Weekend update

Happy Easter! The Senate is out of town for another week and the House of Representatives has left DC for two week. Here is a link to the Week in Congress's report on last week's activities on Capitol Hill.

The American Health Information Management Association ("AHIMA") has isssued a helpful toolkit on consumer engagement which is available here.

Here are a couple of follow-up points on recent posts:

• Health Data Management reports why the addition of 5,600 ICD-10 codes in October may not be a heavy lift for HIPAA covered entities and their business associates. This will be the first regular ICD-10 update in five years. 
• Health Data Management and Healthcare Informatics offer more details on the new round of HIPAA privacy and security rule audits being conduced by HHS's Office for Civil Rights. This round will affect 200 covered entities and for the first time business associates.  

TGIF

The Congressional Budget Office issued two significant reports yesterday -- updated budget projections and a projection of federal subsidies for people under age 65 -- both for 2016 to 2026. On Tuesday March 29, CBO will release its analysis of the President's FY 2017 budget which will reveal CBO's projections for the costs or savings associated with OPM's suggested legislative changes to the FEHBP that were included in the President's budget.

The FEHBlog has been impressed by the American Medical Association's President Steven Stack, a young emergency room doctor.  Healthcare Dive offers an interview with Dr. Stack here. Two points from the interview are worth highlighting here:

Late last month, HHS Secretary Sylvia Burwell announced a commitment among the industry, including companies that provide 90% of EHRs used by U.S. hospitals, toward creating a more user-friendly, physician-usable EHR. AMA was one of the organizations that signed the pledge. "Physicians are avid adopters of technology," Stack said but added, "Health IT is kind of late to the game as far as its sophistication and it's taken a long time to mature to the point where it's a helpful tool." 

Nearly one out of every five dollars in the U.S. economy is spent on healthcare. "In this environment, as the business has escalated in its size and the government has become an ever-larger purchaser of healthcare through programs like Medicare and Medicaid and more involved in efforts like Meaningful Use, the burden of regulations has escalated substantially," Stack said. "So the politics and the business of healthcare have put extra strain and challenge on the humanism of healthcare, which fundamentally is what most patients rely upon in their moment of deepest need."

Finally a few quick hits for this Friday afternoon:

• The Wall Street Journal reports today on a recent clinical study finding a strong correlation between calcium levels in breast and coronary arteries. The upshot is that before long mammograms also may help diagnose heart disease in women. Two for the price of one.
• Employee Benefit News provides more background on the application of gaming theories or "gamification" to wellness programs.
• The Centers for Disease Control have refreshed their National Diabetes Prevention Program website.  

Midweek Update

On Monday, we learneded that Anthem Blue Cross has sued its prescription benefits manager Express Scripts. According to the LA Times, Anthem is

alleging that the latter owes it at least $13 billion, and as much as $14.8 billion, in undelivered savings from negotiating lower prices on prescription drugs for Anthem's customers. The filing is assumed by observers to be the final break after attempts at working things out failed. Earlier this year, Anthem Chief Executive Joseph Swedish told an investment conference that his company was overpaying for drugs by $3 billion a year, and blamed Express Scripts.  Express hasn't responded to the lawsuit in court, but in statements its spokesmen have said Anthem had "mischaracterized" its obligations and that the lawsuit is "without merit."

The case was filed in federal district court in Manhattan.   Anthem is Express Scripts' largest customer.  "Industry observers believe that the lawsuit's aim may be to unwind the two companies' partnership, which is due for renewal in 2019." This is worth following.

In a more mundane bit of analysis, the Drug Channels blog comments here on Express Scripts' recent utilization report.

On Monday, the HHS Office for Civil Rights, which enforces the HIPAA Privacy and Security Rules, announced a second phase of compliance audits which will encompass not only HIPAA covered entities but also their business associates.  The announcement explains the audit process, including how companies will be selected for audit.

The Wall Street Journal reports that health systems are now investing in urgent care centers as their popularity steadily grows.  "For patients, urgent-care centers connected to a health system offer the dual benefit of convenient care and some assurance that they can be quickly transferred to an emergency room or referred to a primary-care doctor or specialist. Conversely, hospitals can steer patients in crowded ER waiting rooms to an affiliated urgent-care center nearby if it isn’t a true emergency." It will be interesting to see whether the telemedicine push will impact this urgent care center growth.

