Congress started its lame duck session today. Federal News Radio’s article helpfully reviews the list of tasks for the lame duck session which of course leads with addressing the continuing resolution funding the federal government which expires on December 11.  In the lame duck session following the Democrat’s takeover of Congress following the 2006 election, Congress did enact a healthcare law which improved the rules for high deductible health plans with health savings accounts. The FEHBlog thought that in view of the Supreme Court’s decision to hear the ACA subsidy case and this recent precedent, Congress would take a crack at fixing this issue pending before the high court and other problems created by the ACA in the lame duck session. We’ll see but the FEHBlog no longer is holding his breath. This type of legislative activity may occur in the next session of Congress.

On Monday, AHIP released information on the value of provider networks which carriers can share with Plan members.

Finally, Fierce Healthcare offers four reasons to be optimistic about the U.S. healthcare system.

We have a big week ahead of us. The Federal Benefits Open Season starts tomorrow and will end on December 8. It will be interesting to see how many temporary, seasonal, and intermittent employees sign up for FEHBP coverage as a result of OPM’s rule implementing the ACA’s employer shared responsibility mandate.

Congress returns on Wednesday for its lame duck session. The continuing resolution funding the federal government expires on December 11.

The ACA health insurance marketplace open enrollment period begins on November 15 and runs until February 15, 2015. So we should hear alot about ACA premium changes this week. Last week, the ACA regulators issued FAQ XXII which puts the kibosh on tax free employer funding of employee coverage in the ACA marketplaces. Pre-ACA marketplace the IRS condoned the common practice of employers reimbursing their employees for individual health insurance premiums on a pre-tax basis. No more.  

The Wall Street Journal reported last week that the big prescription benefit manager (“PBM”) Express Scripts is considering ripping a page out of its major competitor CVS Health’s playbook by offering a no-sin pharmacy network. Express Scripts is considering creating a network of pharmacies that don’t sell tobacco or alcoholic beverages. The CVS no-sin network consists of pharmacies like CVS Health that don’t sell tobacco. Before long you won’t be able to buy a Twinkie at a pharmacy. But after all most sin product sales occur at the gas and liquor stores.

On a related note, the Motley Fool brings us up to date on the third large PBM Catamaran which is not quite in same league as CVS Health and Express Scripts but presumably it tries harder.

Finally the FEHBlog found good and bad news on efforts to solve the hospital readmission problem. Let’s start with the bad but not surprising news. Fierce Healthcare reported on an American Journal of Managed Care report concluding that hospitals cannot control the problem without primary care provider cooperation.

Researchers, led by Ariel Linden of the University of Michigan School of Public Health, analyzed more than 500 patients in two Oregon community hospitals. They gave half the patients an intervention featuring pre-discharge education and planning, post-discharge follow-up, an available hotline and “bridging” techniques such as daily symptom checks. Linden and his coauthor, Susan W. Butterworth, Ph.D., found no statistical difference in readmissions between the two groups after both 30-day and 90-day periods, although mortality was lower in the intervention group than the control group.

Neither of these hospitals could compel PCP cooperation with the intervention group and very little PCP cooperation with offered. How can a health plan help with this mess? The second Fierce Healthcare article offered some light at the end of this tunnel.

One extra day in the hospital cuts costs and significantly reduces the chance of the need to readmit Medicare patients within 30 days, a new study from Columbia Business School found.  That extra day slashed the risk of death for patients treated for pneumonia by 22 percent. Mortality for heart attack patients was cut by 7 percent, as were readmission rates, according to an announcement detailing the findings

Today, the U.S. Supreme Court decided to decide whether or not the Affordable Care Act limits health insurance subsidies to enrollees in State operated health insurance marketplaces. Although the law itself is clear on this point, the IRS decided to provide the subsidies in the federal facilitated marketplaces as well. Most ACA enrollees are in those federally facilitated marketplaces. More information on this Supreme Court action can be found in this Scotusblog post.

How does this relate to the election results? The Obama Administration did not want the Supreme Court to take the case. The FEHBlog expects that the Supreme Court expected its decision to trigger Congressional action.

