Federal Employees Health Benefits Program Research Articles

Addressing insurance-related barriers to novel antiobesity medications: Lessons to be learned from bariatric surgery.

The past decade has witnessed significant progress in the development of new antiobesity medications, with several having greater efficacy than pharmacological agents previously approved by the Food and Drug Administration (FDA). Despite the potential of new medications to combat America's obesity crisis, access to these agents is severely limited. This Perspective presents the current coverage landscape for antiobesity medications, including the recent requirement by the US Office of Personnel Management for Federal Employees Health Benefits Program carriers to offer adequate coverage of FDA-approved antiobesity medications, and it makes parallels with conditions that made expanded insurance coverage for bariatric surgery possible, as well as emphasizes the need for additional action by the legislature and the Centers for Medicare and Medicaid Services to expand coverage of evidence-based obesity treatments.

The Massachusetts Infertility Insurance Mandate: not nearly enough

To assess the impact of statutory federal and state exceptions to the state law mandating insurance coverage for the diagnosis and treatment of infertility. Population-based cross-sectional study comprised of reproductive-age women (defined herein as 20-44 years of age) who resided in Massachusetts during the 2016-2019 interval. Statutory exemptions to the benefits afforded by the Massachusetts Infertility Insurance Mandate were identified in the Massachusetts General Laws as well as in the United States Code. Not applicable. Publicly available, deidentified, population-level data pertaining to state-based reproductive-age women (aged 20-44 years) were procured for the 2016-2019 interval. Data sources included the Massachusetts Census Bureau, Massachusetts Center for Health Information and Analysis, US Department of Defense, and US Office of Personnel Management. None. The proportion of state-based reproductive-age women who constitute beneficiaries of the Massachusetts Infertility Insurance Mandate after accounting for the applicable state and federal statutory exemptions that limit its impact. Public health plans (Medicare, MassHealth [state Medicaid], TRICARE, and the Federal Employees Health Benefits Program) are exempted from the Massachusetts Infertility Insurance Mandate by dint of federal or state statute. Self-insured employer-sponsored health plans are exempted from the Massachusetts Infertility Insurance Mandate by dint of the federal Employee Retirement Income Security Act. It follows that only 26.2%-36.0% of state-based reproductive-age women comprised eligible beneficiaries of the Massachusetts Infertility Insurance Mandate over the 2016-2019 interval. Contrary to commonly held views, multiple statutory exemptions to the Massachusetts Infertility Insurance Mandate render a significant proportion of state-based reproductive-age women ineligible for its cognate benefits. We propose herein that the Essential Health Benefit categories of the Affordable Care Act be expanded by the US Congress to include infertility care services.

Evzio maker agrees to pay $12.7 million in false claims and kickbacks case

Last week, Virginia‐based pharmaceutical manufacturer kaléo Inc. agreed to resolve allegations that it caused the submission of false claims for the drug Evzio, a naloxone product used to reverse opioid overdose. The Department of Justice also charged the company with providing kickbacks to prescribers. Evzio was the highest‐priced version of naloxone on the market, and insurers frequently required the submission of prior authorization requests before they would approve coverage for Evzio. “The United States contends that, between March 14, 2017 and April 30, 2020, kaléo directed doctors prescribing Evzio to send prescriptions to certain preferred pharmacies that in turn submitted false claims for Evzio to Medicare, the TRICARE program and the Federal Employees Health Benefits Program. In particular, the pharmacies allegedly submitted false and misleading prior authorization requests for Evzio and dispensed Evzio without collecting or attempting to collect co‐pays from government beneficiaries. The United States contends that kaléo knew of, or deliberately ignored, this pharmacy misconduct but nevertheless kept directing business to these pharmacies.” The government also alleged that “Evzio sales representatives provided doctors' offices with frequent deliveries of food and beverages, as well as occasional holiday gifts, even when there was no connection to any educational or other business event.” “When a pharmaceutical manufacturer knowingly engages with bad actors, they hurt the federal healthcare system — and they can expect us to see it,” said Acting United States Attorney Nathaniel R. Mendell. “Today's settlement is our latest signal to pharmaceutical manufacturers that my office does not tolerate health care fraud and will continue to pursue enforcement.”

Effect Of Population Size On Rural Health Insurance Premiums In The Federal Employees Health Benefits Program.

