Weekend update

David Ermer–Congress, Rx coverage, U.S. Healthcare–
Bluebonnets — The Texas State Flower

The House of Representatives and the Senate will be in session this week for Committee business and floor voting.

HHS’s Agency for Healthcare Quality and Research reminds us that we observe Patient Safety Awareness Week from March 12 through March 18.

HR Dive reminds us that March 2023 marks the thirtieth anniversary of Congress enacting the Family and Medical Leave Act.

From the public health front —

  • The American Medicare Association explains what doctors wish patients knew about falling U.S. health expectancy and identifies steps patients can take to lower high blood pressure.
  • Fortune Well informs us, “Researchers have found long-term evidence that actively monitoring localized prostate cancer is a safe alternative to immediate surgery or radiation.”
  • A Fortune Well reporter shares lessons learned from wearing a continuous glucose monitor for a decade.

From the Rx coverage front, STAT News reports

The emergence of highly effective obesity drugs has spurred renewed efforts to get Medicare to pay for weight loss medications, but a group of health policy experts is sounding caution.

Even a small amount of uptake would create significant costs for Medicare, likely leading the federal insurer to raise premiums in the long run, the researchers said in a perspective piece Saturday in the New England Journal of Medicine.

The chronic medications may also have fewer benefits and more risks for older people — the population that Medicare serves, they wrote.

OPM advised FEHB carriers in a January 2023 carrier letter

FEHB Carriers must have adequate coverage of FDA approved anti-obesity medications on the formulary to meet patient needs and must make available their exception process to members. Carriers must cover at least one anti-obesity drug from the GLP-1 class for weight loss and cover at least 2 additional oral anti-obesity drug options. As new anti-obesity drugs are approved by the FDA, OPM expects Carriers to evaluate and update their coverage of anti-obesity drugs. Carriers should provide access to a range of obesity drugs on the formulary in order to satisfy OPM’s requirement in Carrier Letter 2022-02 that Carriers must ensure non-discriminatory access to safe, clinically appropriate drug therapy for members with chronic conditions. This includes drug therapies indicated for adolescents age 12 years and older.

In cases where utilization management edits are applied, the process and evidence-based criteria for coverage must be transparent, readily accessible, and follow OPM required turnaround timelines for standard and expedited reviews. We recognize the progress made in covering anti-obesity medications; our goal is to have all Carriers offer adequate coverage.

From the medicare practice front —

  • RevCycle Intelligence relates, “Providers are Increasingly Billing Outpatient Visits at Higher Levels; The share of outpatient visits billed at the two highest complexity levels increased from 24 percent in 2004 to 43 percent in 2021,” and “A study finds that outpatient surgery rates for 4 common procedures rose significantly during the pandemic, while barriers prevent greater uptake for other surgical operations.
  • In an intriguing contrast of news —
    • RevCycle Intelligence highlights, “New data shows that 46% of patients rely on online provider reviews for provider selection. With loyalty on the back burner, a poor patient experience could prompt consumers to look elsewhere.”
    • Meanwhile, the Wall Street Journal reports
      • “Doctor-rating websites regularly fail to mention such black marks on physicians’ records, according to research published in November in the Journal of Empirical Legal Studies. 
      • “The researchers compared two groups of online reviews. One group consisted of ratings for 221 doctors in Illinois and Indiana who had paid medical-malpractice claims and had disciplinary actions against them. The other group had ratings for 221 doctors in the same two states with clean records. Based on their findings across five online rating services—Healthgrades.com, RateMDs.com, Vitals.com, WebMD and Yelp.com—the researchers reported no significant difference in the two groups’ ratings. 
      • “If you have a physician with both discipline and medical-malpractice claims, you should probably be looking for someone else, but that information is not easy to find,” says David Hyman, an author of the study and a health-law and policy professor at Georgetown University Law Center. 
      • “Of the five websites in the study, only Healthgrades reports medical-malpractice claims and disciplinary actions, but it misses 90% of those claims and actions, according to the study authors.”