Happy Easter! Both the House and the Senate have work periods in their home districts / states this week.

The Wall Street Journal today has an enlightening story about the Walmart-Humana merger currently under discussion.

“These vertical deals [e.g. CVS Health -Aetna, Cigna-Express Scripts] are super exciting, mostly for the potential to keep people out of the hospital,” said Zack Cooper, health economist at Yale University.
With a potential Walmart-Humana deal, “there is scope for this new entity to, in a sense, offer a product that has less bells and whistles and is more efficient and lower cost,” he said.
Outside its pharmacies—which operate across 4,700 U.S. Walmart stores—the retailer’s health-service offerings are currently limited. Walmart operates 19 clinics in Georgia, South Carolina and Texas and other providers operate about 50 additional clinics. But Walmart’s expansive retail footprint would make it a formidable competitor should it build out low-cost outpatient offerings, said industry executives and consultants.

In contrast, CVS Health has over 9,800 pharmacies in 49 states, DC, and Puerto Rico (The only state currently without a CVS pharmacy is Wyoming.)

At the OPM carrier conference last month, a speaker on the opioid panel observed, and they New York Times confirmed, that dentists are the leading prescribers of opioid based pain killers to children and young adults aged 10 to 19.  Last week, the American Dental Association announced a new policy supporting statutory opioid prescription limits and continuing education for the members.

Cigna announced “a 25 percent reduction in opioid use among its customers, reaching this key metric one year ahead of its ambitious initial goal” made in 2015.

Becker’s Hospital Review reports on a survey finding the phishing hackers are moving to new tactics:

1. Attacks that are “fileless,” leveraging exploits and scripts rather than installing malicious files. These fileless techniques attempt to bypass traditional security measures that focus on scanning files, such as antivirus solutions.

2. Attacks that are “clickless,” meaning they do not rely on tricking users into selecting a malicious application. Instead, these attacks take advantage of vulnerabilities to deploy remote execution exploits to infect computers.

3. Attacks that misuse legitimate system tools and processes already present on a computer, rather than deploying malicious files. Since these attacks take advantage of legitimate pathways, they are more difficult for many security measures to detect.

4. Attacks with built in “worm” capabilities. A worm, which is a type of contagious malware, will infect software and copy itself without the need for user action. Its goal is to spread malware infections quickly, and.

5. Attacks that leverage “cryptomining” to receive their payloads. In these attacks, a cyberattacker deploys cryptomining malware on a target’s computer to process cryptocurrency transactions without the user’s knowledge.

Fierce Healthcare reports that 

The Department of Health and Human Services (HHS) has created two new positions to lead efforts to bring down prescription drug costs and confront the opioid epidemic.
Daniel M. Best, the former corporate vice president of industry relations for CVS Health’s Medicare Part D business, will serve as senior adviser to the secretary for drug pricing reform. Brett Giroir, M.D., will add to his duties as the assistant secretary for health, serving in a dual role as a senior adviser to the secretary for mental health and opioid policy. The appointments represent two of the four priorities HHS Secretary Alex Azar recently laid out as part of a “transformation agenda” for the agency.

 Good luck to these gentlemen.

Speaking of the opioid crisis, Modern Healthcare reports that

The Blue Cross and Blue Shield Association has adopted a new standard that opioids should not be the first or second treatment options to manage pain, mirroring guidelines set by the Centers for Disease Control and Prevention.

In most cases, ibuprofen and acetaminophen can treat pain more effectively than opioids, said Dr. Trent Haywood, chief medical officer for the Blues association, which has about 106 million members. It’s important that physicians understand that alternatives like medication-assisted treatment exist, which pairs medication with behavioral counseling, he said.

It’s not an absolute decree. In many cases, particularly related to cancer treatment or end-of-life care, opioids may be the best remedy, said Haywood, adding that the association will aid physicians in making the best clinical decision.

