Thursday Miscellany

Congress

Thursday Miscellany

David Ermer–ACA, Congress, COVID-19, COVID-19 vaccine, Electronic health records, Medical / Rx research, NIH, U.S. Healthcare–
Photo by Josh Mills on Unsplash

From Washington, DC —

  • Govexec informs us
    • “The Senate continues to advance spending bills without controversy and with bipartisan support, offering hope that lawmakers will avoid a lapse in appropriations this fall. 
    • “The [Senate Appropriations Committee] has now approved eight of the 12 annual must-pass spending measures, most of which have won unanimous approval. Sen. Patty Murray, D-Wash., who chairs the appropriations committee, announced Thursday her panel would hold votes on the final four funding packages next week. Murray said ahead of Thursday’s votes that she was focusing on passing bills “that can actually be signed into law.”  * * *
    • “The House Appropriations Committee has approved 10 of the 12 spending bills, all largely along party-line votes. House Speaker Kevin McCarthy, R-Calif., said on Wednesday he planned to bring those to the House floor soon, adding his intention was to have the process complete before current funding expires on Sept. 30. Without commenting on the vast differences between the two sets of bills, McCarthy called it “a positive” that the Senate was already moving its spending measures.”
  • The Affordable Care Act regulators issued a letter encouraging employers and other plan sponsors to extend the special employer-sponsored health plan enrollment period for employees who lost Medicaid or CHIP coverage for themselves or family members beyond the sixty days required by law.  
  • The Department of Health and Human Services released guidance “to clarify the prohibition at 45 CFR § 162.412(b) that a health plan may not require a healthcare provider that has been assigned an NPI to obtain an additional NPI.” However, “it does not prohibit a health plan from requiring that a subpart that does not have a unique NPI obtain a unique NPI as a condition of enrollment with the health plan.”
  • The American Academy of Actuaries posted its annual report outlining the factors likely to drive premium changes in the individual and small group insurance markets for the next plan year, in this case, 2024. 

From the public health front —

  • MedPage Today informs us,
    • “A second booster with an mRNA bivalent vaccine offered the best protection against severe COVID-19 due to the Omicron BA.5 variant in older adults, and protection appeared to wane less than with the monovalent shot, a large retrospective study out of Italy showed.”
  • The National Institutes of Health announced
    • “Omega-3 fatty acids, which are abundant in fish and fish oil supplements, appear promising for maintaining lung health, according to new evidence from a large, multi-faceted study in healthy adults supported by the National Institutes of Health. The study provides the strongest evidence to date of this association and underscores the importance of including omega-3 fatty acids in the diet, especially given that many Americans do not meet current guidelines. Funded largely by the National Heart, Lung, and Blood Institute (NHLBI), part of NIH, the study results were published in the American Journal of Respiratory and Critical Care Medicine.” 
  • Cigna Healthcare offers five tips for healthier sleep.

From the EHR interoperability front, check out this fascinating Computer World update

From the U.S. healthcare business front,

  • Healthcare Dive reports,
    • More than three years after the onset of the COVID-19 pandemic, only 1% of primary care clinicians surveyed by the Larry A. Green Center and the Primary Care Collaborative believe their practice has fully recovered from its impacts, and 61% characterize U.S. primary care as “crumbling.”
    • “Nearly 80% of respondents felt the current workforce is undersized to meet patient needs, and just 19% of clinicians report their practices are fully staffed.
    • “The results are emblematic of a “larger national crisis,” and policymakers must act to reinforce primary care, said Rebecca Etz, co-director of the Larry A. Green Center, in a statement. “ … It is not a matter of if, but when there will be another pandemic … If we don’t act soon, primary care won’t be there when it happens.
  • Beckers Hospital Review tells us,
    • “Severe winds from an EF-3 tornado on July 19 crushed a North Carolina Pfizer manufacturing plant that made nearly 25 percent of the drugmaker’s sterile injectables used by U.S. hospitals. 
    • “The facility manufactured and stored injectable drugs, and 50,000 pallets of therapies were destroyed by wind and rain, according to local news outlets, NBC affiliate WRAL and CBS affiliate WNCN. 
    • “At 1.4 million square feet, the facility was one of the largest sterile injectable plants in the world, according to Pfizer’s website. The site made nearly 400 million products every year, including solutions of anesthesia, analgesia, therapeutics, anti-infectives and neuromuscular blockers.
    • “The tornado touched down in Rocky Mount, N.C., at 12:36 p.m., according to a tweet from the county’s government.
    • “Pfizer said there are no reports of workers with serious injuries.” 
  • The Wall Street Journal reports,
    • “A surge in heart procedures and higher demand for cold and flu medicines helped Johnson & Johnson report solid gains in revenue and profit for the second quarter.
    • “J&J’s quarterly earnings are regarded as a bellwether for healthcare because the company has large pharmaceutical, medical-device and consumer-health divisions. The overall improvement in J&J’s results suggests an easing of some of the challenges that have dogged health-product makers in recent years: supply-chain constraints, hospital staffing shortages and Covid-19 pandemic restrictions. “You now have hospital staffing much more on a routine cadence,” J&J Chief Financial Officer Joseph Wolk said in an interview Thursday.” 
  • Healthcare Dive adds,
    • “Abbott on Thursday posted a decline in second-quarter net earnings as demand for its COVID-19 testing supplies continued to wane, but the company raised the outlook for its base business on higher sales of its medical devices and nutrition products.
    • “Excluding COVID-19 tests, organic sales exceeded the company’s expectations with a nearly 12% increase in the quarter.”
  • The Society for Human Resource Management explores the limited impact that the Supreme Court’s affirmative action in education decision may have on employer affirmative action and diversity, equity, inclusion, and accessibility programs.

Midweek Update

David Ermer–Congress, COVID-19, FDA, OPM, U.S. Healthcare–

From Washington, DC,

  • Fedweek compares the House and Senate versions of the appropriations bill that funds OPM and the FEHBP.
  • The Federal Times reports,
    • “Reproductive health advocacy groups and Democratic lawmakers are pressing the Office of Personnel Management on why some insurers offer fewer infertility treatments than they’re required to in federal employee health plans.
    • “In a letter to OPM Director Kiran Ahuja obtained by Federal Times, Rep. Gerry Connolly (D-Va.) and Sen. Tammy Duckworth (D-Ill.) said certain providers under the Federal Employee Benefits Program — which serves 8 million beneficiaries — are denying coverage of standard fertility preservation treatments. * * *
    • “For the 2023 plan year, OPM announced it was requiring all FEHB carriers to “provide coverage for standard fertility preservation procedures for … iatrogenic infertility.” Per KFF, “Iatrogenic, or medically induced, infertility refers to when a person becomes infertile due to a medical procedure done to treat another problem, most often chemotherapy or radiation for cancer.”
  • The Federal Times article contends that FEHB plans are not fully compliant with this mandate. OPM has created a process for members to ask for OPM review of claim decisions (following internal plan reconsideration). This process can work out any compliance kinks.
  • InsiderNJ adds,
    • “Today, U.S. Senator Cory Booker (D-NJ) and U.S. Representative Rosa DeLauro (D-CT) reintroduced the bicameral Access to Infertility Treatment and Care Act, legislation that would require more health insurers to provide coverage for infertility treatment, as well as fertility preservation services for individuals who undergo medically necessary procedures that may cause infertility, such as chemotherapy. * * *
    • “The full text of the bill can be found here.”
  • AHA News informs us,
    • “The Federal Trade Commission and Department of Justice July 19 released for comment through Sept. 18 updated guidance describing how the agencies review mergers and acquisitions to determine compliance with federal antitrust laws. The agencies said the document outlines 13 principles they may use when determining whether a merger is unlawfully anticompetitive and clarifies the frameworks and tools they may use when analyzing a merger with respect to each guideline. 
    • “FTC and DOJ initiated the update with a request for public input in January 2022, and plan to use the comments to update the draft before finalizing the guidelines. For more on the draft guidelines, see the agencies’ fact sheet. AHA intends to submit comments on the proposed guidelines.”
  • Washington Technology tells us,
    • “Maximus is locked in a protest fight after the U.S. Postal Service chose Deloitte Consulting for a $175 million contract to the consulting firm to build a new health benefits system.
    • “By 2025, USPS plans to move that new system for delivering health insurance benefits to its employees. USPS tasked Deloitte Consulting to build the system that would include enrollment processing, eligibility determinations, data analytics and other features, according to solicitation documents on GovTribe.
    • “Maximus filed a protest with the Government Accountability Office on Tuesday to challenge the award. The Office of Personnel Management is managing the contract on behalf of the Postal Service. * * *
    • “A decision from GAO is due Oct. 26.”
  • Cardiovascular Business points out that “The U.S. Food and Drug Administration (FDA) has announced that Medtronic is recalling nearly 350,000 implantable cardiac devices due to continued issues with their ability to deliver high voltage therapy when necessary.”

