returning.
    • “In December, the company reported the two drugs reduced the relative risk of death or recurrence by 44% over Keytruda alone. The new data came from an analysis of the risk of cancer spreading to distant organs or tissues, or “distant metastasis free survival.”
    • “One-third of patients who receive Keytruda in this setting experience such spread, driving researchers’ work to come up with better options. “We know that patients with distant metastases experience more morbidity and mortality,” said Adnan Khattak, a clinical professor at Edith Cowan University in Australia, who presented the Moderna data at ASCO.
    • “In the combination trial, mRNA-4157 and Keytruda reduced the risk of distant spread or death by 65% compared to Keytruda alone.”
  • The Associated Press reports
    • “A growing shortage of common cancer treatments is forcing doctors to switch medications and delaying some care, prominent U.S. cancer centers say.
    • “The National Comprehensive Cancer Network said Wednesday that nearly all the centers it surveyed late last month were dealing with shortages of carboplatin and cisplatin, a pair of drugs used to treat a range of cancers. Some are no longer able to treat patients receiving carboplatin at the intended dose or schedule. 
    • “Dr. Kari Wisinski has had to turn to other treatments for some patients or switch the order in which people receive their drug combinations. She said she’s done that “hoping that within three months there will be a better carboplatin supply.” * * *
    • “The U.S. Food and Drug Administration has taken some steps to try to ease the chemotherapy shortage. The agency is allowing the temporary importation of some foreign-approved versions of cisplatin from factories registered with the FDA.”
  • Beckers Hospital Review adds “Seventy percent of the 20 most commonly prescribed medications from GoodRx are in shortage, according to databases from the FDA and the American Society of Health-System Pharmacists.” The article goes on to list the drugs subject to shortages.

From the Medicare front —

  • Beckers Payer Issues informs us
    • “The FDA and CMS are discussing how to handle obesity drugs in Medicare, Bloomberg Law reported June 7. 
    • “The two agencies are in talks over “what to do about obesity drugs,” FDA Commissioner Robert Califf said at the Biotechnology Innovation Organization convention in Boston. Mr. Califf’s comments indicate CMS could expand weight loss benefits, according to Bloomberg Law’s report. 
    • “New GLP-1 drugs to treat obesity and diabetes can be expensive, costing upward of $10,000 a year without insurance coverage. GLP-1 drugs, including Ozempic, Trulicity, Victoza and Mounjaro, are used to treat Type 2 diabetes. Wegovy and Saxenda are approved for weight loss.  
    • “Under current law, Medicare is prohibited from covering weight loss drugs. Drug manufacturers are lobbying Congress to require the program to pay for the drugs. Proposed legislation to pay for the drugs has stalled. 
    • “The drugs could have a big effect on Medicare Part D spending. If 10 percent of people with obesity covered by Medicare were prescribed a brand-name semaglutide, a type of GLP-1, the drug would cost Medicare $26.8 billion annually, according to a study published in the New England Journal of Medicine in March.”
  • and
    • “Medicare spending per person grew by an average of 4.6 percent annually between 2000 and 2022, according to a June 6 analysis from KFF. 
    • “KFF analyzed data from the 2023 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 
    • “KFF said the “influx of the Baby Boomer Generation added many relatively younger, healthier people to the Medicare beginning in 2011,” while the share of adults aged 80 and older enrolled in the program also continues to grow. Growth in healthcare spending is attributed to this increased volume and use of services, along with the availability of new technologies and rising prices.”
      • 2018: $13,579
      • 2019: $14,189
      • 2020: $14,373
      • 2021: $15,139
      • 2022: $15,727

Tuesday Tidbits

David Ermer–Medical / Rx research, Medicare, U.S. Healthcare–
Photo by Patrick Fore on Unsplash

From the public health front —

  • STAT News reports,
    • “Ten years ago, clinicians in a handful of hospitals around the United States began sequencing the genomes of apparently healthy babies, seeking to understand how the technology might turn up hidden genetic disorders that aren’t being caught by routine newborn blood testing. New research from one such trial suggests the impact of having that kind of information extends far beyond the baby whose DNA is being decoded.
    • “In a study published Monday in the American Journal of Human Genetics, researchers from Mass General Brigham and Boston Children’s Hospital reported that of the first 159 infants to undergo screening through genomic sequencing, 17 were discovered to have unanticipated mutations in disease-associated genes.
    • “Over the next three to five years, in the majority of the 17 infants’ families, these discoveries prompted parents and other relatives to get additional testing that led to uncovering the cause of diseases running through their family trees. In three cases, mothers who learned they carried a gene that drastically elevated their risks of certain cancers chose to undergo prophylactic surgeries to reduce those risks — a finding that the lead researcher says undercuts ethical objections to informing families of genetic findings even when they aren’t immediately actionable for the newborn.
    • “This is a real-world rebuttal to the prevailing notion that we should not be sharing adult-onset disease-risk variants in children,” said Robert Green, a medical geneticist at Harvard and Brigham and Women’s Hospital who leads the BabySeq study that produced the new research. “There are ethicists who say a child should not be used as a genetic canary in a coal mine — that one member of a family should not be used without their consent as the access point for a whole family, but I’d like to challenge that. Look at these mothers. We arguably saved their lives. Are you really going to put that up against a theoretical loss of autonomy at some point in the child’s future?”
  • Health Day tells us,
    • “Women who consistently adhered to mammography guidelines had better odds for survival if they were then diagnosed with breast cancer, study found.
    • “Delays in screening can contribute to being diagnosed with advanced disease.
    • “The findings were to be presented [last] Sunday at the annual meeting of the American Society of Clinical Oncology in Chicago. Findings presented at medical meetings should be considered preliminary until published in a peer-reviewed journal.
    • “There has been much debate about when to start breast cancer screening, how often screening should occur, and how many screening exams are necessary. “This study suggests that a missed breast cancer screening has consequences,” said Dr. Arif Kamal, chief patient officer for the American Cancer Society.”
  • The NIH Director discusses “Encouraging First-in-Human Results for a Promising [mRNA] HIV Vaccine.”
  • As we enter the summer months, Bloomberg Prognosis provides insights into suncreens.

