Tuesday Tidbits

Senate Homeland Security and |Governmental Affairs Committee Chairman Joe Lieberman (I Conn) and Ranking Minority Member Susan Collins (R Maine) have reintroduced their bill to extend FEHB coverage to same sex domestic partners of federal employees.

The HHS Office for Civil Rights which is responsible for enforcing the HIPAA Privacy and Security Rules announced earlier this month that it has begun a pilot program of auditing covered entity and business associate compliance with these rules. The HITECH Act which was part of the 2009 economic stimulus law called for these audits. The 20 audits in the pilot program will be conducted over the next 12 months.  KPMG, one of the large public accounting firms, has been contracted to conduct the audits for OCR.

The AMA News reports with some alarm that

Physician office visits by privately insured patients younger than 65 have fallen 17% in two years, according to a Kaiser Family Foundation analysis released Nov. 15.

The research is the latest to suggest that the decline in how often patients see their doctors, fill prescriptions and stay in the hospital is due to factors beyond the recession and may last for a while.

Perhaps consumerism is working.

Weekend Update

The FEHBlog hopes that everyone has an enjoyable Thanksgiving weekend. Congress returns to work this week as we begin the third week of the annual Federal Benefits Open Season which ends on December 12. What a relief that the Redskins finally won a fourth game today.

CBS News reminds us that the best selling prescription drug Lipitor will be available in generic form beginning this coming Wednesday November 30.  This will be a big savings for consumers and health plans. "Based on Lipitor's sales of $7.2 billion last year, this one generic drug should save the overall U.S. system $6.5 billion." Of course, nothing is simple and Lipitor's manufacturer Pfizer is trying to hang onto some of its Lipitor profits, but the savings will be huge. Medco offers a long list of blockbuster drugs that will be going generic over the next 15 months.

Business Week reports that a cloud continues to hang over Walgreen's due to its ongoing contract dispute with the prescription benefits manager Express Scripts. If the NBA and the NFL can reach settlements with their players so should these companies.

Govexec.com takes a look at the various "reforms" recently proposed for the FEHBP. It simply is odd that the FEHBP -- the largest consumer choice program in this country and the model for Medicare Part D and the Affordable Care Act's health insurance exchanges -- has come under such scrutiny at a time when it is purring along so well -- a 3.5% average premium increase for 2012 which well below the private sector estimate of 5.4% and just above 3.0% increase for Medicare Part B which relies on statutory pricing.

Speaking of Medicare, the President nominated Marilyn Tavenner to succeed Donald Berwick as Administrator of the Center for Medicare and Medicaid Services according to this Kaiser Health News report.

Happy Thanksgiving!

The FEHBlog wishes everyone a Happy Thanksgiving. Of course, the Super Committee did not produce any deficit cutting recommendations. Congress will return to work after the Thanksgiving break. The AMA News makes it clear that the medical community is nervous about the looming end of the Medicare Part B reimbursement patch on December 31.  Modern Healthcare reports that the Democratic leadership in the House of Representatives has sent a letter to House Speaker John Boehner asking the Republican majority to ">to ensure three pieces of legislation get passed before Dec. 16: extension of the SGR [Medicare Part B] fix, extension of unemployment insurance, and extension and expansion of the “payroll tax holiday.”

A pre-holiday tidbit from Business Insurance is that the Early Retiree Insurance Program created by the Affordable Care Act has used up $4.1 billion or 80% of its $5 billion appropriation which Congress intended to last the Program through 2013. That's up half a billion from the mid October 2011 report. It looks like the Program will be out of funding in the first quarter of 2012, and the FEHBlog would bet the ranch that Congress does not replenish the funding. In retrospect, although the FEHBlog considers it inequitable that the Affordable Care Act regulators excluded the FEHBP from the Program, there's no doubt that including the FEHBP, with its large cadre of early retirees, would have accelerated the Program's demise.

Weekend Update

Congress has recessed for the Thanksgiving holiday, and according to news reports, including the Wall Street Journal,  the Super Committee will admit defeat tomorrow. As it turns out tomorrow, not Wednesday, is the Super Committee's effective deadline because the Committee can only vote on proposals that have been made public for at least 48 hours before the vote.