From the public health front –

  • The Wall Street Journal reports,
    • “You might know a Covid-19 super-dodger who was infected with the virus but didn’t get sick. Their luck could be written in their genes. 
    • “A DNA variation that affects the immune system can boost a person’s odds of avoiding Covid-19 symptoms, a study found. The work, published Wednesday in the journal Nature, helps explain why some people infected with the virus that causes Covid-19 don’t fall ill. 
    • “The T cells of some people with the variation can find and kill the virus without having seen it before, researchers said. That is because the part of the virus their T cells home in on is similar enough to common coronaviruses they have already encountered.  
    • “There are people out there that have got strong prior immunity from their common coronavirus exposures,” said Danny Altmann, a professor of immunology at Imperial College London, who wasn’t involved in the study. The work could help researchers design better vaccines, Altmann said.” 
  • STAT News relates,
    • “Cancer drugs can burn through tumors like wildfire, killing off the vast majority of malignant cells. But a few stubborn cells often end up surviving, seeding a recurrence of the disease. The prevailing theory behind this drug resistance is built on natural selection: Among the vast and genetically diverse population of cancer cells in a tumor, some have random mutations that help these cells survive an onslaught.
    • “But this is not the full picture,” said Yogesh Goyal, a cancer researcher at Northwestern University. Goyal and his colleagues at the University of Pennsylvania demonstrated in a series of experiments that cancer cells can survive treatments just by having certain genes turned on, even if they were nearly genetically identical to cancer cells that died but had activated different genes.
    • “We think this work stands to really change how we think about therapy resistance,” said Arjun Raj, the study’s co-senior author and a bioengineer at the University of Pennsylvania.
    • “In other words, mutations alone cannot fully explain resistance to cancer therapy. Instead, researchers may need to look more closely at the assemblage of genes turned on or off at any given time in a cancer cell — what scientists call the cell’s transcriptional profile — to better understand whether it will respond to a certain drug, Goyal said.”

From the U.S. healthcare business front —

  • Healthcare Dive lets us know
    • “Elevance’s second-quarter earnings alleviated recent cost trend and utilization concerns, as the health insurer reported lower medical spending than analysts expected.
    • “The payer beat Wall Street expectations for the quarter with revenue of $43.7 billion, up 13% year over year, and profit of $1.9 billion, up 14% year over year. * * *
    • “Elevance reported a medical loss ratio of 86.4%, down 70 basis points year over year due to premium rate adjustments reflecting the post-pandemic cost of care, CFO John Gallina told investors on a Wednesday morning call.”
  • Fierce Healthcare informs us,
    • “Amar Desai, M.D., wrote in a post on LinkedIn Wednesday that he is “thrilled” to come back to the UnitedHealth Group subsidiary as the CEO of Optum Health. Desai previously spent several years in leadership roles at Optum before taking the role of president of healthcare delivery at rival CVS Health.
    • “Desai is also an associate clinical professor of medicine at the Keck School of Medicine at the University of Southern California. He previously served as president of HealthCare Partners, which was acquired in 2019 by UHG as part of DaVita Medical Group.”
  • The Society for Human Resource Management reports
    • “U.S. organizations are budgeting an average increase of 4 percent in 2024, according to consulting firm WTW, which surveyed more than 2,000 U.S. organizations for its Salary Budget Planning Survey. That number is down from the actual increase of 4.4 percent in 2023, and the 4.2 percent increase in 2022, but the projected 2024 figures remain higher than the 3.1 percent salary increase budget in 2021 as well as other increases in pre-pandemic years.”

Weekend update

David Ermer–Congress, Medical / Rx research, U.S. Healthcare–

From Washington, DC,

  • Both Houses of Congress will be in session this week for floor voting and Committee business. Both Houses go on month-long State / District work breaks next week.
  • HR Dive reports
    • “The U.S. Senate on Thursday confirmed the nomination of Democrat Kalpana Kotagal to the U.S. Equal Employment Opportunity Commission. Her nomination as commissioner gives the workplace rights enforcement agency a Democratic majority. 
    • “The Senate voted 49-47 in favor of the Ohio native Thursday [July 13], after invoking cloture Wednesday. Kotagal will serve as the fifth commissioner of the agency with a term expiring July 1, 2027.” 

From the public health front,

  • Fierce Healthcare discusses an interesting United Healthcare population health program called Catalyst which operates in 28 states.
  • NPR Shots advises avoiding heat stroke and staying healthy when it’s hot outside.

From the medical research front,

  • The Wall Street Journal offers an essay about research underway to “get rid of menopause.”
    • “Imagine if women never reached menopause, that dreaded middle-age milestone—or could delay it, or decide when to have it.
    • “Women could remain fertile longer and would have more choice about when to start a family. They wouldn’t struggle with symptoms like hot flashes, mood swings and brain fog in the prime of their careers and family lives.
    • “Even more significantly, women might live longer and healthier lives. Though menopause—a full year without a menstrual cycle—is associated with the end of fertility, it also marks another profound but less recognized change. When the ovaries stop functioning and releasing important hormones, biological aging in women speeds up, increasing the risk of numerous health problems.
    • “Menopause is the single biggest accelerant of the diseases of aging for women across the board, whether it’s heart disease and stroke, autoimmune disorders, osteoporosis or cognitive decline,” says Piraye Yurttas Beim, founder and CEO of a biotech startup called Celmatix focused on improving ovarian health. “It’s the end of the function of a key organ in our body, and we should not normalize it any more than we would normalize tooth decay, osteoarthritis or cognitive decline.” * * *
    • “At Celmatix, the startup founded by Beim, researchers are seeking to develop what’s called an activator of the AMH hormone. A woman could take a drug to reduce the loss of follicles and eggs in her reserve and thus maintain optimal ovarian health and then go off the drug when she wants more eggs to be released to try to get pregnant.”

Thursday Miscellany

David Ermer–Congress, COVID-19, COVID-19 vaccine, Generative AI, Medicare, Mental health care, U.S. Healthcare–
Photo by Josh Mills on Unsplash

From Washington DC —

  • The Food and Drug Administration announced
    • approve[ing] Opill (norgestrel) tablet for nonprescription use to prevent pregnancy— the first daily oral contraceptive approved for use in the U.S. without a prescription. Approval of this progestin-only oral contraceptive pill provides an option for consumers to purchase oral contraceptive medicine without a prescription at drug stores, convenience stores and grocery stores, as well as online.
  • The New York Times adds,
    • The pill’s manufacturer, Perrigo Company, based in Dublin, said Opill would most likely become available from stores and online retailers in the United States in early 2024.
  • The OTC contraceptive will be available with no member cost sharing from FEHB plan network pharmacies due to the Affordable Care Act’s contraceptive mandate. Per the New York Times,
    • The company did not say how much the medication would cost — a key question that will help determine how many people will use the pill — but Frédérique Welgryn, Perrigo’s global vice president for women’s health, said in a statement that the company was committed to making the pill “accessible and affordable to women and people of all ages.”
  • The American Hospital Association informs us
    • “The Centers for Medicare & Medicaid Services July 13 issued a proposed rule that would increase Medicare hospital outpatient prospective payment system rates by a net 2.8% in calendar year 2024 compared to 2023. This includes a proposed 3.0% market basket update, offset by a 0.2% cut for productivity.”
  • and
    • “The Centers for Medicare & Medicaid Services July 13 released its calendar year 2024 proposed rule for the physician fee schedule. The rule proposes a decrease to the conversion factor by 3.34%, to $32.75 in calendar year 2024, as compared to $33.89 in CY 2023. This reflects the expiration of the 2.5% statutory payment increase for CY 2023; a 1.25% statutory payment increase for 2024; a 0.00% conversion factor update under the Medicare Access and CHIP Reauthorization Act; and a -2.17% budget-neutrality adjustment.  * * * 
      “CMS also proposes several provisions to advance access to behavioral health services. For example, it would create a new benefit category for marriage and family therapists and mental health counselors under Part B. In addition, CMS would establish new payment codes for mobile psychotherapy for crisis services.”\
  • The public comment deadline for both proposed rules is September 11, 2023.
  • STAT News reports
    • “A key Senate health care panel has developed a plan to tackle reforms to middlemen in the pharmacy drug payment system, according to bill text obtained by STAT.
    • “The draft legislation, authored by Senate Finance Chair Ron Wyden (D-Ore.) and ranking member Mike Crapo (R-Idaho), includes several measures to regulate how pharmacy benefit managers are paid by health plans to negotiate with drugmakers.
    • “The most significant measure is a bill from Sens. Bob Menendez (D-N.J.) and Marsha Blackburn (R-Tenn.) that would prohibit PBMs from getting any income outside of service fees, and prohibits those service fees from being related to drugs’ list prices.
    • “Other provisions include a bill from Sens. Catherine Cortez Masto (D-Nev.) and Thom Tillis (R-N.C.) to require PBMs to send annual reports to Medicare insurance plans about their rebate and price negotiations, a policy that would ban PBMs from charging Medicaid more than they pay for drugs (a practice called spread pricing), and a mandate for the Department of Health and Human Services to outline acceptable performance measures for pharmacies.”