From the U.S. healthcare business front —

  • STAT News and EndPoints offer fascinating interviews respectively with Susan Galbraith, head of AstraZeneca’s oncology research and development and Emma Walmsley, the Glaxo Smith Kline (GSK) chief executive officer.
  • Beckers Hospital Review ranks health systems by operating margins.
  • The Wall Street Journal examines why “a growing group of physicians are ditching medicine’s traditional career path and hitting the road as temporary doctors-for-hire.”
  • Kaiser Foundation News reports that doctors of osteopathy are filling the growing MD gap in rural areas of the U.S.
  • MedCity News reports that “Doulas — who provide physical, emotional and informational support to expectant mothers — have shown to improve maternal health outcomes, but there’s little insurance coverage of their services. That’s starting to change, however, particularly in Medicaid programs.”
  • Fierce Healthcare tells us,
    • “Evernorth has inked a strategic partnership with CarepathRx Health System Solutions that aims to boost access to specialty pharmacy care.
    • “Through the partnership, the two will provide integrated specialty pharmacy services to CHSS’ growing clientele, which includes more than 600 hospitals, health systems and physicians. This will allow these providers to diversify the ways they can support patients, according to an announcement.
    • “As part of the partnership, Evernorth will make a “significant minority investment” in CHSS that it expects to close late in the second quarter or in the third quarter of 2023.”
  • and
    • “Humana’s primary care arm opened its 250th clinic in Dallas on Tuesday, marking another milestone in the insurer’s growth in the provider space.
    • “The Medicare Advantage giant has established a multiyear effort to continue scaling CenterWell and expects to open between 30 and 50 centers per year through 2025. In addition to the senior-focused primary care clinics, CenterWell also houses Humana’s home health business, another key strategic focus, and is sister to the Conviva Care Center brand.
    • “Collectively, Humana’s Primary Care Organization cares for 266,000 seniors across its markets.
    • “The ongoing expansion cements CenterWell as one of the country’s fastest-growing providers of value-based, senior-focused care. It operates clinics in 12 states: Arizona, Florida, Georgia, Kansas, Kentucky, Louisiana, Missouri, Nevada, North Carolina, South Carolina, Tennessee and Texas.”

From the litigation front —

  • Roll Call tells us,
    • “Drugmaker Merck & Co. Inc. sued the federal government Tuesday, seeking an injunction against parts of last year’s reconciliation law that allow the Health and Human Services Department to negotiate for lower prices on [a certain subset of prescription] drugs.
    • “The lawsuit, filed in the U.S. District Court for the District of Columbia, argues that the negotiation program is “extortion” and violates the Fifth Amendment by not paying the company “just compensation” for its products.
    • “By coercing Merck to provide its drug products at government-set prices, the Program takes property for public use without just compensation in violation of the Fifth Amendment,” Robert Josephson, Merck’s executive director of global media relations, said in a statement.”
  • Beckers Payer Issues relates,
    • “A federal judge in St. Louis issued a preliminary injunction barring former Cigna executive Amy Bricker from working for CVS Health, while a lawsuit over her noncompete clause moves forward. 
    • “In the June 5 order, Judge Ronnie White said that Ms. Bricker is prohibited from providing any services to CVS Pharmacy, CVS Health, any of its entities or any other business that is “engaged in a business similar to, or that competes with, the business of Cigna.” She is also barred from disclosing Cigna trade secrets or confidential information.” 

From the miscellany / tidbits department

  • The Office of National Health Information Technology Coordinator released
    • “the draft USCDI+ Quality data element list for public comment on the eCQI Resource Center website. This release provides an initial, high-level picture of the USCDI+ initiative in action. It is a harmonized set of data elements for quality measurement that could be used to support measurement and reporting across a wide number of quality programs. ONC requests feedback on this draft list by 11:59pm ET on June 30, 2023, particularly its level of completeness, level of specificity, and the usefulness of companion guidance.
    • “The draft USCDI+ Quality is the most recent milestone for the USCDI+ initiative, which supports our federal agency partners to build on the USCDI standard adopted by ONC in 2020 and was first described in this blogfrom October 2021. The draft USCDI+ Quality includes data elements in the USCDI; however, as a core data set, the USCDI standard itself does not include each data element needed for quality measurement use cases. Through USCDI+ Quality, ONC is seeking to extend from the USCDI model to establish a consistent baseline of harmonized data elements for a wide range of CMS and other quality measurement use cases. Once mature, the USCDI+ Quality data element list can inform technical specifications and implementation guidance needed to enable more flexible, modernized, and robust approaches to standardizing and sharing data.”
  • Fierce Healthcare adds,
    • “The roughly half of American smartphone users with iPhones will notice new health and privacy features on their devices starting today.
    • “In addition to iPhones being equipped with new health features, Apple’s update will give iPad and Apple Watch users access to new tools. All three platforms will gain features that encourage healthy behaviors, reduce the risk of myopia, or nearsightedness, and provide ways to assess and address depression, according to the company. The new features were announced as part of Apple’s Worldwide Developers Conference 2023Monday.
    • “By bringing the Health app to the iPad, the tech giant hopes to inspire even more Apple users to take a proactive approach to their health.
    • “Our goal is to empower people to take charge of their own health journey. With these innovative new features, we’re expanding the comprehensive range of health and wellness tools that we offer our users across iPhone, iPad and Apple Watch,” said Sumbul Desai, M.D., Apple’s vice president of Health, in a press release. “Mental health and vision health are important, but often overlooked, and we’re excited to introduce features that offer valuable new insights to provide users with an even better understanding of their health. These insights help support users in their daily decisions and offer more informed conversations with their doctors.”