Weekend update

The House is in session this week while the Senate is out of town.  Here is a link to The Week in Congress's account of last week's actions on Capitol Hill.

Interesting Congressional Budget Office (CBO) developments for the coming week:

CBO plans to release its updated 10-year baseline projections of federal spending, revenues, and budget deficits on Thursday, March 24 [at 2 pm ET on cbo.gov). At the same time, CBO will release a separate document detailing its updated estimates of the budgetary effects of the insurance coverage provisions of the Affordable Care Act and of enrollment through health insurance marketplaces (sometimes called exchanges). 

Following up on the TGIF post about Walgreen's deal with OptumRX, Crain's Chicago reports that Walgreen's also is investing

nearly $1.2 billion to build its stake in AmerisourceBergen, a pharmaceutical wholesaler that supplies its drugstores, mail order and specialty pharmaceutical businesses. The nation's largest drugstore chain says it will own a 15 percent stake after exercising warrants to purchase 22.7 million shares.  Walgreens Boots Alliance started building that stake in 2013, when the companies entered a 10-year supply agreement. Deerfield-based Walgreens still holds warrants to buy another 22.7 million shares in AmerisourceBergen.

Last week, the Centers for Medicare and Medicaid Services (CMS) released "a new interactive map to increase understanding of geographic disparities in chronic disease among Medicare beneficiaries. The Mapping Medicare Disparities (MMD) Tool identifies disparities in health outcomes, utilization, and spending by race and ethnicity and geographic location.  Understanding geographic differences in disparities is important to informing policy decisions and efficiently targeting populations and geographies for interventions."  This tool may be helpful to FEHBP carriers which cover large cadres of annuitants.

A law school professor warned us against signing petititions or submitting letters to the editor. I generally have followed this advice since 1978.  Today however the FEHBlog signed a petition sponsored by AHIMA which encourages the Obama Administration to

Remove the federal budget ban that prohibits the U.S. Department of Health and Human Services (HHS) from participating in efforts to find a patient identification solution. We support a voluntary patient safety identifier. Accurate patient identification is critical in providing safe care but the sharing of electronic health information is being compromised because of patient identification issues.

This budget item should have been removed when Congress decided to spend $31 billion on electronic medical records, but better late than never.  The FEHBlog is signature #64.  You can sign on here.  

In other healthcare IT news,  Health Data Management reports that last week HHS named 21 members to its healthcare cybersecurity task force which was created the last December's omnibus appropriations act.  "Six of the members represent providers or health insurers, with the rest representing a range of information technology, governance and security expertise, as well as representatives of HHS, DHS and NIST." The taskforce is expecte to report to Congress before its charter expires one year from now.

TGIF

The OPM Director's blog features the government's efforts to improve its employees' eating habits during this National Nutrition Month. Oh, how the FEHBlog wishes that OPM would do a better job coordinating all of the government's wellness efforts with the FEHBP  The article links to a summer 2015 survey of government wellness programs.  84% of federal worksites offer flu shots and yet OPM hammers the FEHBP carriers to provide the vaccines.

On Monday, OPM's acting director indicated that David Vargas would be the acting OPM chief informatin officer. Head fake. Yesterday, Federal News Radio reported that "Lisa Schlosser, the deputy federal chief information officer, is heading over to the Office of Personnel Management to be the acting CIO on a short-term detail."

An email written by OPM Director Beth Cobert, which was obtained by Federal News Radio, said Schlosser also will be a senior adviser as well as acting CIO.
“I worked with Lisa for two years while I was at OMB and can tell you from personal experience that she will bring incredible talent, leadership, and a commitment to public service that will serve this agency well,” Cobert wrote in a note to staff. “I want to thank Dave Vargas for stepping in as acting CIO during this period of transition, and I am glad that he will continue to play a crucial role in OCIO as associate chief information officer. OPM’s CIO team has worked tirelessly and has made significant improvements to our information technology capabilities and security. I applaud their commitment and efforts and look forward to building on our progress in the future. Finally, I am grateful to Lisa for her willingness to continue to serve our nation by joining our talented team on an acting basis. As we work to navigate the National Background Investigations Bureau (NBIB) transition, build on our cybersecurity effort, and find the permanent CIO, Lisa will be a major asset for OPM during her detail with our team.”

