Well that was fast. Yesterday the Senate Finance Committee challenged prescription benefit managers to lower insulin prices and today Cigna’s affiliate Express Scripts was the first to come through according to Healthcare Dive.

Fierce Healthcare reports on yesterday’s Congressional hearing on surprise billing. The FEHBlog’s preference is for the solution under which the hospital requires all doctors who provide care at the facility to participate in the health plans networks used by the hospital.

The Healthcare Payment and Learning Action Network has released a roadmap for high performance in alternative payment models. Check it out.

The Healthcare Cost Institute has informs us that

Where people receive health care matters, especially in terms of costs. The same services may have a much higher price tag when performed in one setting rather than another, but this price difference is rarely publicized to patients. To understand what settings people used and how prices differed, we looked at the utilization and average price paid from 2009 to 2017 for a set of services commonly performed in both physician office and outpatient settings. We found that:

•     The share of these services performed in the outpatient setting increased between 2009 and 2017.
•     For this set of services, the average price was always higher in an outpatient setting than an office setting.

Happy National Employee Benefits Day!

The Office of Personnel Management issued a proposed rule that would amend its Federal Employees Benefits Acquisition Regulation to update certain marketing provisions for the self plus one option and its contract clause matrix. The comment deadline on this proposed rule is May 2, 2019.

The Labor Department released frequently asked questions on the recent federal district court decision torpedoing the agency’s association health plan rule.

The FEHBlog does expect Congress to enact laws this year concerning surprise billing and prescription drug pricing, In this regard, the Wall Street Journal reports today that

“A push to curb surprise medical bills has found support among both Democrats and Republicans on Capitol Hill but also ignited a fight within the health-care industry over how far the federal government should go in regulating prices,” and 

“Smaller profit from the sale of generic drugs is squeezing the two biggest U.S. pharmacy chains, with Walgreens Boots Alliance Inc. joining rival CVS Health Corp. in lowering earnings goals for the year.”

Also the majority and minority leaders of the Senate Finance Committee issued a press release challenging prescription benefit managers to hold down the price of insulin for people with diabetes.

Last month, the senators sent letters to Eli Lilly, Novo Nordisk and Sanofi, the three largest insulin manufacturers in the United States, kicking off their bipartisan investigation into insulin prices.

In their letters today to the PBMs, the senators wrote, “while manufacturers set the list price for insulin, pharmacy benefit managers (PBMs) play a critical role in the pricing of insulin on which people living with diabetes depend…As the primary negotiators for government payers, commercial insurers and individual employers, PBMs are in a unique position to leverage their size to lower drug prices.”

As consumers face rising bills at the pharmacy counter, it is unclear whether PBMs are appropriately leveraging their power for the benefit of taxpayers and patients, especially patients who take multiple or high-cost medications,” the senators continued.

Next week PBM executives will be testifying before this Committee.

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

Govexec.com reports that late last week the President and OPM moved forward with implementing the pay raise and additional pay localities the Congress recently approved.

“Now that OPM has issued the new pay tables and guidance, agencies and payroll providers will work quickly to update their systems and process retroactive pay actions,” the [OPM] spokesperson said. “The exact timing of implementation may vary. Employees should consult their human resource office or payroll providers for further information.”

In disappointing news for small businesses, a federal judge in Washington, DC, has torpedoed the Administration’s association health plan rule. It’s not clear whether this decision will be stayed while the Administration appeals. Several insured association health plans already have been launched.

Healthcare IT News reports that the America’s Health Insurance Plans is concerned about an HHS proposed rule that would impose new electronic health care information interoperability rules in Medicare, Medicaid, CHIP, and qualified health plans in the federal exchange effective January 1, 2020.  Assuming that the concept is OK, the timing is too rushed.

Following up on a FEHBlog post from a week ago Friday, the Centers for Medicare and Medicaid Services has announced a “Compliance Review Program to ensure compliance among covered entities with HIPAA Administrative Simplification rules for electronic health care transactions.”

In April 2019, HHS will randomly select 9 HIPAA-covered entities—a mix of health plans and clearinghouses—for Compliance Reviews. Any health plan or clearinghouse—not just those who work with Medicare or Medicaid—may be selected. In 2018, HHS piloted the program with health plan and clearinghouse volunteers to streamline the compliance review process and identify any system enhancements. In 2019, providers will be able to participate in a separate pilot program  on a voluntary basis.

Finally, the Cleveland Clinic has named its top 10 healthcare innovations of 2019. Check it out.

It’s been a busy week for the FEHBlog topped off by the 27th OPM AHIP FEHBP carrier conference. Here are some things that the FEHBlog learned from the conference:

• Michael Thompson from the National Alliance of Healthcare Purchaser Coalitions (formerly the National Business Group on Health) spoke about a form of health reimbursement account known as medical episode spending allowances. 

• Dr. Daniel Knecht, Vice President, Clinical Strategy & Policy, Aetna expressed his opinion medication assisted treatment is the gold standard for opioid use disorders.  MAT produces a 50% reduction in mortality compared to non-MAT treatment, but only 1 in 5 affected people receive MAT. Aetna is trying to address that problem.

• Dr. Knecht also mentioned that Exparel is a safe alternative to opioids for oral surgery pain. Oral surgeon can administer the product during surgery. Aetna has been promoting this drug.  Other health and dental plans should take note because at the height of the opioid crisis opioids dispensed due to oral surgery lead to a lot of unnecessary addiction.

• Finally Dr. Knecht noted that Aetna uses a the Alosa Health group from Boston to meet with doctors about evidence-based guidelines.   

The excitement is palpable. The OPM AHIP FEHBP Carrier Conference begins today. Here’s a link to the full agenda. More to follow.

