Weekend Update

Uncategorized

Weekend Update

David Ermer–Congress, COVID-19, OPM–

The House and the Senate will be in session this coming week working on a third COVID-19 relief bill. The House returns from a district work week on Tuesday while the Senate cancelled its state work week which had been scheduled for this week.

On the COVID-19 front —

  • OPM posted more COVID-19 emergency related guidance for federal agencies on Friday.
  • The Wall Street Journal explains the current lockdown rules in New York, California, Illinois, and several other states. The California rule cross references to this Department of Homeland Security guidance on essential critical infrastructure workforce. While the guidance is advisory, the FEHBlog finds it significant that the list of “workers who conduct a range of operations and services that are essential to continued critical infrastructure viability” includes “Workers that manage health plans, billing, and health information, who practically work remotely” and “Workers performing cybersecurity functions at healthcare and public health facilities, who cannot practically work remotely.”
  • On Saturday, the Food and Drug Administration issued the first emergency use authorization for a point-of-care COVID-19 diagnostic for the Cepheid Xpert Xpress SARS-CoV-2 test. ” “The test we’re authorizing today will be able to provide Americans with results within hours, rather than days like the existing tests, and the company plans to roll it out by March 30 [a week from today],” explained HHS Secretary Alex Azar. The COVID-19 diagnosis rate will increase more rapidly now that we continue to expand the availability of COVID-19 testing. The Vice President noted on Saturday that 195,000 Americans have been tested so far.
  • The Wall Street Journal informs us about how to avoid COVID-19 misinformation. It’s worth reading.

Midweek Update

David Ermer–AHRQ, COVID-19, OPM, Uncategorized–

The Office of Personnel Management issued a guidance letter to FEHB carriers on the COVID-19 virus today.

The Internal Revenue Service today issued a Notice 2020-15 which permits high deductible health plans used with health savings accounts (under Internal Revenue Code Section 223) to cover COVID-19 testing on a first dollar basis. To its credit, OPM references the IRS notice in the above linked carrier letter.

The U.S. Labor Department also issued FAQ guidance on COVID-19 or Other Public Health Emergencies and the Family and Medical Leave Act.

As noted on Monday, this is Patient Safety Awareness week. The patient safety organization ECRI Institute released a list of top 10 patient safety concerns. The Safety Week’s key sponsor HHS’s Agency for Healthcare Quality and Research issued

Making Healthcare Safer III, a comprehensive report whose pages are filled with practical information on how today’s clinicians can keep patients free from harm.

The report reviews roughly four dozen practices that target patient safety improvement across a variety of settings. If appropriately applied, many of these practices can dramatically reduce high-impact healthcare-related harms.

The 47 patient safety practices and evidence highlighted in the report include technological and staffing-related practices, a series of specific hygiene and disinfection interventions for reducing healthcare-associated infections, and several practices designed to prevent medication errors and reduce opioid misuse and overdoses.

Tuesday Tidbits

David Ermer–COVID-19, Electronic health records, Uncategorized–

The FEHBlog listened to the federal government’s COVID 19 press conference on the drive home from work. The Surgeon General urged listeners to visit coronavirus.gov. When the FEHBlog arrived home, he checked out the website and it turns out to be another url for the Centers for Disease Control’s COVID-19 website that he takes a peak at daily. At least the FEHBlog hasn’t been misdirecting readers. Here is today’s COVID-19 scorecard:

Travel-related83
Person-to-person spread36
Under Investigation528
Total cases647

The FEHBlog learned late this afternoon that COVID-19 concerns have caused OPM and AHIP to cancel the annual FEHBP carrier conference which was scheduled to run from April 1 to April 3 in lovely Crystal City Virginia. The FEHBlog while disappointed understands the decision because the event jams hundreds of people together in one hotel ballroom.

Yesterday’s Health and Human Services rules on electronic health record (“EHR”) interoperability and data blocking gave a big boost to HL7’s FHIR specification. “FHIR (Fast Healthcare Interoperability Resources) Specification is a standard for exchanging healthcare information electronically.” The FEHBlog was excited to hear about the FHIR specification early last year because it appeared to be a solution to the nagging EHR interoperability problem. HHS appears to have jumped into the FHIR specification pool with both feet.

