Fedsmith reports that OPM has announced that this year’s Federal Benefits Open Season will take place from Monday November 11 through Monday December 9, 2019.  This is time when federal and postal employees and annuitants can make changes to their FEHBP and FEDVIP coverage for 2020 and employees can enroll for a flexible spending account (FSAFeds) for 2020.

“Willis Towers Watson’s Rx Collaborative, an employer-based pharmacy benefit group purchasing coalition, disclosed in a statement to HR Dive that 40% of its total drug costs were spent on specialty drugs that accounted for less than 1% of its prescriptions in 2018. It also noted that the top 10 drugs by cost made up a fifth of its pharmacy spend that year. * * * The coalition reported a steady decrease in drug price inflation rates over the last three years: 3.5% in 2018, 4.2% in 2017 and 6.8% in 2016.”

According to Health IT Analytics, “Sixty percent of healthcare executives are using predictive analytics within their organizations, according to a recent survey from the Society of Actuaries (SOA), and 20 percent of payers and providers plan to begin using predictive analytics within the next year.”

Health Data Management reports that “The American Academy of Family Physicians and Health Level Seven International are teaming on a new project to improve the interoperability of social determinants of health data.The Gravity Project, part of HL7’s program to accelerate the adoption of its Fast Healthcare Interoperability Resources (FHIR), is meant to standardize medical codes to support the use of SDOH-related data in patient care, care coordination, population health management, value-based payment as well as clinical research.”

Finally Prof. Timothy Jost offers his overview of current Affordable Care Act litigation.  The FEHBlog finds it interesting that while litigation opposing the Trump Administration’s association health plan and short term limited duration health plan initiatives, no litigation has arisen as yet opposing the Trump Administration’s more recent individual coverage health reimbursement arrangement initiative. The ACA regulators have estimated that once employer become familiar with this rule, 800,000 employers may take advantage of it by 2029 which would result in 11,000,000 more Americans with individual coverage.

The FEHBlog ran across two articles on successful healthcare quality improvement efforts —

• Health Payer Intelligence discusses a Geisinger data analytics effort focused on getting five Medicare Stars, and 
• Employee Benefits News features an Pacific Business Group on Health CEO’s article on a primary care focused initiative to improve quality for large employers in California.

The Office of the National Coordinator is in talks with Congress and the White House on how to regulate secondary uses of healthcare data. ONC doesn’t have statutory authority to vet third-party apps and what they do with consumer data, agency chief Don Rucker told Healthcare Dive, but the agency is looking into a variety of solutions including legislative language on privacy and security provisions or voluntary attestation standards for the apps themselves.  ‘

Experts are concerned privacy and security have been an afterthought for the agency as it continues to push interoperability into the healthcare industry. But “there’s a number of people interested on both sides of the aisle and both sides of the Hill” in addressing the issue, according to Rucker.

The FEHBlog has noted that he has enrolled in the National Institutes of Health’s All of Us program.  Fortune Magazine reports that

NIH has an official genetic counseling partner for its ambitious, million-person All of Us research program: Color, a DNA testing and genomic counseling specialist. 

The NIH announced Wednesday that Color will receive a $4.6 million grant (part of $25 million over multiple years) in order to provide what Color describes as the “technological backbone” for the All of Us project. The company is also the sole grantee selected to set up and deliver genetic counseling for Americans participating in the program. 

All of Us is an NIH initiative that was announced under former President Barack Obama. It aims to ultimately collect health and biometric data – including DNA and blood samples, lifestyle information, and environmental data – from one million Americans. The goal is to use this vast dataset in order to better understand what affects health for people of different races, genders, and geographic locations – and, in the process, help spur the development of personalized medicine.

It’s all good new tidbits today!

• The Associated Press reports

After years of frequent list price hikes, many drugmakers are showing some restraint, according to the analysis of drug prices provided by health information firm Elsevier.  In the first seven months of 2019, drugmakers raised list prices for brand-name prescription medicines by a median of 5 percent. That’s down from about 9 percent or 10 percent over those months the prior four years, the AP found. From January through July this year, there were 4,483 price hikes, down 36 percent from that stretch in 2015.

