As the Wall Street Journal and Fortune report, last week, Sen. Bernie Sanders (I Vt) introduced a new version of his Medicare for All bill which would expand Medicare coverage to include dental and vision coverage and eliminate patient cost sharing but at what cost?  Contemporaneously, a group of Republic Senators lead by Sen. Thom Tillis (R NC) introduced a bill that would use the 1996 Health Insurance Portability and Accountability Act as a backstop to preserve the ACA’s protections for people with pre-existing conditions in the unlikely event that the ACA is struck down by the courts.

It’s worth noting in this regard that the appellee’s briefs in the Texas v. U.S. case raising the ACA constitutionality issue will be due on May 1, and the Justice Department has asked the U.S. Court of Appeals to hear oral argument in the case in July 2019. According to articles which the FEHBlog has read this scheduling is feasible.

Modern Healthcare has an informative article about efforts to cut the cost of healthcare in the U.S. The hospitals and doctors associations are reluctant to cut prices because they think that the reductions will benefit the insurers. This argument reminds me of the prescription benefit manager’s reluctance to drop their manufacturer rebates because there’s no assurance that the manufacturers will reduce their prices in line with the amount of the avoided rebates.  However, insurers have been under ACA price controls since 2011 so the hospital and doctor association concerns are much weaker.

In this regard, Healthcare Dive reports on a recent California-situated study finding the provider capitation can cut costs while improving quality. The silver bullet??

In the Ruh Roh department, Healthcare Dive further reports that

Emergency departments in rural areas are busier than those in urban areas, which is putting a strain on safety net hospitals, according to a new JAMA study.  Rural ED visit rates increased more than 50% between 2005 and 2016 despite a 5% population drop in that time. The increase was a huge jump compared to urban ED visit rates, which saw only a slight increase, according to the report that reviewed National Hospital Ambulatory Medical Care Survey data.

This presumably must be related to the relative absence of urgent care centers and pharmacy clinics in rural areas.

Congress is out of town on a state / district work period this week leading up to Easter and Passover. Here’s a link to the Week in Congress’s report on last week’s actions on the Hill.

The FEHBlog was encouraged by reading this MD Magazine report that “51% of [American College of Physicians] ACP internal medicine physicians and subspecialists have at least 1 form of telehealth service available at their work.” As physician utilization of telehealth grows, the odds increase that patients who seek internist or pediatric telehealth care will receive care from a physician in the primary care practice that they use. That will curb the higher dispensing of antibiotics by telehealth providers recently noted here.

The Boston Globe’s STAT provided a Stanford Medical School professor the opportunity to discuss how electronic medical records can be improved. The FEHBlog heard the American Medical Association’s then President-elect express dismay that the government did not solicit medical profession comment on the development of electronic medical record “meaningful use” standards before shelling out $34 billion to popularize those government approved systems.

Not surprisingly, the good doctor’s number 1 wish is for EMR interoperability. The FEHBlog was encouraged o hear a talk two weeks ago about a developing interoperability technology called the Da Vinci project that would us HL7 code transmitted through what’s known as an FHIR server to connect health plan and provider systems to better coordinate patient/member care.  Health Data Management informs us that

Kansas City-based Cerner has embraced the latest version of HL7’s Fast Healthcare Interoperability Resources [FHIR] standard to encourage third-party developers to build apps on top of its platforms. By adopting FHIR Release 4, the normative version of the interoperability standard, Cerner contends that it is positioned at the “leading edge” in creating healthcare apps and opening its application programming interfaces (APIs) to developers to foster innovation.

Da Vinci is one such API.

CVS Health released its 2018 drug trends report today.

Employee Benefit News (“EBN”) reports that HHS Secretary Alex Azar is urging employers to support the Administration’s programs to control health care and particularly prescription drug spending.  The FEHBlog holds the opinion that high deductible plans should pass along prescription drug rebates to members at the point of sale. In this regard, EBN further reports that “Health savings accounts [which typically are paired with high deductible plans in the employer sponsored coverage environment] continue surging on all fronts. The number of accounts grew 13% over the past year to top 25 million while assets grew 19% to $53.8 billion, according to research firm Devenir. Looking further, Devenir projects the number of HSAs to hit 30 million by 2020, with $75 billion in total assets and $16.7 billion in investment assets.”

