Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 27
3
Purchaser Perspectives on the EHB
Health insurance purchasers at the workshop, including Ms. Jerry Malooley, speaking on behalf of the
U.S. Chamber of Commerce; Mr. Michael Turpin from USI Insurance Services; and Ms. Helen Darling from
the National Business Group on Health (NBGH) stressed the need for flexibility in the essential health benefits
(EHB) package and expressed a strong desire to limit the comprehensiveness of the package. The more expansive
the package, these panelists said, the greater the cost.
PRESENTATION BY MS. JERRY MALOOLEY, U.S. CHAMBER OF COMMERCE
While Ms. Malooley directs benefit program health policy for Indiana’s state employees, on this panel, she
spoke on behalf of the U.S. Chamber of Commerce, which represents a continuum of small to large employers.
Employers, she said, want to offer health benefits to their employees. Such benefits show appreciation to employees
and highlight that the employer values the well-being of its employees. “This, we hope,” she said, “translates into
loyalty, job performance, and less turnover.” At the same time, however, employers must consider the cost of pro -
viding these benefits alongside wages, growth, and the competitive environment. Overall, Ms. Malooley stated,
employers should be permitted the flexibility to offer coverage that both meets the needs of a broad population
and is cost-effective.
Ms. Malooley began by acknowledging that “we all know that for every health product on the market, someone
considers it a need and wants insurance to cover it.” Consequently, any discussion of what constitutes the EHB
package will be controversial. Ms. Malooley stressed, though, that decision makers should remain “objective and
vigilant” when determining the package.
In September 2010, the Chamber of Commerce polled 590 small businesses 1 and found that “the definition of
essential benefits must not be viewed in a vacuum.” In presenting some results of that poll, Ms. Malooley asked
the committee to view the EHB package as a minimum floor and to allow businesses to have the opportunity to
build on those benefits, particularly considering small employer views as a result of passage of the Patient Protec -
tion and Affordable Care Act (ACA),
1The poll included 590 small businesses with up to 199 employees. Of those who responded, 57 percent of businesses employed 5-49
employees, 19 percent employed 50-99, and 25 percent employed 100-199 (U.S. Chamber of Commerce, 2010).
27
OCR for page 28
28 PERSPECTIVES ON ESSENTIAL HEALTH BENEFITS
• 45 percent of businesses are less likely to hire new employees; and
• Only 29 percent are confident about adding new employees and investing in their businesses (U.S.
Chamber of Commerce, 2010).
Comprehensiveness vs. Affordability
To illustrate the complexity of balancing comprehensiveness and affordability, Ms. Malooley posed a question
to the committee: When does one person’s need to have some new or traditionally non-covered procedure paid by
insurance outweigh the majority’s need to keep premiums affordable? The desire to offer the most comprehensive
benefits may not be worth the loss of affordable coverage.
The definition of the EHB, she said, is “critical” because:
• It will affect employers by establishing the floor for what plans and exchanges must offer and establishing
which employer-sponsored benefits will be prohibited from restricted lifetime or annual limits. These
considerations will determine the cost of plans.
• It will limit the options available to consumers. If the “floor” is an extensive, expensive benefit package,
plans will become very costly and therefore fail to meet the needs of most consumers. Many employers
and consumers prefer a more “bare bones plan” and the moderate price it affords. “It would be a mistake,”
Ms. Malooley said, to curtail flexibility on the part of employers and consumers “by requiring all plans
to cover a ‘soup to nuts’ benefit package.”
• An expansive definition will likely force small employers to stop offering coverage. “We do not want
the cost of these plans to force employers to stop offering health care coverage to their employees,”
Ms. Malooley stated.
It has been observed that there is a higher utilization rate for covered services (IOM, 2001). Furthermore,
she continued, while utilization has positive effects on individual and population health if the covered services
are beneficial and necessary for the individual’s circumstances, coverage can also have needless cost implications
if unnecessary care is delivered. Thus, employers need freedom, Ms. Malooley said, to direct the content and
utilization of benefits.