• Fierce Healthcare reports that last week the Food and Drug Administration approved an AbbVie drug that competes with the blockbuster Humira drug to treat rheumatoid arthritis.  The new product Rinvoq should be available in the U.S. by late August, AbbVie said. Rinvoq bears a list price of $59,000, which “is lower than the current leading treatments for moderate to severe rheumatoid arthritis,” an AbbVie spokeswoman said by email. 

• HHS announced the issuance of its 2018 SAMSHA National Survey on Drug Use and Health. “This year’s National Survey on Drug Use and Health contains very encouraging news: The number of Americans misusing pain relievers dropped substantially, and fewer young adults are abusing heroin and other substances,” said Health and Human Services Secretary Alex Azar. “At the same time, many challenges remain, with millions of Americans not receiving treatment they need for substance abuse and mental illness.”  This has been the FEHBlog’s point. Health plans need to focus on covering evidence based treatment for these problems

• The American Association for the Advancement of Science informs us that “The U.S. Centers for Disease Control and Prevention report on the use of antibiotics in health care settings across the United States in 2018 tell us that while progress has been made to promote appropriate use of infection-fighting drugs, strengthened and continued efforts and greater resources are needed to protect some of the most valuable medicines we have and prevent the accelerating development of illness-causing bacteria that are resistant to treatment.”

Primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutations with an appropriate brief familial risk assessment tool,” wrote the panel in the journal JAMA. “Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.”

The Peterson-Kaiser Health System Tracker has released its latest report on the rise in employee premiums and cost sharing for employees with large employer coverage.

For most of those with employer coverage, the cost of the premium is split between the employer and employee. Looking only at the health spending for which workers are responsible (their families’ premium contributions and cost-sharing payments), the average family spent $4,706 on premiums and $3,020 on cost-sharing, for a combined cost of $7,726 in 2018. This represents an 18% increase in the health costs borne by employees and their families from five years earlier ($6,571 in 2013), outpacing the 8% increase in inflation and a 12% increase in workers’ wages over the same period.

Employee Benefit News discusses the use of employer incentives to encourage their employees to price shop for healthcare services.  “These programs [such as Direct Path and Health Joy] both educate employees about the fact that they should price shop for many healthcare services, and encourage them to choose lower-cost options by putting money back in their pockets.”

Fortune’s Brain Storm newsletters discusses the healthcare companies that landed on the magazine’s annual Change the World list. Check it out.

The FEHBlog was bowled over when he read in Modern Healthcare that only this week the federal Environmental Protection Agency is “prohibiting healthcare organizations from flushing hazardous waste pharmaceuticals [like opioids] into the sewer system.” Apparently there are healthcare organizations who must come into compliance with this rule. That’s nuts.

Congress is now just about half way through its August recess.  This is the time of the year when OPM completes its benefit and rate negotiations with carriers.

The Washington Post had a lengthy front page story today on how medical debt adversely affects rural people and rural hospitals. Much of the debt arises from emergency room use according to the article but the underlying problem is that rural areas don’t have the webs of walk-in clinics and urgett care centers found in urban areas. The federal government is planning to funnel more Medicare money to rural hospitals and as noted here last week, Sen. Check Grassley has introduced a bill to permit rural hospitals to do away with inpatient beds in favor of telehealth.  It’s a serious public health problem that the Affordable Care Act does not address.

Health Payer Intelligence offers an article with examples of how health plans and insurers are moving from reactive to preventive care.  In the same vein, Fierce Healthcare discusses how

As the number of high-cost treatments continues to grow, Anthem is launching a new program in Kentucky that aims to work with providers to protect patients from “shock” bills for these therapies. Anthem has teamed up with St. Elizabeth Healthcare, one of the state’s largest providers, as the first partner in the new program. In the model, the health system will absorb part of the cost of these services, discounting them by as much as 45%. 

And NPR’s Shots provides “pro tips’ on how to stick with healthy habits.