The American Medical Association ("AMA") must be freaking out because they were betting that the Super Committee would fix the statutory sustainable rate of growth formula that will impose a 27.4% cut on Medicare Part B compensation to doctors on January 1, 2012. The beauty part of the Super Committee process is that if the Committee had produced a set of proposals with $1.2 trillion in deficit reductions over 10 years, both Houses would have been required to give the proposals an up and down vote with no amendments. Now the AMA has to rely on the vagaries of the usual legislative process during the holiday season.

We enter the second week of the Federal Benefits Open Season. Federal News Radio reports that

For advice, insight and analysis, [its] Federal Drive [program] with Tom Temin and Amy Morris turned to three experts in the Open Season arena — Colleen Murphy, executive for PlanSmartChoice, an ADP product; Walton Francis, editor of the Checkbook Guide to Health Plans for Federal Employees; and Federal News Radio's Senior Correspondent Mike Causey.

Details are available here.

Standard & Poors last week issued the September 2011 report on its healthcare index. Not good news.

Data released today by S&P Indices for the S&P Healthcare Economic Composite Index indicate that the average per capita cost of healthcare services covered by commercial insurance and Medicare programs increased by 5.75% over the 12-months ending September 2011. This is a slight increase over the +5.71% annual growth rate posted in August 2011 and the fifth consecutive increase since the index hit its lowest rate of +5.32% in April 2011.

As measured by the S&P Healthcare Economic Commercial Index, healthcare costs covered by commercial insurance increased by 8.03% over the year ending September 2011, also increasing for the fifth consecutive month. On the other hand, growth rates in Medicare claim costs hit yet another low, rising at an annual rate of +1.97% as measured by the S&P Healthcare Economic Medicare Index. The S&P Healthcare Economic Hospital Medicare Index also posted a record low annual rate of +0.71% in the year ending September 2011. This is a staggering 7.59 percentage points lower than the highest annual growth rate of +8.30% recorded for this index just two years ago in August 2009.

The Hospital and Professional Services Indices posted increases of 5.51% and 5.78%, respectively, from their September 2010 levels. These are marginal changes from the +5.40% and +5.83% respective annual rates posted in August 2011.

That my friends is strong evidence of significant cost shifting from the Medicare Program to the private sector.

Friday Highlights

The Federal Times reports that the President has signed into law a minibus appropriations bill that funds several departments and extends funding for other government agencies and programs, including the FEHBP, until December 16. Congress actually is hopeful that all appropriations matters will be wrapped up by that date. The law also further "defers a legally required $5.5 billion "prepayment" by the U.S. Postal Service for retiree health care, this time until Dec. 16. That payment was originally due Sept. 30; USPS officials said they don't have the money to cover it."

Also the Labor Department, one of the Affordable Care Act regulators, published a new FAQ advising health plans that the obligation to issue four double sided page long summaries of benefits and coverage will be deferred until the final rule's effective date. Obviously that will occur after the statutory effective date of March 23, 2012. According to a Business Insurance report, “This is great news for employers since the initial guidance left much of how the (summary of benefits and coverage) would apply to large employer plans unaddressed,” said Rich Stover, a principal with Buck Consultants L.L.C. in Secaucus. N.J. The FEHBlog agrees.

The publication also includes FAQs about Mental Health Parity Act rule's restrictions on so-called non-quantitative benefit limitations.

Also following up on this week's posts, the FEHBlog thought that he had missed the publication of the annual FEHBP information technology report. But actually OPM announced the report the day after the FEHBlog mentioned it.

The Centers for Medicare and Medicaid Services have given health care providers an additional three months -- until March 31, 2012, to start using the new HIPAA electronic transaction standards known as ANSI X 5010.  Health care providers generally are required to submit claims electronically to Medicare and Medicaid so this is a big deal.

Ihealthbeat provides several reactions to the American Medical Association's stand against the ongoing ICD 10 conversion discussed in Wednesday's FEHBlog post.

Mid-week update

Joe Davidson of the Washington Post reported on the beginning of a quiet Federal Benefits Open Season (so described because the average premium increase is so low for 2012) Mr. Davidson reported from a health fair sponsored by the FEHBlog's Congressman Chris Van Hollen. He observed that "People from health insurance companies, many with logo-laden swag, were available to answer questions about their products." That's a cheap shot. These health fairs have been around for decades and attendees expect a little "swag." What's wrong with that?  It's fun.  It's important to note the "swag" is not purchased with government funds.