Thursday Miscellany

David Ermer–CDC, CMS, Congress, COVID vaccine mandate, FDA, Medicare, Rx coverage, U.S. Healthcare–

From Washington, DC –The Wall Street Journal reports

  • “The Senate passed wide-ranging legislation Thursday [night] that suspends the $31.4 trillion debt ceiling [until January 1, 2025] while cutting federal spending, backing a bipartisan deal struck by President Biden and House Speaker Kevin McCarthy to avert an unprecedented U.S. default.
  • “The 63-36 vote reflected support from both Democrats and Republicans, with backers saying the need to raise the nation’s borrowing limit outweighed concern about provisions related to military and domestic spending and energy policy, among other contentious issues.
  • “The measure now goes to the president for his signature with several days to spare before Monday, when the Treasury Department has said that the government will run out of money to pay all of its bills.”
  • The Journal further informs us,
    • “President Biden plans to pick former North Carolina Health Secretary Dr. Mandy Cohen to lead the Centers for Disease Control and Prevention, according to people familiar with the planning. * * *
    • “Cohen, a medical doctor like Walensky, served in the Obama administration as chief of staff at the Centers for Medicare and Medicaid Services. She helped implement the Affordable Care Act and new payment models at the agency.
    • “She also served as North Carolina’s health secretary for nearly five years into 2021, helping lead the state through the Covid-19 pandemic. She is an executive at Aledade, a network of independent primary-care practices. * * *
    • “The White House and the CDC declined to comment. Cohen’s selection for the role was earlier reported by The Washington Post. The role doesn’t require Senate confirmation.”
  • Healthcare Dive tells us,
    • “The CMS on Wednesday issued a final rule lifting the COVID-19 vaccine mandate for workers in healthcare facilities that receive federal funding as soon as early August. The rule, which will go into effect 60 days after being published in the Federal Register, would withdraw regulations requiring the vaccines for healthcare workers that went into effect last year following a number of legal challenges.
    • “The CMS said it will not be enforcing the provisions between now and August.”

From the public health front —

  • The Wall Street Journal reports,
    • “There is a test that could diminish the toll of the nation’s top cancer killer—if people would use it. Doctors are pushing harder to make that happen.
    • “Lung cancer kills upward of 127,000 people in the U.S. each year. The toll has waned in recent years thanks to declining smoking rates and new treatments, but it remains the deadliest cancer for Americans by far. 
    • “A CT scan can catch the disease early to help save lives. The five-year survival rate when lung cancer is caught early is about 60%, compared with around 7% if it is caught after disease has spread, according to the American Lung Association. Medical groups recommend annual, low-dose scans starting at 50 for people who smoke heavily or recently quit. Insurers often cover the test. 
    • “It’s low-hanging fruit for the country,” said Dr. Patrick Hwu, president and chief executive of the Moffitt Cancer Center in Tampa, Fla. “It would save the most lives immediately.”
  • The Journal also lets us know,
    • “About 3.66 million babies were born in the U.S. in 2022, essentially unchanged from 2021 and 15% below the peak hit in 2007, according to new federal figures released Thursday.
    • “The provisional total—3,661,220 births—is about 3,000 below 2021’s final count, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics. Final government data expected later this year could turn that small deficit positive. * * *
    • “Absent increases in immigration, fewer births combined with ongoing baby boomer retirements will likely weigh on the labor force supply within the next 10 years, said Kathy Bostjancic, chief economist at Nationwide, an insurance and financial-services company.
    • “You’re going to have a real shortage of workers unless we have technology somehow to fill the gap,” Bostjancic said.”
  • The U.S. Preventive Services Task Force released a final research plan for its Perinatal Depression: Preventive Interventions project.
  • The Department of Labor points out,
    • [Last week,] “the White House released the first-ever U.S. National Plan to End Gender-Based Violence. The plan lays out a roadmap for a whole-of-government effort to prevent and address gender-based violence in the United States. One of the groundbreaking aspects of this plan is that it reflects principles from the International Labor Organization’s Convention on Violence and Harassment in the World of Work, recognizing gender-based violence and harassment in the “world of work,” which includes not only traditional workplaces but anywhere workers are paid, in places workers take rest breaks, in work-related training, and through work-related communications.” 
  • HR Dive reports,
    • “The percentage of employees in the general U.S. workforce who tested positive for marijuana after a job accident reached a 25-year high in 2022, according to data released May 18 by Quest Diagnostics.
    • “In 2022, 7.3% of the general workforce (private sector employees in non-safety-sensitive jobs) tested positive for marijuana in a post-accident urine test, up from 6.7% in 2021, according to Quest’s latest Drug Testing Index. After rising steadily each year for the past 10 years, the 2022 positivity rate reflected a 204% jump since 2012, Quest said. 
    • “The increase in post-accident marijuana positivity rates corresponds with the legalization of marijuana for recreational use in certain states, starting in 2012 with Colorado and Washington, Quest noted in a news release. The DTI data “provide compelling evidence that increased use of cannabis products can contribute to greater risk for injuries in the workplace,” Katie Mueller, a National Safety Council senior program manager, stated.”