NPR discusses efforts in the Senate to join the House of Representatives in passing a bill to repeal the ACA’s excise tax on high cost health plans a/k/a the Cadillac tax.

Health Data Management reports that Senate Health Education Labor and Pensions Committee Chairman Sen. Chuck Grassley (R IA) is promoting telehealth as a means to maintain the viability of rural hospitals.

Grassley said he—along with other senators—has reintroduced a bipartisan bill that would allow rural diabetic patients to receive regular vision screening using telemedicine.

More broadly, the Rural Emergency Acute Care Hospital (REACH) Act would create a new “rural emergency hospital” classification under Medicare. Many rural hospitals are currently designated as critical access hospitals under Medicare and as a result have to maintain a certain amount of inpatient beds and provide emergency care services 

However, the REACH Act calls for the creation of a rural emergency hospital designation under the Medicare program that would enable facilities in rural areas to provide emergency medical services without having to maintain inpatient beds. In addition to providing emergency care, rural emergency hospitals could convert the space previously used for inpatient services to provide other medical services, including telemedicine.

Last month, the FEHBlog discussed PBM efforts to create curated wellness apps for their members. CNBC reports that BlueShield of California has rolled out its own curated wellness app called Wellvolution.

[Wellvolution provides] an online portal for members to login via a mobile app or the web. Members will then beasked to answer some basic survey questions about their health goals. From there, they’ll get a recommendation for an app or a service they can use as a wellness perk. If they don’t like it, they can change it up at any time. That way, suggests [BlueShield’s Bryce]Williams, “the best tools that our members really like can rise to the top.  The insurer teamed up with a health-tech start-up called Solera Health to develop the service.

Health Payer Intelligence reports on the merger plan of two large New England non-profit health care systems, Harvard Pilgrim Health Care and Tufts Health Plans.  Subject to federal and state regulatory approval, “The [combined] company will offer plans to consumers across the spectrum of socioeconomic and demographic backgrounds, from employer-sponsored insurance and quality health plans to Medicare and Medicaid and dually eligible plans.” But not FEHBP.

Healthcare Dive discusses a New England Journal of Medicine analysis of U.S. hospital ranking programs. U.S. News and World Report received the top (but not the highest possible) grade of B. CMS’s Hospital Compare website received a C.

Healthcare Dive is reporting that “Average monthly premiums for marketplace plans nationwide are expected to increase 0.6% for 2020 coverage — the lowest increase since the launch of the Affordable Care Act plans, according to an analysis of insurer rate filings submitted to all 50 states and D.C.” The FEHBlog is glad that ACA marketplace premiums are stabilizing. It’s noteworthy that although ACA marketplace plans are subject to the resumption of the ACA’s onerous health insurer tax, the premium don’t show a big bump for that event. At this point this hefty tax has been imposed on health insurers, including insured FEHB plans, from 2014 through 2016 and 2018. FEHB premiums didn’t jump precipitously in those years due to imposition of the tax. FEHB premiums grew very slowly for this year when the tax is suspended. Will there be an FEHB premium boomerang for 2020? Time will tell. Nevertheless, the FEHBlog continues to believe that this tax and the ACA’s medical device tax are misguided.

Following up on the report of a Novartis data manipulation scandal last week, the Boston Globe’s STAT reports that

The company previously said it was “in the process of exiting” scientists who were responsible for the scandal but did not identify them. In a statement on Wednesday, Novartis (NVS) said that it had appointed a new chief scientific officer for AveXis and that other scientists, Brian and Allan Kaspar, “have not been not been involved in any operations at AveXis since early May 2019,” without elaborating.

The person familiar with the situation, who spoke on condition of anonymity, confirmed that the departure of the Kaspars, who are brothers, was connected to the disclosure of data manipulation related to the gene therapy Zolgensma.

Consumer health technology company Ciitizen reports launching a scorecard grading healthcare providers on the level of their cooperation with HIPAA’s individual right to access their medical records. Citizen explains

We plan to refresh the scorecard every few months based on the most recent record requests sent to a particular provider - so improvement and consistency in good performance can be rewarded (and consistency in poor performance can also be brought to public attention).

