Weekend Update

Both Houses of Congress are in session this week as the snow continues to melt here in the D.C. metropolitan area.  At 9 a.m. on Thursday February 4 the full House Oversight and Government Reform Committee will hold an oversight hearing on developments in the prescription drug market. An hour later the Senate Homeland Security and Governmental Affairs Commitee will hold a confirmation hearing on the President's nomination of Beth Cobert to be permanent OPM Director. 

A week from Tuesday on February 9, the President will release his budget for the 2017 federal fiscal year.  This, of course, will be the final budget proposal of his Adminstration.

The Wall Street Journal offered an interesting financial insight yesterday -- that health savings accounts (HSA) offer better tax savings than its retirement plan cousin, the 401(k) plan.  The Thrift Savings Plan is federal employment analog to 401(k) plans.  Contributions to HSAs and 401(k) plans typically are not subject to federal income taxation. If you pull money out of a 401(k) plan to cover medical costs in retirement, the withdrawal is subject to federal income taxation.  However, if you pull that money out of an HSA, the withdrawal is exempt from federal income taxation. Of course, medical costs are a major expense for retirees. The catch is that you have to build up the HSA account balance before you turn 65 because you can't contribute to an HSA when you have Medicare.  All federal employees or annuitants receive Medicare Part A when they turn 65.  A few years ago, a group of federal employees sued the federal government for permission to opt out of Medicare Part A in order to continue to contribute to their HSAs offered by their FEHB plans (without also losing teir Social Security benefits). They lost. 

A friend pointed out to the FEHBlog this New England Journal of Medicine blog called Catalyst.  A recent Catalyst blog post captioned "My Patients Won't Do What They are Supposed to Do" caught my eye

The spotlight has shifted from provider reliability to patient outcomes — the improvement of which is, after all, the real goal of health care. This means the goal of performance analysis is not to judge providers, but instead to assess what is happening to the health of their patients. And if the answer to that question is “Not much,” clinicians have some explaining to do.

Whatever happened to personal responsibility?

TGIF

The snow continues to melt and a warming trend begins tomorrow.  That's good news.

On the bad news front, the New York Times ran an investigative piece this morning on drug shortages afflicting hospitals and the Federal Times tells us that the GAO is concerned the the federal government's multi billion dollar Einstein data protection system is still not up to snuff.

On the too early to tell front, the Centers for Medicare and Medicaid Services announced today

[proposed] rules, as required by the Medicare Access and CHIP Reauthorization Act (MACRA), will allow organizations approved as qualified entities to confidentially share or sell analyses of Medicare and private sector claims data to providers, employers, and other groups who can use the data to support improved care. In addition, qualified entities will be allowed to provide or sell claims data to providers.

The qualified entity program was authorized by Section 10332 of the Affordable Care Act and allows organizations that meet certain qualifications to access to patient-protected Medicare data to produce public reports. Qualified entities must combine the Medicare data with other claims data (e.g., private payer data) to produce quality reports that are representative of how providers and suppliers are performing across multiple payers, for example Medicare, Medicaid, or various commercial payers. Currently, 13 organizations have applied and received approval to be a qualified entity.  Of these organizations, two have completed public reporting while the other 11 are preparing for public reporting. 

Finally the Drug Channels Institute produced a list of the top 15 U.S. pharmacies by dispensing revenues. The top three are CVS/Caremark (22.8%), Walgreen's (14.9%), and Express Scripts (11%). The top 15 pharmacies generate 73.4% of the total dispensing revenue -- $364.1 billion. That's a lot of dough.

Midweek Potpourri

OPM issued a press release today concerning the opportunity for employees to convert from self and family to self plus one coverage during the month of February.  OPM has to create this special opportunity because employees make their contributions toward FEHB coverage with pre-tax dollars.  Annuitants and other enrollees who make their contributions with after tax dollars can drop down an enrollment level at any time.

Modern Healthcare published an article yesterday contending that Sen. Tom Carper's postal reform bill would "push" Postal Service annuitants aged 65 and older into Medicare. Hey Modern Healthcare, those annuitants already are in Medicare for the most part.  Senator Carper's bill would better integrate FEHBP with Medicare, which is an objective that OPM shares.  It's not punitive, and the savings would benefit the Postal Service and Postal service employees and annuitants.

