Pay & Benefits

OPM calls for quality and transparency in healthcare negotiations

The Office of Personnel Management is about to begin negotiations for health insurance providers that cover employees under the Federal Employee Health Benefits program, and the agency is looking for carriers to improve their transparency tools and make a concerted effort to support high-quality care, according to the Feb. 11 call letter sent to providers.

According to an OPM official that spoke to Federal Times about the call letter, the agency wants health insurance carriers to ensure that they aren’t just covering health services and medications, but that the things they do cover are actually providing quality care to federal employees.

“We are, this year, emphasizing to carriers that they need to look at their benefits to ensure that they are not providing or paying for low-value care. And we define that in a variety of ways: it’s healthcare with a high risk of harm versus benefit, it’s generally considered inefficient or frankly inappropriate, or where there are more cost-effective alternatives,” the official said.

Each year, the call letter specifies markers of quality care that OPM are looking for carriers to cover. This year, the agency is focused on coverage for chronic conditions such as diabetes, access to prenatal care and an assurance that carriers are using their resources wisely, in addition to ongoing priorities for the Trump administration.

“We believe FEHB carriers have an increasing role to play in addressing the nation’s opioid epidemic. We’re pleased with some of the progress we’ve seen so far, but we want our carriers to continue to put emphasis on ensuring access to treatment to those that might have an opioid use disorder, and also on the front end to ensure that there are appropriate measures in place to minimize overutilization and educate providers on appropriate utilization,” the official said, adding that carriers should also be active in tobacco cessation programs.

“We feel like carriers can do more to educate the providers in their networks about the availability of that benefit and also to make sure that enrollees are aware of that benefit.”

Similarly mirroring the Trump administration’s nationwide policies, OPM wants its health insurance carriers to place a stronger emphasis on cost transparency.

“This year we’re emphasizing making more information available on online directory tools,” the official said. “We hear a lot of news about surprise billing, and that’s something that we’re concerned about. And one of the ways that surprise bills happen is when people go to an in-network facility but maybe not realize that not all of the doctors are in network.”

Part of ending surprise billing entails calling on carriers to cover inpatient and observation visits equally, as patients often don’t know the difference between the two, and being called in for one versus the other can have significant differences in cost.

Though they’ve long worked with carriers to provide enrollees with transparency about drug costs, OPM officials want those carriers to go one step further by providing healthcare providers with prescription pricing data, so that doctors can talk to federal patients upfront about the cost of the drug they plan to prescribe.

OPM has also turned its focus on drug affordability specifically to genetic therapies for 2021, which can often prove to be some of the most expensive prescriptions. The agency wants carriers to particularly take a look at options for biosimilar drugs, which are designed to closely resemble the original drug.

Carriers will also be asked to put a maximum cap on coinsurance for prescription drugs, ensuring employees that they will never have to pay more than that amount for their medication.

“Usually under a high-deductible health plan, you pretty much have to pay out of pocket up to the deductible before the insurance kicks in. However, there has for some time been an exception for preventative services,” the official said.

That definition of preventative services was expanded in recent years, and OPM said they want carriers to look at expanding their list of covered preventative services that do not trigger a deductible.

OPM will go into negotiations with insurance carriers in the spring and summer of this year to determine what offerings are ultimately announced in early fall and available to feds for 2021 coverage.

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