From the public health front

  • The Wall Street Journal reports
    • Two different arms of the World Health Organization released separate findings on the widely used sweetener aspartame—one calling it safe and the other identifying it as a possible cancer hazard.
    • Here’s what you need to know:
    • Is it safe to drink Diet Coke?
      • Yes, in moderate amounts. Food regulators around the world agree that aspartame is safe. Aspartame has been studied for decades. The WHO reaffirmed its recommendation that people consume no more than 40 milligrams of aspartame a day for each kilogram they weigh—which would be a lot of soda.
      • With around 200 mg of aspartame per 12-ounce can of Diet Coke, that is roughly 16 cans a day for a 175-pound person. People get aspartame from some other food sources, though, and often the presence or amounts of aspartame in them aren’t disclosed. The WHO and other health experts also caution against consuming large amounts of sweetened products, including soda. They recommend drinking water instead.
      • “This is particularly important for young children” whose tastes are developing, said Dr. Francesco Branca, director of the WHO’s department of nutrition and food safety.
    • Obviously, the article continues on with other FAQs, but this is the one that caught the FEHBlog’s attention.
  • The U.S. Preventive Services Task Force finalized its research plan for chronic kidney disease screening.
  • STAT News tells us
    • “Amid ongoing controversy over the cost of medicines, a key Biden administration official told Covid-19 vaccine manufacturers that their next round of shots should be priced reasonably, a move that comes after two key suppliers were accused of price gouging.”
  • The CMS Administration informed insurers and others
    • “As we look toward efforts to provide updated COVID-19 vaccines this fall, we know you may have questions about the shift away from U.S. Government purchasing of vaccines to a more traditional commercial market. To be clear, that shift has not yet occurred, and the currently authorized and approved COVID-19 vaccines continue to be free and widely available nationwide. We also wanted to send these reminders from the Centers for Medicare & Medicaid Services (CMS) about COVID-19 vaccine coverage and encourage you to start planning now for the fall vaccination campaign.
    • “[M]ost private health insurance, like employer-sponsored plans, Marketplace plans, and other individual market coverage that is subject to the Affordable Care Act (ACA) market reforms are required to cover vaccines for COVID-19 authorized for emergency use or approved by the FDA and recommended by the ACIP and their administration, without patient cost-sharing.”
  • Fierce Healthcare relates
    • The Centers for Medicare & Medicaid Services (CMS) is recommending preexposure prophylaxis (PrEP) with oral or injectable antiretroviral therapy to people at risk of HIV without patient cost sharing. * * *
    • Currently, Medicare beneficiaries are only guaranteed access to daily oral PrEP through Part D, facing out-of-pocket costs, said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. Injectable PrEP has not been covered traditionally.
  • Roll Call points out
    • “One year after the creation of the three-digit crisis hotline known as 988, officials say the next step is expanding awareness and local crisis care.
    • “More than 4 million people have called, texted or chatted the suicide prevention hotline in the year since its creation, according to Laurel Stine, executive vice president and chief policy officer for the American Foundation for Suicide Prevention.
    • “She estimates that number will grow in the next fiscal year to 9 million contacts.
    • “We have to be mindful that Rome was not built in a day,” she said. “We’ve had a fragmented mental health behavioral health crisis system for a number of years.”
  • Forbes reports on the “worsening” cancer drug shortage which it describes as a resolvable public health emergency.

From the generative AI front —

  • Healthcare Dive notes
    • Generative artificial intelligence could capitalize on the healthcare industry’s wealth of unstructured data, alleviating provider documentation burden and improving relationships between patients and their health plans, according to a new report by consulting firm McKinsey.
    • The report argues generative AI could help payers quickly pull benefits material for members or help call center workers aggregate information during conversations about claims denials. Providers could use AI to take conversations with patients and turn them into clinical notes, create discharge summaries or handle administrative questions from workers at health systems.
    • But healthcare leaders should start planning now if they want to use generative AI, as the risks can be high, the report said. Data fidelity and accuracy is key, so executives should begin assessing the quality of their AI tech stacks and considering potential problems like bias and privacy concerns, according to McKinsey.
  • Econtalk host Russ Roberts held an informative interview with Marc Andreessen about generative AI.

Midweek update

David Ermer–CMS, Congress, COVID-19, Rx coverage, SDOH, Telehealth, U.S. Healthcare–
Photo by Dane Deaner on Unsplash

From Washington, DC —

  • Politico reports,
    • “The Senate Finance Committee is releasing the next in its parade of legislation targeted at pharmacy benefit managers — an industry that Democrats and Republicans on Capitol Hill argue drives up the cost of drugs.
    • “Sens. Catherine Cortez Masto (D-Nev.) and Thom Tillis (R-N.C.) — along with Chair Ron Wyden (D-Ore.) and ranking member Mike Crapo (R-Idaho) — plan to unveil legislation that would require PBMs, which manage prescription drugs for health insurers, to report a broader range of data about their business practices. The lawmakers seek comment on their proposal.
    • “The bill would require PBMs to submit annual reports to the Medicare drug plans that detail information about the treatments the plan covers, the discounts PBMs negotiate with drugmakers on medicines and the fees they collect.
    • “It’s the latest in a plan from Wyden and Crapo, who released a roadmap in April of PBM-focused legislation they want the committee to pursue.”
  • The Senate Finance Committee adds,
    • “Senate Finance Committee Chair Ron Wyden (D-Ore.) and Ranking Member Mike Crapo (R-Idaho) today announced that the committee will mark up legislative proposals to modernize and enhance federal prescription drug programs on Wednesday, July 26th at 2 p.m. The committee package will focus on addressing pharmacy benefit manager practices that have grown increasingly complex and opaque in recent years at the expense of patients and taxpayers.”
  • The American Hospital Association further informs us,
    • “The House Education & Workforce Committee July 12 voted 39-0 to pass legislation (H.R. 4509) that would require off-campus hospital outpatient departments to obtain a separate unique health identifier and include it on all claims for services billed to commercial group health plans or their enrollees. The legislation would prohibit the health plan from paying the claim and the hospital from collecting payment from the plan enrollee if the claim excludes the identifier, and impose civil monetary penalties on hospitals that violate the requirement. * * *
    • “In other action, the committee also passed bills that would strengthen price transparency requirements for commercial group health plans (H.R. 4507); require that the plans’ contracts with service providers allow the employer/plan fiduciary to access all de-identified claims and encounter data (H.R. 4527); and require the plans to further report to the employer/fiduciary their financial arrangements with pharmacy benefit managers (H.R. 4508).”