And, on the business trends front —

• Healthcare Payer Intelligence informs us that 

A group of commercial payers and other healthcare organizations have formed a coalition to explore how addressing the social determinants of health can lower care costs and improve outcomes.  A number of large payer companies have joined the Aligning for Health (AFH) coalition, including the BlueCross BlueShield Association, CareSource, Humana, UPMC Health Plan, and WellCare. AFH stakeholders cited research that suggests social factors including access to healthy food, safe housing, and financial security account for nearly 70 percent of all health outcomes. Addressing these social factors can have positive effects on healthcare outcomes, costs, and utilization, the coalition said.

•  Health Leaders Media explains that 

Insurers and employers are recognizing the value of providing a consumer advocate who can work directly with a consumer, supported by a team of multidisciplinary professionals, says Tom Meier, vice president of market solutions at Health Care Service Corporation (HCSC), a consumer-owned health insurer in the United States and a licensee of Blue Cross Blue Shield, serving nearly 15 million members.

The increased interest comes partly from the realization that the higher deductibles currently in use don’t make consumers more thoughtful and engaged in using healthcare resources wisely, as many employers hoped, according to a recent healthcare industry survey. Instead, they just make them avoid healthcare altogether, including preventive healthcare.

Some health plans are developing health advocacy programs, and there are companies such as Accolade that offer services to both employers and health plans. Accolade promises employers savings of up to 15% and says health plans can improve utilization and the member experience while reducing medical claims spend.

HCSC is addressing those goals with a program called Health Advocacy Solutions for large employer customers. It’s a personal concierge program to address healthcare issues, answer questions, and encourage members to become advocates for their own health, Meier says. 

The FEHBlog is concerned about the lack of interoperability in electronic medical records. Last evening he ran across this Sure Scripts service which helps bridge interoperability gaps by using its vast database of prescription records to locate related medical providers for specific patients (fully HIPAA compliant of course). Apple has taken a different tack by transmitting a patient’s medical records for about 40 facilities directly to their i-phones. Very cool.

The Wall Street Journal reports this evening that Walmart, which offers retail pharmacy services, in in early talks to buy health insurer Humana. According to the Journal, “The talks come as health-service providers are rapidly pairing off and retailers—particularly pharmacy chains—are looking to diversify and bulk up in the face of the competitive threat from e-commerce giant Amazon.com Inc.”

Aetna announced that like United Healthcare it will be sharing prescription drug manufacturer rebates with fully insured commercial plan members at the point of sale next year. Fierce Healthcare noted HHS Secretary Alex Azar quickly complimented Aetna’s decision on Twitter.

OPM’s community rated contracts with Aetna’s and UHC’s HMOs participating in the FEHBP would permit those carriers to extend this new practice to FEHBP enrollees. OPM’s experienced rated contracts with nationwide carriers don’t allow this flexibility. That’s unfortunate.

Avik Roy in Forbes offers Secretary Azar some advice on how to accomplish the desired healthcare system change to patient driven care.

As Azar himself as admitted, moving to a more patient- and consumer-driven “will require some degree of federal intervention,” he said, “perhaps even an uncomfortable degree…but the status quo is far from a competitive free market…facilitating a competitive, value-based marketplace is going to be disruptive to existing actors.”
This will be the acid test of Azar’s leadership at HHS. Too often, Republicans have accepted the health care status quo, under the premise that changing the status quo would require–egads!—federal intervention.
But federal intervention—of the wrong kind—is the fundamental reason why American health care is so costly today. It will take meaningful policy changes—both by Azar’s agency and by Congress—to repair 70-plus years of Washington’s handiwork.

Mr. Roy suggests simplifying federal laws to allow patients to get and share their health care data, work with the Justice Department and the Federal Trade Commission to improve competition and less consolidation among healthcare providers, and cut drug prices for consumers like these UHC and Aetna moves will do.

Fierce Healthcare also reports on an interesting CNBC interview with Aetna’s CEO Mark Bertolini.