From the U.S. healthcare business front —

  • Beckers Hospital Review shares Newsweek’s list of top-ranked maternity hospitals in the U.S.
  • The American Hospital Association reports
    • “Following discussions between the American Hospital Association (AHA) and United Healthcare (UHC), the insurer late yesterday announced a refocused gastroenterology (GI) policy that relies on additional provider education rather than prior authorizations to address the insurer’s concerns about possible overutilization. The refocused policy avoids potential care denials for patients, particularly vulnerable patients, and will not impact the coverage and payment of claims for these services. The GI policy, which pertains to certain non-screening endoscopy and colonoscopy services, goes into effect today, June 1.
    • “UHC will instead implement a 7-month, or potentially longer, pilot program to collect data that substitutes notification and submission of standard clinical data when services are delivered for prior authorization, removing the risk of potential care delays and claim denials. This data will be applied to UHC’s gold-carding program, beginning sometime in 2024, in order to exempt physicians that are routinely aligned with the insurer’s guidelines. The insurer has yet to determine any additional controls that will be placed on non-gold-carded clinicians at the end of the pilot.”
  • Healthcare Dive tells us
    • “BJC HealthCare and Saint Luke’s Health System announced Wednesday they had signed a non-binding agreement to merge, creating a $10 billion health system serving patients in Missouri, Kansas and Illinois. 
    • “The 28-hospital system would keep their current brands and operate from two headquarters, with the St. Louis base focusing on eastern Missouri and southern Illinois, while the Kansas City, Missouri, headquarters serves western Missouri and parts of Kansas. 
    • “BJC and Saint Luke’s said they’re planning to reach a definitive agreement “in the coming months,” assuming no regulatory hurdles. They expect the deal to close by the end of the year.”
  • and
    • “Oak Street Health plans to enter Arkansas, Iowa, Kansas and Virginia beginning this summer, the value-based primary care chain for seniors announced Tuesday.
    • “The expansion will grow the footprint of Chicago-based Oak Street, which was acquired by CVS for $10.6 billion, to 25 states.
    • “Oak Street also plans to open additional centers in Arizona, Colorado, Georgia, Illinois, Indiana, Louisiana, New York, Ohio and Pennsylvania this year, according to a release.”

From the Rx coverage front —

  • STAT News reports,
    • “In a bold move, Coherus BioSciences plans to sell a biosimilar version of Humira — one of the world’s best-selling medicines — at a steep discount, and will work with Mark Cuban’s generic drug company to make the medicine available directly to consumers for even less.
    • “Specifically, the Coherus medicine will carry a $995 list price for a carton of two autoinjectors, an 85% discount from the $6,922 that AbbVie charges for Humira, which is used to treat rheumatoid arthritis and other conditions. At the same time, Coherus will sell its drug at a discount to the Mark Cuban Cost Plus Drug Company, which will market the treatment for about $579.
    • “The lowball pricing for the drug, which will become available in July, has the potential to alter one of the most closely watched product rollouts by pharmaceutical companies in many years. After enjoying a monopoly that yielded billions of dollars in annual sales, AbbVie is expected to face at least eight biosimilar rivals to Humira by the end of the year.”
  • BioPharma Dive relates,
    • “Medicare on Thursday affirmed plans to limit coverage for certain Alzheimer’s disease drugs, but signaled it’s taking steps to ensure broader access should one of the medicines receive full Food and Drug Administration approval.
    • “In a statement, the Centers for Medicare and Medicaid Services said they would cover drugs like Eisai and Biogen’s Leqembi when patients and their doctors participate in a registry for collecting data on how the treatments work in the real world. The stance is in line with the agency’s current policy, but describes a process that analysts viewed as relatively straightforward to fulfill.
    • “However, the nonprofit Alzheimer’s Association, which has previously attacked Medicare’s policy, criticized the registry requirement and said it “will create unnecessary hurdles to coverage.” The agency’s plan will soon be tested as Leqembi — currently cleared on a conditional basis in the U.S. — is up for full FDA approval, with a decision expected by July.”

Weekend update

David Ermer–Congress, HSA, Medical / Rx research, Medicare, NIH, U.S. Healthcare–
Photo by Thought Catalog on Unsplash

The House of Representatives will be in session for Committee business and floor voting, while the Senate will be on a State work week this week. The Senate press gallery informs us, “In today’s (5/18/23) wrap-up, Schumer reiterated that as discussions concerning the debt ceiling continue over the next week, Senators should be able to return to the Senate within a 24-hour period.”

The Wall Street Journal reports

“President Biden and House Speaker Kevin McCarthy agreed to meet Monday afternoon in a last-ditch effort to reach a deal to avoid a default on U.S. sovereign debt after negotiations to raise the federal borrowing limit reached an impasse.

“Talks between White House and House Republican negotiators largely ground to a halt this weekend, with both sides blaming the other for a failure to bridge their differences over spending levels. But Biden and McCarthy instructed their negotiating teams to resume their discussions, starting with a 6 p.m. meeting on Sunday. * * *

“There’s no agreement. We’re still apart,” McCarthy, a California Republican, told reporters at the Capitol, though he said the call with Biden was productive.” * * *

“Leaders in Washington are rushing to come up with a deal to lift the country’s borrowing limit. If they are unable to do so, the country might be unable to pay all of its bills as soon as June 1, according to an assessment by the U.S. Treasury Department.  

“Appearing Sunday on NBC, Treasury Secretary Janet Yellen said the “odds of reaching June 15th, while being able to pay all of our bills, is quite low.”

“Economists say that failure to lift the debt ceiling, and a subsequent default, would tip the economy into a recession. Moody’s Analytics predicts that a default would cost more than seven million jobs and cause the unemployment rate to move above 8%. The ratings company also predicts that the stock market would lose a fifth of its value.”