From the public health front —

  • Beckers Clinical Leadership and Infection Control tells us,
    • “After identifying a new COVID-19 omicron subvariant — EU.1.1, a descendant of XBB.1.5 — in late June, its growth has slowed, according to the CDC. 
    • “Right now, the subvariant accounts for only 1.1 percent of cases in the U.S., data shows. Nationwide, hospitalizations and deaths both continue to decline. The CDC’s most recent data shows that hospitalizations decreased by 0.8 percent as of July 1, and deaths decreased by 9.1 percent in the same one-week period.
  • CNN reports
    • Childhood cancer diagnoses in the US have been trending up for more than a decade, according to a study published Tuesday in the Journal of the National Cancer Institute.
    • There were 14,381 new childhood cancer diagnoses in the US in 2019: about 177 new cases for every 1 million children and teens up to age 19. Incidence rates have dropped since reaching a peak in 2016 but are still about 8% higher than they were in 2003, when there were about 165 new cases for every 1 million children and teens.
    • “Overall, cancer is very rare in children and adolescents, and the increases were small,” said Dr. David Siegel, a pediatric oncologist and an epidemiologist with the US Centers for Disease Control and Prevention’s cancer division who was the lead author of the study. “Past studies have also reported increased survival rates. So the combination of increases in incidence and decreases in deaths means that there are more and more cancer survivors that need long-term care and resources.”
  • The U.S. Census Bureau issued a report examining “Racial/Ethnic Disparities in Disability by Health Condition.”
    • “The data show patterns in health-related disability among adults age 40 and older and key differences by sex, race and Hispanic origin.
      • “Among findings:
      • “Women were more likely than men to have health conditions that limited their daily activities.
      • “Asian (non-Hispanic) adults reported the lowest rates (17.2%) of disability-related health conditions.
      • “Black (non-Hispanic) adults (31.8%) and those reporting Other or multiple-race non-Hispanic identity (42.9%) were among those with higher rates.
  • The All of Us Program released its July 2023 Medical Minutes.

From the Rx coverage front

  • Per Healthcare Dive,
    • Major pharmacy benefits manager CVS Caremark is partnering with drug discounter GoodRx on a joint program to bring down out-of-pocket drug costs, the companies announced Wednesday.
    • Commercially insured customers will be able to pay GoodRx’s discounted pricing when filling commonly prescribed generic prescriptions at in-network pharmacies. The payments will be automatically applied to their deductibles and out-of-pocket limits.
    • The program, called Caremark Cost Saver, will be available for tens of millions of CVS Caremark clients’ members at in-network pharmacies starting January 2024.
  • Per Beckers Payer Issues,
    • ‘About two-thirds of patients who take popular weight loss drugs end their regimen within a year, according to a Prime Therapeutics study released July 11.
    • ‘Prime, a pharmacy benefit manager owned by 19 Blue Cross Blue Shield companies, analyzed pharmacy and medical claims of 4,255 patients who took GLP-1 receptor agonists — such as Ozempic and Wegovy — for weight loss in 2021. The study found only 32 percent of patients continued their weight loss treatment after one year. 
    • “The majority of patients aren’t getting the value of the product and there’s waste, especially with an expensive therapy,” Patrick Gleason, PharmD, Prime’s assistant vice president for health outcomes and a co-author of the analysis, told Reuters. “I was a little bit surprised by the persistency rate.”
  • STAT News delves into how Medicare Advantage plans are approaching the FDA’s approval of the infused Alzheimer’s drug Leqembi. The most illuminating part of the article concerns the Mayo Clinic.
    • As a condition of coverage, Medicare rolled out a new patient registry to collect more information from physicians prescribing Leqembi. Information is supposed to be submitted every six months. Physicians who had previewed the registry said it appeared to function, though many clinics are still finalizing protocols for prescribing Leqembi.
    • “I’m not sure it’s sufficiently detailed to answer the [coverage with evidence development] questions that the [national coverage decision] put forth. We and others would need to collect more detailed information to understand the true benefits and risks of the medicine,” said Ronald Petersen, the director of the Mayo Clinic Alzheimer’s Disease Research Center.
    • Mayo Clinic isn’t prescribing Leqembi yet, as it’s planning to launch an Alzheimer’s treatment clinic in October, Petersen said. He said there has been interest from patients, but it “hasn’t been a landslide.”
    • Petersen is hoping to start a new research study at Mayo Clinic to do more detailed monitoring on patients. To start, Mayo physicians will likely only agree to treat patients in the geographic area close to the facility so they can oversee the follow-up appointments.
    • “We’d be more than happy to share our data with broader communities or merge it with data from CMS. It is incumbent upon all of us to share data to learn from each other what works,” Petersen said.

From the U.S. healthcare business front —

  • MedPage Today points out
    • “Private equity acquisitions of U.S. physician practices have risen dramatically over the last decade, driving up consumer prices in the process, according to a new report.
    • “In 2012, there were 75 private equity deals for physician practices across a range of specialties; in 2021, there were 484, marking a more than six-fold increase, Richard Scheffler, PhD, of the University of California Berkeley, and colleagues found.
    • “Over the entire period, the largest number of deals occurred in dermatology (376), ophthalmology (276), gastroenterology (120), and primary care (118), collectively accounting for 81% of the activity, Scheffler and colleagues wrote in the report, a joint effort by the American Antitrust Institute, the Nicholas C. Petris Center on Health Care Markets and Consumer Welfare at the University of California Berkeley, and the Washington Center for Equitable Growth.”

In telehealth news,

  • Fierce Healthcare tells us,
    • “While payers should cover telehealth, where these services are the most valuable still requires investigation, according to a study in Information Systems Research.
    • “The Centers for Medicare & Medicaid Services made the rules about telehealth usage more flexible during the COVID-19 pandemic, and some lawmakers want to make those changes permanent. But that should not mean giving providers carte blanche approval in using the new technology, nor should payers cover all uses of telehealth, suggests a study by researchers with the University of Texas.
    • “Telehealth should not be regarded as a one-size-fits-all solution to virtualize healthcare,” the study said.
    • “Despite that, however, the study also states that “insurance plans should expand their telehealth coverage to include more providers and close the healthcare access divide in rural locations, which can reduce subsequent hospitalizations and unnecessary costs.”
    • “The authors argue that telehealth’s benefits can be seen in treating conditions and diseases with “high virtualization potential” such as mental health, skin problems, metabolic conditions and musculoskeletal diseases. However, telehealth did not significantly reduce visits to specialists or emergency departments for circulatory, respiratory or infectious diseases.
    • “Indranil Bardhan, Ph.D., one of the authors of the study, said in a press release that “people believed that telehealth would be the next big thing, the future of healthcare. But our research shows that its impact is not as straightforward as people might think. It’s more nuanced.”

Tuesday Tidbits

David Ermer–Congress, Medical / Rx research, Medicare, Mental health care, Rx coverage, U.S. Healthcare–
Photo by Patrick Fore on Unsplash

From Washington, DC —

  • The Senate Health Education Labor and Pensions Committee held its Superbugs hearing today.
  • STAT News informs us
    • “The witnesses largely seemed to organize behind the Pasteur Act in terms of how Congress should respond. This bipartisan legislation, which has been introduced in both the House and Senate, would encourage drug development by creating a subscription-style business model. In other words, the U.S. government would offer upfront payments to drugmakers in exchange for responsible stewardship policies and unlimited access to their antibiotics. A similar model has been successfully piloted in England over the past year, with the National Health Service planning a wider rollout to more pharmaceutical companies and to Northern Ireland, Scotland and Wales.
    • “The goal, as STAT has previously reported, is to enable pharmaceutical companies to recover their costs and make a profit — without predicating this on large volumes of antibiotics being prescribed. Helen Boucher, Dean of Tufts University School of Medicine, testified that this law would recognize these drugs “for their value, not for their use. It de-links incentives for overusing antibiotics.”
  • The Government Accountability Office released “a new report on the agency’s key findings and recommendations with an eye toward helping federal agencies be better prepared for future emergencies. GAO has regularly reported on the accountability and effectiveness of the federal government’s $4.7 trillion pandemic response since 2020.”
  • Per the White House,
    • “Today, in the continued efforts to fight the dangerous and deadly combination of xylazine mixed with fentanyl, the White House Office of National Drug Control Policy (ONDCP) released a National Response Plan to coordinate a whole-of-government response against this threat. Earlier this spring, ONDCP Director Dr. Gupta used an executive designation authority to designate fentanyl combined with xylazine as an emerging threat to the United States and proactively address this dangerous threat head-on.”
    • “Read the full National Response Plan to Fentanyl Combined with Xylazine HERE.
    • “Read about the Biden-⁠Harris Administration’s efforts to crack down on illicit fentanyl supply chains HERE.
    • “Read the Biden-Harris Administration’s National Drug Control Strategy HERE.”