Health Affairs blog discusses the efforts of accountable care organizations to care for high need, high cost individuals. All types of health plans must consider these issues.

Health Data Management informs us that “Anthem Blue Cross is joining a Stanford University initiative that aims to advance the development of artificial intelligence for use within healthcare.”

Advancements in patient literacy, patient engagement and healthcare transparency have been identified as the first areas to be addressed through the relationship. Exploring these initial topics is an important step in Anthem’s efforts to create solutions to simplify healthcare for consumers.

In same vein, the Wall Street Journal this evening provides an essay on innovative approaches to help people with dementia stay at home for as long as possible.

Modern Healthcare reports that

HHS Secretary Alex Azar on Wednesday redoubled his support for a rule to eliminate the safe harbor protections for Medicare Part D and Medicaid managed-care drug rebates.
Hospital and insurer groups complained in comments on the rule, which replaces the safe harbor for rebates with one for discounts delivered at the point of sale, that it doesn’t give drug companies an incentive to lower prices. Another concern was that the Jan. 1, 2020 implementation date is far too soon.  But Azar said getting rid of rebates one way or another is a linchpin to the Trump administration’s blueprint for lowering drug prices.

The Washington Post offers a lengthy report on the Trump Administration’s efforts to dismantle the Office of Personnel Management.  The article notes that “An executive order directing parts of the transition by the fall is in the final stages of review, administration officials said, with an announcement by President Trump likely by summer. OPM employees were briefed at a meeting in March.”

Acting OPM Director Margaret Weichert discussed this Administration’s initiative at the OPM FEHB carrier conference at the end of last month. According to the FEHBlog’s notes, of that event Ms. Weichert explained that

The Mission of OPM continues. The Administration is committed to merit system principles, diversity and inclusion, and world class benefits. OPM’s structure needs to change. The current structure is not up to the task. We are in a period of restructuring that is required to modernize OPM’s programs so that they are sustainable for the 21st Century. Folks driving the change are business oriented. It’s not about cost cutting. It’s about creating a better structure for the achieving the mission. 

Healthcare Dive informs us that Walgreens is stepping up the pharmacy clinic business by “partnering with provider group VillageMD to operate primary care clinics next to five of the pharmacy chain’s stores in the Houston area.”

VillageMD’s patent-pending data integration docOS system, released in April of last year, is a key part of the collaboration’s benefits for Walgreens, according to the company. The tech, meant to help doctors and patients manage chronic care conditions, identifies and flags gaps in health or missed diagnoses and can be accessed via phone, kiosk, home-based monitoring or telemedicine.

VillageMD has more than 120 primary care physicians in its Houston medical group. If Walgreens wants to explore a deepening of the partnership and scale Village Medical at its stores further, VillageMD already contracts or employs more than 2,500 physicians in eight markets across the U.S.

Who knew?

• The Centers for Medicare and Medicaid Services is proposing to expand Medicare coverage for 

Ambulatory Blood Pressure Monitoring (ABPM).  ABPM is a non-invasive diagnostic test that uses a device to track blood pressure over 24-hour cycles. Ambulatory monitoring allows blood pressure to be measured over entire days rather than at a single moment in time.  ABPM may measure blood pressure more accurately and lead to the diagnosis of high blood pressure (hypertension) in patients who would not otherwise have been identified as having the condition. 

• Becker’s Hospital Review tells us about Optum’s list of five costly drugs that are rolling out this year.  

While the end of HealthVault is an admission of failure for the company’s initial forays into health, Microsoft has refocused its efforts in the industry toward the enterprise market.

The Senate Finance Committee held its prescription benefit manager hearing today. CNBC reports on the hearing here.

Healthcare Dive reports on the comments that were filed on the CMS proposed rule to eliminate prescription drug rebates from Medicare, among other federal health programs offered to the public. The drug manufacturers favor eliminating the rebates. However, they have been unwilling to assure the PBMs and health plans that the rebate savings will lower prescription drug pricing dollar for dollar.

