Congress is in session this coming week as the Hill’s Floor Watch blog reports. The Medicare Part B fix expires at the end of this month unless Congress takes action before then. Upon expiration, Medicare Part B payments to doctors will drop by around 20%.  There is a bipartisan fix on the table but how to pay for the fix remains an open question. The Congress always can kick the can down the road so the issue can be taken up in a lame duck session following the mid-term elections in early November. The Medicare Part B fix has a big FEHBP impact for two reasons. One, there is a large cadre of FEHBP annuitants with primary Medicare Part B coverage, and two, fee for service plans under the FEHB Act pay doctors for services rendered to annuitants over age 65 who have declined Medicare Part B using the Medicare schedule.

Drug Channels.net has an interesting report on the specialty pharmacy business. Specialty pharmacy are biologic or large molecule drugs that require special pharmacy handling because, for example, they often are injectables.  Biologic drugs are more expensive than small molecule / traditional drugs because the FDA still has not created a regulatory pathway for the approval of bio-similar drugs akin to small molecule generics. Drug Channels research

research shows a booming market:

• In 2013, retail, mail, and specialty pharmacies dispensed about $63 billion in specialty pharmaceuticals.
• Specialty drugs accounted for 22% of total pharmacy industry revenues.
• Three companies—Express Scripts, CVS Caremark, and Walgreens—accounted for 63% of revenues from pharmacy-dispensed specialty drugs. The next three largest players had a combined share of about 5%.

Specialty drugs also are dispensed in doctors’ offices and clinics.

Here are a couple of tid bits that caught the FEHBlog’s attention:

• Two major drug manufacturers — Ranbaxy in India and Pfizer here in the good old USA — have recalled drugs due to distribution mix-ups. How often does that happen?
• Healthday is reporting that  “A blood test has been developed that can predict with 90 percent certainty whether a senior will suffer from dementia within the next few years, researchers report.” Fingers crossed that the blood test could help researchers determine the cause of this disease. The Washington Post reported last week that “Alzheimer’s disease likely plays a much larger role in the deaths of older Americans than is reported, according to a new study that says the disease may be the third-leading cause of death in the United States.”

Following up on the CMS’s administrator’s ICD-10 or bust comments at the HIMSS conference last week, the American Medical Association is begging CMS for an ICD-10 contingency plan. Medical Economics reports that 

The President issued his FY 2015 budget proposal today. The Office of Personnel Management’s proposed budget include the following legislative initiatives that the agency also suggested last year:

The health insurance marketplace has changed significantly since the FEHBP was enacted in 1959 and the current governing statute leaves little flexibility for the program to evolve with the changing market. The 2015 budget proposes that beginning in 2016: domestic partners of Federal employees and new retirees would be eligible for health benefits; OPM would be authorized to contract with modern types of health plans rather than being limited to the current four statutorily-defined plans reflective of the 1950s insurance market; OPM would be authorized to contract separately for pharmacy benefit management services; and OPM would be given authority to make adjustments to premiums based on an enrollee’s tobacco use and/or participation in a wellness program.

Well, the FEHBlog was out of town this weekend, and his schedule was discombobulated this morning by winter storm Titan. So the FEHBlog posted the key weekend update this morning and now wants to add a few more points.

The FEHBlog received a tip from his friend and colleague Theresa Defino that on February 18, 2014, the Congressional Research Service issued not one but two FEHBP related reports.  The first is a report on the transition of members of Congress and their official staffs from FEHBP coverage to DC gold level SHOP exchange coverage.  The second is an updated report on law affecting the FEHBP or as the FEHBlog calls it “Thanks for the memories.”

