ESSENTIAL HEALTH BENEFITS
BALANCING COVERAGE AND COST
Cheryl Ulmer, John Ball, Elizabeth McGlynn, and Shadia Bel Hamdounia, Editors
Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans
Board on Health Care Services
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL PRESS
Washington D.C.
www.nap.edu
___________
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
This study was supported by Contract No. HHSP 23320042509XI, Task Order HHSP23337027T between the National Academy of Sciences and the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-21914-3
International Standard Book Number-10: 0-309-21914-0
Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2012 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press.
___________
___________
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON DEFINING AND REVISING AN ESSENTIAL HEALTH
BENEFITS PACKAGE FOR QUALIFIED HEALTH PLANS
JOHN R. BALL (Chair), Former Executive Vice President, American Society for Clinical Pathology
MICHAEL S. ABROE, Principal and Consulting Actuary, Milliman, Inc.
MICHAEL E. CHERNEW, Professor of Health Care Policy, Harvard Medical School
PAUL FRONSTIN, Director, Health Research & Education Program, Employee Benefit Research Institute
ROBERT S. GALVIN, Chief Executive Officer, Equity Healthcare, Blackstone Group
MARJORIE GINSBURG, Executive Director, Center for Healthcare Decisions
DAVID S. GUZICK, Senior Vice President for Health Affairs, and President, UF&Shands Health System, University of Florida
SAM HO, Executive Vice President and Chief Medical Officer, UnitedHealthcare
CHRISTOPHER F. KOLLER, Health Insurance Commissioner, State of Rhode Island
ELIZABETH A. McGLYNN, Director, Kaiser Permanente Center for Effectiveness & Safety Research
AMY B. MONAHAN, Associate Professor, University of Minnesota Law School
ALAN R. NELSON, Internist-Endocrinologist
LINDA RANDOLPH, President and Chief Executive Officer, Developing Families Center
JAMES SABIN, Clinical Professor, Departments of Psychiatry and Population Health, Harvard Medical School, and Director, Harvard Pilgrim Health Care Ethics Program
JOHN SANTA, Director of Consumer Reports Health Ratings Center, Consumer Reports
LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California
JOE V. SELBY, Executive Director, Patient-Centered Outcomes Research Institute
SANDEEP WADHWA, Chief Medical Officer and Vice President of Reimbursement and Payer Markets, 3M Health Information Systems
Study Staff
CHERYL ULMER, Study Director
SHADIA BEL HAMDOUNIA, Research Associate
CASSANDRA L. CACACE, Research Assistant
ASHLEY McWILLIAMS, Senior Program Assistant (through July 2011)
ROGER C. HERDMAN, Director, Board on Health Care Services
This Page is blank
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Linda Burnes Bolton, Cedars-Sinai Medical Center
Troyen Brennan, CVS Caremark
Jon Gabel, National Opinion Research Center, University of Chicago
Neal Gooch, Utah Insurance Department
Jonathan H. Gruber, Massachusetts Institute of Technology
Gail Gibson Hunt, National Alliance for Caregiving
Michael M. E. Johns, Emory University
Timothy S. Jost, Washington and Lee University School of Law
Robert Krughoff, Center for the Study of Services
Eric Larson, Group Health Research Institute
Jerry Elizabeth Malooley, Benefit Programs and Health Policy for the State of Indiana
Wendy K. Mariner, Boston University School of Public Health
Debra L. Ness, National Partnership for Women and Families
Peter Neumann, Tufts University School of Medicine
Sara Rosenbaum, The George Washington University School of Public Health and Health Services
Alice Rosenblatt, AFR Consulting, LLC
Joshua M. Sharfstein, Department of Health and Mental Hygiene, State of Maryland
Gail Wilensky, Project HOPE
Matthew Wynia, American Medical Association
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Christine K. Cassel, American Board of Internal Medicine and Donald M. Steinwachs, Johns Hopkins University. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Foreword
The Patient Protection and Affordable Care Act marks a milestone on a path toward substantially reducing the number of uninsured and underinsured individuals in this nation. The lack of health insurance is harmful to health, and equity in access to needed health care is one measure of a just society. But in creating the conditions for expanded insurance coverage, how, exactly, should one go about deciding what to include as essential in a health insurance plan?