Wow.

From the plan design front, the Wall Street Journal reports

“The Internal Revenue Service on Tuesday announced the largest-ever increase to the amount Americans can set aside in health-savings accounts each year.

“For 2024, the maximum HSA contribution will be $8,300 for a family and $4,150 for an individual. That is up from $7,750 for a family and $3,850 for an individual for 2023.

“Participants age 55 and older can contribute an extra $1,000, which means an older married couple could sock away $10,300 a year, up from $9,750 this year. In the last ten years leading up to retirement, a couple could accumulate more than $100,000 in these accounts. * * *

While workers can tap 401(k)s and individual retirement accounts for medical costs, health savings accounts offer more tax savings than both traditional or Roth retirement accounts. There is no tax going in, tax-free growth and tax-free withdrawals if used for eligible healthcare expenses.”

The FEHBlog came to love the high-deductible health plan/health savings account arrangement. The Wall Street Journal endorses the FEHBlog’s viewpoint. The FEHBlog was cut off from the arrangement when he became Medicare primary in late 2019. Because the FEHBlog’s law firm has less than 20 employees, the FEHBlog found it necessary to drop his employer-sponsored coverage in favor of Medicare. Medicare coverage has been fine, but the FEHBlog misses contributing to his HSA. Younger employees should give the HDHP / HSA arrangement a close look.

The Wall Street Journal adds

“Remember one important caveat, however: If you’re sure to spend over the deductible, other plans may be more appropriate for you, such as the PPO plan that will cost you an additional $800. (You forgo the ability to save, but you also face a lower out-of-pocket maximum.) For instance, if you know with reasonable certainty that you need access to a more-expensive provider for a one-time procedure, then you should pick a plan that gives you this access, such as a PPO plan, and switch back to an HMO plan with an HDHP-and-HSA option during next year’s open-enrollment period.

“If you do end up choosing an HDHP, please remember: Do not cut back on care haphazardly, as many people do. Following a doctor’s recommendations is much more important than saving a bit of money.”

While the FEHBlog is not yet retired, he is intrigued by the Fortune Well article on cognitive decline following retirement. The article offers four ways to avoid this otherwise “universal trend.”

  1. Keep or get connected.
  2. Keep active.
  3. Keep stress to a minimum
  4. Keep working, regardless of pay.

Next stop, Walmart greeter??

From the U.S. healthcare business front, Healthcare Dive tells us

“Physician staffing firm Envision Healthcare has filed for Chapter 11 bankruptcy, citing its $7.7 billion in debt obligations, declining patient volumes, “flawed” implementation of the No Surprises Act and exclusionary health insurers as reasons for its financial decline in a restructuring announcement on Monday.

“The bankruptcy wipes out private equity firm KKR’s investment in Envision. In 2018, the PE firm shelled out over $5 billion in 2018 to take Envision private in a deal valued at $9.9 billion, including debt. Last week, The Wall Street Journal reported that an Envision bankruptcy filing would be one of the steepest losses in KKR’s history.”

From the miscellany department, NPR Shots offers articles evaluating experimental cancer treatments and looking into a new NIH study:

There’s plenty of one-size-fits-all nutrition advice. But there’s mounting evidence that people respond differently to food, given differences in biology, lifestyle and gut microbiome.

“The National Institutes of Health wants to learn more about these individual responses through a Nutrition for Precision Health study, and this week researchers began enrolling participants to take part in the study at 14 sites across the U.S.

“It’s part of the All of Us research initiative that aims to use data from a million participants to understand how differences in our biology, lifestyle and environment can affect our health.

“Holly Nicastro of the NIH Office of Nutrition Research says the goal of the precision nutrition study is to help develop tailored approaches for people. “We’ll use machine learning and artificial intelligence to develop algorithms that can predict how individuals will respond to a given food or dietary pattern,” Nicastro says.

“The study will take into account a person’s genetics, gut microbes, and other lifestyle, environmental and social factors “to help each individual develop eating recommendations that improve overall health,” Nicastro says.”

Monday Roundup

David Ermer–ACA, CMS, Medicare, OPM, Rx coverage, Telehealth, U.S. Healthcare–
Photo by Sven Read on Unsplash

From Washington, DC —

  • The Wall Street Journal reports, “Weight-loss drugmakers are lobbying Congress to grant them access to a monster payday for their blockbuster treatments: Medicare coverage.” At last Thursday’s carrier conference, OPM pointed out a related advantage of the Medicare Part D EGWPs that the FEHBP will offer next year. Although the weight loss drugs may not be on the Medicare formulary, those drugs would be made available to FEHB annuitants via the Plan’s formulary, which can gap-fill the Medicare formulary.
  • CMS announced that the updated MMSE Section 111 GHP User Guide version 6.8 has been posted to the GHP User Guide page on CMS.gov. Refer to Chapter 1 for a summary of updates.”
  • Per Health Payer Intelligence, AHIP launched a marketing campaign targeting Pharma’s prescription drug pricing. “The payer organization stated that prescription drug pricing is out of control and explained health insurance’s role in reducing the impact.”
  • The Department of Health and Human Services proposed a rule to extend ACA marketplace, Basic Health Program, Medicaid, and CHIP coverages to 580,000 DACA recipients.

