Tuesday, October 18, 2011

Essential Health Benefits – IOM process recommendations: Part 1

Our post today comes from guest blogger David Jacobson. He is a consultant for HealthCare Strategic Management – SM. He is a knowledgeable and creative thinker of healthcare reform strategies, and a subject matter expert about Medicaid managed care and the Affordable Care Act including the purchasing Exchange and other reform initiatives. David has over 16 years’ experience and developed Medicaid managed care products for chronically ill, disabled and long term supports and services. 

Affordability is key to ACA Essential Health Benefits

Essential Health Benefits (EHB) of the Affordable Care Act (ACA) require a balance between coverage and cost, and affordability was weighted heavily by the Institute of Medicine (IOM). The IOM committee introduction said “If you don’t control costs, the goal to increase coverage will be undermined” when they released the anxiously awaited recommendations to the Department of Human and Health Services (HHS) on October 7. The recommendations are for the guidelines and criteria for HHS to specify the EHB package. The EHB packages will be offered through purchasing Exchanges and have far reaching impacts on the success of the ACA. More than 68 million people are expected to meet EHB requirements.

The regulations received intense public interest during the IOM development process and there were several hundred people on Friday’s teleconference meeting. The website with the full report became blocked on Friday afternoon as a surge of people retrieved the report.

To put this in context, the principal reason for ACA is to enable people to purchase health insurance and cover more of the population. This is supported by subsidized plans for low and moderate income individuals and small employers that is sold through a purchasing Exchange.

Specifying the EHB is a tremendously difficult task due to the competing goals of comprehensiveness and affordability, many trade-offs, and diverse public interests. It’s a balance of wallet and heart. If EHB is too expansive, then it will be too expensive and there will be less consumer uptake. If it is too limited, individuals will not get access to the services they need and outcomes will suffer. The IOM created a multi-stakeholder committee and obtained extensive public input to set the parameters and guidance.

The IOM recommendations are a solid point of departure and reference point for HHS, even if it seems vague in spots. The IOM committee recognized that benefit packages need to be affordable to obtain the necessary level of enrollment and we also have limited resources. They viewed it as a ‘market basket” to know what you can spend and spend it carefully rather than a filling up your shopping cart with as much as you can. A committee member said: “Everyone cannot have everything they want. “

This raises tough questions about the level of benefits, especially for chronically ill and disabled. Special consideration, programs, and rate adjustments will be required for high-risk individuals.

The IOM suggested benchmarking the average covered benefits and premiums for small employer health plans. They were also required to add benefits to reflect the ten categories specified by the ACA. This will increase the cost and create pressure to limit benefits in order to meet premium price-points.

The IOM approach is to start with what we have and then readily adjust as we learn how the Exchange market works. This is a prudent way to begin – progress over perfection – and let the free market do its work. This allows the opportunity for increased consumer take-up rates which will allow a broader selection mix and the ability of Exchanges to learn, adapt and grow. It would allow states and/or insurers to offer additional plans with enhanced benefits vs. overly specific regulations.

Certainly, ACA and healthcare reform will not be successful with the right Exchanges and EHBs alone. Other changes are needed to address the high cost and quality variation in the American system. For instance, other critical success factors include benefit design (i.e. cost-share), administration (i.e. care management), and network requirements. Reform must also address improvements to delivery and payment, risk-adjusted rates for insurers, health information technology, and informed and engaged consumers.

Stayed tuned for Part 2 of this Blog: Specific Recommendations and Implications next Tuesday, October 25.  Contact the author at djacobson@healthcaresm.com.

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