Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
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9 Updating the EHB
9 Updating the EHB
Pages 135-152
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From page 135... ...
Further, to preserve the intent of Congress in extending coverage for a basic set of benefits to most Americans, the committee recommends that the Secretary, in collabo ration with others, develop a strategy to restrain health care spending. A standing multidisciplinary National Benefits Advisory Council (NBAC)
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From page 136... ...
However, the committee believes that over time, the Secretary will have an opportunity to provide leadership through the EHB updating process to improve the content and structure of the EHB to better reflect the scientific evidence base, to reflect societal priorities in providing a basic set of benefits, to ensure greater clarity about what services are and are not eligible for coverage in those policies covered by the EHB definition, and to promote high-value utilization. Evidence-Based Science Should Be the Guiding Force The committee concluded that the scope of benefits eligible for coverage should be guided by scientific evidence about which screening, diagnosis, treatment, management, and monitoring interventions are effective in improving or maintaining people's health and functioning.
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From page 137... ...
Additionally, as discussed in Chapter 7, health plans should provide greater specificity and transparency around clinical policies and the operation of medical necessity determination processes. Structure of Benefits Should Promote High-Value Utilization Finally, the committee concluded that the financial structure of benefit packages should be consistent with and reinforce the use of high-value, necessary care.
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From page 138... ...
CONSIDERING TYPICAL EMPLOYER IN THE FUTURE Section 1302 of the ACA also requires that the Secretary of HHS' report to Congress on revising benefits con tain a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services (CMS) indicating the essential benefits are equal to the scope of benefits provided under a typical employer plan.
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From page 139... ...
At the federal level, costs would be considered at an aggregate level -- without explicit efforts to address regional variation in wages, prices, population characteristics; variations in the intensity and use of technology; and other potential cost drivers. For example, the Secretary could obtain an actuarial estimate from the CMS Chief Actuary of the expected cost to purchase the EHB package in the coming year based on a national standard population,4 with explicit assumptions about the degree of medical management, network configuration, and other factors typically included in pricing plans for employers.
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From page 140... ...
would affect changes in the premiums, total costs, or rates of change in health care spending. Using cost information to establish voluntary goals would encourage states and health plans to take action to achieve the goal.
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From page 141... ...
. Using cost information as a binding constraint would be done in the context of authority to enforce a consideration of cost in future updates to the EHB package.
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From page 142... ...
The committee concluded that adjustments to the EHB should be cost neutral, that is, any changes could not result in a package that is more expensive than the estimated cost of the existing package in the next year. Putting the design choices together, the committee recommends that costs be incorporated into updates to the EHB at the federal level, using premiums as the unit at which the costs of the EHB are characterized, using cost information to create a binding constraint on the content of future year packages, enforcing a cost-neutral approach to updates, and achieving the premium target only through changes in the EHB.
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From page 143... ...
national health care spending relative to growth in gross domestic product (GDP)
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From page 144... ...
This threat to the long-term integrity of the EHB caused the committee to consider what could be done in order to mitigate these adverse consequences. Serious efforts to change the rate of increase in health spending will have to go beyond the definition of essential health benefits -- the cost trend cannot be moderated through this mechanism alone.
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From page 145... ...
Because coordinated federal action would increase the likelihood of success in the public sector, the Secretary of HHS could coordinate federal participation in a commission and oversee federal implementation of such a commission's recommendations. In summary, while it may appear that addressing the rate of growth in health care spending is beyond the scope of the EHB provisions, the committee views its Recommendations 4b and 4c as necessary complements.
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From page 146... ...
If state-based public deliberations are widespread, sufficient information may be gathered and there may be no need to duplicate the process. The NBAC is to focus on what is appropriate for subsidized coverage in insurance programs that incorporate essential health benefits, not what should be covered in every public or private insurance program.
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From page 147... ...
Consumer Operated and Oriented CO-OP's purpose is to foster the creation of CO-OP's focus is on encouraging the Plan (CO-OP) Program Advisory qualified nonprofit health insurance issuers development of qualified health plans and not Board (PPACA § 1322)
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From page 148... ...
Timeline Annual updates of the scope of benefits in health insurance contracts are the norm. Such updates reflect continuous review processes conducted throughout the year by insurers to consider evidence in the peer-reviewed literature, guidelines, and consensus statements; changes in regulatory agency approvals or in medical protocols that may necessitate a modification in benefits; or other information that is material to the status of a medical technology such as the quantity of use and importance of questions that have arisen regarding specific technolo gies (McDonough, 2011)
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From page 149... ...
The NBAC provides an important forum for a transparent, public dialogue about how best to update the EHB in light of advances in science, information about the trends in health care spending, current societal assessments about the relative importance of newly available interventions compared to the existing set, and results from research about the effects of the current EHB on access to appropriate care. Recommendation 5: As soon as is feasible, the Secretary should establish a National Benefits Advisory Council (NBAC)
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From page 150... ...
2010. Online questionnaire responses submitted by Carmella Bocchino, Executive Vice President, America's Health Insurance Plans to the IOM Committee on the Determination of Essential Health Benefits, December 6.
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From page 151... ...
2010. Online questionnaire responses submitted by Steve Wojcik, Vice President, Public Policy, National Business Group on Health to the IOM Committee on the Determination of Essential Health Benefits, December 6.
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