OPM holds its last Open Season webinar tomorrow at 1:30 pm ET. Tomorrow's webinar is on the topic of the FEHBP and Medicare. The previous webinars are available on YouTube. (Seriously.) The FEHBlog listened to Tuesday's webinar about how to select the right health plan. OPM recommended three sources of information for comparing FEHB plans -- OPM, Plan Smart Choice  (a tool which has improved over the years), and Consumers Checkbook.

The Administration made announcements today about reductions in improper payment rates in many high error programs such as Medicare and Medicaid.. You won't hear the FEHBP's name called here because the FEHBP has a low improper payment rate that will be disclosed soon in OPM's FY 2011 financial statements. Carriers do a good job of managing their plans.

Business Insurance reports that according to a Mercer survey, the average cost of employer sponsored health insurance has cracked $10,000 in the U.S. That's not good news particularly as we creep ever closer to the Affordable Care Act's tax on health insurance premiums that takes effect in 2014 and its tax on high premium plans that takes effect in 2018. Of course, the U.S. Supreme Court announced on Monday that it will consider the constitutionality of the Affordable Care Act in a five and 1/2 hour long argument early next year that will consider the constitutionality of the individual mandate and the constitutionality of the law's provisions expanding Medicaid and imposing significant new costs on States. The Court also will consider two related issues -- whether the appeal is premature because the relevant provisions do not take effect until 2014 (a decision reached by the U.S. Court of Appeals for the Fourth Circuit) and whether these two challenged features of the law are severable from the rest of the law which would allow the law to remain in effect except for features that the Court finds unconstitutional. C-SPAN has asked the Supreme Court for permission to televise the argument according to the WSJ's Law Blog. The Supreme Court has a web page on this important case here.

The Washington Post reports that OPM has been named one of the top ten places to work in the federal government. Kudos to OPM.

Finally, in a truth is stranger than fiction piece, Medscape reports that the American Medical Association's Board of Governors wants the federal government to stop implementing the International Classification of Diseases 10 (ICD 10) code set because implementation will cost doctors too much money. (Oddly enough, the Chairman of the AMA's Board of Trustees is Dr. Wah as in wah! wah!)

The International Classification of Diseases and Related Health Problems, 10th Revision, contains approximately 68,000 codes, and its implementation is slated for October 2013. ICD-10 will replace ICD-9, which has just 14,000 codes.

The Department of Health and Human Services two years ago finalized a HIPAA rule requiring health plans to implement a new set of electronic billing transaction standards known as the ANSI X5010 by January 1, 2012, and implement the ICD-10 by October 1, 2013. Doctors and hospitals who want to bill health plans electronically must use the same transaction standards and code sets.

The ICD blew up in order to improve public health reporting which is not the purpose of electronic billing. The current ICD 9 works fine. However, while the FEHBlog shares the AMA's sentiments, this train left the station two years ago and health plans have spent millions implementing the new requirements. The AMA's only hope is Congress. We'll see., but I would not bet the ranch on the AMA succeeding with this one.

Weekend Update

The Federal Benefits Open Season starts tomorrow and ends on December 12.  During the Open Season, federal and postal employees and annuitants can switch their FEHB plans for 2012 without concern of for pre-existing conditions.

While surveying OPM's Open Season web page, the FEHBlog ran across OPM's annual report on the use of health information technology in the FEHBP. OPM finds robust use.

In an odd twist on the government's efforts to incent the use of electronic health information technology ("HIT"), particularly by health care providers, the U.S. Institute of Medicine issued a report last week recommending that Congress create an independent agency similar to the National Transportation Safety Board that would investigate and attempt to curb patient safety problems created by HIT. According to the Federal Times, "The  [IOM} study cites reports of patient deaths and injuries due to "medication dosing errors, failure to detect fatal illnesses and treatment delays due to poor human-computer interactions or loss of data." Modern Healthcare provides the HIT industry's reaction to this study.

Congress is making progress on the appropriations bills for the current federal fiscal year. There is a House - Senate conference committee which is expected to complete work on a "minibus" appropriations bill "covering NASA and the Agriculture, Justice, Commerce, Transportation, and Housing and Urban Development departments, along with a number of smaller agencies" according to the Federal Times.  This bill will include an extension of the continuing resolution for the rest of the government and the moratorium on the Postal Service's $5.5 billion pre-retirement health care funding obligation until mid-December.

We are ten days away from the deadline for the Joint Committee on Deficit Reduction a/k/a the Super (Duper?) Committee to submit its deficit reduction package to Congress. According to this Washington Post report, Committee members remain hopeful for a compromise that leads to submission of such a package.