OptumRx, a major prescription benefits manager, and Walgreen's Pharmacies announced a deal yesterday under which beginning in 2017 "eligible" OptumRx members will have 'the option to fill 90-day prescriptions at home delivery copay levels at any of Walgreens nearly 8,200 pharmacies nationwide or through OptumRx home delivery. " Good strategic move.

Mid-week update

Acting OPM Director Beth Cobert appeared before a House Appropriations subcommittee on Monday afternoon to discuss her agency's FY 2017 proposed budget.  The hearing, which lasted about 70 minutes, focused on the Obama adminstration's new approach to conducting background investigations and OPM's efforts to remediate the massive data breach. Here's a link to an FCW article on the latter topic.

Last month, CVS Health issued a 2015 prescription drug trends report. Yesterday the other major prescription benefits manager Express Scripts issued its 2015 trend report:

Working collaboratively with our clients, we kept the increase in drug spending to just 5.2% in 2015, roughly half the increase seen in 2014. More importantly, at a time when many plans around the country have been shifting more costs to patients via higher deductibles and out-of-pocket expenses, Express Scripts members’ average copayment decreased 3.2% last year. 

Here's a link to an Employee Benefits News interview with Express Scripts' Chief Medical Officer Steve Miller about the report.

Kudos to the Drug Channels blog for expand sharing and expanding on the FEHBlog's reservations about the Obama Administration's proposal to control Medicare Part B drug spending.

And here are a few more quick hits:

• HHS's Office for Civil Rights smacked a Minnesota healthcare provider with a $1.55 million fine for failing to comply the business associate agreement and risk assessment provisions of the HIPAA Privacy and Security Rules.
• Health Data Management reports that CMS plans to roll out thousands of new ICD-10 codes effective October 1, 2016. Oh joy. Most of them are new hospital procedure codes. 
• Modern Healthcare reports that electronic medical record systems begin to bury doctors in electronic messages as interoperability grows. Get used to it, doc.
• Employee Benefits News also interviewed the new CEO of the National Business Coalition on Health (not to be confused with the National Business Group on Health).
• The Minnesota Star Tribune reports about a small United Healthcare subsidiary Harken Health based in Chicago that sells health coverage in competition with its big sister. 

Oops I forgot

The FEHBlog forgot to mention in yesterday's Weekend Update that last Friday afternoon the ACA regulators issued their latest ACA frequently asked question ("FAQ").  In this FAQ, the ACA regulators confirmed Prof. Timothy Jost's prediction that the new but not yet final summary of benefits and coverage template will be place in use for plan years beginning on or after April 1, 2017 - in other words for the FEHBP Open Season that takes place in late 2017 for the plan year beginning January 1, 2018.  Also the ACA regulators switched the FAQ number from Roman to Arabic / regular numbering.

While the FEHBlog is on line, here are a few quick hits:

• The Wall Street Journal reports this morning that Bristol-Myers is bucking the personalized medicine tide by marketing a specialty cancer drug with an optional diagnostic test. Merck's latest personalized medicines to combat cancer require a diagnostic test before use.  Evidently, Bristol-Myers is banking on the fact that doctors who prescribe these drugs aren't crazy about taking the time to perform the diagnostic test. That's reassuring. 
• The Boston Globe's Spotlight team (featured in the Academy Award winning movie called Spotlight) is reporting on problems associated with "concurrent surgery" where one surgeon moves back and forth between two patients. Again that's reassuring. The Globe reports today that Sen. Orrin Hatch, the chairman of the Senate Finance Committee, has asked twenty hospital systems to report back to his committee on their use of concurrent surgery. Put that question down on your list for the next time you need surgery. 
• NPR reports on how hospital emergency rooms are adapting their operations to provide routine care in a welcoming environment, given the wealth of insured patients created by the ACA. 