From the public health front —

  • Federal News Network reports that twelve House of Representatives members are asking the Postal Service about steps being taken to protect letter carriers against the effects of high outdoor heat following the death of a letter carrier who passed away while delivering the mail in Texas.
    • “Eugene Gates Jr., a 66-year-old letter carrier in Texas, died June 20 while delivering mail during a heat wave with temperatures as high as 115 degrees. * * *
    • “The National Association of Letter Carriers, which represented Gates, said he collapsed and died in a customer’s yard while delivering mail. Gates, an Army veteran, served as a letter carrier for 36 years.
    • “Eugene was a dedicated letter carrier with a long and successful Postal Service career,” NALC National President Brian Renfroe said in a statement. “He will be greatly missed.”
  • STAT News tells us,
    • Weight loss medications from Novo Nordisk are being investigated by the European Medicines Agency after several reports of suicidal risks were referred to the watchdog, Bloomberg News reports. The regulator is looking at adverse events noted by the Icelandic Medicines Agency, including two cases of suicidal thoughts linked to the drugs Saxenda and Ozempic. One additional case relating to thoughts of self-injury has been raised in connection with Saxenda. The agency is investigating the possible side effects in relation to patients who have used medicines containing the active ingredients semaglutide or liraglutide for weight loss. Novo’s hit weight loss drug Wegovy also contains semaglutide.
  • The Bloomberg article adds,
    • “Wegovy is currently available in the US with a warning and precaution for suicidal behavior and ideation on the label. While clinical trials of Wegovy did not support an increased risk of suicidal behavior, suicidal ideation, or other psychiatric adverse events, clinical trials of other weight management drugs have reported suicidal behavior and ideation, a spokesperson for the Food and Drug Administration said Monday.
    • “If newly identified safety signals are identified, the FDA will determine what actions are appropriate after a thorough review of the body of evidence,” the spokesperson said.”

From the medical research front,

  • According to the National Science Foundation —
    • “While it’s known that sleep plays a crucial role in strengthening memory, scientists are still decoding how the process plays out in the brain overnight.
    • “U.S. National Science Foundation-supported research led by scientists at UCLA and Tel Aviv University offers new evidence from inside the human brain supporting the dominant theory of how the brain consolidates memory during sleep.
    • “The researchers found that targeted deep brain stimulation during a critical time in the sleep cycle improved memory consolidation. The result came from a novel “closed loop” system that delivered electrical pulses in one brain region that activated the cerebral cortex, synchronized with brain activity recorded in another area, the hippocampus.
    • “The research, published in Nature Neuroscience, could offer new clues to how deep brain stimulation during sleep could help patients with memory disorders, said study co-author and physician-scientist Itzhak Fried of UCLA.”

From the Medicare front, NerdWallet identifies four Medicare policies that “should come with warning labels.” Number 1 is the Part B late enrollment penalty. The article encourages picking up Part B at the first opportunity, even if health expenses at the time are modest. Granted, this article is aimed at people, like the FEHBlog, who have Medicare without supplemental employer coverage. Nevertheless, federal employees should consider the advice too.

From the Rx coverage front

  • Beckers Hospital Review notes
    • “The FDA is allowing 10 more lots of cisplatin from a China-based pharmaceutical company to be imported to the U.S. to ease the ongoing cancer drug shortage, Bloomberg reported July 10. The additional lots are set to arrive next week. 
    • “In June, federal regulators cleared four lots of cisplatin from Qilu Pharmaceutical. While the version of the drug is unapproved in the U.S., it is similar to the approved version distributed across the country. 
    • “We will continue the importation until manufacturers can meet all needs,” Chanapa Tantibanchachai, an FDA spokesperson, told Bloomberg.
    • “Shortages of the essential cancer drug began in February and have caused some cancer centers to ration cisplatin and carboplatin, another cancer drug in shortage, treatments for patients. More recently, there have been signs of supplies stabilizing.” 
  • Fierce Healthcare discusses a recent HHS report on approaches to avoiding drug shortages.
  • Following up on its recent report about the lead-covered cabling problem in our country, the Wall Street Journal points out
    • “Supplies are running out for a key antidote for life-threatening lead poisoning.
    • “The drug, named dimercaprol, has been a go-to treatment for years for the worst cases of lead poisoning. But doctors have had to scrounge for dwindling doses since the medicine’s sole manufacturer for the U.S. declared bankruptcy in February.
    • “Now that some parts of the country don’t have any supplies left, doctors have been forced to turn to other, less preferred treatments.
    • “We’re using whatever we can get, knowing it will help, but not knowing if it’s doing as good of a job,” said Dr. Diane Calello, who directs the New Jersey Poison Control Center at Rutgers New Jersey Medical School.”

In U.S. healthcare business news

  • Beckers Payer Issues tells us
    • “The Cigna Group’s network of behavioral health providers grew by more than 30 percent in 2022, according to the company’s 2022 Environmental, Social, and Governance Report.
    • “The July report said the behavioral health network has grown to include more than 300,000 mental health and substance use providers, doubling its size over the past four years. The company also nearly doubled its virtual care network, which has grown to include more than 163,000 virtual behavioral health providers. In-network providers who support cultural and race-related counseling were increased.
    • “For behavioral health providers that specifically work with children, Cigna added 27,000 providers to its network in 2022, or an increase of 19 percent. It also increased the numbers of facilities treating children by 8 percent to 2,700 total.”
  • The Wall Street Journal delves into high-priced “clinics cater[ing] to a growing number of people obsessed with fighting aging.”
    • “Practitioners at Healthy Longevity Clinic, which has locations in Boca Raton, Fla., and Prague, build patients a personalized “longevity road map.” Those maps can include recommendations for diet, exercise, sleep and supplements. Patients are encouraged to stick with the program for at least a year, over which time their bill can run between $25,000 to more than $100,000, says Petr Sramek, the clinic’s chief executive.
    • “Longevity-clinic treatments aren’t often covered by health insurance. Some providers say they work with insurers to get coverage for medications or laboratory tests. 
    • “Many clinics use membership-based models in an effort to keep client loads low enough that providers can spend time with each patient. Others are fee-for-service or use a combination of the two.”

Weekend Update

David Ermer–Congress, Mental health care, U.S. Healthcare–
Mount Rushmore

From Washington, DC, both Houses of Congress return to work here this week for floor voting and Committee business. On Tuesday, July 11, 2023, the Senate Health, Education, Labor and Pensions Committee will hold a hearing titled “Superbugs: The Impact of Antimicrobial Resistance on Modern Medicine.”

From the public health front, the Wall Street Journal reports

  • “The U.S. has spent decades eradicating lead from well-known sources such as paint, gasoline and pipes. The Journal’s investigation reveals a hidden source of contamination—more than 2,000 lead-covered cables—that hasn’t been addressed by the companies or environmental regulators. These relics of the old Bell System’s regional telephone network, and their impact on the environment, haven’t been previously reported.
  • “Lead levels in sediment and soil at more than four dozen locations tested by the Journal exceeded safety recommendations set by the U.S. Environmental Protection Agency. At the New Iberia fishing spot, lead leaching into the sediment near a cable in June 2022 measured 14.5 times the EPA threshold for areas where children play. “We’ve been fishing here since we were kids,” said Tyrin Jones, 27 years old, who grew up a few blocks away.
  • “For many years, telecom companies have known about the lead-covered cables and the potential risks of exposure to their workers, according to documents and interviews with former employees. They were also aware that lead was potentially leaching into the environment, but haven’t meaningfully acted on potential health risks to the surrounding communities or made efforts to monitor the cables.” * * *
  • “The Journal’s findings “suggest there is a significant problem from these buried lead cables everywhere, and it’s going to be everywhere, and you’re not even going to know where it is in a lot of places,” said Linda Birnbaum, a former EPA official and director of the National Institute of Environmental Health Sciences, a federal agency.”

Big ruh-roh.