From the healthcare spending and plan design fronts

  • Fierce Healthcare informs us,
    • “About a year ago, Elevance Health launched a pilot program to offer digital concierge care to members who were recovering from COVID-19 infections.
    • “Since then, the insurer has expanded that initiative to offer concierge care management to members with a number of chronic conditions, including Crohn’s disease, cancer and diabetes. Anthony Nguyen, M.D., the chief clinical officer at Elevance, told Fierce Healthcare that the program was born from a desire to be “more engaging with our members.”
    • “The challenge for not only the programs that we have, the traditional ones, as well as others in the market, is that it’s not personalized,” Nguyen said. “It is not tailored to an ‘n’ of one.”
    • “Greater personalization was built into the foundation of the program, he said. For example, concierge care deploys a nurse matching tool that connects members with a clinician who is likely to connect and resonate well with them, improving the care journey.”
  • and
    • “Healthcare spending declined dramatically in 2020 thanks to the COVID-19 pandemic, but expenditures rebounded the following year, according to new data from the Health Care Cost Institute.
    • “The group released its annual look at cost and utilization trends last week, which found the average health spending for people with employer-sponsored coverage reached $6,457, up 15% from the 2020 average of $5,630. Spending declined by 4% in 2020 as utilization decreased, the researchers said.
    • “John Hargraves, director of data strategy at HCCI, told Fierce Healthcare that the 2020 data are an aberration in the long-term spending trends, which had grown steadily prior to the pandemic.
    • “It’s almost like 2020 is a missing data point in the long-term growth in the healthcare spending and use patterns that we’ve noted,” Hargraves said.”

From the telehealth and fraud waste and abuse fronts, the HHS Inspector General made available a “toolkit intended to assist public and private sector partners—such as Medicare Advantage plan sponsors, private health plans, State Medicaid Fraud Control Units, and other Federal health care agencies—in analyzing their own telehealth claims data to assess program integrity risks in their programs.”

Tuesday’s Tidbits

David Ermer–End of the PHE, NE, Medicare, U.S. Healthcare, Uncategorized–
Photo by Patrick Fore on Unsplash

From the U.S. healthcare business front —

  • STAT News reports
    • “UnitedHealth Group has acquired Crystal Run Healthcare, a prominent physician group in New York.
    • “The deal for Crystal Run, a network of almost 400 doctors, nurse practitioners, and other clinicians, closed in late February. There was no fanfare. Neither company issued a press release. The deal only came to light from an email obtained by the Mid-Hudson News.
    • “The move brings yet another large group of providers into UnitedHealth, which had more than 70,000 employed clinicians at the end of 2022. UnitedHealth is most-known for its health insurance arm, UnitedHealthcare. But the company has made a concerted effort over the past several years to buy physician groups, surgery centers, and other outpatient providers, and then funnel its insurance members to those entities as a way to keep more of the insurance premiums.”
  • Health Payer Intelligence tells us “58% of Payers Use Outcomes-Based Contracts for Prescription Drugs; While 10 percent of payers had between two and five outcomes-based contracts in place in 2022, 35 percent had 10 or more contracts.”
  • Fierce Healthcare relates “Evernorth’s Accredo specialty pharmacy arm has rolled out a new program that aims to assist members and plan sponsors in better managing the cost and complexity of therapies for rare conditions.”
  • Health Payer Intelligence reports
    • “Aetna launched a partnership with a virtual care company to provide chronic disease management for members with digestive issues.
    • “Aetna’s partner offers a virtual care platform dedicated to digestive health called Oshi.
    • “Oshi’s virtual-first, integrated approach to GI care aligns with our mission to invest in companies that are improving health for more people,” said Vijay Patel, managing partner at CVS Health Ventures. “Our collaboration with Oshi is a powerful example of how our investments in high-potential, early-stage companies are helping to make consumer health care more accessible, affordable and simpler.”
  • STAT News helpfully delves into the topic of how much a Medicare increase do hospitals need for the next federal fiscal year? It’s an enlightening read.

Sermonette — The squib from the lead story about UHG’s acquisition of Crystal Run ends with a cheap shot at the profit motive. As the FEHBlog noted at the time the ACA imposed the medical loss ratio on insurers, insurers will find a way to circumvent the MLR with other products which are not so limited. In this case, UHG has pulled a page out of Kaiser Permanente’s successful and admirable approach of pairing a medical group with a health plan to improve healthcare quality over time. Both the profit motive and the achieving quality goals underlie these business combinations, which the ACA’s MLR and other features invented.

From the end of the public health emergency front, the American Hospital Association informs us

  • “HIPAA enforcement discretion implemented for the COVID-19 public health emergency will expire with the end of the PHE on May 11, but covered health care providers will have until Aug. 9 to comply with the HIPAA rules with respect to telehealth, the Department of Health and Human Services’ Office for Civil Rights announced today.”
  • “OCR is continuing to support the use of telehealth after the public health emergency by providing a transition period for health care providers to make any changes to their operations that are needed to provide telehealth in a private and secure manner in compliance with the HIPAA Rules,” explained OCR Director Melanie Fontes Rainer.
  • “OCR in 2020 implemented enforcement discretion policies under HIPAA and the Health Information Technology for Economic and Clinical Health Act for community-based testing sites; telehealth remote communications; use and disclosure of protected health information by business associates; and online scheduling for COVID-19 vaccination.”

Here is a link to the notice.

From the COB with Medicare front, here is a link to a March 29 CMS Webinar for group health plans on Section 111 compliance. Speaker notes can be found at the end of the slides.

Monday Roundup

David Ermer–End of the PHE, NE, Medicare, U.S. Healthcare–
Photo by Sven Read on Unsplash

From the end of the PHE/National Emergency (NE) front, yesterday President Biden signed into law a bill (HR 7) that ends the Covid NE immediately, instead of May 11, as the Administration planned. In addition, the NE law calls for a 60-day phase-out period following termination. Consequently, the statutory changes tied to the NE end will phase out on June 7, 2023.

