• Congress returns to work this week. We should learn this month whether the mental health parity act will be enacted. However, the Washington Post is reporting that appropriations battles in this major election year may lead to a federal government shutdown, which can disrupt the Open Season. The House Ways and Means Committee’s Health Subcommittee will hold a hearing on Sept. 11 on the difficult issue of reforming Medicare’s physician reimbursement system.

• The Centers for Disease Control is reporting that childhood vaccination rates are at an all time high. “According to the U.S. Centers for Disease Control and Prevention, immunization rates remain at or near record levels, with at least 90 percent coverage for all but one of the vaccines in the recommended series for children.” Furthermore, the San Francisco Chronicle reports that “New research further debunks any link between measles vaccine and autism, work that comes as the nation is experiencing a surge in measles cases fueled by children left unvaccinated.”

• U.S. News and World Report informs us that “Potentially groundbreaking discoveries involving genetic mutations of two deadly cancers — the brain cancer glioblastoma [which afflicts Sen. Ted Kennedy and Robert Novak] and pancreatic cancer [which afflicts Steve Jobs] — may lead to new treatments and even cures, researchers say.” Scientists are mapping the genomes of these cancers. The Wall Street Journal explains that “Now, scientists are using powerful gene-sequencing machines to identify which genetic alterations cause which cancers — an ambition reflected in three papers published this week. The hope is to offer differentiated treatment to patients based on their different tumor profiles. But the picture is enormously complicated.” U.S. News concurs in this assessment.

• In response to new federal law, the Food and Drug Administration (FDA) issued its first quarterly report on FDA-approved drugs that are under investigation for adverse side effects. Modern Healthcare.com explains that “Under the FDA Amendments Act signed in September 2007, the FDA is required to alert the public to new safety information and potential drug risks based on events analyzed through its events reporting system. Subsequent reports will not be cumulative; each quarter will list only drugs for whichever safety issues have been identified during the previous quarter, according to the FDA.”

• OPM issued a proposed amendment to the Federal Employees Health Benefits Acquisition Regulation that closes that saga of the GHS v. OPM case. The Federal Register preamble explains that In prior years, carriers were not subjected to rate reconciliation in the final year of their contracts. [That was the issue in the GHS case. The courts invalidated this regulation.] Information technology and electronic transmission and storage of data now make it possible to efficiently perform rate reconciliation for the final contract year. Therefore, OPM will begin conducting such rate reconciliation on community rated contracts that terminate after January 1, 2009.

• The Baltimore Sun reported on a Mercer consulting report on rising deductibles and co-pays. Health Plan Week reports that
  

  At a recent briefing sponsored by the Washington, D.C.-based Council for Affordable Health Care, several reinsurers told attendees that their high-dollar claims had increased by a factor of 10, according to CAHI Director MerrillMatthews, Ph.D.Over the past six years, ING Reinsurance says, it has seen an increase in the number of million-dollar claims. The three most frequent diagnoses for these high-dollar claims, according to the company, are (1) premature infants, (2) congenital defects and (3) cancer.

  The Pittsburgh Post Gazette reported on creative health care cost cutting measures undertaken by employers. The article notes that

  For sheer innovation, it would be tough to top the Hannaford Brothers Co. grocery chain of Portland, Maine. When health costs spiraled upward, Hannaford went international, offering employees full coverage for knee replacements in Singapore, where a hospital charged $10,000, instead of U.S. hospitals where the cost typically ran $30,000. Once the program was publicized, though, Hannaford Brothers started hearing from U.S. hospitals willing to match or beat what Singapore charged. Those negotiations are ongoing. “The hope is that we never have to send anyone to Singapore,” said Chris Washburn, employee benefits supervisor.

• AHIP reported on consumer and provider heath fraud schemes.

• The National Center for Policy Analysis discussed the recent Census Bureau report finding that the number of uninsured fell last. “In fact, the proportion of people without health insurance was a percentage-point lower in 2007 than a decade earlier (16.3 percent in
  1998). The slight increase in the number of uninsured over the past decade is largely due to immigration and population growth — and to individual choice.”

• Inside Consumer Directed Care and the Society for Human Resource Management discussed think tank reports on the future of health savings accounts.

The Michigan Business Review reports today that

An estimated 70 million people do have access to basic personal health records through their health insurers, with millions more scheduled to receive the service this year, according to health care benefit company Aetna. A July 2007 survey by the Financial Planning Association and Aetna found that 64 percent of respondents said they didn’t know what a personal health record was and of those who did, only 11 percent said they were currently using one.

Why aren’t people more interested in personal health records? Are there any studies on that? Perhaps people don’t consider PHR’s a priority because they are basically satisfied with their health status. Perhaps people are concerned about the security of PHRs. A recent Harris Poll found that “four percent or an estimated nine million American adults believe that they or a family member have had confidential personal medical information either lost or stolen.” It appears to be an uphill battle to gain consumer acceptance of PHRs.

Business Week reports on the practice of health care providers balance billing patients for expenses that insurance does not cover. Medicare strictly regulates this practice, but there are bills pending in Congress to override this restriction, according to the article. A provider’s right to balance bill FEHBP members (other than those with primary Medicare coverage) generally depends on the health plan’s contracts with its PPO network and participating providers.