Congress can fix the law during the lame duck session, and it will be interesting to see whether the Republicans are willing to fix the law and what will be their quid pro quo. It strikes the FEHBlog that fixing the law in return for repeal of the medical device tax, increasing the number of hours for ACA full time employment from 30 to 35 or 40 hours, and one or two other sensible changes in the lame duck session is the most sensible course of action. We shall see.

In yesterday’s elections, the Republicans increased their majority in the House of Representatives by 13 seats and obtained a working but not veto proof majority in the Senate with 52 seats and a chance to gain two more in Alaska and Louisiana. Never underestimate the power of the gavel. Business Insurance and Modern Healthcare have articles on where the Affordable Care Act may fit in the Congressional Republican’s agenda.

The FEHBlog heard the President say today that he would veto bills to undo the Affordable Care Act but would consider bills to improve the Act. One item in bipartisan Congressional cross hairs is the medical device tax. The medical device tax like many other ACA taxes is a demonstrable job killer. Nevertheless, the President threatened to veto a repeal of that tax in 2012 before it took effect in 2013. It will be interesting to see if the President will reconsider that position or green light other changes with bipartisan support such as changing the ACA’s definition of full time employee (30 hours) to match reality (at least 35 in the FEHBlog’s view).  Business Insurance suggests that the Republicans also may have their eye on repealing the transitional reinsurance fee and the Cadillac plan tax. Hopefully, the health insurrr fee would be in that repeal mix too. But nothing is simple. 2015 and perhaps the lame duck session will be interesting.

In another interesting development, Reuters reports that a federal district court rejected the Equal Employment Opportunity Commission’s motion for a preliminary injunction against a Honeywell employee biometric screening program. The EEOC alleges that the program which the ACA encourages violates the Americans with Disabilities Act and the Genetic Information Anti-Discrimination Act. This is the EEOC’s third recent lawsuit challenging the legality of employer wellness programs which are are quite common among large employers but have not entirely caught on yet with the FEHBP.

Congress remains on the campaign trail. Of course, the mid-term election day is tomorrow. Congress’ lame duck session begins about a week or so following the election. The continuing resolution funding the federal government in the current fiscal year which began on October 1 (H. J. Res. 124) will expire after December 11, 2014. Extension of the CR and foreign affairs items clearly are on the lame duck agenda.

The Federal Benefits Open Season starts a week from today November 10.  OPM will post its Open Season website later this week.

The Washington Post took its own look at FEHBP coverage of gender reassignment surgery over the weekend. The Post notes that

Interestingly, employers who have added transition-related coverage report very low costs tied to the these benefits, according to a 2013 study from the Williams Institute at the UCLA School of Law. Very few have actually used the benefit, the researchers found.

The Pittsburgh Star Ledger reported on the expanded use of high quality specialist networks by large insurers. The FEHBlog thinks that these networks are jim dandy. The article expresses a concern that these networks will reduce choice and represent a return to old school gatekeeper HMOs. The first point is true. The FEHBlog is not so sure about the second point because the old school gatekeeper system focused on directly lowering costs (cheaper specialists) while the new networks focus on improving quality as a means to improved health and lower costs. What’s more the government, including OPM, is pushing for the use of these new networks.

As we inch ever closer to the beginning of the Federal Benefits Open Season, November 10 / a week from Monday, the federal employee press gets busy,  The Federal Times has an article about the low 3.2% average FEHBP premium increase for 2015 which it illustrated with this OPM chart that goes back 25 years.  The FEHBlog has a problem with percentage charts like this because premiums were much lower in 1990. A 10% increase on a low dollar amount can be less consequential than a 3.2% increase on a high dollar amount. It would be more illuminating to track the average premium.