From skimming through the Senate testimony, it’s clear to the FEHBlog that the Medicare rebate rule needs to be withdrawn and re-evaluated. Removing rebates would not create overall healthcare savings even if rebates are fully traded for lower drug prices. It would benefit plan members with high deductibles or co-insurance arrangements for their prescription drug coverage.

Ironically, the commercial PBMs did not originate the rebate idea. The PBMs ripped a page out of the federal government’s playbook which included prescription drug rebate arrangements for Medicaid, the Veterans Administration, and the Defense Department going back at least into the 1980s.

The most effective step that Congress can take to lower prescription drug prices is to reform the patent system for prescription drugs, including specialty drugs.  The UnitedHealthcare witness at today’s hearing explained (p. 6)

An effective intellectual property environment plays an indispensable role in both promoting drug discovery and ensuring innovations are affordable and sustainable. Today’s intellectual property system does not work as intended. The most important step Congress can take to address the high cost of prescription drugs is to modernize the intellectual property system for the 21st century and eliminate drug manufacturers’ ability to manipulate the patent and regulatory system and thereby prevent lower-cost genericsand bio-similars from reaching consumers more quickly 

Amen to that.  If the rebate debate leads Congress to take action to reform the patent laws, the debate will have served its purpose.

Forbes reports that “The venture capital arm of five Blue Cross and Blue Shield plans has partnered with global primary care provider Sanitas USA to open medical centers in Texas as a precursor to a U.S. multi-state rollout.”  That expansion is bound to happen in view of the experience of UnitedHealthcare.

The Associated Press informs us of a new study finding that “Children received prescriptions for antibiotics more than half the time during telemedicine visits, compared with 42% at urgent care clinics and 31% at doctors’ offices.”  It’s not surprising that the providers who best know their patients provide the best care. As pediatric offices begin to offer telemedicine service to their patients, this trend should work itself out. In the meantime, parents should be aware of it.

Healthcare Dive discusses a new government study finding that emergency room use increased in 2016 while emergency room misuse dropped.

The American College of Emergency Physicians celebrated the report’s numbers. EDs play a critical role in healthcare, as nearly two-thirds of emergency visits happen after doctors’ offices are closed, Vidor Friedman, president of the organization, said in a statement.

“Emergency care is growing more complex and some of the larger trends that will impact emergency department planning and resource discussions include the rising number of elderly patients, preventing and treating opioid abuse and the role of the emergency department in treating and managing patients with mental illness,” Friedman said.

The U.S. Justice Department reports that “A federal jury found a South Florida health care facility owner [ Philip Esformes] guilty today for his role in the largest health care fraud scheme ever charged by the Justice Department, involving over $1.3 billion in fraudulent claims to Medicare and Medicaid for services that were not provided, were not medically necessary or were procured through the payment of kickbacks.”  That’s a lot of boxes of ziti (Sopranos reference).

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 there. Attention will be directed to the Senate Finance Committee on Tuesday morning as the Committee holds a prescription drug pricing hearing with top five prescription benefit managers appearing as witnesses.

Speaking of prescription drugs, Healthcare Dive reports that the CVS pharmacy chain announced last Thursday that

it has expanded its same-day prescription delivery service to 6,000 CVS Pharmacy locations, for $7.99. The drugstore unit, the retail division of CVS Health, began piloting same-day service in 2017 and has been delivering prescriptions nationwide for about a year, according to a company press release. Delivery, often within an hour, is provided through Target-owned same-day delivery company Shipt.

Here’s a link to the CVS press release.

Also, the Wall Street Journal informs us that

The Trump administration said the federal government would offer a risk-sharing system to reimburse health insurers for financial losses resulting from a proposed ban on certain pharmaceutical-industry rebates in Medicare. 

The backstop on most of insurers’ losses could help prevent premiums from rising significantly as a result of the rebate-rule changes, while making taxpayers responsible for a greater share of cost overruns in Medicare’s prescription-drug program. 

The offer to assume most of the financial risk for the loss of the discounts is a sign the administration is likely to proceed with its push to end rebates, and it could address some critics’ concerns. 

Finally, in other news, Health Payer Intelligence relates that

UnitedHealthcare recently announced that it has invested more than $400 million to address the social determinants of health and increase affordable housing access for people in underserved communities. The healthcare payer has invested in more than 80 affordable-housing communities across the US, with more than 4500 homes for people in need.