Govexec.com is reporting that the Obama Administration is mobilizing to stop the spread of the Zika virus.  The University of Connecticut, the FEHBlog's alma mater, offered an illuminating article this morning concerning that virus which has "dengue fever like symptoms.

Should people be worried?
Once Brazilian officials learned about the link between Zika virus and microcephaly, they took the unprecedented action of advising women in the most affected areas to avoid or delay pregnancy. The Brazilian outbreak has now spread to a number of countries in South and Central America, including the Caribbean, and more recently, Mexico, and thus cases of microcephaly in these areas are also likely to start rising in the next few months. Even in Brazil, as infected pregnant mothers continue to reach full term, these numbers are expected to increase. That has led the Centers for Disease Control (CDC) to recently issue travel advisories to the countries battling the outbreak. So at this very moment, unless you have traveled or are planning to travel to these areas while pregnant, you should not be worried. 

Do you see Zika becoming widespread in the U.S.? If so, how soon?
In the U.S., a dozen cases of human infection have been reported, but so far they have all been acquired abroad. The potential for what we call autochthonous, or local, transmission exists, because the Aedes mosquitos that are required to transmit the virus are present in the U.S., particularly in the southeast. Locally acquired cases of Zika virus infection have been reported in Mexico and Puerto Rico, so the potential for active transmission in the U.S., particularly as summer approaches, is real. The World Health Organization (WHO) now estimates that all countries in the Americas, with the exception of continental Chile and Canada, where Aedes mosquitos are not found, will likely have outbreaks. As an example, Hawaii is currently battling an outbreak of dengue fever in the Big Island transmitted by Aedes mosquitos. But in general, any outbreaks in the U.S. will be restricted to areas where Aedes mosquitos are found, and careful surveillance, vector control, and other preventive practices such as use of insect repellent, should minimize their effects.

Tuesday's Tidbits

Snowzilla pushed back Beth Cobert's confirmation hearing before the Senate Homeland and Governmental Affairs Committee to next Thursday February 4 at 10 am.  

Employee Benefits Advisor offers a list of ten regulatory issues to watch in 2016. For example, did you know that beginning next year employers will be obligated to furnish W-2 forms to both employees and the Internal Revenue Service by January 31? Apparently the current approach which allows the employer to furnish the form by January 31 and submit the form to the IRS by March 31 encourages fraud.  Take a peak. 

The Hill reports that federal spending on health care programs, e.g., Medicare, Medicaid, ACA subsidies, was higher tha federal spending on Social Security in 2015. (FYI, FEHBP is an employee benefit, not a federal health, program.)  This result was a historical first but the FEHBlog doubts that this result will be an outlier.  

Snowzilla aftermath

Well the weather forecasters were correct on this snow storm. It was a doozy as evidenced by the backyard of the FEHBlog's house this morning.

The federal government is shutdown tomorrow. The House of Representatives is punting all votes to next week and the Senate is holding off on votes until Wednesday. It is not clear whether or not Ms. Cobert's confirmation hearing will be held as scheduled on Tuesday. Here's a link to the Hill's article on the hearing.

The FEHBlog nearly fell out his breakfast nook when he read this Wall Street Journal article yesterday. Due to overuse of antiobiotics, medical reseachers are turning to an old school cure called bateriophages.

Little known among doctors in the West, phages have been part of the antibacteria arsenal in countries of the former Soviet Union for decades. Doctors in the U.S. and much of Europe stopped using phages to fight bacteria when penicillin and other antibiotics were introduced in the 1940s. Now, though, Western scientists are turning back to this Stalin-era cure to help curb the dramatic growth of bacterial resistance to antibiotics.

Heavens knows what the drug manufacturers will charge for this specialty drug.

Snowzilla Day 1

The Washington Post's Capital Weather Gang has nicknamed the ongoing winter storm Snowzilla so the FEHBlog will go with that moniker. The snow started early afternoon today and is expected to continue until early Sunday morning.

Earlier today,  OPM announced a number of administation reforms to its personnel background check process in reaction to the massive breach of background check records last year.  A new OPM unit will continue to manage the process while the Defense Department will operate the information technology systems. Here's a link to a Govexec article with reactions to the announcement.