The trend of premiums is generally up which aligns with the trend in health care spending. No surpise there. The chart shows a drop in premium gIn the 1990s health plans cracked down on spending with gatekeeper arrangements (now known as patient center medical homes.) While there was a consumer backlash against those arrangements in the late 1990s, the FEHBlog credits premium growth in the late 1990s to the growth of prescription benefit managers (every Rx a claim) and Medicare relative value schedule for Part B which shifted costs to the private sector. Medicare cost shifting in the FEHBlog’s view has been the cause of much of the growth in health plan premiums particularly over the last 30 years.

It’s interesting that the dip in premium increases in the last decade begins at the same time Blue Cross launched its low premium basic plan with an exclusive provider arrangement. That plan grew like crazy in the first five years along with other low cost plans like GEHA’s.

The last decade’s bump followed by the more recent lower trend generally follows the economy and health care spending. Although it’s not mentioned in the Federal Times article, the FEHBlog credits the carriers for sticking with the program and doing their level best to control premiums.

Govexec reports that more that 25,000 Federal employees and annuitants will have to switch plans in the coming Open Season because their current plans are leaving the FEHBP at the end of the year.

Next Wednesday November 5 is the deadline for health plans to obtain a HIPAA plan identifier. Today HHS which administers HIPAA announced that

Effective October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) Office of e-Health Standards and Services (OESS), the division of the Department of Health & Human Services (HHS) that is responsible for enforcement of compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard transactions, code sets, unique identifiers and operating rules, announces a delay, until further notice, in enforcement of 45 CFR 162, Subpart E, the regulations pertaining to health plan enumeration and use of the Health Plan Identifier (HPID) in HIPAA transactions adopted in the HPID final rule (CMS-0040-F).
This enforcement delay applies to all HIPAA covered entities, including healthcare providers, health plans, and healthcare clearinghouses.
On September 23, 2014, the National Committee on Vital and Health Statistics (NCVHS), an advisory body to HHS, recommended that HHS rectify in rulemaking that all covered entities (health plans, healthcare providers and clearinghouses, and their business associates) not use the HPID in the HIPAA transactions (see http://ncvhs.us/wp-content/uploads/2014/10/140923lt5.pdf). This enforcement discretion will allow HHS to review the NCVHS’s recommendation and consider any appropriate next steps.

The HIPAA plan identifier is not intended to replace the other numerical identifiers that plans currently use. (Repeal HIPAA??) Meanwhile Congress continues to prevent HHS from issuing a HIPAA patient identifier (for privacy reasons). Common sense dictates, however, that a common patient identifier would improve the interoperability of providers’ electronic medical records systems. The number also would facilitate a move away on relying on Social Security Numbers for Medicare coordination of benefits.

HHS has announced that Dr. Karen DeSalvo will continue to serve as National Health Care IT Coordinator while she also acts as an assistant HHS Secretary for Ebola matters.  The American Medical Association is pleased with this news.

The Hartford Courant confirms what the FEHBlog noted earlier this month — Aetna has announced that all 2015 health plans it offers to federal workers will provide coverage for sex-change operations, a decision that follows a shift in U.S. government policy allowing insurance to pay for gender reassignment surgery..

The New York Times has an opinion piece in which a health care economist describes consumer difficulties in selecting a health plan during the open enrollment period. The writer complains

A crucial feature of health plans is not as easily or widely accessible: the extent to which each covers services provided by one’s favorite doctors and hospitals. Except on a handful of Affordable Care Act exchanges and for federal-employee participants in the Washington area, such network information is typically available only on plans’ websites, making gathering and comparing plan networks prohibitively difficult. Moreover, which doctors are in a plan’s network can change over time.

The health care provider knows. Ask the provider. In any event, the OPM website links to plan websites. It’s not that difficult. Moreover, the FEHBlog thinks that Congress missed an opportunity in the ACA when it failed to require providers to give patients information about the health plan networks in which they participate (and their pricing?).