The FEHBlog believes that few federal laws have spawned more litigation than the Affordable Care Act. Last week, the Health Affairs blog had two posts on that litigation.

Congress returns to Capitol Hill this week.

The Federal Times reports that “The federal government will soon be announcing the award of a contract to study what compensation and reward practices matter most to federal employees and stand the greatest chance of encouraging merit in government service, according to Margaret Weichert, deputy director for management at the Office of Management and Budget and acting director of the Office of Personnel Management.”  The article adds that  “According to Weichert, pay and benefits both received above 60 percent in [Federal Employee Viewpoint Survey] FEVS satisfaction scores, while performance rewards scored between 30 and 40 percent. * * * Those rewards may include practices that improve work-life balance, provide better access to job progression or offer training to transition into more-needed, higher-paying positions.”

The Government Accountability Office issued a report last week finding that

There may be several companies selling health insurance in a given market, but we’ve previously found that most people generally enroll with one of a few companies. When that happens, it can mean less competition and higher premiums for that area.

We updated our work with more recent private insurance data. The overall story is similar: The 3 largest companies held 80% or more of the market in at least 37 states. 

Modern Healthcare reports on an Urban Institute report that builds on the GAO findings.  Any competition is better than Medicare for all in the FEHBlog’s view.

Yahoo Finance offers an interview with Aetna’s former CEO Mark Bertolini.  The FEHBlog values Mr. Bertolini’s insights. Here’s the piece of the interview that struck home with the FEHBlog —

Presently, health care in the U.S. is like a “warranty system” that waits until people are “broken” to fix them, according to Bertolini. “It’s a warranty system today,” Bertolini said. “You get a warranty card when you join a health plan. If you get broke and present yourself to the nearest dealer, we’ll fix you at some cost. It’s not free. And so we have to change that model to what are we doing in the community.”

“This is why we did the CVS deal. We got to do something in the community where we can get people into the stores, have the stores reach out to the community as a way of finding better ways to take care of people, keeping them away from the system,” Bertolini said.

All forms of insurance are warranty systems. The FEHBlog agrees that the old warranty model is outdated. But how can either the new community model work or the old warranty model work with personal responsibility for one’s wellbeing being at the forefront?

The Centers for Medicare and Medicaid Services, which enforces the HIPAA electronic transaction standards and code set rules, announced their findings from a voluntary study of health plan and healthcare clearinghouse compliance with those standards.

Ten organizations met the criteria for participation in the Optimization Pilot. Of these, four clearinghouses and one health plan completed the pilot. All but one of these entities underwent a corrective action plan as part of the pilot. Each participating entity received an acknowledgement stating their participation and compliance. By participating in the pilot, covered entities assisted HHS with streamlining the compliance review process, including review tracking, coordinating and communicating with participating entities, and assessing violations.

CMS advises health plans and clearinghouses to look forward to “a future Information Bulletin for details about full implementation of the Compliance Review Program.”

In Thursday tidbits, the FEHBlog called attention to Choosing Wisely Campaign flyers that can be shared with patients and plan members. The FEHBlog noticed today that the Choosing Wisely campaign also offers a free smartphone app.

The Wall Street Journal reports that while current flu season has not been as severe as last year, it is lasting longer. Thankfully Spring arrived yesterday so the flu can’t hang around much longer.

According to Govexec.com, OPM’s Acting Director Margaret Weichert today provided more insight on the process of folding certain Office of Personnel Management functions into the General Services Administration.

[T]he changes would take place in two broad phases: this year, functions the White House believes can be done administratively, like HR Solutions and OPM’s IT services, will go to GSA, while remaining offices, such as those that work on retirement and administration of the Federal Employees Health Benefits Program, will have to wait for Congress to pass legislation.

“We’re finalizing some of the legal authorities, but we think there’s a huge amount around HR services, IT and many shared services that we will be able to do administratively using a variety of vehicles,” Weichert told reporters. “I think some of the pure statutory elements defined in Title 5 and elsewhere, particularly around the trust funds and pure policy and oversight activities, would require legislation. And we have a forthcoming legislative proposal that will be coming out soon, although I can’t give an exact date.”

The FEHBlog ran across this useful Choosing Wisely Campaign webpage with educational communications for patients / plan members.

This Healthcare Dive article touts the value of electronic prior authorizations of health plan coverage. HHS created standard electronic formats for these transactions long ago. Considering how much the provider organizations complain about prior authorization, the FEHBlog is surprised by the relatively slow provide uptake on electronic prior authorization.

Becker’s Hospital Review discusses the recent release of the Robert Wood Johnson’s rankings of the healthiest U.S. counties. The FEHBlog lives in the healthiest county in Maryland.

The tidbits keep on coming. The International Foundation of Employee Benefit Plans reviews seventeen popular measures that employer sponsored health plans are adopting to control prescription drug cost.

Healthcare Dive reports that “America’s Health Insurance Plans, the BlueCross BlueShield Association and other payer and employer groups sent a letter Monday [March 18] asking Congress to prohibit doctors from sending a surprise bill for emergency or involuntary care.”

Finally, earlier this week the FEHBlog pointed out that Amazon now will let users link health savings account debit cards to their accounts. The FEHBlog should have added that the same feature will allow users to link healthcare flexible spending accounts to their accounts.

The current government contribution toward FEHBP coverage is the lesser of 72% of the enrollment weighted average premium or 75% of the selected plan’s premium. According to Fedweek, the legislative proposals associated with the President’s FY 2020 budget, which the FEHBlog has not been able to find online, would adjust the government contribution based on OPM’s plan performance system. The enrollment weighted average factor would be 76% for plans that score high in that system and 71% for other plans. OPM offered a similar idea but never circulated a draft of the legislative language. As always, the devil is in the details.