Friday, October 14, 2011

How bare should the bare essentials be?

An article by Jessica Zigmund in Modern Healthcare (October 10), entitled “The Bare Essentials,” presents an interesting conundrum for the federal government as it defines what should be covered by the health insurance programs that will be offered by state exchanges under the Patient Protection and Affordable Care Act.

The short version of the controversy is that an advisory panel from the Institute of Medicine has made recommendations concerning what clinical conditions should be covered.  But the National Association of Public Hospitals and Health Systems would like to see “critical enabling services,” such as language interpretation, transportation, and case-management included as well.

The balancing job for the Department of Health and Human Services is to create insurance plans that are reasonably expansive in terms of coverage, but not so much so that they cannot be offered at affordable prices.  The law requires insurance plans to cover at least ten general categories of health services: ambulatory services, emergency care, hospitalization, laboratory services, maternity and newborn care, mental health and substance abuse programs, pediatric services, including oral and vision, prescription drugs, preventive and wellness services and chronic disease management, and rehabilitative and habilitative services and devices. The coverage must also be similar to those provided by typical employers.  Over 68 million people will be likely to procure insurance under these standards.

The IOM committee viewed its role as reviewing evidence-supported medical conditions.  NAPH took a broader view.  Of course, there are cost implications here, with interest groups on both sides.  As noted in the article, “If the rule is very robust, it could make plans too expensive and not meet the law’s goal of coverage and access for all.  But if it’s too bare-boned . . . then the package could be viewed as depriving millions of people of the coverage they need.”

I have great sympathy for the points raised by NAPH.  For language interpretation, for example, it is not appropriate to rely on a family member or friend to be the go-between in a discussion between a patient and a doctor.  Indeed, it can raise grave cultural difficulties:  Imagine an English-speaking teenage son translating for a Southeast Asian woman and her gynecologist.  Neither can you expect family members to maintain clinical dispassion in an emergency room setting.  Good communications is not just a convenience:  It can be a matter of life and death.

The issue is whether the insurance plans should cover such expenses when they are essential to the treatment of the categories of illness envisioned by the law.  They are not always covered by private insurance plans now.  The hospitals absorb those expenses when they are not covered.  Perhaps it is a good time to make them an accepted and expected portion of the insurance products.

It looks like we might have to wait a while for the answer, though.  The article notes that, in typical Washington fashion, “There has been talk that a final rule might be pushed back until after the 2012 elections because of the political implications attached to it.”


Barry Carol said...

I think the insurance coverage vs. affordable cost conundrum highlights the necessity of attacking underlying costs. Massachusetts, for all of its reform efforts, has not yet done that in any serious way. There is a lot that can be done in such areas as price and quality transparency tools for both patients and referring doctors, safe harbor protection from failure to diagnose lawsuits for doctors who follow evidence based guidelines where they exist, and a much more sensible approach to end of life care. Insurers and employers could do their part through greater use of tiered and limited networks to try to steer patients toward the most cost-effective high quality providers. I also think that phasing out the tax preference for employer provided health insurance in favor of lower tax rates and a higher standard deduction to keep the change revenue neutral would also be helpful.

Paul Levy said...

That is such a thoughtful and on-target menu of things to do, Barry. Thank you!