From the health care cost front —

  • Health Payer Intelligence informs us
    • “What drivers influence the medical cost trend, and what steps can payers take to address these factors?
    • “The medical cost trend is the percentage that experts anticipate treatment costs will grow year-over-year, the PwC Health Research Institute’s (HRI) medical cost trend report for 2024 explains.
    • “The higher medical cost trend in 2024 reflects health plans’ modeling for inflationary unit cost impacts from their contracted healthcare providers, as well as persistent double-digit pharmacy trends driven by specialty drugs and the increasing use of the GLP-1 agonists for Type 2 Diabetes or weight loss,” the report summarized.
    • “In 2024, overall inflation, consolidation, pharmaceutical costs, and other factors will drive medical cost trend inflation, while biosimilars and site-of-care changes will exert deflationary force.”
  • Revcyle Intelligence points out
    • “Healthcare spending is still on the rise, with median costs per person increasing to over $6,000 in 2021, according to a new analysis from the Health Care Cost Institute (HCCI).
    • “Median per person healthcare spending increased by 24 percent from 2017 through 2021, HCCI’s latest Healthy Marketplace Index shows. But healthcare spending varied significantly depending on where people lived. For example, patients in metropolitan areas with the highest utilization rates paid nearly three times more for healthcare services that year compared to their neighbors in metropolitan areas with the lowest utilization rates.”
    • The American Medical Association (AMA) reports patients spent $433.2 billion, or 10.2 percent of total healthcare spending, in 2021, the same year of the HCCI analysis.
    • “High and growing health spending is forcing families, employers, and governments across the country to make difficult tradeoffs,” Katie Martin, HCCI’s president and CEO, said in a statement. “The Healthy Marketplace Index shows that health care costs depend a great deal on where you live, the result of market dynamics like prices, practice patterns, and competition. Therefore, we need a multi-dimensional approach to making [healthcare] more affordable.”
  • FEHBlog note — The AMA report indicates that health plan cost sharing for members is reasonable.
  • In related news, the Wall Street Journal warns us the “Last mile of the inflation flight will be the hardest; Housing and used-car sectors are expected to help push down the core index, but progress could then stall so long as the economy doesn’t weaken.”

From the medical research front, NPR offers a story about personal achievement

  • “Sixteen years ago, when Calliope Holingue was in high school, she had a problem. Two, actually. She developed gastrointestinal symptoms severe enough to force her to give up running, plus she had a long history of anxiety and obsessive-compulsive disorder. 
  • “And I wondered if maybe there was a link between my mental health and the GI symptoms I was experiencing,” she recalls now. 
  • “Her doctors shrugged off her questions. “That led me to start reading a lot about the gut microbiome, the autonomic nervous system, and their connection with the brain and mental health,” she says. 
  • “Today, Holingue [who holds a Ph.D degree in public health] has joined the ranks of scientists seeking to understand the interplay between the brain (and the rest of the nervous system) and the gut microbiome – that is the vast array of organisms, including bacteria, fungi and viruses, that thrive in the human gut. 
  • “She’s now an assistant professor of mental health at the Johns Hopkins School of Public Health and part of the faculty at the Center for Autism and Related Disorders at Kennedy Krieger Institute. She’s currently leading research on gut microbes and symptoms that cooccur with autism, including GI and behavioral symptoms.”

The article goes on to interview Dr. Holingue. The FEHBlog wishes her good luck.

Midweek Update

David Ermer–CDC, CMS, Congress, COVID-19, Employee Wellness Programs, FDA, Federal employment benefits, Medical / Rx research, Medicare, Rx coverage, U.S. Healthcare–

The FEHBlog hopes his readers enjoyed their Fourth of July weekend. The FEHBlog certainly did.

From Washington, DC —

  • FedWeek informs us
    • “The House version of the annual defense authorization bill would require DoD and OPM to conduct a “comprehensive review of the civilian workforce on FEHB to ensure that all family members and dependents who are currently receiving benefits are in fact eligible.”
    • “The language, inserted as an amendment to a bill that could come to floor voting in the upcoming weeks, would be the most concrete response to date regarding an issue that has been the subject of repeated warnings from OPM’s inspector general’s office and most recently from the GAO: ineligible persons being covered in the program as family members.”
  • FEHBlog note — The largest internal control problem with FEHB eligibility stems from the fact that OPM does not take advantage of the HIPAA 820 electronic enrollment roster, which allows health plan carriers to reconcile premium to headcount. For example, if the carrier finds via the HIPAA 820 that it is not receiving premiums on a self and family enrollee, then the outcome may be disenrolling the individual and their covered family members in a fair way. In the FEHBlog’s view, it does not make sense to move forward with a family member eligibility audit until the HIPAA 820 transaction is operational in FEHB. That is the most logical first step.
  • Federal News Network provides us with background on OPM’s new employee assistance program guidance. In the FEHBlog’s opinion, OPM should team up EAPs with FEHB plans in order to better coordinate their respective coverages.
  • Fedweek also explains for the benefit of federal and postal employees how to continue FEGLI coverage into retirement.
  • Healthcare Dive relates
    • “The CMS is proposing to cut Medicare reimbursements to home health agencies by 2.2% next year, or $375 million less than providers received in 2023, according to draft regulation released Friday. 
    • “The agency said the proposed rule includes a 2.7% payment bump that’s offset by a 5.1% cut related to the Patient-Driven Groupings Model, which aimed to better sort patients into different payment categories by clinical need and other factors.
    • “The reimbursement changes also reflect an estimated 0.2% increase due to an updated fixed-dollar loss ratio, according to regulators.”

From the public health front —

  • CBS News reports
    • “Nearly 1 in 4 U.S. adults and older teens had still not caught COVID-19 by the end of last year, according to new estimates from the Centers for Disease Control and Prevention, while 77.5% had antibodies from at least one prior infection. The figures are based on the final batch of results from the agency’s nationwide studies of antibodies in Americans ages 16 and up. * * *
    • “Virtually every American ages 16 and older — 96.7% — had antibodies either from getting vaccinated, surviving the virus or some combination of the two by December, the CDC now estimates. The study found 77.5% had at least some of their immunity from a prior infection. * * *
    • Rates were similar among men and women. Black and White people also have similar prior infection rates, between 75% and 80%. 
    • Among other racial and ethnic groups, Asian Americans had the smallest proportion of people with antibodies from a prior infection, at 66.1%, while Hispanic people had the highest, at 80.6%.

From the Rx and medical devices coverage front —

  • BioPharma Dive points out
    • “Moderna on Wednesday said it’s submitted applications to regulatory agencies around the world in a bid to win approval of a new vaccine to fight respiratory syncytial virus, or RSV, in older adults.
    • “The company filed with regulatory agencies in Europe, Switzerland and Australia and began a rolling submission to the U.S. Food and Drug Administration for the vaccine, which is currently known as mRNA-1345. Future applications are planned for other nations as well.
    • “Moderna’s submissions come two months after the FDA approved the first RSV vaccine, developed by GSK. The agency cleared a second RSV shot from Pfizer weeks later. Both products are approved for use in patients who are at least 60 years old, the same group Moderna aims to treat.”
  • Forbes reports
    • “On Wednesday, medtech giant Abbott announced that its new leadless pacemaker system, Aveir DR, has been approved by the FDA. This is the first time the FDA has given a thumbs up to a device of this type for two different chambers of the heart, which opens up this technology to nearly any patient who needs a pacemaker.
    • “From a clinical perspective, we know that leadless pacing offers a number of important advantages to patients in terms of getting away from the complications related to traditional pacemakers,” says Leonard Ganz, a cardiologist and Abbot’s chief medical officer for cardiac rhythm management. “This will expand the number of patients who can benefit from leadless pacing many, manyfold,” he tells Forbes.” * * *
    • “Although pacemakers have been life-changing for millions of people, they do carry downsides, explains Ganz, in particular, risk of infection both from the surgical procedure needed to implant them as well as the leads themselves should their insulation become compromised. Leadless pacemakers, by contrast, are much smaller, don’t require surgical implantation and have no wires connected to the heart. Instead, they are injected using a catheter in a vein and placed directly in the heart in a way that allows for removal if need be. All of these factors significantly reduce the risk of complications.
    • “The first leadless pacemaker, manufactured by Medtronic, was cleared by the FDA in 2016. Abbott’s first leadless pacemaker, the Aveir VR, was approved by the FDA in March 2022. [In contrast to the new Abbott device, b]oth of these products only work in a single chamber of the heart. About 80% of the patients that require a pacemaker need shocks in two cardiac chambers in order to keep the desired heart rhythm.”
  • The New York Times discusses “food noise,” which the new weight loss drugs dissipate.
    • “The active ingredient in Ozempic and Wegovy is semaglutide, a compound that affects the areas in the brain that regulate appetite, Dr. Gabbay said; it also prompts the stomach to empty more slowly, making people taking the medication feel fuller faster and for longer. That satiation itself could blunt food noise, he said.
    • “There’s another theoretical framework for why Ozempic might quash food noise: Semaglutide activates receptors for a hormone called GLP-1. Studies in animals have shown those receptors are found in cells in regions of the brain that are particularly important for motivation and reward, pointing to one potential way semaglutide could influence cravings and desires. It’s possible, although not proven, that the same happens in humans, Dr. Hwang said, which could explain why people taking the medication sometimes report that the food (and, in some cases, alcohol) they used to crave no longer gives them joy.”