Federal News Radio offers more details on the House Democrats inquiry into the merger of OPM’s remnants into GSA. The FEHBlog’s money is on Ms. Weichert ultimately convincing Congress about the value of the merger.

To the FEHBlog’s surprise, the Wall Street Journal reports that “A federal judge on Friday said he wants to hear in court from witnesses who object to the Justice Department’s decision last year to approve CVS Health Corp.’s nearly $70 billion acquisition of Aetna Inc.—a highly unusual move that threatens to shake up the already-consummated deal.”  The hearing is expected to last a week sometime next month.

Becker’s Hospital Review discusses Walmart’s successful experts to direct employees to high quality doctors for surgery and cancer care, regardless of cost, because the level of care drives down costs over the long run..  The Boston Globe’s Stat also offers a report from the provider side suggesting that high quality care can lower health care costs.

The Federal Times reports today that

Government Operations Subcommittee Chairman Gerry Connolly, D-Va., sent a letter to acting OPM Director Margaret Weichert March 22 asking her to appear before the committee May 1 to go over detailed plans for the merger that have yet to be disclosed.
In the meantime the members of the Oversight and Reform Committee asked that the Appropriations Committee include language in the FY20 funding legislation to prohibit the use of any funds for an OPM merger, unless the administration can provide detailed plans, analysis of necessary legal authorities, a cost-benefit analysis, confirmation that the administration has addressed all merger recommendations and concerns by the Offices of Inspector General, and a detailed analysis proving that the merger would actually make government more efficient and effective.

The FEHBlog is a fan of the Econtalk podcast. This week the podcast’s host Russ Roberts interviewed philosopher and author Jacob Stegenga of the University of Cambridge concerning his recent book titled Medical Nihilism. Mr. Stegenga advocates for less interventionist gentle medicine. The FEHBlog found the interview to be thought provoking. You can read a transcript here. The FEHBlog also came across this opinion piece from the British Journal of Medicine about the book. The BMJ article’s author observes

The word “nihilism” may be unfortunate. Stegenga and I spoke at a meeting chaired by the president of the Academy of Medical Sciences, where the president objected to the word nihilism, thinking that Stegenga was suggesting that medicine has achieved little and is more of a bad than a good thing. That is not Stegenga’s argument, and he ends his book with some positive ideas on how medical nihilism might lead to better medicine.

He advocates “gentle medicine,” borrowed from the 19th century term la médécine douce. Gentle medicine “encourages a moderate form of therapeutic conservatism.” Many doctors, particularly general practitioners, already practice medicine gently, and gentle medicine clearly overlaps with realistic medicine, prudent medicine, and slow medicine, all of which have their proponents.

On the healthcare information technology front, Amazon announced today that Alexa is not HIPAA compliant. The announcement states that

The new healthcare skills that launched [on Alexa devices]  today are:

• Express Scripts (a leading Pharmacy Services Organization): Members can check the status of a home delivery prescription and can request Alexa notifications when their prescription orders are shipped.
• Cigna Health Today (by Cigna, the global health service company): Eligible employees with one of Cigna’s large national accounts can now manage their health improvement goals and increase opportunities for earning personalized wellness incentives.
• My Children’s Enhanced Recovery After Surgery (ERAS) (by Boston Children’s Hospital, a leading children’s hospital): Parents and caregivers of children in the ERAS program at Boston Children’s Hospital can provide their care teams updates on recovery progress and receive information regarding their post-op appointments.
• Swedish Health Connect (by Providence St. Joseph Health, a healthcare system with 51 hospitals across 7 states and 829 clinics): Customers can find an urgent care center near them and schedule a same-day appointment.
• Atrium Health (a healthcare system with more than 40 hospitals and 900 care locations throughout North and South Carolina and Georgia): Customers in North and South Carolina can find an urgent care location near them and schedule a same-day appointment.
• Livongo (a leading consumer digital health company that creates new and different experiences for people with chronic conditions): Members can query their last blood sugar reading, blood sugar measurement trends, and receive insights and Health Nudges that are personalized to them.