Weekend Update

Both Houses of Congress will be in session this coming week. (honest!) A House appropriations subcommittee will consider OPM's FY 2017 budget at a hearing tomorrow afternoon at 3 pm.

The Hill reports that early next month the Senate Health Education Labor and Pensions Committee will consider a bill to speed up approval of generic drugs at the Food and Drug Administation. A slow FDA approval has been identified as a principal cause of pricing spikes in generic drugs.

Modern Healthcare reports on AHIP's recent healthcare policy conference. The FEHBlog got a kick out of this line from the article -- "The ACA has encouraged the healthcare system to work more together to reduce costs and improve clinical outcomes, but it has rarely led to consensus on policies." The next AHIP conference is the FEHBP carrier conference on March 31 and April 1 in beautiful Arlington VA. The FEHBlog will be there.

TGIF

Yesterday the Senate passed by a 94-1 margin a bill to combat opioid abuse. The Washington Post reports that 

The legislation would establish grant programs to help state and local governments improve education and treatment for drug abuse, encourage medical providers to reduce unnecessary prescriptions, commit resources to help veterans deal with addiction, and give local law enforcement and mental health officials tools to lower the death rate from overdoses. A key provision would provide states with incentives to make naloxone, which can counteract overdoses, more widely available by offering liability protections to officials who distribute it. The bill’s fate in the House remains unclear.

Earlier this week, the Centers for Medicare and Medicaid Services unveiled "a public data set that provides information on services provided to Medicare beneficiaries by skilled nursing facilities (SNFs).  The Skilled Nursing Facility Utilization and Payment Public Use File (SNF PUF) contains information on utilization, payments, and submitted charges organized by provider, state, and resource utilization group (RUG).  The data include information on 15,055 skilled nursing facilities, over 2.5 million stays, and almost $27 billion in Medicare payments for 2013."

On March 9, the Antitrust subcommittee of the Senate Judiciary Committee held an oversight hearing on the enforcement of antitrust laws. Fierce Health Payer reports that

While [Assistant Attorney General William] Baer was careful not to offer too many details about the DOJ's pending investigation of the [Cigna / Anthem and Aetna / Humana] mergers, he did offer some clues about the factors the agency is taking into account as it conducts its review. In response to a question from Chuck Grassley (R-Iowa) about whether the DOJ will consider how the mergers affect consumers' in-network provider choice, Baer noted that "If there's a reduction in quality that results from a merger--even if there's no price increase--that is a legitimate concern of merger enforcement both at the FTC and the antitrust division."

CVS Health announced this week according to Fortune Magazine that the company will spend $50 million on efforts to reduce tobacco use in the U.S. over the coming years. As evidence of its focus on good health, CVS Health took tobacco products off its retail shelves last September which resulted in a $2 billion loss in sales.

The company said on Thursday it would provide funding over five years to leading anti-tobacco and youth-oriented programs with a view to further reducing tobacco use among young people, under the name “Be the First,” a reference to the goal of making today’s youth the first tobacco-free generation. Smoking rates have sharply declined over the past decade — from 20.9% of American adults in 2005 to 16.8% in 2014, according to the Centers for Disease Control and Prevention.

Let's wrap the week up with a couple quick hits.

• Fierce Health Care offered an interesting review of studies on effective approaches to reducing hospital readmissions. 
• Fierce Health Finance reported that hospitals "throw out about $3 billion worth of oncology drugs each year unused." The problem evidently stems from the fact that manufacturers put too much cancer medicine in a single use vial. 

Some drugs, such as bortezomib, used to treat multiple myeloma, comes only in 3.5 milligram vials in the United States, even though 2.5 milligrams is the standard dose. Some $309 million in annual sales are attributed to the discarded doses. But 1 milligram vials of the drug are available in the United Kingdom.

The study noted that not every cancer drug creates such a quandary of waste; bendamustine, which is used to treat leukemia, comes in a wide array of vials, which means that about 1 percent of that drug is wasted every year.

 

Midweek update supplement

Whoops, I realized today that the Senate is in session this week. The Hill reports that the Senate is tearing apart the House's mental health reform bill, which is a shame in the FEHBlog's view. The House is out of town.