On Tuesday morning, November 15, the Federal Workforce subcommittee of the House Oversight and Government Reform Committee will hold hearing titled "Back to Basics: Is OPM Fulfilling its Mission?" OPM's Director and the agency's Inspector General will testify. Joe Davidson from the Washington Post provided background on the hearing in a column last Thursday.

Friday highlights

Federal News Radio reported on the AEI conference that I discussed in Wednesday's FEHBlog post. Federal News Radio who had a reporter at the event did a good job capturing the concerns that the panelists made about the Administration's proposal to carve out FEHBP prescription drug contracting from the carriers -- who bear the underwriting risk -- to OPM. The report further states that

The Office of Management and Budget did not respond to a request for comment on why it believes the FEHB proposal makes economic sense. The American Federation of Government Employees supports the proposal because carving out the pharmacy benefits is the only way to get better prices because there is little competition and less transparency, said Jackie Simon, the union's public policy director. She said in an email to Federal News Radio that statutory pricing is what the VA and DoD and Bureau of Prisons and the Indian Health Service have, and can do direct negotiations for maximum prices.

The FEHBlog wishes to assure that OPM contractually has imposed on fee for service plan carriers a transparent pricing initiative applicable to prescription drug pricing that just took effect this year. That initiative which is still being implemented is stronger than that found in the private sector.  Moreover, statutory pricing simply shifts costs to other employer sponsored plans and does not work unless the government clamps down on utilization.

Govexec.com picks up on FEHB expert Walt Francis's opposition to the Postal Service's effort to carve out its employees from the FEHBP. The Postmaster General has told Congress that he could cut USPS healthcare costs in half. That's unlikely because the Postal Service's demographics are worse than the Civil Service's.  The Govexec.com article explains

If the Postal Service leaves FEHBP, its health care expenses would rise by about 10 percent, Francis said, largely because of the agency's aging workforce, which currently benefits from being in the larger and more age-diverse FEHBP pool.

What's more the FEHBP's competitive model has done a very good job controlling costs -- 3.8% increase for 2012 versus Mercer's 5.4% estimated increase for private sector employer sponsored plans. Group health insurance principles embraced by the FEHBP work over time. Caveat -- the Postal unions have the right to collectively bargain a USPS only plan with the Postal Service. Everyone should respect that right.

Mid-week update

The Senate Homeland Security and Government Affairs Committee held a business meeting today at which it marked up the 21st Century Postal Service Act (S. 1789) that the Chairman, Sen. Lieberman (D CT) and the Ranking Member, Sen. Collins (R Maine) introduced. The FEHBlog, who watched the meeting on the internet, was relieved when the Committee approved by an 11-6 vote a motion by Sen. Akaka (D Hawaii) to delete Section 103 which would have forced Postal Service retirees into a Medigap plan.

Section 103 would have refused employer health insurance coverage to Postal Service retirees who declined to purchase Medicare Part B. Sen. Akaka said at the meeting that OPM's actuaries have opined that the bill's Medigap plan would not produce the savings that the Postmaster General has projected and that it also would weaken the FEHBP. (The FEHBlog agrees and so did FEHBP expert Walton Francis at an AEI conference today that the FEHBlog also watched.) Sen Begich (D Alaska) asked Sen. Lieberman whether the Centers for Medicare and Medicaid Services has expressed its opinion on this significant cost shift to Medicare. The bill's sponsors did not think that was necessary. Sen. Lieberman was not pleased with this result, and he said that he would raise the Medigap plan issue on the Senate floor.

The American Enterprise Institute ("AEI") had a meeting today titled Dismantling the FEHBP at which two FEHBP experts Walt Francis and Jim Morrison and an AEI economist Joe Antos spoke. All of the speakers spoke out against the Administration's proposal to carve out prescription benefit contracting from the carriers to OPM  Walt Francis described this initiative as a solution in search of a problem. In support of that position, the FEHBlog notes that the FEHBP's 2012 premium increase is lower than the Mercer estimated projected 2012 increase for private sector employers.  Mr. Francis also pointed out that at a 2009 House Oversight Committee hearing he learned that TRICARE drug costs rose at a rate two times higher than FEHBP drug costs. The TRICARE drug program is managed and self-funded by the government while the FEHBP is managed and insured by the carriers.