The Effect of State Mandates on Premiums
State-mandated benefits all “critically affect” the rise in premiums across the states, Ms. Malooley argued,
such as those that cover marital and family counseling, contraceptives, and care by specific providers (e.g., acu -
puncturists, athletic trainers, massage therapists, and pastoral counselors) (CAHI, 2010). While an individual
mandate may have a small impact on premiums, when these mandates accumulate, costs aggregate and “premiums
really rise.” As states add additional benefit mandates, the “base” cost of a plan rises. Iowa, for instance, has 27
mandates, which she stated raises the base cost of a plan by 13 percent. Figure 3-1 illustrates how mandates can
contribute to higher costs.2
This effect is significant, Ms. Malooley noted, because experience has shown that when premiums increase,
more people drop or decline coverage (Chernew et al., 2005; Goldman et al., 2004). Thirty states now require
fiscal analysis before the implementation of mandates (Bunce and Wieske, 2010), and at least 10 states offer a
“mandate-light” program for people who feel they do not need certain mandated benefits (Bunce and Wieske, 2010).
Nothing precludes a state from requiring additional benefits beyond the EHB. “That is an issue,” she said,
because the federal subsidy provided to individuals will not account for “how rich the benefit plan is and what the
premiums are” for state-added benefits. Consequently, states will assume the additional cost of these state-specific
mandates and make payments to individuals to defray the cost of these additional benefits in public programs. 3
2 See further discussion of the full and marginal cost of state mandates in Chapter 4, Dr. Cowdry.
3 Patient Protection and Affordable Care Act of 2010 as amended. Public Law 111-148 § 1311(d)(3)(B)(ii), 111th Cong., 2d sess.
OCR for page 29
29
PURCHASER PERSPECTIVES ON THE EHB
Conservative Estimate @½% per Mandated Benefit
40.00%
35.00%
Additional Premium
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
13 27 41 57 69
13 6.50%
27 13.00%
41 20.50%
57 28.50%
69 34.50%
FIGURE 3-1 Insurance premiums can rise as state-mandated health benefits accumulate.
SOURCE: Malooley, 2011. Adapted from data in Bunce and Wieske, 2010.
Figure 3-1
PRESENTATION BY MR. MICHAEL TURPIN, USI INSURANCE SERVICES
As a speaker knowledgeable of small and mid-sized employer needs, Mr. Turpin, Executive Vice President
and National Practice Leader of Healthcare and Employee Benefits agreed with Ms. Malooley that employers
want to offer health benefits as a means of attracting and retaining employees. He also emphasized that small and
mid-sized employers will decrease or stop offering health benefits if the EHB package is too rich or not designed
to drive market-based reforms.
Over the past five years, insured employers with fewer than 100 employees experienced annual double-digit
health care cost growth.4 These increasing costs, he said, resulted from “supply-side components” including
increasing physician costs, inpatient facility costs, outpatient facility costs, and prescription drug costs (Engdahl-
Johnson and Mayne, 2010). The double-digit growth rates are normally “mitigated,” Mr. Turpin said, by reducing
plan design and by cost-shifting to employees through higher co-pays, co-insurance, and deductibles. Towers
Watson data show that between 2005 and 2010, employer costs for an individual policy rose 28 percent ($6,169
to $7,920) while employee cost sharing has increased over 40 percent ($1,642 to $2,292) (Towers Watson, 2009).
Mr. Turpin described current employer plans as “driven by access, not affordability.” Small employers have
disproportionately chosen to increase cost sharing rather than to reduce access to a network of specified providers
or to centers of excellence. Medical trends have not moderated as they would if network access limitation became
the catalyst for outlier facilities to lower costs to be more consistent with more cost effective and equally high
quality competitors. Compass Health Analytics, Inc., a private, non-profit consumer data management company,
reports how approved provider MRI costs can range from $442 to $1,093 within the same PPO (preferred provider
organization) network (Compass Professional Health Services, 2011).
4 Annual pooled trend and yield averages shared annually by insurers for businesses of different sizes. USI Insurance routinely requests and
compares annual trend factors for insured businesses each year to gauge medical inflation and underwrite expected cost increases—independent
of the insurer. Data is compiled through an analysis of USI’s own book of business, insurers, and the subset of employers who respond to a
variety of surveys. Personal communication with Michael Turpin, USI Insurance, August 15, 2011.
OCR for page 30
30 PERSPECTIVES ON ESSENTIAL HEALTH BENEFITS
Aligning Incentives
Many employers are concerned about an EHB package that will be “too generous,” and believe that a “basic”
level of benefits would help reduce cost growth. Most of USI Insurance’s clients recognize that the current health
care system is designed to treat rather than prevent chronic illness. As a result of “misaligned incentives,” plan
design is the only lever employers can pull to manage their costs. Mr. Turpin acknowledged, though, that the ways
in which employers usually manage plan costs (e.g., rationing plan design, increasing co-pays, and increasing
deductibles) can inadvertently create barriers to care and ultimately increase long-term costs by limiting access to
preventive procedures that could control an individual’s chronic illness.