In conjunction with the scorecard, we also released survey of 3003 hospitals and healthcare systems who responded to anonymous questions about their record release processes. Their responses suggest that 56% of health care providers are out of compliance with one or more aspects of the HIPAA Right of Access.

Here’s a link to the HHS website that explains this individual right.  This right also is discussed in your healthcare provider or your health plan’s HIPAA notice of privacy practices.

The National Business Group on Health issued its 2020 Large Employers’ Health Care Strategy and Plan Design Survey today.

The 2020 Large Employers’ Health Care Strategy and Plan Design Survey found employers project the total cost of health benefits will rise 5% in 2020, taking cost management initiatives into account. That increase is identical to 2019’s projected increase – but actual costs are coming in lower. Large employers reported the actual increase in 2018 was 3.6%. Including premiums and out-of-pocket costs for employees and dependents, the total cost of health care is estimated to be $14,642 per employee this year, and projected to rise to an average of $15,375 in 2020.  Employers will cover nearly 70% of costs while employees will bear about 30%, or nearly $4,500.  Forty-four percent of employers ranked musculoskeletal issues as the top condition impacting their costs while 85% ranked it among the top three conditions. One in four (25%) employers ranked cancer as the top condition.  

“One of the challenges employers face in managing their health care costs is that health care is delivered locally and change is not scalable.  It’s a market-by-market effort,” said Brian Marcotte, President and CEO of the National Business Group on Health. “Employers are turning to market-specific solutions to drive meaningful changes in the health care delivery system.”

Good point.

Speaking of which, Kaiser Health News reports on 29 Hepatitis A outbreaks across the United States which often follow the path of the opioid crisis.

Dr. Monique Foster, a medical officer in CDC’s Division of Viral Hepatitis, said vaccinating those at highest risk remains the best strategy. “Outbreaks will stop when we have effectively vaccinated the vulnerable people,” she said.

Although the federal government isn’t recommending universal vaccination, several experts said the more people vaccinated, the better. 

“The risk is there. The disease is circulating,” said the University of Kentucky’s Winter. “It’s good for the general public to be vaccinated.” 

With the virus continuing its advance, Penn State’s Haeder said, “it won’t be long before we have it everywhere.”

Meanwhile according to the Wall Street Journal, the U.S. Preventive Services Task Force today “released a draft [“B” level] recommendation that doctors ask their patients about illicit drug use, including opioid painkillers, so they can be directed to treatment.” Health plans must cover with enrollee cost sharing final “A” and “B” recommendations when carried out by in-network provider. New USPSTF “A” and :B” level recommendations will be required to be covered without cost-sharing starting with the plan year (in the individual market, policy year) that begins on or after the date that is one year after the date the recommendation is issued / finalized. The Journal’s report explains

The group’s draft recommendation, which reverses its previous [2008] stance of not asking about illicit drug use, said it is taking the step in part because 7.5 million people 12 years old and older in the U.S. have been diagnosed with dependence or abuse of illicit drugs in the past year, according to the task force. 

Healthcare Dive reports on healthcare provider suggestions to the Centers for Medicare and Medicaid Services on how to reduce the Medicare administrative burden on them.

Companies took the request for information as an opportunity to air perennial grievances about the highly regulated environment, including inequitable quality measures and reporting requirements, prior authorization that slows down care delivery for patients and problems with interoperability and telehealth.

The FEHBlog dearly wishes that OPM would take a page out of this CMS playbook and apply it to the FEHBP.

Last week, the FEHBlog attended the American Bar Association’s annual meeting in San Francisco. Here is a link to an ABA story about an opioid crisis presentation by the American Medical Association’s President-elect, Susan Bailey, MD.  Dr. Bailey encourages the FEHBlog’s profession to sue health insurers for adequate treatment coverage.

The doctor highlighted three recent legal cases that focus on opioid issues. These cases, she said, show “how legal and medical experts can work together to make sure there is evidence-based care for opioid use disorder patients in correctional settings, and that health insurance companies must use medical evidence to evaluate claims, not just financial evidence. We must work together to hold them to that standard.”