Reports, reports, reports!

• The Segal Co. issued its 2009 Health Plan Cost Trend Survey. The report predicts single digit trend increases in prescription drug spending (excluding specialty drugs) for the first time in the reports 12 year history.
• USA Today has posted a website reporting on hospital death rates for heart attack, heart failure and pneumonia using CMS data.
• The Harris Poll and the Center for Studying Health System Change have published reports on public use of the internet to investigate health care issues.
• The Wall Street Journal reports on a study of the cost-effectiveness of Merck’s new Gardasil vaccine.
  

  “The study published by researchers from the Harvard School of Public Health suggests Gardasil’s cost is justified in pre-adolescent girls, partly because they are less likely to have already been exposed to HPV. But among older females, the cost-effectiveness of Gardasil becomes less and less favorable, researchers concluded. ‘Under most scenarios, extending the catchup to 26 wasn’t cost effective,’ Jane Kim, an assistant Harvard professor, said in an interview.”

• Meanwhile, the AP reports that “Measles cases in the U.S. are at the highest level in more than a decade, with nearly half of those involving children whose parents rejected vaccination, [according to] health officials” at the Centers for Disease Control.
• Finally, the New York Times headlined a confidential HHS Inspector General report questioning the effectiveness of Medicare’s anti-fraud efforts. How much of a surprise is this considering the recent story about Medicare paying claims based on prescriptions “written” by dead doctors?

The AMA News reports that “Legislation creating an approval process for generic biopharmaceuticals could save billions of dollars in the next decade, but a crowded congressional agenda and a lack of consensus among lawmakers may prevent passage of a bill this year.” The generic and brand name manufacturers are fighting over the patent exclusivity period. I was surprised to read that the AMA is agnostic on the legislation:

The American Medical Association has not taken a position on the bills. It is concerned about any measure’s effect on patient safety, incentives for innovation and physicians’ independence. Legislation should not compel doctors to treat biogenerics as interchangeable with brand-name biologics and should balance the need for market exclusivity with competition, according to the AMA.

How can we ever expect the price of these specialty drus to come down without generic alternatives? But of course no one expected the price of gasoline to come back down.

In more heartening news, Medco is teaming up with the Food and Drug Administration to “study
pharmacogenomics, or “personalized medicine” – the way genes can
alter the effectiveness of drugs. At the 2007 OPM AHIP FEHBP conference, Medco CEO David Snow explained how genetic tests can help doctors identify the appropriate dosage at an individual patient level for certain widely prescribed medicines like the blood thinner warfarin (brand name Coumadin).

• OPM is beginning to gear up for the upcoming Federal Benefits Open Season which will begin on November 10 and end on December 8, 2008.
• On a related Open Season note, the Centers for Medicare and Medicare Services (CMS) “estimates that the average monthly premium that beneficiaries will pay for standard Part D coverage in 2009 will be $28. This is about 37 percent lower than originally projected when the benefit was established in 2003.” Medicare beneficiaries will have their annual Open Season later this year as well. “In addition to average premiums for 2009, CMS has announced: the 2009 national average monthly bid; the base beneficiary premium; the regional low-income subsidy premium amounts for 2009; and the 2009 Medicare Advantage regional preferred provider organization benchmarks.”
• The Washington Post reported on a Bethesda MD company Wellnet Healthcare which is launching a social network for doctors,patients, and insurance company disease / case managers called Point to Point Healthcare. The article points out that the unproven service has competitors like Google Health, Steve Case’s Revolution Health, and an Arlington VA start-up Healthcentral. I was struck by this comment from an HR manager whose company has signed up with Wellnet:
  

  Janice Algie, Peterson’s director of human resources, said she wondered if her employees would use more online tools like Point to Point. “It’s difficult to get them involved in their own health care,” she said. “Every time a claim is processed, whether it’s health insurance and dental insurance, it’s submitted and tells them what they owe. I can’t tell you how many employees look at those. Even though they have online access, they still don’t look at them.” But perhaps it’s generational, Algie said. With few entry-level positions, about 45 percent of Peterson’s workforce is age 40 and above.

The U.S. Department of Health and Human Services announced on Friday a proposed regulation (required by HIPAA) “that would replace the ICD-9-CM code sets now used to report health care diagnoses and procedures with greatly expanded ICD-10 code sets, effective Oct. 1, 2011. In a separate proposed regulation, HHS has proposed adopting the updated X12 standard, Version 5010, and the National Council for Prescription Drug Programs standard, Version D.0, for electronic transactions, such as health care claims. Version 5010 is essential to use of the ICD-10 codes” effective April 1, 2010.

The announcement further explains

Developed almost 30 years ago, ICD-9 is now widely viewed as outdated because of its limited ability to accommodate new procedures and diagnoses. ICD-9 contains only 17,000 codes and is expected to start running out of available codes next year. By contrast, the ICD-10 code sets contain more than 155,000 codes and accommodate a host of new diagnoses and procedures.

These coding changes will require a host of claims system changes.