In the study of health insurance access and affordability in rural areas, a recurring issue is to understand the challenges that programs based upon the competitive market model, such as the Affordable Care Act's Marketplaces, may experience in less populated areas. This article analyzes data for 2013-16 from the Federal Employees Health Benefits Program, focusing on premium and enrollment data for "state-specific" plans-which offer insurance policies and set premiums at the regional level. In nonmetropolitan counties, each additional plan enrollee was associated with a $0.10 lower per capita biweekly premium, whereas this effect was trivial in metropolitan counties. Low health care provider counts were not associated with higher premiums in nonmetropolitan areas, nor was the degree of insurer competition an important predictor of premiums. However, there was substantial correlation over time, which suggests that some variables may be viewed less as sources of premium variation and more as influencing long-term premium levels. These findings suggest that small risk pools may contribute to the challenges faced by private plans in rural areas, in which case risk reinsurance is a potential policy solution.

The pathophysiology of extracellular hemoglobin associated with enhanced oxidative reactions.

Hemoglobin (Hb) continuously undergoes autoxidation producing superoxide which dismutates into hydrogen peroxide (H2O2) and is a potential source for subsequent oxidative reactions. Autoxidation is most pronounced under hypoxic conditions in the microcirculation and for unstable dimers formed at reduced Hb concentrations. In the red blood cell (RBC), oxidative reactions are inhibited by an extensive antioxidant system. For extracellular Hb, whether from hemolysis of RBCs and/or the infusion of Hb-based blood substitutes, the oxidative reactions are not completely neutralized by the available antioxidant system. Un-neutralized H2O2 oxidizes ferrous and ferric Hbs to Fe(IV)-ferrylHb and OxyferrylHb, respectively. FerrylHb further reacts with H2O2 producing heme degradation products and free iron. OxyferrylHb, in addition to Fe(IV) contains a free radical that can undergo additional oxidative reactions. Fe(III)Hb produced during Hb autoxidation also readily releases heme, an additional source for oxidative stress. These oxidation products are a potential source for oxidative reactions in the plasma, but to a greater extent when the lower molecular weight Hb dimers are taken up into cells and tissues. Heme and oxyferryl have been shown to have a proinflammatory effect further increasing their potential for oxidative stress. These oxidative reactions contribute to a number of pathological situations including atherosclerosis, kidney malfunction, sickle cell disease, and malaria. The toxic effects of extracellular Hb are of particular concern with hemolytic anemia where there is an increase in hemolysis. Hemolysis is further exacerbated in various diseases and their treatments. Blood transfusions are required whenever there is an appreciable decrease in RBCs due to hemolysis or blood loss. It is, therefore, essential that the transfused blood, whether stored RBCs or the blood obtained by an Autologous Blood Recovery System from the patient, do not further increase extracellular Hb.

Employer contribution and premium growth in health insurance

We study whether employer premium contribution schemes could impact the pricing behavior of health plans and contribute to rising premiums. Using 1991–2011 data before and after a 1999 premium subsidy policy change in the Federal Employees Health Benefits Program (FEHBP), we find that the employer premium contribution scheme has a differential impact on health plan pricing based on two market incentives: 1) consumers are less price sensitive when they only need to pay part of the premium increase, and 2) each health plan has an incentive to increase the employer's premium contribution to that plan. Both incentives are found to contribute to premium growth. Counterfactual simulation shows that average premium would have been 10% less than observed and the federal government would have saved 15% per year on its premium contribution had the subsidy policy change not occurred in the FEHBP. We discuss the potential of similar incentives in other government-subsidized insurance systems such as the Medicare Part D and the Health Insurance Marketplace under the Affordable Care Act.