From the U.S. healthcare business front

  • Segal Consulting delves into health plan prior authorization practices.
  • The Wall Street Journal reports that “Some hospitals that spent big on nurses during the pandemic are now short on cash; Distressed institutions are closing unprofitable services, selling assets to avoid default on debts.” Ruh-roh!
  • Forbes reports
    • “Rite Aid reported a quarterly loss of more than $306 million as the drugstore chain grapples with the loss of customers from its Elixir pharmacy benefits business as executives work to turn around the struggling drugstore chain.
    • “Rite Aid, which has closed more than 140 unprofitable stores in the last two years, reported a fiscal first-quarter loss of $306.7 million, or $5.56 per share, for the period ended June 3, 2023. That compares with a loss of $110.2 million, or $2.03 per share, in last year’s first quarter.”

From the fraud, waste, and abuse front, HealthTech explains how the Justice Department is using advanced analytics to combat healthcare fraud.

From the medical research front, the National Institutes of Health announced that “The first clinical trial of a three-month TB treatment regimen is closing enrollment because of a high rate of unfavorable outcomes with the investigational course of treatment.” The FEHBlog appreciates NIH’s transparency.

Monday Roundup

David Ermer–CMS, Congress, FDA, Federal employment benefits, Mental health care, Rx coverage, U.S. Healthcare–
Photo by Sven Read on Unsplash

From Washington, DC —

  • The House of Representatives and the Senate remain on a District / State work break until next week. Of course, tomorrow is a federal holiday even for Congress as our Nation celebrates its 247th birthday.
  • Roll Call reports that the House Republican leadership is already
    • “discussing the possibility of putting a stopgap spending bill on the floor as soon as this month as a fail-safe option while they try to build support for passing fiscal 2024 appropriations bills that appear on shaky ground.
    • “The idea, according to one person familiar with the conversations, is to have a stopgap in place to continue government funding past Sept. 30 in the event all the regular appropriations bills are not passed by the end of the fiscal year. That move would avoid a partial government shutdown in October if the Senate also passed the stopgap and President Joe Biden signed it into law.”
  • The Food and Drug Administration (FDA) is expected to decide this week whether or not to accept its advisory committee’s recent unanimous decision to give full marketing approval to Eisai / Biogen’s Leqembi. If that approval is given, the Centers for Medicare and Medicaid Services plans to provide Medicare Part B coverage for the drug based on the following prerequisites identified by Pharmacy Practice News
    • “To receive benefits for lecanemab-irmb [marketed as Leqembi], a Medicare patient must be:
    • “1. enrolled in Medicare Part B;
    • “2. diagnosed with mild cognitive impairment or early dementia caused by Alzheimber’s Disease;
    • “3. have an appropriate clinical team and follow-up care;
    • “4. meet any label requirements the FDA specifies; and
    • “5. be attended by a qualified physician participating in a registry that collects evidence about the drug’s performance.
  • “CMS will offer a nationally available online portal where clinicians can submit data via an “easy-to-use” format, the agency said. This kind of registry, which has been used after regular approval of other drugs, is critical for researchers to better understand the benefits and risks of this new class of drugs.”
  • The intravenously delivered drugs is retail priced at $26,500 annually.
  • The Washington Post and NPR offer lengthy articles on this development that are worth reading.
    • From NPR:
    • “The first drug shown to slow down Alzheimer’s disease is likely to receive full approval from the Food and Drug Administration by July 6.
    • “In theory, the move would make lecanemab (Leqembi) available to more than a million Medicare patients in the early stages of Alzheimer’s. In practice, though, the number is likely to be much smaller.
    • “I’d be surprised if right away we saw demand from that many people,” saysDr. David Rind, chief medical officer of the Institute for Clinical and Economic Review. The number could be in the hundreds of thousands, though, he says.
    • “Lecanemab’s rollout could be slowed by factors ranging from the extra paperwork required of doctors to a shortage of medical personnel trained to diagnose and treat patients, experts say.”
  • MedPage Today emphasizes the importance of cognitive assessments in the rollout of this new drug.
    • “Clinical trials show that lecanemab can be highly effective in clearing the brain of amyloids, the plaque-like substance closely associated with Alzheimer’s. Physicians must confirm the presence of amyloid beta pathology before starting treatment.
    • “Reducing amyloids in individuals who have advanced symptoms, however, is pointless. The amyloids need to be cleared before they can ravage the brain, which puts greater emphasis on cognitive screening to find individuals most at risk.”
  • In related news, Medscape tells us
    • “Roche has received US Food and Drug Administration (FDA) 510(k) clearance for additional cerebrospinal fluid (CSF) assays for Alzheimer’s disease (AD), supporting timely diagnosis and treatment decision-making.
    • “The Elecsys beta-amyloid (1-42) CSF II (Abeta42) and Elecsys total-tau CSF assays (tTau) (used as a tTau/Abeta42 ratio) are for use in adults ages 55 and older being evaluated for AD.
    • “They join the Elecsys beta-amyloid (1-42) CSF II (Abeta42) and Elecsys phospho-tau (181P) CSF (pTau181) assays (used as a pTau181/Abeta42 ratio) that received FDA 510(k) clearance in 2022, as reported previously by Medscape Medical News.
    • “An early and accurate diagnosis can help patients, caregivers and physicians determine a path forward, and the Elecsys CSF assays support diagnosis at early disease stages, when treatment is most effective,” Brad Moore, president and CEO of Roche Diagnostics North America, said in a statement.
    • “Appropriate use recommendations for new and emerging AD drugs call for confirmation of amyloid pathology. Currently, the only FDA-cleared methods to confirm amyloid pathology are CSF tests and PET scans.”

In other FDA news,

  • Medscape informs us
    • “The US Food and Drug Administration (FDA) has approved Suflave, a new low-volume, lemon-lime flavored liquid osmotic laxative for colonoscopy preparation in adults, the manufacturer, Sebela Pharmaceuticals, has announced.
    • “Suflave comes in a carton containing two bottles and two flavor packets. Each bottle contains 178.7 g polyethylene glycol 3350, 7.3 g sodium sulfate, 1.12 g potassium chloride, 0.9 g magnesium sulfate, and 0.5 g sodium chloride. One bottle and one flavor packet are equivalent to one dose.
    • “Administration of both doses is required for complete preparation for colonoscopy. After each dose, an additional 16 ounces of water must be consumed. 
    • “In a clinical trial, 94% of patients achieved successful bowel cleansing with Suflave, the company said in a news release. 

In Rx coverage news —

  • Reuters brings us up to date on the Humira biosimilars that charged out of the starting gate on July 1.

In public health news —

  • HHS’s Health Resources and Services Administration published in the Federal Register
    • “the first of two notices planned for the coming months informing the public of the availability of the complete lists of all geographic areas, population groups, and facilities designated as primary medical care, dental health, and mental health professional shortage areas (HPSAs). This notice includes the lists of HPSAs in a designated status as of April 28, 2023. The lists are available on the shortage area topic page on HRSA’s data.hrsa.gov website * * *.”
  • The Journal of the American Medical Association published an original investigative report on “Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States.”

From the mental health front, NPR offers a step-by-step guide to finding a therapist “taking both your mental health needs and your budget into account.”

From the federal employee benefits front,

  • FedWeek shares last-minute checks for federal and postal annuitants.
    • “Are you enrolled in the Federal Employee Health Benefits (FEHB)program? Most employees are. If you are one of them and are planning to retire, you need to be aware of the 5-year rule. To carry your FEHB coverage into retirement, you must have been enrolled in the program for 5 consecutive years before you retire or from your first opportunity to enroll (note: there is an exception for those retiring with an early retirement offer). If you meet the requirement, your coverage will continue, and your premiums will be the same as they were when you were an employee.
    • “If you retire but haven’t met that retirement, you’ll be given 31 days of coverage at no cost to you. After that, you’ll have the option of continuing in that plan (or another plan of your choice) under the Temporary Continuation of Coverage (TCC) provision for up to 18 months. If you choose to do that, you’ll pay 100 percent of the premiums plus 2 percent to cover the administration cost incurred by your agency. When that coverage ends, you’ll need to make other arrangements for your health insurance.”