Stat reports on an HHS report on prescription drug spending which accompanied the Medicare Part B drug spending control initiative announcement yesterday. Needless to say cost curve up.  In this regard, Drug Channels discusses the top 15 speciality pharmacies here.

In a Benefits listserv message on Monday, OPM announced  at least to the FEHBlog's surprise that

This Listserv is a follow up to BAL 14-205 dated April 14, 2014 and BAL 15-206 dated September 28, 2015, concerning the Federal Employees Health Benefits (FEHB) Program Family Member Audit).  BAL 15-206, advised that OPM contracted with HMS Federal Solutions to perform the audit.  The purpose of this ListServ is to inform you that the audit is postponed indefinitely.   OPM will notify the agencies when we are prepared to move forward.

Also on Monday, OPM awarded the FSA Feds administration contract to WageWorks. Presumably the change from ADP to WageWorks will take effect on 1-1-2017. Here is a link to the WageWorks press release.  

In other government contracting news, HHS gave a two year contract to Accenture for the purpose of establishing "a framework of best practices for the effective use of patient-generated health data (PGHD) [e.g. Fitbit results] in research and care delivery." MobiHealth's report on the contract adds that

The preference for remote doctor visits is increasing too: 29 percent said they prefer virtual visits to in-person ones with their doctors. That's up from 24 percent in 2014. The benefits of remote visits are apparent to both consumers and doctors. Lower costs are one such benefit, according to 58 percent of consumers and 62 percent of doctors, while convenience is a benefit, according to 52 percent of consumers and 80 percent of docs. Timely access to care was cited as a benefit of virtual care by 42 percent of consumers and 49 percent of physicians.

Midweek update

The Washington Times reports that before heading out of town the Chairman and minority leader of the House Oversight and Government Affairs Committee sent a letter to the Senate asking the Senate approve the nomination of Beth Cobert to be OPM Director.

Yesterday, the Centers for Medicare and Medicaid Services announced a proposal to control drug costs in Medicare Part B.  Medicare Part B covers doctor administered drugs which tend to be more expensive that the drugs that patients pick up at the local pharmacy or receive by mail and self administer.  The Wall Street Journal reports that "the proposal is meeting stiff opposition from the pharmaceutical industry and some providers—especially cancer centers where many high-price specialty drugs are used—because of the proposed drop in reimbursement."  This looks like another major cost shift from Medicare to the employer sponsored and exchange plans is brewing.  In this regard, and to reinforce an ongoing FEHBlog leitmotif, take a look at this AHIP Coverage article, "It's not the cost of health care, it's the price" that's the problem. Also with regard to these Medicare intiatives, read this Health Data Management report from the HIMSS conference that health care providers are concerned about the pace of the shift to value based compensation.

Fierce Health Payer reports on an academic study published in Health Affairs cautioning insurers about the growing use of retail clinics typically based in pharmacies.  But as a practical matter what are insurers expected to do as the cat is out of the bag.

Modern Healthcare informs us that Health Affairs includes another study which estimates the high cost of provider reporting of quality measures -- time that otherwise could be spent with patients.

Researchers at Weill Cornell Medical College in New York City teamed up with the Medical Group Management Association to put a price on the time providers spend to enter the data into the electronic health record, keep track of newly introduced measures and create protocols to track and report them.
The answer is about $15.4 billion a year, according to their study published Monday in the health policy journal Health Affairs.
That's “a large amount of money being wasted on checking this box and that box,” said lead study author Dr. Lawrence Casalino, chief of the division of health policy and economics at the Weill Cornell Medical College in New York City. “It's time physicians could spend on not rushing a patient, or thinking about a diagnosis more carefully.”

This study emphasize the importance of health plan implementation of the recent CMS-AHIP collaborative consensus on core quality measures. 

Weekend update

Congress is out of town this coming week. Here's a link to the Week in Congress's account of last week's activities.

Speaking of last week's activities, here's a link to Healthcare IT News' summary of major events at the HIMSS conference, which focuses on healthcare technology.

The New York Times offered an interesting piece on wellness programs this morning. The upshot of the article is that "adjusting people’s health insurance premiums is not a good way to motivate them to lose weight. Such incentives need to be designed better." OPM is asking Congress for that authority.  The article discusses ways to craft effective programs with incentives that are separated from the insurace premiums.