This morning the FEHBlog listened to a HIMSS webinar on FHIR accelerators. The four HL7-designated FHIR accelerators are leading the FHIR charge to solve interoperability problems in different spheres:

  • The DaVinci Project is focused using FHIR to fix healthcare business to business exchange issues.
  • The Carin Alliance is focused on using FHIR to fix healthcare business to consumer exchange issues.
  • CodeX is focused on using FHIR to share clinical trial appropriate data found in EHRs with researchers in an effort to find cancer cures.
  • The Gravity Project is focused on sharing social determinant of health data found in EHRs with healthcare businesses for care coordination and SDOH benefit purposes.

Good luck to them all.

Monday Musings

David Ermer–CDC, Congress, SCOTUS, Uncategorized–

The FEHBlog got to work this morning around 8:30 am. Before he knew it, it was past 9:30 am, the time at which the Supreme Court releases online its orders from the latest conference of the Justices. He clicked on the Adobe Acrobat PDF link to the Court’s order list — no go. Bad PDF. He tried different browsers — same result. Twitter ho and there it was “blue State victory” the Supreme Court had agreed to review the Texas v. U.S. case holding the ACA’s individual mandate unconstitutional. The political comment did not make sense to the FEHBlog because only four Justices need to approve a petition for certiorari / review and there are four Democrat appointees on the Court. However, you need five Justices for a final victory. In any event by then the FEHBlog was able to open the Court’s order list and he found the following on page 3:

CERTIORARI GRANTED

19-840 CALIFORNIA, ET AL. V. TEXAS, ET AL.

19-1019 TEXAS, ET AL. V. CALIFORNIA, ET AL.
The motion of 33 State Hospital Associations for leave to file a brief as amici curiae in No. 19-840 is granted. The petitions for writs of certiorari are granted. The cases are consolidated, and a total of one hour is allotted for oral argument.

Case No. 19-1019??!! The FEHBlog was aware of the unmentioned Case No. 19-841 which is the House of Representative’s cert. petition. But what is Case No. 19-1019? It turns out that on Valentine’s Day the red states had filed a cross motion for review / cert with the Supreme Court. So it appears that both sides won at the first stage of the Supreme Court proceedings.

The Supreme Court will hear oral argument in the cases early in its next Term which begins on the first Monday in October 2020. There is no way the Court will decide the case before the Presidential election day on November 3. Hopefully, to avoid a political kerfuffle at the oral argument, the Court will schedule the argument for later in November.

Meanwhile the federal district court for the Northern District of Texas will hold off reconsidering the unconstitutional individual mandate’s proper degree of severance from the remainder of the massive law. The Fifth Circuit in its December order vacated the lower court’s initial decision that the remainder of the law was inseparable and therefore equally unconstitutional. The FEHBlog’s guess is that the Supreme Court took the case in order to short circuit that remand. But time will tell.

In another surprise, the FEHBlog learned along with the healthcare world today that President Trump will speak on the issue of electronic health record interoperability at the next Monday’s opening day of the monstrous HIMSS conference in Orlando, Florida. Health IT News reports that while former Presidents Clinton and Bush 43 have spoken at this conference, President Trump’s appearance will be the first by a sitting President.

Trump’s speech will touch on various aspects of interoperability, innovation and digital health. If past HIMSS conferences are any indication, his appearance may also be timed with the long-awaited final rules on information blocking and patient access from the Office of the National Coordinator for Health IT.

Another probable topic of discussion will be an update on the Trump Administration’s ongoing response to the COVID-19 coronavirus outbreak.

Again time will tell.

Medicare provides coverage for Americans under age 65 with end stage renal / kidney disease for Americans. However,

Medicare is the secondary payer to group health plans (GHPs) [including FEHB plan] for individuals entitled to Medicare based on ESRD for a coordination period of 30 months regardless of the number of employees and whether the coverage is based on current employment status.  Medicare is secondary to GHP coverage provided through the Consolidated Omnibus Budget Reconciliation Act (COBRA), or a retirement plan.

Given the FEHBP’s role in the early stages of this serious disease, the FEHBlog wanted to point out this Centers for Disease Control page on understanding chronic kidney disease. End stage renal disease is a later stage of chronic kidney disease. The CDC explains that

The two main causes of CKD are diabetes and high blood pressure. About 1 in 3 adults with diabetes and 1 in 5 adults with high blood pressure have CKD.

People may not feel sick or notice any symptoms until CKD is advanced. The only way people find out if they have CKD is through simple blood and urine tests. The blood test checks for creatinine (a waste product) in the blood to see how well the kidneys work. The urine test checks for protein in the urine (an early sign of kidney damage).