Finally, Reuters reports that “pharmacy benefit manager Express Scripts Holding Co said it may quickly change its preferred drug formulary to favor an expected new hepatitis C drug from AbbVie if it is clinically equivalent and less costly than Gilead Science Inc’s $84,000 Sovaldi and $94,500 Harvoni treatments.” Hope spring eternal. According to the article, the FDA is expected to approve AbbVie’s drug which is equivalent to Harvoni, later this year but AbbVie has not announced its pricing. A speaker at the ESI conference that the FEHBlog attended last week explained that the difference between big Pharma, e.g., Pfizer, and biotech companies like Gilead Sciences is that big Pharma has a lot of irons in the fire while the biotech company only has a few. So when the biotech company hits the jackpot, it has to cash in big time.

Congress remains on the campaign trail this week.

Last Friday, OPM released its 2014 Government-wide Federal Employee Viewpoint Survey results. This report concerns employee attitudes toward their jobs, Federal New Radio has a two useful articles that review and analyze the survey results.

At last week’s Express Scripts conferernce, I heard a futurist J.D. Kleinke express his opinion that the cost curve is down because of among other factors a public backlash against high cost care, e.g., see use of retail clinics. Of course, health plans are in the vanguard encouraging this trend. According to this Fierce Health Payer article, insurers are pushing back against “Rolls Royce” treatments. However, because no good deed goes unpunished, members of the FEHBlog’s profession, who represent the doctors are criticizing this practice:

“I think the Affordable Care Act has really helped in many ways,” William Shernoff, a healthcare attorney in Beverly Hills, California, told the Daily News. “But I think they left one big loophole.”

Shernoff is referring to the fact that the ACA allows insurers to deny procedures, even ones recommended by doctors, if they consider them unreasonable or not up to the standard of care. “There doesn’t seem to be anything in the ACA that lays down any guidelines or standards on who determines medical necessity,” he added.

The Washington Post reports that

Federal retirees will receive a cost-of-living adjustment to their annuities of 1.7 percent in January, which translates into an increase of about $50 a month on average for those who retired under the older of the two main federal retirement systems, and about $20 a month on average for those retired under the newer system.

Today, the pay.gov website initiated a new page to collect headcount data from FEHB and other health plans so it can invoice those plans for the ACA’s transitional reinsurance fee.  The deadline for submitting the necessary information on this site is November 15, 2014.  This fee is designed to collect $25 billion over three to support the carriers in the ACA’s health insurance marketplaces and reimburse the U.S. Treasury for $5 billion spent on an early retiree reinsurance fund which the government prohibited FEHB plans from accessing.

Karen DeSalvo, who spoke at the WEDI conference on Tuesday as head of the Office of National Coordinator of health information technology switchted jobs today. She is now HHS’s point person for Ebola according to this ihealthbeat.com report. Her deputy also is resigning effective at the end of next month.

Drug Channels adds perspective to CVS Health’s new business venture, a PBM retail pharmacy network composed entirely of pharmacies like CVS Health and Target which don’t sell tobacco products.

Yesterday, the FEHBlog attended an Express Scripts Federal Pharmacy Symposium. Here are some tidbits from that conference:

• Express Scripts expects that the Hepatitis C biotech drug Sovaldi will add 5% to the prescription drug trend for this year (20% trend in total). Speakers noted that while Sovaldi does cure Hepatitis C, it is not a vaccine. The disease can reoccur. 
• Best of times / worst of times (?) — 5400 new drugs currently are in the development pipeline. Express Scripts expects FDA approval next year of a new biotech cholesterol drug PCSK9( (?) and a new biotech drug that “revs up the immune system” in an effort to control cancers (BPI Inhibitor). Express Scripts projects that the cholesterol drug which will be used over the patient’s lifetime could add 5% to trend. 
• Biosimilars will hit the marketplace next year. 
• While the number of people taking opioids (oxycodone, etc.) is down, the users are taking more of these drugs. 259 million painkiller prescriptions were written in 2012. 60% of users take dangerous combinations of drugs. Express Scripts thinks that doctors, pharmacies, and patients need to be better educated about pain treatment, e.g., use longer acting pain killers for people with chronic pain, Express Scripts has an interesting program under which it can lock in a member to using particular pharmacies and/or doctors for their prescriptions, e.g., discourages doctor and pharmacy shopping.