Parity and Out-of-Pocket Spending for Children With High Mental Health or Substance Abuse Expenditures

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act required health plans to provide mental health and substance use disorder (MH/SUD) benefits on par with medical benefits beginning in 2010. Previous research found that parity significantly lowered average out-of-pocket (OOP) spending on MH/SUD treatment of children. No evidence is available on how parity affects OOP spending by families of children with the highest MH/SUD treatment expenditures. We used a difference-in-differences study design to examine whether parity reduced families' (1) share of total MH/SUD treatment expenditures paid OOP or (2) average OOP spending among children whose total MH/SUD expenditures met or exceeded the 90th percentile. By using claims data, we compared changes 2 years before (1999-2000) and 2 years after (2001-2002) the Federal Employees Health Benefits Program implemented parity to a contemporaneous group of health plans that did not implement parity over the same 4-year period. We examined those enrolled in the Federal Employees Health Benefits Program because their parity directive is similar to and served as a model for the new federal parity law. Parity led to statistically significant annual declines in the share of total MH/SUD treatment expenditures paid OOP (-5%, 95% confidence interval: -6% to -4%) and average OOP spending on MH/SUD treatment (-$178, 95% confidence interval: -257 to -97). This study provides the first empirical evidence that parity reduces the share and level of OOP spending by families of children with the highest MH/SUD treatment expenditures; however, these spending reductions were smaller than anticipated and unlikely to meaningfully improve families' financial protection.

Parity: An Ongoing Challenge and Research Opportunity

Parity: An Ongoing Challenge and Research Opportunity

The Effects of Mental Health Parity on Spending and Utilization for Bipolar, Major Depression, and Adjustment Disorders

The Mental Health Parity and Addiction Equity Act requires insurance parity for mental health/substance use disorder and general medical services. Previous research found that parity did not increase mental health/substance use disorder spending and lowered out-of-pocket spending. Whether parity's effects differ by diagnosis is unknown. The authors examined this question in the context of parity implementation in the Federal Employees Health Benefits (FEHB) Program. The authors compared mental health/substance use disorder treatment use and spending before and after parity (2000 and 2002, respectively) for two groups: FEHB enrollees diagnosed in 1999 with bipolar disorder, major depression, or adjustment disorder (N=19,094) and privately insured enrollees unaffected by the policy in a comparison national sample (N=10,521). Separate models were fitted for each diagnostic group. A difference-in-difference design was used to control for secular time trends and to better reflect the specific impact of parity on spending and utilization. Total spending was unchanged among enrollees with bipolar disorder and major depression but decreased for those with adjustment disorder (-$62, 99.2% CI=-$133, -$11). Out-of-pocket spending decreased for all three groups (bipolar disorder: -$148, 99.2% CI=-$217, -$85; major depression: -$100, 99.2% CI=-$123, -$77; adjustment disorder: -$68, 99.2% CI=-$84, -$54). Total annual utilization (e.g., medication management visits, psychotropic prescriptions, and mental health/substance use disorder hospitalization bed days) remained unchanged across all diagnoses. Annual psychotherapy visits decreased significantly only for individuals with adjustment disorders (-12%, 99.2% CI=-19%, -4%). Parity implemented under managed care improved financial protection and differentially affected spending and psychotherapy utilization across groups. There was some evidence that resources were preferentially preserved for diagnoses that are typically more severe or chronic and reduced for diagnoses expected to be less so.

Federal Employees Health Program Experiences Lack Of Competition In Some Areas, Raising Cost Concerns For Exchange Plans

The Affordable Care Act calls for creation of health insurance exchanges designed to provide private health insurance plan choices. The Federal Employees Health Benefits Program is a national model that to some extent resembles the planned exchanges. Both offer plans at the state level but are also overseen by the federal government. We examined the availability of plans and enrollment levels in the Federal Employees Health Benefits Program throughout the United States in 2010. We found that although plans were widely available, enrollment was concentrated in plans owned by just a few organizations, typically Blue Cross/Blue Shield plans. Enrollment was more concentrated in rural areas, which may reflect historical patterns of enrollment or lack of provider networks. Average biweekly premiums for an individual were lowest ($58.48) in counties where competition was extremely high, rising to $65.13 where competition was extremely low. To make certain that coverage sold through exchanges is affordable, policy makers may need to pay attention to areas where there is little plan competition and take steps through risk-adjustment policies or other measures to narrow differences in premiums and out-of-pocket expenses for consumers.

Economic Grand Rounds: The Price Is Right? Changes in the Quantity of Services Used and Prices Paid in Response to Parity

The impact of parity coverage on the quantity of behavioral health services used by enrollees and on the prices of these services was examined in a set of Federal Employees Health Benefit (FEHB) Program plans. After parity implementation, the quantity of services used in the FEHB plans declined in five service categories, compared with plans that did not have parity coverage. The decline was significant for all service types except inpatient care. Because a previous study of the FEHB Program found that total spending on behavioral health services did not increase after parity implementation, it can be inferred that average prices must have increased over the period. The finding of a decline in service use and increase in prices provides an empirical window on what might be expected after implementation of the federal parity law and the parity requirement under the health care reform law.