AEI summarized Jim Morrison's position as follows:

Health plans integrate pharmacy benefits with the medical benefits they provide; imposing one set of pharmacy benefits on all of the plans unwisely ignores the complex interaction between the benefit components of each plan.

He noted that there are several recent studies that find that carving out prescription drug benefit administration costs more money for this reason. The most recent study is one conducted by CIGNA and Health Partners that was released last February.

Here's a link to this event where you can watch it (about 1 hour and 15 minutes) and read background materials.

Weekend Update

Well, this is getting repetitive. Congress is in session this week. 12 days to go until the Continuing Resolution funding the Federal government's operations expires and 17 days until the Super Committee must make its recommendations to Congress. The Washington Post reports on the status of the appropriations process -- now featuring "minibuses." Your guess about the outcome of the Super Committee discussions is as good as mine.

OPM is in the process of creating an all payer claims database for the FEHBP. A similar database has existed for the Medicare Program (and it doesn't seem to have helped too much). The Medicare database is subject to Freedom of Information Act requests. Many moons ago, the American Medical Association obtained a federal court injunction stating that CMS cannot disclose the identities of physicians who receive Medicare payments when it answers those FOIA requests. Last year, the Wall Street Journal studied the data that it could obtain from the database and it found (SHOCK!) patters of Medicare fraud. On Friday, the Wall Street Journal reports that

A New York-area family-practice doctor [Dr. Emma Poroger] who was featured in a Wall Street Journal articleabout Medicare abuses last year was indicted by a federal grand jury this week for allegedly submitting more than $13 million of false claims to the program.

* * *
\Dr. Poroger, 56 years old, is the second health-care professional cited in a series of Journal articles about Medicare abuses who has since been indicted. A Brooklyn physical therapist, Aleksandr Kharkover, pleaded guilty in May to submitting fraudulent claims to Medicare for services that were medically unnecessary and never performed.

Another doctor featured in the series, Theresa Rice, has been suspended by the Texas medical board. And a fourth, Portland neurosurgeon Vishal James Makker, is under investigation by the Oregon medical board and is no longer allowed to operate on patients without supervision.

The Journal has gone to court in an effort to overturn the AMA injunction.

Modern Physician reports that Sen Charles Grassley (R Iowa) is challenging the Health and Human Services Department's decision to close public access to a separate data base known as the National Practioner Database that contains information on medical malpractice awards and sanctions against doctors.

On a related note the Privacy, Technology and the Law subcommittee of the Senate Judiciary Committee will be holding a hearing Wednesday afternoon about protecting potected health information in a digital world.

AHIP announced last week that

A new technical analysis by Oliver Wyman estimates that the new health insurance tax in the Affordable Care Act (ACA) “will increase premiums in the insured market on average by 1.9% to 2.3% in 2014,” and by 2023 “will increase premiums 2.8% to 3.7%.”

Ironically this tax, which takes effect in 2014, will fall predominately on the insured plans in the health insurance exchanges that serve individuals and small business. It also adversely impacts insured FEHBP plans like the Federal Employees Plan and the HMOs participating in the Program. Self-insured plans, Medicare, and Medicaid, are exempt from the tax.

Friday Highlights

The American Enterprise Institute will be holding an expert panel discussion on the Administration's proposal to carve out FEHBP prescription benefit administration to one prescription benefits manager under contract with OPM. The discussion will be held next Wednesday November 9 at 9:15 am and you can watch it remotely on the internet.

Fortunately the AEI session does not conflict with OPM's Federal Benefits Open Season webcasts. It will however, conflict with the Senate Homeland Security and Governmental Affairs Committee's markup of the 21st Century Postal Service Act that a bipartisan group of Senators introduced on Wednesday. The American Postal Workers Union website summarizes the bill's provisions. The provisions impacting the FEHBP would

Authorize the Postal Service to enter into negotiations with the unions to develop a USPS healthcare plan inside or outside of the Federal Employee Health Benefits Program (FEHBP)., and

Require Medicare-eligible retirees to enroll in Medicare Parts A and B and require the Postal Service to develop Medigap-like plans that offer comparable benefits within the Federal Employee Health Benefits Program for retirees and their dependents [whether or not the unions agree to a USPS healthcare plan].