Many small and mid-sized employers, Mr. Turpin said, “are gravely concerned” that the EHB will be designed
to require more generous levels of benefits while “doing nothing to change the underlying cost drivers.” With -
out changing cost drivers, generous benefits will only contribute to higher rates of utilization and cost inflation.
Employers, he noted, believe “strategy should drive structure.” The structure of the EHB should aim to improve
health status and better manage chronic illness, which will also serve to “achieve affordable care.”
He cautioned that starting with a rich package would “commit the cardinal sin of letting structure drive
strategy” because the benefits package would be unaffordable at the outset. In addition, he said that open-access
preferred provider organizations (PPOs) and lack of care coordination through primary care providers have resulted
in unsustainable medical utilization and an unrealistic expectation from employees that “access means quality.”
As a result, “there is increasing openness” to the use of “medical homes” as a way to transition from a system
focused on treatment to one focused on “rewarding prevention.” Employers are uncertain, however, if the EHB
package will enable or preclude this transition to medical homes.
Shared Responsibility on the Part of Employers and Consumers
Small and mid-sized businesses are “uninformed” as they have little knowledge of their own employees’
health benefit claims—“most feel trapped in pooled risk arrangements.” Consequently, these employers have
little incentive to engage their employees in wellness activities because their claims are pooled with higher risk
employers who have “rich plans and unengaged employees.” Mr. Turpin believes legislation should be considered
to require the release of paid and incurred employer claims data to help employers better understand population
health information. Precedent has already been set in Texas under House Bill 2015 which requires release of data
down to two covered lives5 (Mr. Turpin believes two lives is a bit extreme and that 50 covered lives would be
sufficient). In addition, he said, states should encourage the development of self-insured alternatives that allow
employers with more favorable claims and cost management strategies to directly benefit from their own efforts.
Essential health benefits can be designed, Mr. Turpin argued, “to get individuals to engage more and for
employers to actively participate in engaging in the population health of their employees and trying to drive a
healthier lifestyle.” Figure 3-2 shows a continuum of “consumer activation” that ranges from healthy individuals
to those who are chronically and catastrophically ill. The EHB must consider that every insured person exists
somewhere along this continuum and benefit design should reduce barriers to care and drive improved consumer
engagement. For example, the EHB should aim to promote identification of those individuals who are asymptomati-
cally ill. Statistically, an alarming number of catastrophic claimants are revealed to have not filed a single claim in
the 12 months preceding a catastrophic medical event. Primary care, mandatory screening for key risk factors, and
incentives to engage in wellness activities will activate consumers and reduce gaps in care (ICMA and CIGNA,
2008; U.S. Corporate Wellness, 2011). Mr. Turpin noted, though, that individuals must be committed to their own
personal health improvement. Additionally, if “we want to reach individuals who are chronically ill and make them
stable, we need to reduce barriers to care for certain common chronic illnesses prevalent in certain populations.”
5 Texas HB 2015 (June 15, 2007).
OCR for page 31
31
PURCHASER PERSPECTIVES ON THE EHB
Staying Healthy Getting Healthy Living with Illness
5%-15% high risk population
40% low risk population 40%-60% elevated risk population
Chronic,
Asymp- Chronic,
Acute
Healthy Acute Catastrophic
Catastrophic
Unstable
Stable
tomatic
Healthy Illness
with Illness
Illness/
Minor Major
Risk
Disease
Factors
factors
Condition-specific and wellness
Prevention and wellness Intensity-based and condition-specific
• Healthy living programs targeting • Predictive outreach … claims, health risk
• Treatment programs
assessments
risk factors
• Disease management focusing on reducing the
• Case management to ensure efficient
• Online and biometric health
chronic and unstable populations
consumption of services
assessments
• Compliance based incentives and tools
• Integrated pharmacy, medical, behavioral,
• Utilizing ACA to focus on reducing dental to drive economies • Integrated pharmacy, medical, behavioral, dental
barriers to primary/preventive care
• Targeted interventions using preventive coupled with case management to ensure
compliance to identify asymptomatic illness optimal care
FIGURE 3-2 Insurers use a continuum of patient risk factors to guide consumer engagement efforts.