Sigh. Why can’t physicians and health plans work together on these important issues?

A UnitedHealth Group report finds that

The annual cost of hospital inpatient services for privately insured individuals exceeded $200 billion in 2018 and is projected to exceed $350 billion in 2029.1 Hospital inpatient spending growth is in luenced by several factors, including prices charged by hospital facilities (hospital prices), prices charged by physicians practicing within these hospitals (physician prices), and patients’ utilization of inpatient services

United notes that hospital prices increases materially exceed physician price increases.  United opines that “Slowing the growth of hospital inpatient costs – by reducing hospital price increases to the level of physician price increases – would make health care more a ordable for consumers and employers.” That’s easier said than done, of course. Hopefully, S. 1895, the bipartisan bill to lower healthcare costs, will help if enacted.

In the same vein, Healthcare Dive reports that

The frequency and price tags on surprise medical bills for emergency and inpatient services at in-network hospitals is on the rise, according to a study published Monday in JAMA Internal Medicine.

The percentage of emergency department visits resulting in a surprise bill jumped from 32.3% in 2010 to 42.8% in 2016 while the increase for inpatient admissions went from 26.3% to 42%. The cost of the bill in both categories nearly doubled in that time period, with the top 10% of ED visits resulting in a bill of more than $1,000, and the top 10% of inpatient visits costing more than $3,000.

Patients at some hospitals were far more likely to receive a surprise bill. For inpatient, the chance was less than 10% at about half of the nearly 3,300 hospitals included, but the chance was more than 90% at about 15% of hospitals. For ED visits, it was a greater than a 90% chance at 23% of at the more than 4,000 hospitals studied.

For this reason, the FEHBlog’s principal goal last week as he travelled through the California sub-acute care system was to avoid the emergency room.

Here’s a link to an interesting  Signal story about “8 Emerging Healthcare App Development Trends to Follow in 2019.” Check it out.

The FEHBlog is in the San Francisco airport waiting for his flight back to DC.  He enjoyed the American Bar Association meeting and side trips to the Napa Valley and Yosemite (spectacular).

While in San Francisco, the FEHBlog realized that he had a bacterial infection. He located and visited a walk in clinic. It turned out that treating this particular infection was outside the walk in clinic’s scope so he had to visit an urgent care center, which he did. The FEHBlog got the antibiotic prescription that he needed and filled the prescription at Walgreen’s, The FEHBlog was surprised by the distinction between walk in and urgent care centers. It strikes the FEHBlog that these types of rather arcane distinctions (from the patient’s perspective at least) could push patients to the emergency room. Perhaps the FEHBlog should have checked with insurer first.

Congress remains on state work periods until after Labor Day. Congressional staff comes back early to work in DC on FY 2020 appropriations and big legislation such as S. 1895, the bipartisan bill to lower healthcare costs.

As you know, in the fourth quarter of 2018, CVS Health acquired Aetna, and Cigna acquired Express Scripts, The FEHBlog thought that both PBM / health insurer mergers made sense from a improving health care quality perspective. Healthcare Dive reports that CVS Health and Cigna each reported strong 2nd quarter 2019 earnings earlier this month.

The Boston Globe’s STAT reports

The Trump administration finalized late Wednesday [in a Medicare national coverage decision] long-sought rules for when Medicare will cover CAR-T treatments, the cutting-edge, often curative therapies that harness patients’ own immune cells against their cancer. 

Under the new policy, Medicare will pay for CAR-T therapies so long as they’re administered in health care facilities that follow the Food and Drug Administration’s special safety rules, known as risk evaluation and mitigation strategies, or REMS. Medicare will also pay for CAR-T even when it’s used to treat conditions that aren’t FDA-approved. The two CAR-T treatments on the market, Gilead’s Yescarta and Novartis’ Kymriah, are approved to treat non-Hodgkin lymphoma and acute lymphoblastic leukemia, respectively. The policy is likely a positive development for hospitals . . . .