Expanding Choice through Defined Contributions: Overcoming a Non-Participatory Health Care Economy

The fate of the Patient Protection and Affordable Care Act of 2010 is uncertain. Much of the opposition is grounded in popular hostility to expansive federal control over individuals' health care decision-making. But the new law reinforces existing third-party payment, primarily through employers and government programs. This financing already restricts personal choice of health plans and coverage options. Private employers, managed care executives, and public officials make the key spending decisions in health care. Unlike consumers in other sectors of the economy, individuals are mostly passive spectators. Normal market dynamics do not exist, and consumer choice is frustrated. Curiously, public programs, such as the Federal Employees Health Benefits Program (FEHBP), the Medicare Advantage Program, and the Medicare Part D Drug program, are the main exceptions to the norm. In these programs, individuals control the flow of dollars over the purchase of health plans. In crucial areas such as access to care and benefits, cost control, quality, and patient satisfaction, these programs have a strong record. By realigning health reform with the primacy of personal choice, and building on the experience of these programs, policymakers can expand consumer control through defined-contribution financing. Specifically, Congress can replace the existing tax regime for commercial private health insurance with a national tax credit system, provide generous financial assistance for the poor, and transform Medicare into a "premium support" program.

Using Multiple Control Groups and Matching to Address Unobserved Biases in Comparative Effectiveness Research

Studies of large policy interventions typically do not involve randomization. Adjustments, such as matching, can remove the bias due to observed covariates, but residual confounding remains a concern. In this paper we introduce two analytical strategies to bolster inferences of the effectiveness of policy interventions based on observational data. First, we identify how study groups may differ and then select a second comparison group on this source of difference. Second, we match subjects using a strategy that finely balances the distributions of key categorical covariates and stochastically balances on other covariates. An observational study of the effect of parity on the severely ill subjects enrolled in the Federal Employees Health Benefits (FEHB) Program illustrates our methods.

Regulating a Health Insurance Exchange: Implications for Individuals With Mental Illness

Under the newly enacted health reform law, millions of lower- and middle-income Americans will purchase individual or family health insurance through state-based markets for private health insurance called insurance "exchanges," which consolidate and regulate the market for individual and small-group health insurance. The authors consider options for structuring choice and pricing of health insurance in an exchange from the perspective of efficiently and fairly serving persons with mental illness. Exchanges are intended to foster choice and competition. However, certain features-open enrollment, individual choice, and imperfect risk adjusters-create incentives for "adverse selection," especially in providing coverage for persons with mental illness, who have higher overall health care costs. The authors review the experience of persons with mental illness in insurance markets similar to the exchanges, such as the Massachusetts Connector and the Federal Employees Health Benefit Program, and note that competition among health plans for enrollees who are "good risks" can undermine coverage and efficiency. They review the possible approaches for contending with selection-related incentives, such as carving out all or part of mental health benefits, providing reinsurance for some mental health care costs, or their preferred option, running the exchange in the same way that an employer runs its employee benefits and addressing selection and cost control issues by choice of contractor. The authors also consider approaches an exchange could use to promote effective consumer choice, such as passive and active roles for the exchange authority. Regulation will be necessary to establish a foundation for success of the exchanges.

A Bayesian Two-Part Latent Class Model for Longitudinal Medical Expenditure Data: Assessing the Impact of Mental Health and Substance Abuse Parity

In 2001, the U.S. Office of Personnel Management required all health plans participating in the Federal Employees Health Benefits Program to offer mental health and substance abuse benefits on par with general medical benefits. The initial evaluation found that, on average, parity did not result in either large spending increases or increased service use over the four-year observational period. However, some groups of enrollees may have benefited from parity more than others. To address this question, we propose a Bayesian two-part latent class model to characterize the effect of parity on mental health use and expenditures. Within each class, we fit a two-part random effects model to separately model the probability of mental health or substance abuse use and mean spending trajectories among those having used services. The regression coefficients and random effect covariances vary across classes, thus permitting class-varying correlation structures between the two components of the model. Our analysis identified three classes of subjects: a group of low spenders that tended to be male, had relatively rare use of services, and decreased their spending pattern over time; a group of moderate spenders, primarily female, that had an increase in both use and mean spending after the introduction of parity; and a group of high spenders that tended to have chronic service use and constant spending patterns. By examining the joint 95% highest probability density regions of expected changes in use and spending for each class, we confirmed that parity had an impact only on the moderate spender class.