Today, the consulting firm Truven Health Analytics released the results of its annual survey of top 100 hospitals. Check your PPO lists! One local hospital made the list, the Virginia Hospital Center in Arlington, VA. The Truven press release explains that

“Employers and payers are increasingly seeking network hospitals that consistently provide demonstrated value — hospitals that deliver higher quality, higher satisfaction and lower cost. The 100 Top Hospitals have been objectively proven to provide high value, and the majority of them have demonstrated year-over-year increased value, as well,” said Jean Chenoweth, Truven Health Analytics senior vice president, 100 Top Hospitals Programs. “The results show 100 Top Hospitals to be strong, well-managed hospitals with consistently high performance. This year, 59 percent of the 2014 100 Top Hospitals were winners last year. In 2013, 51 percent were repeat winners; in 2012, 42 percent were repeat winners.”

The FEHBlog also was reminded today that the Choosing Wisely campaign which OPM has endorsed is continually updating its member medical association lists of medically unnecessary procedures. The most recent posts were from the American Geriatrics Society and the American Academy of Allergy, Asthma, and Immunology.

The Obama Administration is expected to release its FY 2015 budget proposal tomorrow. Federal New Radio reports that OPM’s Director hinted on Friday about OPM initiatives in that proposal which focus on employee training. Congress is in session this week, and the Hill’s Floor Blog reports that major Congressional committees will be questioning Administration officials about their budget proposals.

Moreover, TGI the end of February.

Recently, the FEHBlog wrote about a New York Times article concerning a study on the value of mammography.  A Wall Street Journal op-ed by two physicians explaining that

Every three or four years, a “new” announcement about the usefulness of mammograms leads to a flurry of news reports. Most recently making the rounds is an update of one Canadian study that suggested mammograms do not reduce breast cancer mortality. [The study discussed in the NY Times article.] Mammogram studies continue to yield competing results, which has led some countries such as Switzerland to discontinue recommending their regular use. Women are left to worry whether to undergo a procedure debated among doctors, expert panels and advocacy groups.
The confusion and angst are unnecessary. Women can find relief in reviewing what we already know about mammography: Screening works for all women 50 to 74, helping to reduce breast-cancer mortality and making treatment less onerous. Given the current data for women under 50, any age to begin mammographic screening will be controversial, but at least to us, starting at 45 seems to be a reasonable compromise.

The FEHBlog discussed the New York Times article with his doctor earlier this week and his doctor made the same point.  The FEHBlog’s concern is that the ACA’s preventive care mandate like mandates is not sufficiently flexible given the science (about which the FEHBlog claims no expertise).

In recognition of the HIMSS conference The FEHBlog also wrote last Sunday about a Wall Street Journal op-ed about advances in digital medicine — virtual doctor apps. He noticed a letter to the editor from a Portland Oregon doctor who makes the point in response to this op-ed that

The things that enhance and maintain our health that have been proven effective for decades are, not surprisingly, very low-tech efforts: Eat a low-fat diet, maintain a nonobese body weight, don’t smoke, use alcohol only in moderation and exercise daily. 

Personal responsibility is key, and it cannot be mandated.

Finally, the FEHBlog was heartened by a Wall Street Journal story published today about a teenage girl, Elana Simon, the daughter of a medical researcher, successfully helped research her own disease, a rare form of cancer.

When she turned 16, she landed an internship at a lab at Mount Sinai School of Medicine in New York through a science program at the Dalton School, a private school in Manhattan where she is a student. “I wanted to go off and be my own scientist,” she said of the idea, which she pursued without consulting her father.
Her project: to compare genetic data sequenced from tissue from eight pancreatic cancer patients to hunt for mutations that might separate cancerous samples from normal ones. But the tissue was from older patients who through normal aging had accumulated thousands of harmless mutations that made spotting one or two potentially meaningful ones difficult.
For Ms. Simon, a light went on. Younger people have far fewer potentially confounding mutations. Maybe performing a similar study on tissue from young fibrolamellar patients [her disease] would yield the genetic secrets of the disease.

First, he expected that OPM would implement the self plus one option for the FEHBP which Congress OKed in December for 2015 because after all it was OPM’s idea. Wrong. The Washington Post reports this morning that OPM will postpone implementation of the self plus one option to 2016.