Midweek Update

David Ermer–Congress, FDA, OPM, Rx coverage, U.S. Healthcare–
Photo by Manasvita S on Unsplash

From Washington, DC —

  • Federal News Network tells us
    • “Almost 33,000 federal civilian employees are a step closer to a bigger pay raise in 2024 after the Office of Personnel Management published a proposal to establish four new locality pay areas for the General Schedule.
    • “OPM’s proposed rule, added to the Federal Register Wednesday, comes after the President’s Pay Agent in December approved recommendations from the Federal Salary Council to establish the four new locality pay areas.
    • “The four new proposed locality pay areas are:
      • Fresno-Madera-Hanford, California
      • Reno-Fernley, Nevada
      • Rochester-Batavia-Seneca Falls, New York
      • Spokane-Spokane Valley-Coeur d’Alene, Washington-Idaho.”
  • The Congressional Budget Office released its 2023 Long-Term Budget Outlook. In short,
    • “The U.S. faces a challenging fiscal outlook in the coming years, according to CBO’s projections. Measured as a percentage of GDP, large and sustained deficits lead to high and rising federal debt that exceeds any previously recorded level.”
  • Roll Call adds
    • “This month’s law suspending the debt ceiling and capping appropriations has lowered projected spending, deficits and debt over the long haul, the Congressional Budget Office said in its latest long-term budget outlook.
    • Compared to the agency’s report issued last year, overall spending and deficits are higher over the next several years in the updated forecast released Wednesday. But in part because of the spending caps in the debt limit law, estimated spending in the latter part of the 30-year projection period will be lower than the agency estimated last summer.”
  • The Justice Department announced,
    • “The Justice Department, together with federal and state law enforcement partners, announced today a strategically coordinated, two-week nationwide law enforcement action that resulted in criminal charges against 78 defendants for their alleged participation in health care fraud and opioid abuse schemes that included over $2.5 billion in alleged fraud.
    • “The defendants allegedly defrauded programs entrusted for the care of the elderly and disabled, and, in some cases, used the proceeds of the schemes to purchase luxury items, including exotic automobiles, jewelry, and yachts. In connection with the enforcement action, the Department seized or restrained millions of dollars in cash, automobiles, and real estate.  * * *
    • “Health care fraud is a complex and ever-evolving threat that negatively impacts the American people,” said Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division. “Today’s nationwide coordinated law enforcement action is a testament to the tenacity of the FBI and our partners, as well as our combined efforts to pursue anyone who conspires to exploit our health care system for financial gain.”

From the public health front —

  • Beckers Payer Issues informs us,
    • “UnitedHealthcare executives recently warned of rising healthcare utilization rates as they saw a higher-than-expected number of hip replacements, knee surgeries and other elective procedures. Analysts from UBS Group AG are suggesting that pickleball could be one factor driving the higher rate of injuries, Bloomberg reported June 26. “UnitedHealthcare executives recently warned of rising healthcare utilization rates as they saw a higher-than-expected number of hip replacements, knee surgeries and other elective procedures. Analysts from UBS Group AG are suggesting that pickleball could be one factor driving the higher rate of injuries, Bloomberg reported June 26. 
    • “The firm estimates that there could be between $250 million and $500 million in medical costs attributable to pickleball injuries this year, according to the report. Analysts said that the number of pickleball players is expected to grow by 150 percent this year  to 22.3 million. They estimate about a third of the core players who play at least eight times per year are older adults.   
    • “The analysts looked at two studies regarding pickleball injuries and concluded that players go to the emergency department at a rate of about 0.27 percent, with the majority of injuries occurring among those 60 and older, according to the report. The most common injuries are strains, sprains, and fractures. The wrist and lower legs are the most likely areas to be injured. “

From the Rx coverage front —

  • The Wall Street Journal features an article titled “Ozempic Can Make You Thin, Not Necessarily Healthy; Diet and exercise still matter when you take drugs for weight loss, and not only for the reasons you expect.”
    • “For those taking these drugs, exercise is still vital to keep your heart healthy and muscles strong. Exercise lowers your risk of cardiovascular disease, cancer, Type 2 diabetes and Alzheimer’s disease, according to scientific studies. And strength-training is especially important when you lose a lot of weight quickly.
    • “People taking these drugs to lose weight also need the right foods to provide nutrients, fuel their body and keep them healthy. This approach isn’t just about eating better. It’s about eating a specific diet tailored to these drugs. If you don’t, that could lead to health problems down the road or exacerbate side effects.” 
  • STAT News reports offers a new perspective on the country’s shortage of cancer drugs, which is a big bowl of wrong.
    • “A young girl, maybe 5 or 6 years old, had come into Yoram Unguru’s clinic with acute lymphoblastic leukemia, the most common of all childhood cancers. One of the drugs needed for treatment was methotrexate. The only problem was that the drug was in short supply.
    • “Oftentimes we can cure kids of their disease, but we can’t do that without the drugs,” said Unguru, a pediatric hematologist oncologist at Children’s Hospital at Sinai in Baltimore and the Johns Hopkins School of Medicine. “It’s just so, so maddening.” * * *
    • “Methotrexate isn’t the only essential chemotherapy clinicians are having a hard time getting their hands on right now. Two other key chemotherapies, cisplatin and carboplatin, which are also generic injectable drugs, have been in shortage for the last few months. But Unguru didn’t see this particular patient recently or even in the last year. He saw her over a decade ago, when the country was facing a different methotrexate shortage back in 2012.
    • “For me, it was my first real world encounter with shortages. That was back when more of this was darker, and I had more of it on my head,” he said, gesturing to his graying beard. * * *
    • “Since then, he’s dealt with countless drug shortages in not only essential cancer medicines but many crucial generic drugs including injectables and antibiotics — nearly all of which have been around and off patent for decades. At any given time, there are dozens or hundreds of generic drugs on the Food and Drug Administration’s shortage list.
    • “These shortages are really omnipresent. In the modern era, it’s not even the new normal. It’s the normal. From 2011, they have really never gone away,” Unguru said. “It’s like Groundhog Day.”
    • “The underlying problem for this hasn’t really changed either — which is that the economics of the generic drug market drive hospitals and producers to emphasize low prices and profits rather than the reliability of the drug supply. The worst part, Unguru said, is that “these shortages are preventable. They’re absolutely preventable.”
  • Reuters relates,
    • “The U.S. Food and Drug Administration has approved Pfizer Inc’s (PFE.N) drug to treat hair loss caused by an autoimmune disease, the company said on Friday [June 23].
    • “The drug, branded as Litfulo, has been approved for people aged 12 years and older suffering from severe alopecia areata (AA), a condition where the immune system attacks hair follicles and causes hair to fall out, often in clumps.
    • “The FDA’s decision makes Litfulo the first to be allowed for the treatment of the condition in adolescents.”
  • Fierce Healthcare points out,
    • “Pharmacy benefit managers and their role in the drug supply chain have been under the microscope, and a new playbook aims to arm employers with strategies to strengthen their negotiating power.
    • “The guide, released by the National Alliance of Healthcare Purchaser Coalitions, identifies several key strategic recommendations that employers can adopt when looking to better navigate their relationship with PBMs.”

From the U.S. healthcare business front —

  • Healthcare Dive reports
    • “In May, the median year-to-date operating margin index for hospitals hit 0.3%, marking the third consecutive month of positive performance, according to a new hospital report from Kaufman Hall.
    • “Hospitals’ financial stabilization is attributable in part to patients’ increased utilization of outpatient hospital services and decreased labor costs, the consultancy found.
    • “To keep the positive momentum, hospitals should pay attention to the trend toward outpatient services, Erik Swanson, Kaufman Hall SVP of data and analytics, said in a statement, calling the shift “particularly important.”
  • Benefits Pro notes
    • “Increased investment in urgent care centers is needed as health care delivery models change and patients with non-life-threatening conditions opt for ease of access, according to a recent analysis by Colliers.
    • “The analysis notes several data points to back up its message. The Urgent Care Association found that since 2019 patient volume has spiked by 60%, while Data Bridge Market Research has predicted a compound annual growth rate of 5.35% between 2022 and 2029.”
  • STAT News explains why “After a late start, Eli Lilly has the momentum in battle for $30 billion weight loss market.”
    • “It was Novo Nordisk’s Ozempic and Wegovy that set off a new era in obesity medicine, delivering unprecedented levels of weight loss and working its way into popular culture, inescapable ads, and hundreds of thousands of medicine cabinets.
    • “But Eli Lilly has been following close behind with new treatments, and after dropping result after result from successful trials at the American Diabetes Association conference here this past weekend, the Indianapolis-based drugmaker looks to be gaining an edge over its Danish competitor in the race to supply obesity drugs.”