This Institute of Medicine report Essential Health Benefits: Balancing Coverage and Cost answers this question. The Patient Protection and Affordable Care Act sets out parameters and guidance that serve as a point of departure and a constant reference for the committee’s deliberations. This report lays out criteria and methods to define and update the essential health benefits package. The committee’s recommendations aim at promoting evidence-based practices and prudent stewardship of resources. They encourage innovation and suggest ways to remain sensitive over time to evolving public preferences for coverage. This study was initiated at the request of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services, and we sincerely hope the report will prove useful in the implementation of broader insurance coverage.
I am grateful for the support of our sponsors and to the committee, led by John Ball, which grappled with the complexity of balancing coverage needs of individuals and the sustainability of the essential health benefits package. Their work was reinforced by staff working under the direction of Cheryl Ulmer and including Shadia Bel Hamdounia, Cassandra Cacace, and Ashley McWilliams. I commend both committee and staff for this product and believe it provides a sound basis for the defining, and future refining, of an essential health benefits package.
| Harvey V. Fineberg, M.D., Ph.D. | |
| President, Institute of Medicine | |
| July 2011 |
This Page is blank
Preface
A critical element of the Patient Protection and Affordable Care Act (ACA) is the set of health benefits—termed “essential health benefits” (EHB)—that must be offered to individuals and small groups in state-based purchasing exchanges and the existing market. If the package of benefits is too narrow, health insurance might be meaningless; if it is too broad, insurance might become too expensive. The Institute of Medicine (IOM) Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans concluded that the major task of the Secretary of the Department of Health and Human Services (HHS) in defining the EHB will be balancing the comprehensiveness of benefits with their cost.
Not surprisingly, the work of this committee drew intense public interest. Opportunity for public input was offered through testimony at two public hearings and through the Web. The presentations at the hearings reinforced for the committee the difficulty of the task of balancing comprehensiveness and affordability. On the one hand, groups representing providers and consumers urged the broadest possible coverage of services. On the other, groups representing both small and large businesses argued for affordability and flexibility. The committee thus viewed its principal task as helping the Secretary navigate these competing goals and preferences in a fair and implementable way.
The ACA sets forth only broad guidance in defining essential health benefits, and that guidance is ambiguous—some would say contradictory. First, the EHB “shall include at least” 10 named categories of health services per Section 1302. Second, the scope of the EHB shall be “equal to the scope of benefits provided under a typical employer plan.” Third, there are a set of “required elements for consideration” in establishing the EHB, such as balance and nondiscrimination. Fourth, there are several specific requirements regarding cost sharing, preventive services, proscriptions on limitations on coverage, and the like. Taken together, these provisions complicate the task of designing an EHB package that will be affordable for its principal intended purchasers—individuals and small businesses.
The committee’s solution is this: build on what currently exists, learn over time, and make it better. That is, the initial EHB package should be a modification of what small employers are currently offering. All stakeholders should then learn enough over time—during implementation and through experimentation and research—to improve the package. The EHB package should be continuously improved and increasingly specific, with the goal that it is based on evidence of what improves health and that it promotes the appropriate use of limited resources. The committee’s recommended modifications to the current small employer benefit package are (1) to take into account the 10 general categories of the ACA; (2) to apply committee-developed criteria to guide aggregate and
specific EHB content and the methods to determine the EHB; and (3) to develop an initial package within a premium target.