Here’s another reason why annual physical exams are important.

Monday Musings

David Ermer–Federal employment benefits, SCOTUS, Uncategorized–

Today’s U.S. Supreme Court order list from its February 21 conference made no mention of the Texas v. U.S. cases (Nos. 19-840 and 19-841) concerning the Affordable Care Act’s constitutionality, one way or the other. This means that the Court will take up (or continue consideration of) the cases at a later conference. At this stage the Court is deciding whether to review the Fifth Circuit’s decision now or wait for further proceedings in the lower courts. The Court’s docket sheet states that the cases have been re-distributed for the February 28, 2020, conference.

The Federal Employees Dental and Vision Programs’ (“FEDVIP”) laws requires OPM to bid out all of the FEDVIP contracts every seven years. Currently OPM has contracted for 10 FEDVIP dental plans and four FEDVIP vision plans. Last week, OPM released its request for proposals for the next seven year FEDVIP contract cycle which begins on January 1, 2021. OPM states in the RFP document that it has capped the upper limit of dental plans at 12 and vision plans at 5. The deadline for submission of proposals is March 23, 2020. OPM expects to announce the successful contractors in May.

The Washington Post reports that the focal point of the national drug overdose crisis has shifted to the California and other western states. The drugs causing overdose deaths are principally two illicit drugs — fentanyl and methamphetamine.

In California, fatal drug overdoses over the previous 12 months increased 13.4 percent between July 2018 and July 2019, the last month for which the CDC has compiled provisional data — an additional 728 deaths.

Fentanyl delivers an immediate, powerful high but can also render the user unconscious and unbreathing almost instantly. * * * [San Francisco based harm reduction worker Kristen Marshall] noted that thousands of overdoses have been reversed by peers on the street who were supplied with naloxone as part of harm reduction efforts. For many years, San Francisco saw a growing population of drug users but had a strikingly low rate of fatal overdoses. But that was before fentanyl showed up.

In contrast, Illinois’ fatal drug deaths were down 8 percent, Pennsylvania’s down 10 percent, Michigan’s down 13 percent and Maine’s down 20 percent.

Weekend update

David Ermer–CDC, Congress, Rx coverage, Uncategorized–

Congress is back at work on Capitol Hill this week. The FEHBlog did find an easy to read list of upcoming Congressional hearings on Congress.gov. The FEHBlog did not find any hearing relevant to the FEHBP coming up.

The FEHBlog is following news about the COVID-19 epidemic. The Wall Street Journal reports that the number of cases outside China is growing particularly in South Korea (602 cases) and Italy (155 cases). There are 34 cases in the U.S. In a Centers for Disease Control conference with the press last Friday, Dr. Nancy Messonnier explained that

We are making our case counts in two tables.  One only tracks people who were repatriated by the state department, and the second tracks all other cases picked up through U.S. public health network.  CDC will continue to update these numbers every Monday, Wednesday, and Friday.  We are keeping track of cases resulting from repatriation efforts separately because we don’t believe those numbers accurately represent the picture of what is happening in the community in the united states at this time.  As of this morning, when you break things up this way, we have 13 U.S. cases versus 21 cases among people who were repatriated [here].  The repatriated cases include 18 passengers from the “diamond princess” and three from the Wuhan [China] repatriation flights

The Wall Street Journal confirms the growing trend of large health insurers to offer their own primary care delivery services to their health plan members [previously documented by the FEHBlog].

“It’s very worrisome for hospitals,” said Chas Roades, a health-care consultant. “Suddenly, the plan you’re relying on for payment is also competing with you at the front end of the delivery system.”

Hospitals’ biggest concern may be the power that primary-care doctors have over where their patients go for care such as imaging scans and specialist procedures. Hospitals rely on doctors to direct patients to them for such services—one reason they have bought up physician practices. Insurer-owned clinics might refer patients away from certain hospital systems, cutting off important revenue. 

The FEHBlog in contrast is delighted with this trend which will hold down costs while improving health care quality. Competition itself is healthy. “’Health care has got to be more seamless and more integrated,” said Rob Falkenberg, chief executive of UnitedHealthcare’s California operation.” Agreed.