What do Aetna CEO Mark Bertolini and Warren Buffett of Berkshire Hathaway agree on regarding healthcare? It’s stranglehold on the economy.
“Warren Buffett said healthcare is a ‘tapeworm’ on the U.S. economy. It’s true,” Bertolini said Monday on CNBC. Taming that tapeworm will require a shift towards community-focused health, he added.
Bertolini was referencing Buffett’s statement earlier this year when the Berkshire Hathaway CEO announced a healthcare venture with Amazon and JPMorgan. Buffett said he believes the private sector can have more success in lowering healthcare costs than the federal government.

Ditto.  The FEHBlog is concerned that the ACA’s “consumer protections” will complicate Buffett’s efforts as it does for other health plans. In that vein, Mr. Bertolini added that “he hopes combining the three massive companies on the project will yield good results due to the necessary resources needed. ‘I’m hopeful, but don’t expect any miracles,’ he added. “

Finally, a couple of new surveys:

• Becker’s Hospital Review discusses a WalletHub survey identifying the ten best and ten worst states for physicians. 
• The same publication discusses a U.S. News survey identifying the 36 healthiest counties in our country. 

From time to time, the FEHBlog has reminded readers of a truism — science is as much an art as a science.

Yesterday, after completing an outstanding recent biography of our first Chief Justice John Marshall (“Without Precedent: Chief Justice John Marshall and His Times by John Richard Paul, after all the FEHBlog is a lawyer), he started reading Kenneth A. Fisher, M.D.’s book titled “Understanding Healthcare: A Historical Perspective.”

Right there in the introduction a quote which forms the basis for this truism:

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Sir William Osler (1849 – 1919).

Dr. Fisher goes on to state in the introduction that

No matter how much science advances our knowledge of the mechanisms of disease, however, medicine remains an art, combining science with humanity to address each individual’s specific needs. “As essential, as invaluable as was the study of specific diseases through close, scientific investigation,” eloquently observed Dr. Oliver Wendell Holmes [(1809 – 1894, whose son was the Supreme Court Justice O. W. Holmes, Jr.)], “there had to be more to the physician’s comprehension and approach. There had to be concern for and some understanding of the patient. Medicine was a science to be sure, but also an art, the noblest of arts.” 

How true that is.  The FEHBlog submits that you cannot assess that expertise in an NCQA HEDIS measure or a CAHPS survey question.

Congress is out of town until April 2. Here’s a link to the Week in Congress’s report on last week’s actions on Capitol Hill.

Healthcare Dive has an interesting article on the millenial generation’s (DOB between 1980 and 2000) attitudes on healthcare delivery. The article is based on this recent EBRI survey.

Healthcare Payer Intelligence reports that

Payers and employers who offer high-deductible health plans (HDHPs)
to attract low-cost members may need member engagement strategies to
generate higher value for these beneficiaries.

Member engagement is critical for HDHP success because low premiums
aren’t enough to keep members satisfied, says Jeff Oldham, Senior Vice
President of Global and Institutional Markets at Benefitfocus, believes
that.

Member engagement was a key theme of OPM carrier conference last week.  The FEHBlog was disappointed that OPM Director Pon was unable to attend because of flight problems. The conference was interesting. The FEHBlog already covered the many of the highlights over the past few months. Here’s some stuff that the FEHBlog missed:

• The keynote speaker from the National Business Group on Health mentioned a new benefit design approach called Bind that’s growing popularity.
• OPM’s medical director mentioned the President’s initiative to address the opioid crisis.  The U.S. Surgeon General by videotape reminded the attendees that “Everyone has a role to play in this crisis. Addiction
  requires a coordinated response.” 

On Thursday, a bipartisan group of Senators introduced a 2018 postal reform bill (S. 2629).  While the bill’s text is not yet publicly available, Govexec.com reports that the bill “largely mirrors” the House bipartisan 2017 Postal reform bill (HR 756) which the House Oversight and Government Reform Committee unanimously approved last Spring.