Defining a premium target, which is a way to address the affordability issue, became a central tenet of the committee. Why the Secretary should take cost into account, both in defining the initial EHB package and in updating it, is straightforward: if cost is not taken into account, the EHB package becomes increasingly expensive, and individuals and small businesses will find it increasingly unaffordable. If this occurs, the principal reason for the ACA—enabling people to purchase health insurance and thus covering more of the population—will not be met. At an even more fundamental level, health benefits are a resource, and no resource is unlimited. Defining a premium target in conjunction with developing the EHB package simply acknowledges this fundamental reality. How to take cost into account became a major task. The committee’s solution in the determination of the initial EHB package is to tie the package to what small employers would have paid, on average, for their current packages of benefits in 2014, the first year the ACA will apply to insurance purchases in and out of the exchanges. This “premium target” should be updated annually, taking into account trends in medical prices, utilization, new technologies, and population characteristics. Since, however, this does little to stem health care cost increases, and since the committee did not believe the HHS Secretary had the authority to mandate premium (or other cost) targets, the committee recommends a concerted and expeditious attempt by all stakeholders to address the problem of health care cost inflation.
An additional task was related to that part of the committee’s charge directing it to examine “medical necessity.” Medical necessity is a means by which insurers and health plans determine whether it is appropriate to reimburse a specific patient for an eligible benefit. For example, the insurance contract may specify that diabetes care is a covered benefit; whether it is paid for depends on whether that care is medically necessary for the particular patient—whether, for example, the patient has diabetes. The committee believes that medical necessity determinations are both appropriate and necessary and serve as a context within which the EHB package is developed by a health insurer into a specific benefit design and that benefit design is subsequently administered. The committee favors transparency both in the establishment of the rules used in making those determinations and in their application and appeals processes. Indeed, since the design and administration of health benefits rather than the scope of benefits themselves are what appear to differentiate small employer plans from each other and from large employer plans, monitoring benefit design and administration is an important step in the learning process and updating of the EHB.
Further, the committee states that a goal of the updated EHB package is that its content becomes more evidence-based. The committee wishes to emphasize the importance of research about the effectiveness of health services and to emphasize that the results of this research, including costs, should be taken into account in designing the EHB package. New and alternative treatments, in the view of the committee, should meet the standard of providing increased health gains at the same or lower cost.
Since the committee saw balancing comprehensiveness and affordability as the Secretary’s major task, it also recognized that any such balancing affected, and was affected by, individual and societal values and preferences. Thus, the committee recommends that both in the determination of the initial EHB package and in its updates, structured public deliberative processes be established to identify the values and priorities of those citizens eligible to purchase insurance through the exchanges, as well as members of the general public. Such processes will enhance both public understanding of the tradeoffs inherent in establishing an EHB package and public acceptance of what emerges.
The committee recommends that the Secretary develop a process that facilitates discovery and implementation of innovative practices over time. A key source for this information will come from what states are observing or enabling in their own exchanges. Moreover, the committee recommends that for states that operate insurance exchanges, requests to adopt alternatives to the federal essential health benefits package be granted only if they are consistent with ACA requirements and the criteria specified in the report and they are not significantly more or less generous than the federal package. State packages also should be supported by meaningful public input.
The committee hopes that its work will be useful in assisting the Secretary of HHS to determine and update the essential health benefits and that its deliberations will be informative to the public. As with most issues of
importance, the committee’s work involved balancing tradeoffs among competing interests and ideas. We hope this work is a positive step toward effective implementation of a key provision of the ACA.
On a personal note, the chair wishes to thank the committee members for their tireless efforts in the work of the committee. In the chair’s experience, the input—extensive and intensive—of the committee members is unprecedented. When qualified people of good intent, of whatever political persuasion, come together for a common purpose, the process is full of learning and enjoyable. Thus it was with this committee, and I thank its members for the experience. In addition, no work of this sort can be done without a highly qualified professional staff. On behalf of the committee, the chair thanks Cheryl Ulmer and her staff for their efforts to capture the substance of the committee’s deliberations, their provision of the most detailed background material, and their logistical acumen, especially in designing the public hearings.