Fierce Healthcare reports that Oscar Health has creating a $3 per prescription formulary of about 100 popular prescription drugs and insulin. The formulary went into effect on January 1, 2020 for about half of Oscar’s health plan members. The other half if covered by Medicare or live in certain states like New York which have not approved the formulary. The article explains that

Oscar was able to price the drugs so low through plan design.“The price we pay to acquire the drug for our members has not changed,” [Oscar spokesperson Jackie] Kahn said. “Instead, we chose to have our members pay $3 and we are covering the rest.”

Midweek Update

David Ermer–OPM, Uncategorized–

Thanks to a Govexec.com article, the FEHBlog ran across the joint General Services Administration / Office of Personnel Management Fiscal Year 2021 budget justification for the benefit of our Congress. OPM’s FEHBP discussion may be found on pages 69-70 and its FEHBA legislative proposals may be found on 30 of the OPM section of the document. The OPM Inspector General budget discussion begins on page IG-24 of the document. The FEHBlog is waiting for OPM to release the revised FEHBA language for its FEHBA legislative proposal, which is a retread from the FY 2020 budget proposal. (No such detailed language was released last year.)

Federal News Network reports that “an estimated 200,000 military family members and retirees would lose their ability to get health care through military hospitals and clinics under a ‘rightsizing’ plan the Defense Department sent to Congress on Wednesday.” The details may be found in this plan document. This proposal if implemented would impact the FEHB because many military retirees are active federal employees / FEHB enrollees. Thank you veterans for your double service to our Country. The FEHBlog will keep an eye on this one too.

Finally, Healthcare Dive calls attention to a new trend:

  • Private equity firms acquired 355 physician practices from 2013 to 2016, accounting for a total of 1,426 sites of care and more than 5,700 physicians, according to the latest research in JAMA.
  • Acquisitions accelerated each year over that time period, from just 59 acquisitions in 2013 to 136 in 2016.
  • Off the 355 acquisitions, the most targeted area was anesthesiology with 69 practices acquired, followed by emergency physicians at 43, the report published Tuesday showed.

As noted in the article, these investors in turn are pressing for surprise billing proposals that would keep out of network practices profitable.

Monday Musings

David Ermer–CDC, Congress, Medicare, Uncategorized–

Federal News Network offers a useful report on the President’s Fiscal Year 2021 budget priorities for the federal workforce. Particularly in an election year, the President’s budget proposal is principally a political document. Now let Congress do its job.

Coordinating benefits when group health plan members have coverage under more than one plan is complicated. Nothing is more complicated than coordinating group health plan benefits with Medicare, and FEHB plans have to do a lot of this work due to the large number of Medicare eligible annuitant members, some of whom remain employed while most are retired. The FEHBlog could go on and on. See Section 9 of your plan brochure.

About ten years ago, Congress passed a law colloquially known as Section 111 which requires group health plans, among others, to report demographic information to the Centers for Medicare and Medicaid Services (“CMS”) in order to facilitate coordination of benefits. Now in its infinite wisdom CMS has decided to move forward with a proposed rule to impose civil monetary penalties on Section 111 reporting entities, including FEHB plans, for certain Section 111 errors. More details are available in this CMS fact sheet.

Bear in mind that larger FEHB plans in particular are under OPM Inspector General scrutiny for the accuracy of their Medicare coordination of benefits efforts. Moreover, the carriers, not the federal government, are on the risk for the FEHBP coverage. In short, Medicare coordination of benefits creates enough headaches for FEHBP carriers without the added risk of civil monetary penalties. How about a little comity between CMS and OPM? (E.g. Because OPM does not seek to penalize CMS for its COB goofs, CMS should not penalize FEHBP for their COB goofs.) The public comment deadline on the proposed CMS rule is April 20.

In a bit of hopeful news, Health Payer Intelligence discusses a successful Horizon New Jersey Blue Cross initiative to apply value based pricing to pediatricians. “If value-based care in pediatric healthcare truly is the future of value-based care, payers need to leverage strong provider relationships to establish effective pediatric quality measures in order to improve their pediatric value-based care performance, Horizon’s executive vice president for healthcare management and transformation Allen Karp illuminated.” Yes indeed.

Finally, on the disease front, HHS reports that

U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis [an extremely dangerous infection] over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion according to an unprecedented study by researchers from the U.S. Department of Health and Human Services.

Researchers determined that the increase in sepsis was not due to the growing number of American seniors enrolling in Medicare. From 2012 through 2018, the U.S. saw a 22 percent increase in the Medicare enrollment rates but a 40 percent increase in the rate of sepsis-related hospital admissions among beneficiaries.

