The Boston Globe’s STAT reports that “New federal data released Tuesday found the number of new diabetes diagnoses fell to about 1.3 million in 2017, down from 1.7 million in 2009.” The article observes that

Increasingly, more doctors have been diagnosing “prediabetes,” a health condition in which blood sugar levels are high but not high enough to hit the diabetes threshold. Physicians typically push such patients into exercise programs and urge them to change their diet. “Prediabetes is becoming a more accepted diagnosis” and may be causing an increasing number of patients to improve their health before becoming diabetic, said Dr. Tannaz Moin, a UCLA expert.

This is exactly what should be happening.

The Society for Human Resource Management, of which the FEHBlog is a proud member, called attention to the fact that the Internal Revenue Service had issued 2020 inflation adjustments for high deductible insurance plans and related health savings accounts.  And always remember that according to the IRS

A high deductible health plan that is a group health plan will generally be subject to both the out-of-pocket maximum for high deductible health plans under Section 223 and the out- of-pocket maximum for group health plans under Section 1302(c)(1) of the Affordable Care Act (via Section 2706(b) of the Public Health Service Act). If two different out-of-pocket maximum levels apply to a plan, the plan complies with both if it complies with the lower out-of-pocket maximum. Thus, in the case of a high deductible health plan subject to the maximum out-of- pocket limit under Section 223 and the maximum out-of-pocket limit under Section 2706(b) of the Public Health Service Act, the plan must comply with the lower amount. In any event a high deductible health plan must satisfy the maximum out-of-pocket limit under Section 223 in order to be a high deductible health plan supporting an HSA.

Fierce Healthcare informs us about a UnitedHealth Group study concluding that “Price variation leads to gross overspending for many consumers, even for common health care services such as diagnostic tests, which play an important role in the diagnosis, monitoring and treatment of disease.”  The report finds that

Significant price variation is not primarily driven by differences in the underlying cost or quality of care. The complex and fragmented health care delivery system, which includes opaque cost structures and varying treatment protocols, makes it challenging for providers to determine the actual cost of treating their patients.

• Geographic cost differences have relatively little impact on actual provider price variation.
• Prices are not predictive of provider quality or patient outcomes.
• Rather than cost or quality primarily driving price variation, a more likely reason is that health care providers generally are incentivized to use their market power to increase prices, often resulting in overpriced services.

Perhaps health plans and Medicare Part B should stop making geographic adjustments to their negotiated prices.

Employee Benefit News discusses an interesting approach that employers have been adopting — making mental health first aid available to employees.  “[M]ental health first aid [is[ a relatively new system of providing employees with basic training on spotting signs of emotional distress and engaging with the troubled individual in what could be a potentially crucial intervention to help the person find treatment.”

Happy Memorial Day. Congress is on a state/district work period this coming week. Here is a link to the Week in Congress’s report on last week’s actions on the Hill.

The FEHBlog notes the following entry in the Senate executive calendar concerning the President’s nomination of Dale Cabaniss to become OPM Director — “05/15/2019 – Placed on Senate Executive Calendar. Calendar [Item] No. 246. Subject to nominee’s commitment to respond to requests to appear and testify before any duly constituted committee of the Senate.”

Health Affairs blog offers an interesting article about ways to integrate social determinants of health in medical care. According to the article more evidence is needed before settling on a preferred approach. Not surprisingly, doctors want to be reimbursed for such discussions with patients.

The FEHBlog strongly recommends this Avik Roy column about the importance of expanding consumer choice in order to preserve commercial health plans. The FEHB Act is nearing its 60th anniversary of passage. The FEHBP as enacted was a model for consumer choice. It’s a shame that Congress adopted a single payer option instead of the FEHBP model when Medicare and Medicaid were enacted six years later. Again the FEHBlog is encouraging adoption of consumer choice in health plans not FEHBP for all. The FEHBP is an employer sponsored health benefits program not a public program.

Today, the Department of Health and Human Services proposed revisions to the complicated Obama era Affordable Care Act Section 1557 non-discrimination rule. The rule change will be controversial but I doubt that few will oppose this sensible change:

The proposed revisions would eliminate $3.2 billion in unneeded paperwork burdens imposed by the 2016 rule. Covered entities report that the 2016 rule requires them to send billions of “tagline” notices each year informing patients and customers of their ability to have “significant documents” translated in at least 15 languages. When HHS adopted the 2016 rule, it projected notice and taglines costs of about $7.2 million in the first five years. Because the 2016 rule did not fully account for printing and mailing costs associated with these notices and taglines, it underestimated the burden of these requirements by over three billion dollars over five years. Instead of requiring regulated health companies to mail billions of paper taglines to mostly English speakers, the money saved could be used to more effectively address individual needs of non-English speakers such as by providing increased access for translators and interpreters.