SOURCE: Turpin, 2011. Reprinted with permission by Sam Ho, committee member, and Executive Vice President and Chief
Medical Officer, UnitedHealthcare.
Figure 3-2
PRESENTATION BY MS. HELEN DARLING, NATIONAL BUSINESS GROUP ON HEALTH
As president and CEO of an association of large employers, Ms. Darling began by urging the committee to
focus not only on the goals of providing comprehensive coverage and promoting evidence-based, effective care,
but also on the “equally important triple financial goals” of assuring people affordable coverage, protecting them
from catastrophic financial losses when faced with serious illness, and helping them avoid unnecessary costs. She
proceeded to describe the perspectives and concerns of large employers, including that they should be permitted
and encouraged to provide flexible options to their employees, a point, she said, that is built into the ACA. It is
very important, she said, that the EHB “be set up in a way that allows for flexibility and also allows for evidence
to be constantly created and used in a feedback loop to what is being considered the floor.” The “minute the gov -
ernment” defines the package, the benefit floor will be established and will “become the pressure point in every
way,” she argued.
Committee member Mr. Koller asked Ms. Darling to explain the connection between the committee’s work
and the decisions made by large self-insured groups. She replied that the ACA outlines broad categories of care.
Let’s take a category like rehabilitation services; what will be in the EHB should not be just anything that might
be considered rehabilitation services. Thus, questions remain as to whether rehabilitation is more specifically
going to be set to a maximum of 60 visits or to only visits that restore function. Self-insured employers, she said,
make these kinds of decisions “all the time.” Generally, if a service is prescribed or ordered by a licensed physi -
cian, the service will be paid for unless the employer specifically sets upfront limits or if the service is considered
investigational and experimental.
OCR for page 32
32 PERSPECTIVES ON ESSENTIAL HEALTH BENEFITS
Using Evidence to Evaluate Effectiveness
A properly structured learning health care system6 “will enable continuous assessment of actual effects on
patients and change what might be considered essential benefits, or at least the circumstances in which they would
be considered essential,” Ms. Darling said. She cautioned that “it is really hard to take things away” but noted that
“when there is compelling data that something is downright harmful under certain circumstances, the public actually
stops doing it” (e.g., hormone replacement therapy for women, autologous bone marrow transplant for breast cancer,
and clinically inappropriate use of Vioxx). An EHB package, then, should support effective, efficient care while
also “weeding out” unnecessary and wasteful care. The NBGH recommends, she said, that the committee heavily
weigh demonstrated evidence and a track record for clinical effectiveness as a criterion for the EHB package.
Ms. Darling referred to academic studies that have found that a third of U.S. health care dollars are wasted
(Kelley, 2009) as reason to support an EHB package with demonstrated evidence of clinical effectiveness. These
wasted dollars, she said, are spent on unnecessary, redundant, and ineffective care, all of which should be excluded
from the EHB package. “We need a constant process of evidence generation and feedback,” she said, to manage
care and benefit design in a way that ensures patients are protected from wasteful and harmful practices.
She suggested the committee recognize the tools and resources used by employers and plans for care man -
agement and benefit design. Where evidence warrants, employers and plans routinely use care and medical
management tools (e.g., step therapy, limits, radiology management) to promote effective care. Step therapy
encourages providers and patients to utilize proven effective drugs that are less costly or risky to patients’ health
than new “blockbuster” drugs that may have less evidence. In addition, dental plans use a combination of limits—
annual, frequency, age, and tooth structure—to provide low-cost dental coverage for Americans. This plan design,
Ms. Darling said, has improved oral health, prevented overutilization, and minimized the cost of providing oral
health care. Less than 3 percent of Americans reach their annual dental limits (NADP, 2009). Furthermore, plans
use radiology management programs to ensure patients receive appropriate screenings and that patients are not
subject to excessive radiation exposure or unnecessary scans. Studies have found that up to 50 percent of diag-
nostic imaging is redundant and may lead to unnecessary radiation exposure, particularly for children and pregnant
women (AHIP, 2008; Brenner and Hall, 2007; Dehn et al., 2000).
Ms. Darling noted that “by placing high importance on proven clinical effectiveness, the IOM will ensure that
patients receive the highest value, safest, and most medically appropriate health care services to meet their indi -
vidual needs.” This focus on clinical effectiveness will also help plans balance comprehensiveness and affordability.