Modern Healthcare reports on healthcare provider CEO reactions to healthcare mergers and acquisitions activity which has been brisk.

Although 72% of the surveyed healthcare leaders said they believe government scrutiny will grow regardless of who wins the White House, it won't deter executives from pursuing transactions they deem beneficial. “The market forces, quite frankly, have been unleashed, [by the Affordable Care Act] and they are going to move regardless of what happens in the presidential election,” [one executive] said.

TGIF

OPM announced today steps to boost federal hiring to address the Zika virus. The OPM blog post notes that

Like all Americans, Federal employees who plan to travel for business or personal reasons in the upcoming weeks and months may be understandably concerned. My advice is to visit the State Department and Centers for Disease Control and Prevention’s (CDC) Travelers' Health websites for the most updated travel information. This CDC website also details preventive measures you can take to protect yourself against Zika if you do plan to travel to one of the affected areas. The locations with ongoing Zika virus transmission are likely to change over time, so be sure to check back to these websites before each trip you are planning to take.

Several years back, the New York Attorney General successfully took up the cudgel against health insurer use of the commonly used out of network fee "reasonable and customary" fee schedule then in use.  According to a Fierce Pharma report, that Attorney General now is tangling with health insurers over Hepatitis C drug coverage. The Attorney General believes that eligibility for the expensive drugs should include members who are in the chronic / asymptomatic as well as the acute / sympotomatic stage of the disease.

Unsurprisingly, the health insurance industry is not pleased about the recent probe. The New York AG's subpoena "is overly broad and does not take into account evolving guidance related to these new therapeutic classes of drugs," Leslie Moran, a spokeswoman for the industry group New York Health Plan Association, told the news outlet.  And some of the blame should be placed on drugmakers, rather than insurers, Moran said. The latest investigation "does not take into consideration the impact of excessive and unsupported pricing of these drugs--which has a negative impact on affordability of coverage," Moran said, as quoted by Bloomberg.

The FEHBlog will be following this fight.

The FEHBlog is interested in genomic developments.  The Wall Street Journal this morning included an interesting opinion piece by two medical specialists titled "Genetics and Mental Illness - Let's not get carried away." It's worth a read.  

Mid week update

Following up on Monday's post about the final HHS 2017 benefits and payment parameter notice (to be published in the March 8 Federal Register), Prof. Tim Jost published three blog entries -- here, here, and here where you can find out everything about this annual monster notice.  For FEHBP purposes, the key aspect of the notice is that the maximum out of pocket limits for group health plans in 2017 will be $7,150 for self only coverage and $14,300 for other than self only coverage. The current limits are $6,850 for self only coverage and $13,700 for other than self only coverage. Most of notice applies to the ACA marketplace plans.

The New York Times reports on the resurgence of HMO plans in the ACA marketplaces. The new HMOs typically feature lower cost sharing, no primary care gatekeeper to limit access to specialists, and a narrow provider network.

[P]atients must sacrifice choice for the promise of lower costs and managed care, whether the plan is called an H.M.O., an A.C.O. or a narrow network. Insurers are able to get low prices for care when they can offer doctors and hospitals a large volume of patients, and providers say they need to have more control over where their patients can get care if they are going to be responsible for costs and the long-term quality of care.

That's a logical product of the ACA.

OPM's call letter included several points on Rx benefits, including speciality drugs and medication adherence, Business Insurance lead me to this 2016 Pharmacy Benefit Management Institute Report on  Specialty Drugs (sponsored by Walgreen's). If you want a copy, you'll have to register with PBMI.  The FEHBlog nearly fell off his chair when he read on Medpage Today that

Getting physicians to focus on patients' medication adherence may result in more patients taking their medicines, but it does not necessarily lead to improved health outcomes, a small pilot study has found.

Wow.

Finally, Physicians' Briefing reports that according to a New England Journal of Medicine study hospital readmissions are down since the ACA began imposing readmission penalties on hospitals. What's more, "After implementation of the ACA there was no significant correlation between changes in observation-unit stays and readmissions, within hospitals."