The statutory changes about employer-sponsored health plans falling into this category directly impact employers and concern topics, e.g., COBRA continuation coverage and ERISA appeal rights, that do not affect FEHBP.

In contrast, the statutory changes tied to the end of PHE, e.g., no-cost Covid testing, preventive services etc., do not impact FEHB plans. The available guidance on that matter is found in ACA FAQ 58.

From the post-Dobbs front, the Wall Street Journal reports

  • “The Biden administration filed an emergency request Monday asking a federal appeals court to block a ruling that suspended approval of a widely used abortion pill, while some Democratic-led states announced contingency plans to stockpile abortion drugs.
  • “In a filing with the New Orleans-based Fifth U.S. Circuit Court of Appeals, the Justice Department said a federal judge in Texas engaged in an “extraordinary and unprecedented” usurpation of the U.S. Food and Drug Administration’s authority by ruling that the pill shouldn’t have been approved. 
  • “The department said U.S. District Judge Matthew Kacsmaryk in Amarillo, Texas, upended decades of reliance on the abortion pill, known as mifepristone, “based on the court’s own misguided assessment of the drug’s safety.”
  • “The drug’s brand-name manufacturer, Danco Laboratories, which sells mifepristone marketed as Mifeprex, filed a similar motion. The company said that in addition to the potential harm the ruling posed to millions of women who rely on the pill, it also threatened Danco’s livelihood as a one-drug company. 
  • “Hundreds of pharmaceutical industry leaders, meanwhile, weighed in, saying in an open letter that the Texas decision could threaten FDA regulation of medicines more broadly.”

From the Medicare front, Fierce Healthcare informs us

  • “The Centers for Medicare & Medicaid Services (CMS) released the proposed Inpatient Prospective Payment Systems (IPPS) rule and the Long-Term Care Hospital pay rule. In addition to changes to payment rates, the agency is proposing to measure hospitals on how they tackle health equity. 
  • “CMS is helping to build a resilient healthcare system that promotes good outcomes, patient safety, equity and accessibility for everyone,” said CMS Administrator Chiquita Brooks-LaSure in a statement. 
  • “Hospitals that participate in the IPPS Quality Reporting Program and meaningfully use electronic records are projected to get a 2.8% increase to payments for fiscal year 2024, which begins in October. The pay raise is based on a 3% projected hospital market basket update of 3%, which is “reduced by a projected 0.2 percentage point productivity adjustment,” according to a release on the rule. 
  • “Overall, this will lead to a $3.3 billion increase in inpatient payments. However, long-term care hospitals are expected to get reduced payments by 2.5%, or $59 million.
  • “Overall, CMS expects [long-term care] payments under the dual-rate payment system to decrease by 0.9%, or $24 million, primarily due to a projected decrease in high-cost outlier payments in FY 2024 compared to FY 2023,” the agency said.”
  • Hospital groups slammed the proposed payment rates for the IPPS and long-term care hospitals as inadequate.

From the Postal Service front, Federal News Network tells us that USPS marked the first anniversary of the Postal Reform Act by proposing a price increase on stamps for the summer of 2023.

  • “The agency announced Monday that it plans to raise rates again. The proposed rates would go into effect on July 9, and would raise the price of a first-class stamp to 66 cents.
  • “USPS said operating expenses fueled by inflation continue to rise, and that the agency making up for years of operating under a “defective pricing model.”
  • “USPS raised the price of a first-class stamp to 63 cents in January, after raising it from 58 cents to 60 cents in July 2022.”

In consumer health news, the Wall Street Journal discusses the impact of the new generation of weight loss drugs on the $76 billion diet industry and offers guidance on buying lower-priced hearing aids over the counter. Interesting tidbit, most OTC hearing aids include useful customer support.

Midweek Update

David Ermer–CMS, COVID-19, Federal employment benefits, Medicare, OPM, Rx coverage, Telehealth, U.S. Healthcare–
Photo by Manasvita S on Unsplash

Govexec and the Federal Times report about yesterday’s release of OPM’s Postal Service Health Benefits Program interim final rule.

Fedweek offers interesting observations on the federal workforce demographics:

“For years, [federal agencies] focused on the “retirement wave”—or still more sweeping, the “retirement tsunami”—when the Baby Boom population hit retirement eligibility. That view continues today, with the constant repetition of statistics such as that 15 percent of the federal workforce is already eligible to retire, and that in five years 30 percent of current employees will be eligible.

“That wave never happened and there is no reason to believe it will.

“What has actually happened is that federal retirements have been a fairly steady flow at around 60,000 to 70,000 each year from agencies apart from the Postal Service (which accounts for about 40,000 more on average). That’s around 3 percent per year, so when it’s five years later, 15 percent or so already have retired and there’s still only 15 percent who are eligible.

“Since those first soundings about a retirement wave, the workforce actually has been increasing in age. The average is now 47—five years older than the overall U.S. workforce—with about 28.7 percent age 55 or above, up by a half-point just in the last six years. The percentage aged 60 and older—which more or less equates to retirement eligibility—rose from 9.4 to 14.5 percent over the last 15 years.”

This is the demographic challenge facing the FEHB Program which is ameliorated by the coordination of benefits with Medicare beginning at age 65. OPM improved the opportunities for coordination of benefits with Medicare by allowing carriers to integrate Medicare Part D prescription drug plans for 2024.

From the public health front —

  • Dana Farber Cancer Institute offers insights into which States have the highest cancer rates.
  • The Department of Human Services announced making progress in the “whole of government” response to long Covid.