Most patients with sepsis arrived at the hospital with the condition, rather than developing sepsis in the hospital, a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis. However, two-thirds of these sepsis patients had a medical encounter in the week prior to hospitalization. This finding represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.

Let’s get going with those efforts.

Also the FEHBlog learned that the Centers for Disease Control has issued interim guidance on COVID-19 for businesses and employers which also is probably good advice for controlling the flu. The FEHBlog appreciates the CDC’s work as should we all.

Mount Rushmore

Presidents’ Day Weekend Update

David Ermer–Uncategorized–

Congress is out of town this coming week following the Presidents’ Day holiday.

Healthcare Dive provides a helpful review of large publicly traded health insurer fourth quarter 2019 financial results. “Every major payer reported an uptick in their medical cost ratios and many boasted of increased enrollment.”

The FEHBlog admires Kaiser Health News for its sensible approach to reporting on the COVID-19 epidemic in China. The Wall Street Journal’s numbers column yesterday provided interesting insights into calculating the contagion factor of diseases, known as R naught, and in particular COVID-19. Kaiser Health News points out that

It’s not surprising that mortality rates [# of deaths / # of infections] for the coronavirus [COVID-19} vary dramatically, based on where diagnoses were made, Schaffner said. For example, a report Monday from the Imperial College of London found a mortality rate of 18% for cases detected in Hubei, where only patients with unusual pneumonia or severe breathing problems were being tested for the virus. Outside China, health officials test anyone with a cough and fever who has visited Hubei — a much larger number — producing a mortality rate of 1.2% to 5.6%.

In personnel news

  • The Federal Times reports that U.S. Office of Management and Budget Deputy Director Margaret Weichert will return to the private sector [in mid-March] to work as the managing director of commercial practice for Accenture. Deputy Director Weichert contemporaneously served as acting OPM director for around 18 months of her 30 months at OMB.
  • Fierce Healthcare reports on leadership changes at Cigna’s Express Scripts prescription benefit manager unit.
  • Drugstore News reports on leadership changes at CVS Health’s Caremark prescription benefit manager unit.

Good luck to them all.

TGIF

David Ermer–Uncategorized–

The Health Care Cost Institute has released its 2018 healthcare cost and utilization report.

Average employer-sponsored insurance (ESI) spending rose to $5,892 per person in 2018, according to the Health Care Cost Institute’s annual Health Care Cost and Utilization Report, which analyzes 2.5 billion medical claims to inform the public about trends affecting approximately 160 million U.S. individuals with employer-sponsored insurance. This spending growth outpaced 2017’s growth due to continued price growth combined with an uptick in utilization.

“Prices, spending, and out-of-pocket costs continue to rise for the 160 million Americans with employer-sponsored health insurance,” said Niall Brennan, president and CEO of HCCI. “Higher prices for medical services continue to drive most spending increases, but in 2018 we also saw an uptick in utilization for the first time in several years. If these price and utilization trends continue, we expect spending growth to stay on an upward trajectory in the coming years.”

Despite recent increases in utilization, rising prices were the primary driver of spending growth over the 5-year study period. After adjusting for inflation, spending rose by $610 per person between 2014 and 2018. “Higher prices for medical services were responsible for about three-quarters of overall spending increases between 2014 and 2018, after inflation,” said Jean Fuglesten Biniek, report co-author and senior researcher at HCCI.

Shocker. (-;

Becker’s Hospital Review lists the 20 most expensive prescription drugs in our country according to the prescription drug discounter, Good Rx. Topping the list is “Amryt Pharma’s drug, Myalept, used to treat lipodystrophy, with a list price of $71,206 per month.” The Children’s Hospital of Philadephia explains that

Lipodystrophy is a rare disorder that affects how the body stores and uses fat. Children with lipodystrophy may have little or no body fat. Instead, fat builds up in places it shouldn’t, like the blood and internal organs. This can lead to diabetes and other health problems.

Lipodystrophy can be inherited, which means the condition is passed down from the parents and it can develop at any time in life. Lipodystrophy can also be acquired without a known genetic cause.

Three medical directors of major health plans have explained in the Washington Examiner why heath plan prior authorization practices are smart medicine. They don’t have to convince the FEHBlog but their article may be helpful to health plans in rebutting physician complaints.