The above HHS link provides links to the text of, and a fact sheet on, the proposed rule. The proposal will be open for public comment for sixty days after publication in the Federal Register.

The Wall Street Journal reported this morning that

President Trump is expected to release an executive order as early as next week to mandate the disclosure of prices in the health-care industry, according to people familiar with the discussion. The order could direct federal agencies to pursue actions to force a host of players in the industry to divulge cost data, the people said. The administration is also looking at using agencies such as the Justice Department to tackle regional monopolies of hospitals and health-insurance plans over concerns they are driving up the cost of care, according to two people familiar with the discussions. The White House declined to comment on its plans.

Time will tell.

Following up on yesterday’s announcement of a HIPAA Privacy and Security Rule alleged violation settlement with a business associate, HHS issued a new Fact Sheet on Direct Liability of Business Associates under HIPAA, a law that was enacted in 2009. Reminders are helpful. Health Data Management discusses implications of the settlement here.

Health Data Management also calls attention to an HHS Office of Inspector General report finding that Medicare accountable care organizations with robust health information technology tools provide better patient care.

“ACOs that used a single electronic health record system across their provider networks were able to share data in real time,” states the OIG’s report. “A small number of ACOs had access to robust health information exchanges, which gave ACOs access to patient data even when patients saw providers outside the ACOs’ networks. Most of the ACOs we visited use data analytics to inform their care coordination by identifying and grouping patients according to the potential severity and cost of their health conditions.”

In a good news / bad news story, the Boston Globe’s STAT reports this afternoon that

the Food and Drug Administration on Friday approved the first gene therapy for a type of spinal muscular atrophy, a lifesaving treatment for infants that will also be the most expensive drug in the world. Known as Zolgensma, the gene therapy treats children under 2 years of age with spinal muscular atrophy, an inherited neuromuscular disease that causes progressive loss of muscle function. The most severe form of SMA causes infants to die or rely on permanent breathing support by the age of 2. The disease is caused by a defect in a gene that makes SMN, a protein necessary for the survival of motor neurons. Zolgensma uses a re-engineered virus to deliver a functional copy of the defective gene so that SMN protein can be produced. Novartis is pricing Zolgensma at $2.125 million, or an annualized cost of $425,000 per year for five years, the company said.

This is another reason why it makes sense for small and even mid-sized health plans to consider purchasing specific risk stop loss insurance.

Becker’s reports that the measles outbreak has spread to 25 states in the United States for a total of 880 cases. The Health Affairs Blog offers an article explaining why linking adult vaccines and quality is a public health imperative. 

There are currently 13 recommended vaccines on the adult immunization schedule and many additional adult vaccine candidates in the pipeline. Despite proven efficacy and favorable recommendations from the Advisory Committee on Immunization Practices, availability and accessibility of vaccines alone are insufficient to encourage uptake. 

Traditional policy levers such as school-entry requirements and the Vaccines for Children program have successfully improved vaccination rates in pediatric populations. For adult populations, however, complex challenges have driven the need for stakeholders to explore alternative solutions. As the country innovates in the areas of health care payment and delivery, quality measurement tied to payment presents a promising lever to drive adult immunization uptake and achieve national population health targets. 

The FEHBlog was happy to read about the discussion draft of bipartisan healthcare reform bill released today by the chair, Sen. Lamar Alexander, and ranking minority member, Sen. Patty Murray, of the Senate Health, Education, and Pensions Committee. Kaiser Health News reports that the bill picks up two of the FEHBlog favorite cost saving approaches:

The novel [“surprise bill”] part from Alexander and Murray is the idea of an “in-network guarantee.” It requires that any hospital considered “in-network” for a health plan must promise that everyone working there is also in-network.  This would avoid situations in which patients choose a hospital because they know their insurance company will cover the bill, only to find out that one of the doctors they saw was out-of-network, leaving the patient with a hefty bill.  It also requires that labs and diagnostic tests be in-network, cutting off another avenue of surprise bills, [and]

Instead of regulating drug prices, the package would address patent protections, making it easier for generics to get to market and harder for brand-name drugs to maintain exclusive patents for lengthy periods. 

The Senate HELP committee is requesting comments on the discussion draft. Comments must be submitted to LowerHealthCareCosts@help.senate.gov by 5 PM on Wednesday, June 5, to be considered.

Speaking of surprise bills, Health Payer Intelligence reports on a House Ways and Means Committee hearing on surprise billing held earlier this week.