Second, he expected that the Centers for Medicare and Medicaid Services would give health care providers some leeway on the October 1, 2014, compliance date for the ICD-10 code set, particularly given the AMA’s Twitter campaign.  Wrong again. Information Week reports from the HIMSS Conference that

The ICD-10 deadline will not change, the administrator of the Centers for Medicare and Medicaid Services [Marilyn Tavenner] told HIMSS14 attendees at a keynote on Thursday.

* * *
“There are no more delays and the system will go live on Oct 1. Let’s face it guys, we’ve already delayed it several times and it’s time to move on. It’s a standard in the rest of the world,” said Tavenner.
CMS won’t offer a 90-day window where it operates both ICD-9 and ICD-10, something several health IT professionals requested. Their fear: Hospitals won’t receive Medicare or Medicaid payments on time.
“The onus is going to fall on healthcare facilities, not the government. A three-month window is not unreasonable, given the amount of data involved,” said one clinical engineer manager from a Texas hospital who asked not to be named. “Anything would be better than, ‘Hey, we’re going live on Oct. 1.'” 

The federal government evidently plans to give us another train wreck on the first anniversary of the healthcare.gov failed launch.

Accordingly the FEHBlog is on the market for a new crystal ball.

As the FEHBlog mentioned on Sunday, the big HIMSS conference is underway this week in Orlando. Aetna’s CEO Mark Bertolini gave the first keynote speech. According to Healthcare Informatics   Mr. Bertolini  spoke about the need for payment reform, taking care of the chronically ill better, investing in wellness for the next 25-30 years and reducing waste in healthcare in order to control health care spending. Agreed.  The head of CMS Marilyn Tavenner speaks tomorrow but Modern Healthcare reports that she likely will not give any ICD-10 extension to the medical community. The Orlando Sentinel reports on some of the healthcare technology shown off at HIMSS, including one of OPM’s favorites, the Blue Button Connector.

Picking up on one of Mr. Bertolini’s points, the Wall Street Journal discussed various initiatives to create transparency in healthcare pricing. The article notes one the initiative that the FEHBlog likes — reference pricing:  

“[R]eference pricing” has yielded some savings. Where local prices differ substantially for a service like a colonoscopy, an insurer publishes a list of providers’ rates and agrees to pay a set amount. If patients choose a provider that charges more, they must pay the difference themselves.
In one pilot project, the California Public Employees’ Retirement System, found prices for hip and knee replacements ranging from $15,000 to $110,000 in the San Francisco area. It agreed to pay up to $30,000, and some 40 hospitals cut their prices to match. Such initiatives have helped Calpers save nearly $3 million in the past two years, one study found.

The Wall Street Journal and the Philadelphia Inquirer reported on the results of the first large scale study of patient centered medical homes. The FEHBlog thinks that PCMHs which involve greater coordination of primary care make sense but the study found “almost no benefits.”  Nevertheless, it’s not a matter of going back to the drawing board because according to the stories the PCMHs were making improvements to their operations as the study progressed. So perhaps this is just a baseline. The Wall Street Journal points out that the study may have focused too heavily on whether the PCMH achieved NCQA accreditation.

Speaking of medical homes, USA Today reports that the pediatrics association is complaining that convenient pharmacy based clinics are interfering with doctors’ medical home efforts. More likely the clinics are hitting the pediatricians bottom line but if this study creates better communication between the clinics which aren’t going away and the doctors offices all the better.

Finally the Wall Street Journal published a great article on how people can avoid falls in later years by improving their balance in young adulthood.  The article includes tips for older folks like the FEHBlog too. It’s important information because

In the U.S., falls are the leading cause of injury for people over 65, according to a 2005 report by the Centers for Disease Control and Prevention. Every 17 seconds, someone in this age group is treated in an emergency room for a fall. Every 30 minutes, one will die from injuries caused by falling.

