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PrintHealth Care Reform, Part III
Dr. Jesse Hsieh
As Heath Care Reform moves towards reality, regulators will define 10 Essential Benefits –the basic medical services that health plans must cover under the law.
There are 10 categories of care that plans must provide for customers of the health-insurance starting in 2014. On the surface, as you can see in the list below, it seems sensible. Ahhh, but with anything governmental, the devil’s in the details, and the law leaves those details up to regulators who are now starting to develop the rules.
The bottom line: if it’s not on the list, it may not be paid for. Get ready for the biggest lobbying fight yet, which started in March of this year.
Insurers and other groups are lobbying intensely with the Institute of Medicine, which has been charged by the Department of Health and Human Services to make recommendations on what “Essential Benefits” mean. The Institute has received over 330 comments from groups including insurers, patient advocates and medical professionals.
America's Health Insurance Plans, an industry trade group, is telling regulators that costs will rise if insurers have to cover too many specific services without limits. Insurers want to keep the categories as broad as possible so they have flexibility in designing benefits packages.
The medical organizations are asking to be more specific and coverage limits to be lifted. The American Academy of Pediatrics has said, "All of it needs to be spelled out because if it isn't spelled out it can be denied.”
Here are the 10 general categories of benefits and questions on which services in each will be covered. There are examples of some that will cause a lot of debate as regulators develop the rules governing insurance plans:
Ambulatory patient services
Physicals, paps, mammograms, immunizations, all will be included, but at what ages? (Remember, the big controversy about when to do mammograms?) Some argue that varicose vein treatment is not an essential need.
Emergency services
Nonemergency care administered in the ER: How will non-emergent care be defined? Is anything that could have been taken care of in an office not an emergency? How will the patient know -- Like when chest pain is due to anxiety?
Hospitalization
Total hip replacement and any surgeries that do not prolong life or save lives. Bariatric surgery, and even cardiac surgery and stenting are all are being examined for cost-effectiveness.
Maternity and newborn care
Fertility treatments are controversial. Will birth control treatments be affected, like tubal ligations? What about severely premature babies?
Mental health and substance-abuse disorders
There are questions over the length of stay limitations in a facility.
Prescription drugs
"Lifestyle" medications such as Viagra, brand name versus generic choices: Will we have a government preferred drug list?
Rehabilitative and habilitative services and devices
Limitations on physical therapy, and especially treatment of habilitative care.
Laboratory services
Biometric testing, including genetic markers or DNA analysis.
Preventative and wellness services and chronic disease management
Nutritional counseling and dieticians. When can we do colonoscopies and bone densities?
Pediatric services, including oral and vision care
Braces, glasses, dental and allergy care.
The debate over what habilitative services to include in the new rules is a good example of trying to define what health benefits are truly essential.
Rehabilitation helps patients recover skills they have lost. An example would be a small child sustaining a head injury and losing their speech. This would require rehabilitation and is considered essential.
Habilitation helps patients acquire new skills. There is a lot of controversy over this being defined as an essential benefit. Habilitation can take years, can be costly and difficult to define, and insurers haven't typically covered them, labeling them educational or experimental. Take for example a young child diagnosed with autism who has not yet learned how to speak. He would require habilitation. These services could also be used to help children with cerebral palsy learn to walk, children with Down syndrome to acquire language skills or people with schizophrenia to learn basic social skills.
So…in the new plans, who will decide what is considered an essential service?
Regulators, within the government, are empowered by the new legislative directives to make the decisions. The list is huge, the lobbyists are many, and the opportunity for shenanigans and someone getting left out is great. Picking on varicose vein providers, if they had a huge lobbying organization and showered attention and dollars to this process while the allergists sat back, will we all have great veins but swollen stuffy heads and wonder why?
