Thursday Miscellany

Medicare

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Thursday Miscellany

David Ermer–COVID-19, HIPAA Privacy and Security Rules, Medicare–

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

David Ermer–CDC, COVID-19, Medicare, OPM–

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

David Ermer–Medicare, OPM–

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

David Ermer–AHRQ, Congress, COVID-19, Medicare, OPM–

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

David Ermer–COVID-19, Federal employment benefits, Medicare, Rx coverage–

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.”

Monday Musings

David Ermer–CDC, Congress, Medicare, Uncategorized–

Federal News Network offers a useful report on the President’s Fiscal Year 2021 budget priorities for the federal workforce. Particularly in an election year, the President’s budget proposal is principally a political document. Now let Congress do its job.

Coordinating benefits when group health plan members have coverage under more than one plan is complicated. Nothing is more complicated than coordinating group health plan benefits with Medicare, and FEHB plans have to do a lot of this work due to the large number of Medicare eligible annuitant members, some of whom remain employed while most are retired. The FEHBlog could go on and on. See Section 9 of your plan brochure.

About ten years ago, Congress passed a law colloquially known as Section 111 which requires group health plans, among others, to report demographic information to the Centers for Medicare and Medicaid Services (“CMS”) in order to facilitate coordination of benefits. Now in its infinite wisdom CMS has decided to move forward with a proposed rule to impose civil monetary penalties on Section 111 reporting entities, including FEHB plans, for certain Section 111 errors. More details are available in this CMS fact sheet.

Bear in mind that larger FEHB plans in particular are under OPM Inspector General scrutiny for the accuracy of their Medicare coordination of benefits efforts. Moreover, the carriers, not the federal government, are on the risk for the FEHBP coverage. In short, Medicare coordination of benefits creates enough headaches for FEHBP carriers without the added risk of civil monetary penalties. How about a little comity between CMS and OPM? (E.g. Because OPM does not seek to penalize CMS for its COB goofs, CMS should not penalize FEHBP for their COB goofs.) The public comment deadline on the proposed CMS rule is April 20.

In a bit of hopeful news, Health Payer Intelligence discusses a successful Horizon New Jersey Blue Cross initiative to apply value based pricing to pediatricians. “If value-based care in pediatric healthcare truly is the future of value-based care, payers need to leverage strong provider relationships to establish effective pediatric quality measures in order to improve their pediatric value-based care performance, Horizon’s executive vice president for healthcare management and transformation Allen Karp illuminated.” Yes indeed.

Finally, on the disease front, HHS reports that

U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis [an extremely dangerous infection] over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion according to an unprecedented study by researchers from the U.S. Department of Health and Human Services.

Researchers determined that the increase in sepsis was not due to the growing number of American seniors enrolling in Medicare. From 2012 through 2018, the U.S. saw a 22 percent increase in the Medicare enrollment rates but a 40 percent increase in the rate of sepsis-related hospital admissions among beneficiaries.

Most patients with sepsis arrived at the hospital with the condition, rather than developing sepsis in the hospital, a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis. However, two-thirds of these sepsis patients had a medical encounter in the week prior to hospitalization. This finding represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.

Let’s get going with those efforts.

Also the FEHBlog learned that the Centers for Disease Control has issued interim guidance on COVID-19 for businesses and employers which also is probably good advice for controlling the flu. The FEHBlog appreciates the CDC’s work as should we all.

Weekend update

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

Congress remains in session this coming week on Capitol Hill. Tomorrow the President will deliver his proposed FY 2021 budget to Congress. The Wall Street Journal reports that the

$4.8 trillion budget [proposal] charts a path for the start of a potential second term, proposing steep reductions in social-safety-net programs and foreign aid and higher outlays for defense and veterans.

[The safety net program savings include] $130 billion from changes to Medicare prescription-drug pricing.

Federal News Network advises that

Signs indicate the Trump administration is still pursuing the merger of the Office of Personnel Management with the General Services Administration, despite recent congressional language prohibiting the transfer of OPM statutory functions to other agencies.

The administration will, for example, issue a joint budget request for OPM and GSA for 2021 [just like the FY 2020 budget], Federal News Network has learned

Of course, rather than prohibiting the transfer, Congress more accurately put the merger on hold pending an independent study of the transfer by the National Academy for Public Administration. The report on the study is expected to be submitted in June 2020.

OPM released additional guidance on the Wuhan or novel coronavirus to Chief Human Capitol Officers on Friday February 7. Here’s a link to the Centers for Disease Control’s website about reports of the disease in our country.

Healthcare Dive reports that

Telehealth and remote monitoring are becoming significant forces in healthcare delivery, according to a new survey of 1,300 primary care and specialty physicians released Thursday by the American Medical Association.

The number of physicians who use telehealth for visiting with patients has doubled between 2016 and 2019, although the overall number remains relatively low with 28% of surveyed physicians reporting they have adopted telehealth technology. Remote patient monitoring has also grown, from just 13% of physicians using it in 2016 to 22% in 2019.

That’s encouraging news.

Midweek update

David Ermer–ACA, Congress, Medicare, SCOTUS–

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

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

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

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

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

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

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

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

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

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

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

Monday musings

David Ermer–Medicare–

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

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

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

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

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

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

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

Midweek update

David Ermer–Federal employment benefits, Medicare–

CVS announced the following six health trends for 2020

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

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

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

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