Yesterday the Senate Homeland Security and Governmental Reform Committee held a postal reform hearing. A Federal News Radio account of the hearing can be found here.  The Committee's ranking minority member, Sen. Tom Carper from Delaware, has been pushing postal reform legislation. With respect to health benefits, Sen. Carper observed in his opening statement that

The most important of these provisions [which the Committee has debated over the years"] address health care costs at the Postal Service, and the fact that the agency is the single largest payer into Medicare yet can’t get full value from the program. I’ve put forward legislation both last year with our former colleague Dr. Coburn and this year with Senators McCaskill, Moran, and Blunt that would allow the Postal Service to do what private business do when they coordinate their retiree health plans with Medicare.  This has the potential to virtually eliminate the unfunded liability for retiree health benefits and save the Postal Service $32 billion over 10 years.

Carper's iPOST bill would create a Postal Service Health Program within the FEHBP. The PSHP would be fully integrated with Medicare as the Senator indicates.

The FEHBlog also noticed on the Committee's website that on January 26 at 10 am (assuming Snowzilla does not interfere) the Committee will be holding a hearing on the President's nomination of Beth Cobert to be the permanent OPM director.

Pre-snowmadgeddon update

The weather forecasters here in DC are predicting a big snowstorm for the weekend. Preparing for the storm can be more disruptive than the storm itself.  In any event,  following up on a couple of items mentioned recently in the FEHBlog:

• Health Care IT News reports on HHS's effort to provide more details on its plans to transition the meaningful use program which the medical community detests to a new program "focused on care" rather than electronic medical record clicks. 
• HHS announced reductions in the number of special event that allow people to enroll in ACA exchange plans outside of the ACA Open Season which ends  on January 31.  
• Senate leadership announced its plans to pass several "small bore" bills in lieu of the House's titantic 21st Century Cures Act. The FEHBlog certainly favors small bore legislation as a general rule. 

JAMA Internal Medicine reported on a study concluding that

Simply increasing a deductible, which gives enrollees skin in the game, appears insufficient to facilitate price shopping. Members of HDHP and traditional plans are equally likely to price shop for medical care, and they hold similar attitudes about health care prices and quality. Despite considerable focus on increasing price transparency, HDHP enrollees express interest in greater access to health care price information.

Healer heal thyself. It's up to the medical community to provide more price transparency.  

Happy King Day!

The Senate will be in session on Capitol Hill this week following the holiday while the House of Representatives is hold a district work week.

Here are a few insightful pieces to consider:

• A Wall Street Journal article blames humanity for cybersecurity problems. 

"History has shown us we aren’t going to win this [cybersecurity] war by changing human behavior. But maybe we can build systems that are so locked down that humans lose the ability to make dumb mistakes. Until we gain the ability to upgrade the human brain, it’s the only way."

• Kaiser Health News reports that the Affordable Care Act is spurring the development of  new markets, e.g., ACA, Medicare, Medicaid, for a form of concierge medicine known as "direct primary care." 

"In direct primary care, patients pay about $100 a month or less directly to the physician for comprehensive primary care, including basic medication, lab tests and follow-up visits in person, over email and by phone. The idea is that doctors, who no longer have to wade through heaps of insurance paperwork, can focus on treating patients. They spend less on overhead, driving costs down. In turn, physicians say they can give care that’s more personal and convenient than in traditional practices.

"The 2010 health law, which requires that most people have insurance, identifies direct primary care as an acceptable option. Because it doesn’t cover specialists or emergencies, consumers need a high-deductible health plan as well. Still, the combined cost of the monthly fee and that plan is often still cheaper than traditional insurance.

"The health law’s language was “sort of [an] ‘open-for-business’ sign,” said Jay Keese, a lobbyist who heads the Direct Primary Care Coalition. Before 2010, between six and 20 direct primary care practices existed across the country. Now, there are more than 400 group practices."

•  Modern Healthcare in response to the President's State of the Union call for a cure to cancer reports on the state of cancer research.  Good read. 

TGIF

Here's a link to the Week in Congress's useful review of activities on Capitol Hill.

Federal News Radio posted an article on the upcoming limited open season in the month of February that will allow federal employees another opportunity to switch to self plus one.  Annuitants can always drop down an enrollment type. The FEHBlog was intrigued by these Open Season transaction statistics provided by OPM:

2015 — 709,556
2014 — 434,853
2013 — 421,553
2012 — 304,439

OPM advised that around 1,000,000 FEHB enrollees were in a position to elect self plus one. Even assuming that some of these folks switched to self plus one and another plan concurrently, one would have expected at least 300,000 more transaction in the 2015 Open Season. It does take a while for changes to take hold in large programs like this one.