John R. Ball
Chair
Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans
September 2011
This Page is blank
Acknowledgments
The committee and staff are grateful for many individuals and organizations who contributed to the success of the report. Many thanks go to the numerous individuals to whom staff spoke before and during the study process, as well as those who submitted responses to the committee’s online comment form and other materials. In addition, the committee wants to thank those who testified before it during the two public workshops:
Jessica Banthin, Agency for Healthcare Research and Quality
Carmella Bocchino, America’s Health Insurance Plans
Meg Booth, Children’s Dental Health Project
David Bowen, The Bill & Melinda Gates Foundation
Virginia Calega, BlueCross BlueShield Association
Arnold Cohen, American Congress of Obstetricians and Gynecologists
Rex Cowdry, Maryland Health Care Commission
Helen Darling, National Business Group on Health
Jina Dhillon, National Health Law Program
James Dunnigan, Utah State House of Representatives
Cindy Ehnes, California Department of Managed Health Care
John Falardeau, American Chiropractic Association
Linda Fishman, American Hospital Association
Marty Ford, The Arc and United Cerebral Palsy Disability Policy Coalition
Jean Fraser, San Mateo County Health System
Brian Gallagher, American Pharmacists Association
Alan Garber, Stanford University Center for Health Policy
Andrew George, California Department of Managed Health Care
Jonathan Gruber, Massachusetts Institute of Technology and the National Bureau of Economic Research
Gerald Harmon, American Medical Association
Mark Hayes, Greenberg Taurig, LLP
Leah Hole-Curry, Washington State Health Technology Assessment Program
Carolyn Ingram, Center for Health Care Strategies
Louis Jacques, Centers for Medicare & Medicaid Services
Jeffrey Kang, CIGNA Corporation
Jon Kingsdale, Wakely Consulting
Sharon Levine, The Permanente Medical Group
Jerry Malooley, U.S. Chamber of Commerce
Robert McDonough, Aetna
Maureen McKennan, California Department of Managed Health Care
Sean Morrison, National Palliative Care Research Center
Robert Murphy, American Society of Plastic Surgeons
Samuel Nussbaum, WellPoint
Kavita Patel, University of California, Los Angeles (UCLA) Semel Institute
Susan Philip, California Health Benefits Review Program
Joseph Piacentini, Employee Benefits Security Administration, Department of Labor (DOL)
Andrew Racine, American Academy of Pediatrics
Sara Rosenbaum, George Washington University School of Public Health and Health Services
Somnath Saha, Portland VA Medical Center and Oregon Health Services Commission
Matthew Salo, The National Governors Association
Beth Sammis, Maryland Insurance Administration
Paul Samuels, Legal Action Center and Coalition for Whole Health
Cathy Schoen, The Commonwealth Fund
David Schwartz, Senate Finance Committee
Thomas Sellers, National Coalition for Cancer Survivorship
Jeanene Smith, Office of Oregon Health Policy and Research
Richard Smith, Pharmaceutical Research and Manufacturers of America
Katy Spangler, U.S. Senate Committee on Health, Education, Labor, and Pensions
Stuart Spielman, Autism Speaks
Peter Thomas, Consortium for Citizens with Disabilities
Jeffery Thompson, Washington State Department of Social and Health Services
Michael Turpin, USI Insurance Services
Gary Ulicny, The Shepherd Center
Barbara Warren, Consumers United for Evidence-Based Healthcare
Kenneth B. Wells, David Geffen School of Medicine, UCLA
William Wiatrowski, Bureau of Labor Statistics, DOL
Bruce Wolfe, Obesity Action Coalition
Anthony Wright, Health Access California
Troy Zimmerman, National Kidney Foundation
Funding for this study was provided by the Assistant Secretary for Planning and Evaluation (ASPE). The committee appreciates ASPE’s support for this project and would like to especially thank Sherry Glied, Richard Kronick, Caroline Taplin, Lee Wilson, and Pierre Yong for their expertise and guidance on the project.
Lastly, many individuals within the Institute of Medicine were helpful throughout the study process, including Clyde Behney, Daniel Bethea, Patrick Burke, Marton Cavani, Greta Gorman, Laura Harbold, Abbey Meltzer, Elisabeth Reese, Vilija Teel, Stephanie Tioseco, and Lauren Tobias. We would also like to thank Florence Poillon for assisting in copyediting this report. Christine Stencel of the National Academies’ Office of News and Public Information provided substantial support in preparing for the public release of this consensus report and its companion workshop report; Rachel Marcus of the National Academies Press helped facilitate the publication of both manuscripts.