The Centers for Disease Control issued a report yesterday on Trends in Cancer and Heart Disease Death Rates Among Adults Aged 45–64, 1999–2017.”  Here are the top line results:

Cancer death rates for middle-aged adults aged 45–64 declined by 19% from 1999 to 2017 (224.9 deaths per 100,000 to 182.6), whereas heart disease death rates declined by 22% from 1999 (164.3) to 2011 (127.9) and then increased 4% from 2011 to 2017 (133.6). The same trend patterns were observed for both men and women. The cancer death rate was always higher than the heart disease death rate from 1999 to 2017, and was 37% higher in 2017.  

The Health and Human Services Department’s Office for Civil Rights (“OCR”) announced another settlement of HIPAA privacy and security rule violation allegation today.

On July 23, 2015, [Medical Informatics Engineering (MIE), an Indiana based HIPAA business associate] filed a breach report with OCR following discovery that hackers used a compromised user ID and password to access the electronic protected health information (ePHI) of approximately 3.5 million people. OCR’s investigation revealed that MIE did not conduct a comprehensive risk analysis prior to the breach. The HIPAA Rules require entities to perform an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of an entity’s electronic protected health information.

“Entities entrusted with medical records must be on guard against hackers,” said OCR Director Roger Severino. “The failure to identify potential risks and vulnerabilities to ePHI opens the door to breaches and violates HIPAA.”

The Federal Times, Govexec, and Federal News Network all reported on the House Oversight and Reform Committee hearing yesterday on the Administration’s plan to dismantle OPM. The FEHBlog heard the acting Director Margaret Weichert, who was not combative, explain that she was hoping for a bipartisan legislative solution, but she received no support from the subcommittee members or the other witnesses at the hearing.  Unfortunately watching the hearing was not entertaining.

The Office of Management and Budget posted its Spring 2019 regulatory agenda today.  The FEHBlog regrettably has not seen much deregulation, if any, in the FEHBP. In any event, here’s a link to OPM’s regulatory agenda.

Health Payer Intelligence reports that “At Health Partners Plans [which is based in Philadelphia], a medically-tailored meal delivery program is improving outcomes and reducing costs for members with chronic disease.” It’s certainly worth reading.

As price transparency is referenced in OPM’s 2020 call letter for benefit and rate proposals, it is worth noting this Modern Healthcare article which explains that ]

Here’s a link to House Oversight and Reform subcommittee hearing on the OPM reorganization held this afternoon. At the link, you can find witness testimony and a video recording of the hearing.

Things are looking up for judicial affirmation of the CVS – Aetna merger settlement with Justice Department as a combination of red and blue states who originally opposed the settlement have not filed a brief supporting it, according to Healthcare Dive.  The hearing will be held beginning June 4 in the federal district court in Washington DC.

Fierce Healthcare reports on a study concluding that “there was little variation among primary care physicians when it comes to hospital readmission rates, leaving the researchers questioning whether policies that hold these doctors accountable for reducing readmissions may miss the mark.” If doctors shouldn’t be held responsible for hospital readmissions then why should health plans which has several more degrees of separation from the event be held responsible?

The Kaiser Family Foundation published an interesting study on third party reimbursement of prescription drug costs.

Highlights from this analysis include:

• Private health insurance, Medicare, and Medicaid accounted for 82% of total retail prescription drug spending in the U.S. in 2017, while patients paid 14% of the total as out-of-pocket payments.
• For spending on specific drug products, the top five drug products with the highest total spending alone account for at least 10% of total prescription drug spending in large employer plans, Medicare Part D, and Medicaid.
• While some of the same drug products appear among the top 10 drug products with the highest total spending in large employer plans, Medicare Part D, and Medicaid, there is also variation that reflects differing covered populations.
• Out-of-pocket drug spending per user among people in large employer plans and Medicare Part D is highest for drugs to treat cancer, multiple sclerosis and rheumatoid arthritis.
• Antidiabetic agents, antivirals and psychotherapeutics are among the top therapeutic classes by total spending in large employer plans, Medicare Part D, and Medicaid.

No one in the private sector would blink if corporate management decided to merge two related overhead departments like human resources and internal services. Nevertheless, it appears from the House Oversight and Reform Committee meeting notice and this Federal News Network article that tomorrow’s Congressional hearing on the Trump Administration’s plan to take a similar approach with OPM is going to be a real three ring circus. Get the popcorn ready.

Kaiser Health News reports that

Walmart Inc., the nation’s largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company’s workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out not to need those operations. They were either misdiagnosed by their doctor or needed only non-surgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended since March that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City-based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Walmart will enforce this policy with increased cost sharing on those who fail to follow this policy. The FEHBlog hopes that Walmart will evaluate, and share with the public, whether this policy delivers results.  

A healthcare quality pal of the FEHBlog’s called his attention to this Joint Commission announcement about a sea change in hospital quality reporting. The Joint Commission is the principal accrediting body for hospitals.