Managed Care Firms Sue to Stop Federal Parity Law

Managed Care Firms Sue to Stop Federal Parity Law

Psychiatrists Lobby Congress on Health Reform, Privacy Issues

Psychiatrists Lobby Congress on Health Reform, Privacy Issues

2009 Public Policy Agenda Reflects Member Input

You have accessThe ASHA LeaderASHA News1 Dec 20082009 Public Policy Agenda Reflects Member InputResearch Funding, Autonomy for Audiologists, IDEA Funding Are High Priorities for ASHA James Potter James Potter Google Scholar More articles by this author https://doi.org/10.1044/leader.AN2.13172008.28 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In More than 1,000 ASHA members—20% more than responded last year—provided comments to help shape the association’s public policy agenda for 2009. The comments were reviewed by ASHA’s Government Relations and Public Policy (GRPP) Board, which develops an annual list of priorities for advocacy. The Board of Directors accepted the 2009 agenda at its October meeting. Implementation of the agenda may be somewhat delayed by the upcoming presidential transition and the new 111th Congress, as government agencies await possible changes in the fiscal year 2009 federal budget and deliberations on an additional stimulus package for the banking and auto industries. However, DeAnne Wellman Owre, ASHA’s vice president for government relations and public policy, noted that “implementation of various successes in the 2008 public policy agenda is likely to keep our government relations teams and volunteer leaders very busy through at least the first half of 2009.” These successes include instituting the Medicare Part B private practice status (direct billing) for speech-language pathologists; participation in reporting of quality measures under the Medicare Physician Quality Reporting Initiative (PQRI); work on at least two ongoing studies on alternatives to the Medicare therapy caps; and work on expanded coverage for hearing aids and speech-generating devices under the Federal Employees Health Benefits Program. Each objective was assigned to one of the following categories: Highest Priority—requires immediate federal or state legislative or regulatory attention and major ASHA resources. Priority—is important to ASHA members; activities to be determined as opportunity and resources permit. Monitoring—is relevant to the ASHA members, but will be acted upon only when specific opportunities arise or conditions change member needs and priorities. Planning—requires concerted planning to develop specific objectives. Within each category, the order of the objectives is not a reflection of their relative level of importance or resources expended. In addition, placement of these objectives may be adjusted as the course of Congress, state legislatures, or federal and state agencies change. Highest Priority Objectives Higher education and research funding. Promote state/federal financial aid policies and research funding opportunities, while collaborating with state agencies/communication sciences and disorders programs to support recruitment and retention of master’s and doctoral students and clinicians in education and health care settings. Autonomy for audiologists. Promote audiologists’ autonomy through direct patient access and comprehensive coverage of audiology services under Medicare. IDEA funding. Support increased funding of the Individuals with Disabilities Education Act and the following goals: establishment of effective service delivery and manageable workloads to maximize student outcomes; participation in early intervening activities using the Response-to-Intervention model (Part B) and increased access to appropriate early intervention services (Part C); increased professional development through dissemination of information about research-based practices in speech-language pathology and audiology. The GRPP Board members responsible for the agenda are Linda Tepperman (chair), Martin Audiffred, Craig Champlin, Linda Jacobs-Condit, Roberta Kreb, Joan Mele-McCarthy, Ninevah Murray, J. Timothy O’Neill (public member), Carolyn Wiles Higdon, DeAnne Wellman Owre (monitoring vice president), and James Potter (ex officio). ASHA’s complete 2009 public policy agenda is available on the ASHA Web site. Author Notes James Potter, director of government relations and public policy, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 13Issue 17December 2008 Get Permissions Add to your Mendeley library History Published in print: Dec 1, 2008 Metrics Current downloads: 54 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2008 American Speech-Language-Hearing AssociationLoading ...

Critical

Critical

Use of Substance Abuse Codes Growing Under Medicaid

Use of Substance Abuse Codes Growing Under Medicaid