“[E]xperts say there is little public awareness about CMV compared to other viral infections that can infect a fetus in utero, such as HIV, Zika, and toxoplasmosis, all of which are far rarer than CMV infections. Professional societies recommend pre-pregnancy counseling and monitoring for HIV, but not for CMV. And testing for the infection in newborns isn’t widespread.”[E]xperts say there is little public awareness about CMV compared to other viral infections that can infect a fetus in utero, such as HIV, Zika, and toxoplasmosis, all of which are far rarer than CMV infections. Professional societies recommend pre-pregnancy counseling and monitoring for HIV, but not for CMV. And testing for the infection in newborns isn’t widespread.

“Through my entire career, it’s been so clear that this field is really lacking in progress,” said Laura Gibson, an infectious diseases physician at UMass Memorial Health. “It’s just been frustrating to all of us in the field over decades.”

“That is starting to change, as state public health committees and legislatures begin to debate whether to mandate doing more robust screening for CMV. In 2019, Ontario became the first region in the world to test every baby for CMV. This year, Minnesota followed suit.”

“Obesity and diabetes in mothers have traditionally been considered risk factors for the child to also develop obesity. But a new study suggests that more narrow measures of health during pregnancy could help better assess that risk.

“Researchers grouped pregnant women based on specific metabolic traits and found that insulin resistance was associated with the highest risk, compared with other traits such as high cholesterol and triglycerides, according to a study published in JAMA Network Open on Tuesday.

“The risk linked to insulin resistance was even higher than that associated with prepregnancy obesity, defined as a body mass index over 30, and with diabetes diagnosed in gestation, the study said.”

From the Rx coverage front —

  • AHIP offers a new resource that “highlights how biosimilars offer an effective, lower-cost alternative to a brand name biologic product. In the last 10 years, for example, $36 billion of biosimilar medication spending was associated with $56 billion in savings. And savings from biosimilars are expected to exceed $180 billion over the next 5 years — a more than 4-fold increase from the last 5 years.”
  • STAT News reports on cancer drug shortages that have plagued our country for years.

From the telehealth front, mhealth intelligence informs us that “According to the FAIR Health Monthly Telehealth Regional tracker, telehealth use increased [7.3%] across the country in January, with rates rising at the national level and in all US Census regions.” My word, telehealth use increased in the winter?!?

Finally, in Medicare Advantage and Part D News, CMS lowered the boom on Medicare Advantage and Part D plans with a new final rule to “strengthen Medicare Advantage and hold health insurance companies to higher standards for America’s seniors and people with disabilities by cracking down on misleading marketing schemes by Medicare Advantage plans, Part D plans and their downstream entities; removing barriers to care created by complex coverage criteria and utilization management; and expanding access to behavioral health care.” This action follows a payment policy and risk adjustment rule compromise last week.

PSHBP IFR Released

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

This afternoon, OPM’s Postal Service Health Benefits Program Interim Final Rule was timely posted on the Federal Register’s website. The FEHBlog estimates that deadline for public comment on the rule is Monday June 5, 2023.

From the Omicron and siblings front, Becker’s Hospital Review tells us

“The FDA is planning to make another COVID-19 booster that targets omicron available for high-risk individuals, The Washington Post reported April 3.

“Under the authorization, people 65 and older and those with weakened immune systems would be eligible to receive a booster dose four months after their last bivalent shot.

“The policy will be “permissive,” meaning the agency will allow people to get another booster but will not definitively recommend it, sources familiar with the matter told the Post.

“The FDA is expected to announce the plan within several weeks, and the CDC is expected to quickly endorse it, sources said. “

From the anomalies front, Fierce Healthcare informs us

“Cash prices for certain hospital services were lower than the average insurance rate in nearly half of the facilities examined in a new study, which could influence rate negotiations between payers and providers. 

“The study was published Monday in the journal Health Affairs and makes use of cash price data hospitals are required to disclose for 70 shoppable services. The findings suggest that some self-insured employers pay prices higher than the cash price, which could influence future negotiations with insurers or direct talks with providers. 

“Researchers looked at the cash prices, commercial negotiated rates and chargemaster prices disclosed by 2,379 hospitals as of Sept. 9, 2022, per a federal rule that went into effect in 2021.

“The average and the median cash price made up 64% and 65% of the chargemaster rate.

“About 12% of the cash prices were set the same as chargemaster rates, and other cash prices were predominantly priced in increments of 5% off the chargemaster rates (64% of the time),” the study said. 

“The study found that the cash prices were lower than the median commercial rates in 47% of cases, most often at hospitals with government or nonprofit ownership, located outside of metropolitan areas or located in counties with relatively high uninsurance rates or low median household incomes.

“Researchers also discovered that evaluation and management services were the most likely to have a lower cash price with 55% compared with medicine and surgery at 48%.”

From the Medicare Advantage front, Healthcare Finance confirms

“Health insurers and stakeholders have expressed support for the Centers for Medicare and Medicaid Services’ plan to phase in changes to the risk adjustment model over three years, in the 2024 Medicare Advantage Program and Part D Payment Policies released Friday.

“The model changes will begin in 2024, with the full brunt of phased-in risk adjustment to take effect in 2026, according to Susan Dentzer, president and CEO of America’s Physician Groups.

“We’re satisfied with this,” said Ms. Dentzer. “They mostly listened.”

“Insurers also voiced their support for the payment increase in the 2024 Medicare Advantage and Part D Rate Announcement.

“CMS anticipates a payment increase for Medicare Advantage plans of 3.32% from 2023 to 2024 as a result of various changes, including in risk adjustment.

“This compares to the 1.03% increase in revenue proposed in the 2024 Advance Notice released in February.”

“We appreciate that CMS recognized the serious concerns with several proposed policies in the Advance Rate Notice that would affect MA enrollees in 2024, including by phasing in changes over a period of three years,” said Matt Eyles, president and CEO of AHIP.