The bill’s sponsors invoked a rule on Thursday—the same day the bill was introduced—to allow the measure to skip the normal committee process and head straight to the floor for a vote. The timing of such a vote remains unclear.

As previously discussed here, these Postal reform bills would create a new Postal Service Health Benefits Program within the FEHBP. The PSHBP plans would only be open to Postal Service employees and annuitants. The law would require full integration with Medicare Parts A, B, and D for annuitants. That requirement in turn would lower premiums for everyone. The third bounce of the ball is that those savings would redound to the benefit of enrollees and the Postal Service which would see its FEHBP pre-funding for retirees obligation decrease.

The Postal Service reform bill is important to the America economy because, among other reasons, there are large geographic swaths of the country with no deliver service other than the Postal Service.  It’s not surprising therefore to see the Postal Service, the Postal Service labor unions, and customers coalesce around this bill which has been a long time coming.

The FEHBlog has been attending the FEHBP Carrier Conference.  He learned that OPM’s medical liability reform legislative proposal which the FEHBlog discussed in a post last Saturday reflects a Trump Administration proposal to make nationwide changes to state medical malpractice laws. The initiative is not limited to the FEHBP. This makes more sense. The FEHBlog will be providing more observations from the conference over the weekend.

Also according to the Hill, Congress last night approved the $1.3 trillion omnibus spending bill. The President is expected to sign it today.

The House Appropriations Committee site has posted information on the FY 2018 Omnibus Appropriations bill, which has bipartisan Congressional and White House support. Here’s a link to the text of the Financial Services appropriations section of the bill which includes FEHBP related appropriations.  The FEHBlog has confirmed that the bill includes the three traditional FEHBP appropriations measures — the abortion coverage restriction (Secs 613 and 614), the contraceptive coverage mandate (Sec. 726) and the prohibition against applying the Federal Acquisition Regulation’s cost accounting standards to FEHBP contracts (Sec. 611).

Congress is making progress toward an omnibus spending bill for the current fiscal year, according to the Hill. The deadline is Friday, March 22.

The FEHBlog ran across an excellent op-ed written by a couple of physicians explaining why your doctor’s computer is so “clunky.” Hint: as the FEHBlog has pointed out the problem lies with the $37 billion dollar electronic medical record giveaway in the 2009 stimulus law. The author’s recommendation?

In announcing the [recent] Trump-administration initiative, White House aide Jared Kushner and Seema Verna, administrator of the Centers for Medicare and Medicaid Services, said health-technology companies, insurers, doctors, hospitals and patient groups have been working together for six months on an initiative called MyHealthEData to modernize EHRs and achieve interoperability. But the usual suspects can only do so much. This is a market begging for competition from the likes of Amazon, whose cost-cutting and ease-of-use expertise is well established. Apple has also made a welcome entrance into the market. The administration can help by directing HHS to allow EHR competition.

Healthcare Dive reports on a Fair Health survey that not surprisingly finds that “Private insurance claim lines for services rendered in urgent care centers grew 1,725% between 2007 and 2016. That was well above the growth rate of 229% for emergency room (ER) claims during the same period.” After all, if you build it, they will come. The report does indicate that prices are lower in the urgent care centers as compared to the hospital emergency rooms.

Modern Healthcare informs us that a shortage in injectable opioids is threatening patient care due to a manufaturing problem at a Pfizer factory.

Other companies can’t make up the difference because they don’t have the capacity. Even if they did, the Drug Enforcement Administration is unwilling to give them large amounts of raw materials. The DEA implements annual caps on the amount of raw material a manufacturer can use to make opioids—one mechanism it has to try to limit the diversion of the addictive drugs amid the addiction epidemic.  

The DEA has not shifted those caps to allow other manufacturers to produce enough to offset the shortage of injectable narcotics, according to Premier, which has advocated for the agency to loosen its quota restrictions. 

Ruh roh.