Let's end the week with some good news.  According to this NPR article, "the teen pregnancy rate has halved since its peak in 1990, declining in all 50 states and among all racial and ethnic groups."  That is a public health victory.

Mid-week update

The Obama Administration announced in evident response to the Robert Pear article discussed in the latest Weekend Update that it would be tightening up the rules for enrolling in the ACA exchange plans outside of the ACA open season according to the Wall Street Journal. The power of the press in action.

In other Obama Administration news, Health Care IT News reports that the Centers for Medicare and Medicaid services plan to replace their unloved meaningful use program with a new pay for performance program intended to win over the hearts and minds of the medical community. The meaningful use program was the consideration for the $30 billion that the federal government used to fund electronic medical record systems for health care providers which don't communicate with each other.

In other healthcare IT news, MedCity News reports on the recent demise of HealthSpot a telehealth kiosk operator that had appeared to be gaining traction with pharmacies and healthcare systems.

Competitors are not exactly celebrating the failure of HealthSpot. “I am actually not happy at all about the demise of HealthSpot,” said Dr. Roy Schoenberg, CEO of American Well. He lauded the company for demonstrating through its partnerships with the likes of Rite Aid, Cleveland Clinic and others that there is value in remote care. * * *
Schoenberg, for one, does not believe the kiosks were HealthSpot’s Achilles’ Heel, since AmericanWell also offers a kiosk option. “Our kiosks have actually been a very fast-growing part of the business,” he said. A bigger issue, according to Schoenberg, is that HealthSpot required patients and providers to pre-arrange appointments; it was not truly telemedicine on demand. “You actually have to build a lot of administration around it,” he said.

The Wall Street Journal reported that prescription drug manufacturer have continued their practice of jacking up prices around the beginning of the new year. For example,

Since New Year’s Day, Pfizer has raised list prices an average of 10.6% for more than 60 branded products with annual U.S. sales of at least $10 million, according to Deutsche Bank. Prices for eight of the products went up at least 20%. Pfizer also left prices unchanged for about 10 products.

No bueno.

FCW.com reports that the FBI and DHS have released an unclassified report full of "recommended security practices [evidently] based on the OPM breach."  The report is informative but does not provide a link to the report.

Finally seekingalpha.com reports that Aetna and Anthem independently have stated their corporate expectations that their mergers with Humana and Cigna, respectively, remain on track to close later this year.

Weekend update

Interesting weekend, all of the home teams in the NFL wild card playoffs lost, including the FEHBlog's team, the Washington Redskins.  Time marches on.

Congress is in session this week. The FEHBlog was cheered to find that the Hill is again printing its summary of events that will be occuring on Capitol Hill this week, such as the President's final State of the Union address.

For decades, the FEHBP had Open Seasons with no pre-existing conditions. There were limited opportunities during the calendar year to enroll. There was no penalty for waiving coverage. The system has worked smoothly.  The ACA adopted the same approach. Nevertheless, the FEHBlog expected that there would be implementation bumps in the road because it was a much larger diverse population with a penalty for not signing up. And there were. But one expected bump that didn't show up was outrage by people with health problems who needed to enroll outside of the ACA Open Season but couldn't.  Robert Pear of the New York Times reported yesterday that

Eager to maximize coverage under the Affordable Care Act, the Obama administration has allowed large numbers of people to sign up for insurance after the deadlines in the last two years, destabilizing insurance markets and driving up premiums, health insurance companies say. * * * 

The National Association of Insurance Commissioners, representing state officials, is troubled by the trend.

“State regulators are concerned that consumers are not required to provide documentation to substantiate their eligibility for a special enrollment period,” the association said in a letter to the federal Department of Health and Human Services. “We know of many cases where individuals with serious medical conditions purchased coverage midyear by simply checking the right box or using the right language, and their eligibility was not questioned.”

There you go.

TGIF

The House of Representatives joined the Senate in voting to repeal fundamental provisions of the Affordable Care Act, such as the individual and employer mandates and related taxes, on Wednesday and the President vetoed the bill today. The particulars may be found in the latest Week in Congress report. According to that report, the House will vote on overriding the veto on January 26. The vote again illustrates the importance of the Presidential election later this year.