On the health care quality front, the Centers for Medicare and Medicaid Services added quality measure scores related to the treatment of diabetes and heart disease for 66 group practices and 141 accountable care organizations to its Physician Compare website. Here are links to Modern Healthcare and Kaiser Health News reports on this development. Here is a link to the quality reporting page on the Physician Compare website.

This coming week, the big healthcare technology conference known as HIMSS will be held down in Orlando. As if to kick off that conference, yesterday’s Wall Street Journal offered an op-ed on digital medicine which included the following prognostications:

In a very real sense, your smartphone, loaded with a heuristic medical algorithm, is poised to become an avatar physician. You wake up at 3 a.m. on Christmas morning with a bout of chest pain. Your smartphone reads your ECG and reassures you that you are not having a heart attack—or tells you to call an ambulance and places the call, meanwhile instantly transmitting all the data to a hospital ER. And while you are at the hospital receiving treatment or care, your avatar doctor remains at your side as a constant adviser and ombudsman.
In the very near future, your avatar doctor may be able to warn you days in advance that you are going to have a heart attack by sensing certain genomic signals circulating in your blood stream and sending you to your cardiologist or to the ER. It can tell you if that sore throat you feel coming on is strep, and if it is, automatically send a prescription by email to the local pharmacy for an appropriate antibiotic. And with so many routine exams, labs, and aches and pains and handled by the avatar, your flesh-and-blood primary care physicians will have more time to talk to you when you do need to see them.
The other large benefit from this new world of digital medicine will come in lower costs. 

Hope springs eternal.

Mark the tape! Yesterday, the Affordable Care Act regulators issued a final rule on the law’s maximum 90 day waiting period for initial health insurance coverage. Compliance with this rule is not an FEHBP concern because FEHBP coverage begins on the first day of the first pay period after the employee’s SF 2809 enrollment form is received by the employing agency.  What’s remarkable is that this rule eliminates at the end of this year the long standing obligation imposed on health plans to providing terminating members with a HIPAA certificate of creditable coverage that could be used to reduce or eliminate a successor group health plan’s pre-existing condition limitation period. In the new ACA world, there are no pre-existing condition limitations. You have to wonder why the agencies did not terminate this burden as of the end of last year, but no one should look a gift horse in the mouth.  For once, the ACA reduces an administrative burden on health plans.

Yesterday evening, HHS’s Office for Civil Rights issued lengthy informal guidance on the HIPAA Privacy Rule and sharing information related to mental health. The FEHBlog found the information to be accurate and believes that OCR’s heart is in the right place. But the advice includes so many qualifications that he doubts that simply issuing the advice will open the information spigot to family members and friends. It’s always easier for the provider to clam up.

The Advisory Board reports on an AHRQ study that identifies the five costliest surgical procedures in 2011

•Heart valve procedures ($53,400 per hospital stay)
•Coronary artery bypass graft ($38,700);
•Small bowel resection ($34,500);
•Procedures related to cardiac pacemakers or cardioverters ($33,200); and
•Spinal fusion ($27,600).

According to the AHRQ study, “the average hospital stay with an OR procedure costs $3,300 per day and lasts about five days. By comparison, a hospital stay with no OR procedure costs an average of $1,700 per day and lasts about 4.4 days.”  Over 15.6 million surgeries were performed in U.S. hospitals in 2011. Cost curve up.

USA Today reports that the flu is hitting younger adults harder than seniors and children this year due to a lower vaccination rate for that group. “The good news was that this season’s flu vaccine did a good job. Being vaccinated reduced the chance of having to go to the doctor for the flu by about 60%, the CDC reported. That effectiveness rate is comparable with previous years. The CDC recommends that everyone 6 months and older get an annual flu vaccine.”  Of course, there is no enrollee cost sharing for a flu vaccination administered in-network under the ACA.