Contents
Status of Current Health Insurance Coverage
Impact of the EHB Across Insurance Programs
Stakeholder Decisions Will Reshape Health Insurance Markets
2 APPROACHES TO DETERMINING COVERED BENEFITS AND BENEFIT DESIGN
Understanding Contributors to Costs
Illustrative Approaches to Coverage Decisions
Finding the Meaning of Essential
10 Categories of Care vs. Typical
Understanding Typical Specificity in Scope of Benefits
Typical Employer: Small vs. Large
Step 1: Develop the Starting Point
Step 2: Incorporate Cost into the Development of the Initial EHB
Step 3: Reconcile Initial List to the Premium Target
Step 4: Issue Guidance on Inclusions and Permissible Exclusions
Committee Recommendation on Defining the EHB
Other Areas for the Secretarial Guidance Related to the EHB
Components of Public Deliberation Processes
Examples of Public Participation and Deliberative Processes
Summary of Guidelines for Public Participation
7 PROGRAM MONITORING AND RESEARCH
Setting a Research Framework for Data Collection and Analysis
Program Monitoring and Research
8 ALLOWANCE FOR STATE INNOVATION
Flexibility in Determining the EHB
Criteria for Approving a State-Specific EHB Definition
ACA Direction to the Secretary on Updating the EHB
Considering Typical Employer in the Future
Methods for Incorporating Costs into Updates to the EHB
Consequences for the EHB and ACA of Failing to Address Rising Health Care Costs
A Patient Protection and Affordable Care Act, Section 1302, and Web Questions for Public Input
B Stakeholder Decisions on Health Insurance
C Examples of Possible Degrees of Specificity of Inclusions in Small Group and Individual Markets
D Examples of Benefit Package Statutory Guidance
E Description of Small Group Market Benefits, Provided by WellPoint
This Page is blank
Boxes, Figures, and Tables
Box
S-1 Essential Benefits Categories in the Patient Protection and Affordable Care Act
Figures
Boxes
1-1 Statement of Task for the Institute of Medicine Committee
1-2 Which Programs Incorporate Essential Health Benefits (EHB)?
Figures
1-1 Nonelderly population with selected sources of health insurance coverage, 2009
1-3 Learning cycle for defining and revising essential health benefits (EHB)
Table
1-1 Transitions from Status Quo Insurance Status to Post-Reform Insurance Status
Boxes
2-1 Understanding Basic Terms Used in This Chapter and Report
2-2 Description of Benefit Design
2-4 UnitedHealthcare’s Hierarchy of Criteria for Benefit or Coverage Determination
2-5 Hierarchy of Evidence Employed by Washington State
2-6 Oregon Treatment-Condition Pair Examples
2-7 Inclusion Criteria for Oregon’s Value-Based Services (VBS)
Figures
2-1 Illustration of multiple medical management tools used by UnitedHealthcare
2-2 Real spending on health care in selected categories, 1965-2005
Tables
2-2 The State of Oregon Uses a Prioritized List of Services to Make Coverage Decisions
Box
Figures
3-3 Criteria to guide methods for defining and updating the essential health benefits (EHB)
Table
3-1 Uses of Evidence for Decision Making
Figure
Table
4-1 Percentage of Firms Offering Health Benefits, by Firm Size, 1999-2011
Boxes
5-1 Steps in Recommended Process for Defining an Essential Health Benefits (EHB) Package
5-2 General Exclusions: Federal Employee Health Benefit Program Fee-for-Service Option
5-3 Selected Required Elements for Consideration
Tables
5-6 Sample Approach to Incorporating Costs into the Definition of Essential Health Benefits
5-7 Key Elements in Definitions of Medical Necessity
Tables
Figures
7-1 CIGNA coverage decisions and appeals for preauthorization of health benefits (2010)
Table
7-1 Comparison of 2010 Independent Medical Review (IMR) Results in California Managed Care
Tables
Figures
9-1 U.S. health care expenditure trends
9-2 U.S. national health care spending relative to growth in gross domestic product (GDP)