The Joint Commission is shepherding in the next generation of clinical quality by expanding the capabilities of its quality measure program to provide accredited hospitals with year-round, real-time access to quality measures. Over the last two years, The Joint Commission has transformed its electronic clinical quality measure (eCQM) reporting process to increase value and reduce burden for thousands of their 4,500 accredited hospitals with a Direct Data Submission Platform (DDSP). The Joint Commission is now continuing that digital transformation by making the platform and quality measure results continuously available, allowing providers to measure and improve performance in near real-time without additional outside vendors.

In today’s Econtalk podcast, the host Russ Roberts, who has a Ph.D. in economics, spoke with Mary Hirschfeld, who has Ph.Ds in economics and theology. It was interesting conversation between Mr. Roberts who is a fan of Adam Smith and Ms. Hirschfeld who is a fan of St. Thomas Aquinas. In any event this Russ Roberts quote gave the FEHBlog a knowing smile:

“[Economic] incentives have problems * * * when you use incentives only for the things * * * that are measurable. * * * And you ignore the things that aren’t measurable.

Congress remains in session this week on Capitol Hill. Here’s a link to the Week in Congress’s report on last week’s actions on the Hill.

The Health Subcommittee of the House Ways and Means Committee will hold hearing concerning surprise medical bills on Tuesday afternoon. Fierce Healthcare looks at the differences between the two bipartisan surprise medical bills pending the Senate and the House.

The House Budget Committee will hold a hearing concerning the Congressional Budget Office’s recent report on key design considerations and components of establishing a single payer system on Wednesday morning. In this regard, Rep. Rosa DeLauro (D Conn.) re-introduced a Medicare for America bill (HR 2452). This bill would add a super-charged public option to the Affordable Care Act exchanges. In the FEHBlog’s view, and as explained in this Wall Street Journal op-ed, this bill is a Trojan horse for the single payer system.

Following up on yesterday’s leading items, Federal News Radio breaks down the Trump’s administration’s legislative proposal to dismantle OPM and Avik Roy offers some observations on CMS’s Medicare Advantage and Part D drug pricing final rule.

In the examples of how federal law impacts healthcare department —

• The Boston Globe reports on a recent study finding a substantial increase in mental health are claims over the past decade, a good thing which the FEHBlog attributes to the 2008 federal mental health parity law among other factors, and 
• The American Medical Association reports that “2018 marked the first year in which there were fewer physician owners (45.9 percent) than employees (47.4 percent), not so good thing for professionals which the FEHBlog attributes to the Affordable Care Act. To that end, “more than half of physicians, 54.0 percent in 2018, continue to work in practices that are wholly owned by physicians, sometimes referred to as “private practice.” This share is statistically lower than that of 2012 (60.1 percent) and 2014 (56.8 percent), but not that of 2016 (55.8 percent). More than half of the 2012 to 2018 shift away from physician- owned practice occurred during the first two years of that period.

If all these [electronic health record interoperability] APIs [such as HL7’s Da Vinci] work, the whole reporting of quality measures will, over time, eventually go away”  Dr. Rucker suggested that one day payers could access data from a provider through an API, and apply machine learning to extract quality measures. That would eliminate the need for clinicians to generate these measures “in a one-off kind of way,” he said.

A win-win for payers and providers.

Today, the Centers for Medicare and Medicaid Services issued their final Medicare Advantage and Part D Drug Pricing rule and it does not include the anxiety inducing provision to lower prescription drug prices by doing away with prescription drug rebates.  Part I.D. to the rule’s preamble explains, “We sought comment on the possibility of adopting a new definition of “negotiated price” under which plan sponsors would be required to pass through all pharmacy price concessions at the point of sale. We will carefully review all input received from stakeholders on this issue [nearly 8,000 public comments in total] as we continue our efforts to meaningfully address rising prescription drug costs for beneficiaries.”  Here’s a link to the CMS fact sheet on the final rule.

Govexec.com this evening shared with the public a May 16, 2019, Office of Management and Budget letter to the heads of Congress proposing legislation to dismantle OPM. In pertinent part,

The primary purpose of the legislative proposal is to authorize the transfer of the vast majority of the current functions and resources of OPM to GSA, including Human Resources Solutions, Information Technology, Retirement, Health and Insurance Services. GSA will create a new Personnel Service to house the human resources and employee lifecycle management shared service offerings. Agencies will benefit from GSA helping them to obtain more strategic and comprehensive support for their needs.

A bi-partisan group of Senators including Sen. Bill Cassidy (R LA), a physician who sits on the Senate Health Education Labor and Pensions Committee, introduced a bill to stop surprise billing. It’s a different approach from the House bi-partisan proposal discussed here last week as it covers all surprise situations, not just emergency cases, and it allows for independent dispute resolution.  The bill would apply to the FEHBP. The FEHBlog does expect a bill on this topic to enacted this year.