Nextgov.com reports that

When a foreign power as early as 2013 first hacked the Office of Personnel Management and retrieved IT manuals for its network, swept up in the heist were the usernames and the last four digits of the Social Security numbers of certain system users. That detail was not disclosed to lawmakers until Thursday [at a House Oversight and Government Reform Committee hearing].  Federal officials had always maintained the attackers -- who would go on to nab 21.5 million background check records last year -- never obtained personally identifiable information during the first breach.  

That's a bit of a stunner considering the number of Congressional hearing on the breach that were conducted last summer. More hearing details are available at the Committee's website.  The Committee clearly is distraught.

HHS's Office for Civil Rights issued a compendium of guidance on patient and health plan member access to their records held by health care providers and insurers.

Fierce Health Care offers health care system executives predictions for 2016 that are worth a glance. The executives should take a look at this Reuters report that hospital discharge instructions are too complicated for most patients to understand.

Patient reading level didn’t appear to influence the odds of returning to the hospital within a month of discharge or the likelihood that they would call the hospital with questions, the study found. But often, when these things happened, the patient had a reading level too low to understand the discharge notes.

Back to the drawing board on that one.

Have a good weekend and go Washington Redskins.  

Midweek update

A pending matter of interest for 2016 is the pending mergers between two sets of major health insurers -- Aetna and Humana on the one hand and Anthem and Cigna on the other.  Business Insurance reports that the stockholders of the four companies have approved the respective merger agreements. Nevertheless, either agreement could be derailed by federal and state regulators conducting anti-trust reviews.

This “isn't just a ballgame” for the [U.S.] Justice Department, explained David Balto, a Washington-based antitrust lawyer and former policy director for the Federal Trade Commission. State insurance commissioners will be reviewing the mergers and will likely take a “tough stance,” Mr. Balto said. ***  Most sources said it's unclear what the Justice Department will decide to do. It is likely to be a long negotiation process, and if negotiations fall apart, the health insurers may go to court with the department to force a decision or they could call the deals off.

The FEHBlog ran across two article which illustrate the impact that Medicare has on healthcare:

• The New York Time Upshot discusses how a change to Medicare's reimbursement policy for inpatient confinements, which occurred 30 years ago, has reduced hospital stays, a factor which contributed to to the hospital readmission problem.  
• A contributor to the Hill explains why giving Medicare the power to purchase prescription drugs is a bad idea. The same considerations apply to OPM's idea to assume control over FEHBP prescription drug benefits. 

And in an interesting twist, Modern Healthcare reports that

Healthspan, the [Ohio-based] insurance arm of Catholic health system Mercy Health [and an FEHBP carrier], is getting rid of its medical group and halting sales of Affordable Care Act policies just two years after acquiring Kaiser Permanente's Ohio subsidiary

The move represents a failure of one health system trying to replicate the much-heralded Kaiser model of healthcare, which integrates the payment and delivery sides. HealthSpan has been severely hurting the finances of Mercy Health, and executives felt they had to address “the operational challenges,” according to recent financial documents. 

Happy New Year

Tomorrow everyone, including the FEHBlog, returns to work for a full work week following the year end holidays.  The FEHBlog has a spring in his step because his Washington Redskins are headed into the NFL playoffs with a winning record after two woeful seasons.  Consequently there is not much to report FEHBlog-wise.

What's goodies does the ACA bring for 2016?

• Under the ACA, all of the U.S. Preventive Services Task Force A and B recommendations must be offered by FEHB carriers in-network with cost sharing if the recommendation was made before January 1, 2015. Here's the list.  The 2014 recommendations become cost-free on January 1 in the FEHB when rendered in-network.  The earlier recommendations already were cost free. 
• Also for 2016, all FEHB plans will have self only out of pocket maximums embedded in self plus one and self and family coverages.
• FEHB plans will be providing their enrollees with IRS Form 1095-B to document enrollee and covered family member compliance with the ACA's individual shared responsibility mandate.  The current IRS deadline for furnishing the 2015 form is March 31, 2016.  The forms should be maintained with your tax records in case the IRS has questions.  The ACA requires plans to send one form to the enrollee. If the enrollee has adult children covered under his FEHBP coverage, he or she should provide a copy of the Form 1095-B to each of those separate taxpayers.  

The FEHBlog was amused by the lengthy Washington Post article about the future of the stethoscope.