Tuesday's Tidbits

The U.S. Office of Personnel Management begins to hold a series of five Federal Benefits Open Season webinars beginning tomorrow. Of course the first session is an introduction to the Open Season. OPM advises that

• Each webcast will be viewable starting at 1:30pm Eastern Time. To view the webcast online, you must use a broadband (high-speed) internet connection.
• The webcast stream will become active 24 hours before the webcast is scheduled to begin. Be sure to test the webcast stream during that 24 hour window. To test the webcast stream, click on the link below.
• The link to view the webcast is http://pointers.audiovideoweb.com/stcasx/il83winlive3146/play.asx.
  • You will need Windows Media Player 9.x or higher to view the webcast.
• If you miss one of our shows, or if you need to see part of one again, you can watch a recording of each webcast at www.opm.gov/insure/openseason/videos.asp. The recordings will be posted the same day that they are broadcast.

The Centers for Medicare and Medicare Services announced the sustainable rate of growth formula driven change to Medicare Part B physician reimbursement in 2012 -- a 27.4% reduction instead of the initially estimated 29.4% reduction. The announcement explains certain adjustments that are being made to the geographic factor in the resource based relative value schedule that Medicare Part B uses. This factor has been a hot bed of litigation and contention between urban and rural areas. Also,

In the CY 2012 final rule, CMS is expanding the potentially misvalued code initiative, an effort to ensure Medicare is paying accurately for physician services and more closely managing the payment system.  This year, CMS is focusing on the codes billed by physicians in each specialty that result in the highest Medicare expenditures under the MPFS to determine whether these codes are overvalued.  In the past, CMS has targeted specific codes for review that may have affected a few procedural specialties like cardiology, radiology or nuclear medicine but has not taken a look at the highest expenditure codes across all specialties. This effort results in increased payments for primary care services that have historically been undervalued by the fee schedule.

Modern Healthcare reports on the industry's take on this annoucement. As the FEHBlog has explained, Congress has to dig the physicians out of this hole and soon.

Following up on last Thursday's post, here's a link to a better chart discussing the changes to the Medicare Parts A and B deductibles and premiums for 2012. With respect to Medicare Part A which provides inpatient coverage

The Part A deductible paid by a beneficiary when admitted as a hospital inpatient will be $1,156 in 2012, an increase of $24 from this year's $1,132 deductible.  The Part A deductible is the beneficiary's cost for up to 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay an additional $289 per day for days 61 through 90 in 2012, and $578 per day for hospital stays beyond the 90th day in a benefit period. For 2011, per day payment for days 61 through 90 was $283, and $566 for beyond 90 days. For beneficiaries in skilled nursing facilities, the daily co-insurance for days 21 through 100 in a benefit period will be $144.50 in 2012, compared to $141.50 in 2011.

Speaking of waste and abuse, Kaiser Health News reports that primary care doctors are running up the Nation's health care bill to the tune of $6.8 billion in 2009 by ordering unnecessary tests and procedures in connection with routine visits, which now are cost sharing free to patients thanks to the Affordable Care Act.

For many adults, a routine visit to a primary care physician might involve blood tests, a urinalysis, an electrocardiogram, maybe a bone density scan. Too often, however, these tests are inappropriate and they cost a bundle, according to a recent study,  not only for the health care system but also for individuals, who are increasingly footing more of the bill for their care.

The study, led by physicians from the Mount Sinai Medical Center and the Weill Cornell Medical College in New York, was published online in October in the Archives of Internal Medicine. The researchers examined the cost of common primary care practices that were identified as being overused earlier this year in a study by another group of physicians, known as the Good Stewardship Working Group.

The newest study, using data from federal medical surveys, estimated that 12 of those unnecessary treatments and screenings accounted for $6.8 billion in medical costs in 2009. The activity most frequently performed without need was a complete blood cell count at a routine physical exam. In 56 percent of routine physicals, doctors inappropriately ordered such tests, accounting for $32.7 million in unnecessary costs. In terms of dollars, the biggest-ticket item by far was physicians ordering brand-name statins before trying patients on a generic drug first: That accounted for a whopping $5.8 billion of the $6.8 billion total.

But let's wrap things up with good news, the AMA News reports, much to the medical profession's chagrin that

The number of visits patients make to physicians in a given month -- a vital sign for the whole health care economy -- has been declining consistently, according to multiple tracking studies, companies and researchers.

Analysts say those numbers may not bounce back, even with health system reform. That's because a struggling economy, higher insurance deductibles, and the efforts by health plans and others to reduce utilization have altered patient patterns, perhaps permanently. Patients now often seek office visits -- or any interaction with the health system -- only when a problem can't be ignored.

The cost curve bends down for once!