Finally, it will create “synergy” between the efforts of employers and plans and the efforts of the government to
promote evidence-based benefit design.
Criteria for Effectiveness
To make coverage decisions, Ms. Darling said, employers and plans often use medical necessity along with
several other criteria of effectiveness, including:
• Clinical appropriateness of the service setting;
• Sufficient evidence of clinical effectiveness of the service;
• Sufficient evidence of meaningful clinical utility;
• Comparative effectiveness of the service to alternatives;
• Comparative cost and actuarial valuation of the service to alternatives;
• Demonstrated performance and quality of the providers; and
• Individual eligibility criteria (e.g., Herceptin for patients who meet genetic profile, disease state, and
treatment history criteria; BMI ≥ 40 for metabolic surgery).
6 The IOM is currently undertaking a consensus study on the learning health care system, seeking to foster “the development of a learning
health care system designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider;
to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care”
(IOM, 2010).
OCR for page 33
33
PURCHASER PERSPECTIVES ON THE EHB
Ms. Darling stated that the opportunity to individually apply criteria to specific types of cases is necessary
because “you cannot just have a flat benefit. You cannot just say we are going to pay for physical therapy on an
unlimited basis, because then everybody would get physical therapy on an unlimited basis, and the system would
give us probably two or three times what we would find beneficial.” Furthermore, personalized medical therapies
are being developed that should apply to specific types of cases; these would not, she said, be considered discrimi -
natory under the required elements for consideration. Comparative effectiveness research will “provide us with
very valuable information about how to fine tune” coverage decisions.
Medical Management Practices
Ms. Darling outlined management practices used by employers to promote efficiency in benefits. Employers
of all sizes, she said, are provided these resources by their health plans through their insured package of services.
She advised the committee that efficiency is an important criterion to consider when designing the EHB package.
Coverage, she said, can promote efficiency by requiring “best management practices” to keep benefits affordable:
Evidence-based benefits: An evidence-based benefit model links coverage to the effectiveness of
•
treatments. Cost sharing, provider selection, and plan payments can be used to support evidence-based
care and discourage ineffective care. For example, by reducing or eliminating co-pays for maintenance
drugs (e.g., for diabetes, asthma, and hypertension) with a strong evidence base for effectiveness, the
employer’s plan design can encourage patient adherence to drug regimens.
Targeted evidence-based preventive care: To improve health and reduce long-term costs, employer plans
•
can provide incentives such as “first dollar coverage” (i.e., little or no co-payment) for evidence-based
preventive care services for targeted populations. Education programs to improve employees’ awareness
of preventive care are just one example.
Emphasize primary care: Employers are often willing to pay more for primary care coordination and
•
patient management, for example, by choosing providers who incorporate the “advanced medical home
concept.”
Meaningful cost sharing: Employers set cost sharing at levels that reduce excessive and inappropriate
•
utilization but ensure access to needed, appropriate medical care by, for instance, varying cost sharing based
on clinical necessity and therapeutic benefit. Employers have reduced cost sharing when plan participants
use evidence-based care such as using decision supports and participating in disease management
programs.
Prescription drug management: Employers manage prescription drug use and pharmacy spending by
•
establishing preferences for select generics and brand-name drugs. Step therapy, generic substitution
requirements or incentives, generic education programs for plan participants and physicians, a separate
deductible for prescription drugs, preauthorization for selected drugs, reduced cost sharing for mail order
compared to retail purchase, mandatory mail order of maintenance medications, tiered co-payments,
co-insurance rather than co-payments for medications, dose optimization, and quantity-duration protocols
for certain medications are all used to manage prescription drug costs.
Health improvement programs: Employers offer incentives such as premium discounts to plan
•
participants who engage in health improvement programs and adopt healthier lifestyles.
Targeted disease management programs: Employers provide targeted, evidence-based disease
•
management programs for certain chronic and potentially high-cost conditions. Employers use incentives,
rewards, and premium discounts to encourage participation.
Retail/convenience care clinics: To add convenience and reduce inappropriate emergency room visits,
•
employers offer access to retail clinics for common, basic medical services. Employers promote services
at retail clinics through education campaigns and by lowering co-pays for retail clinic services.
Consumer decision-support tools: Employers offer decision-support tools (both during plan selection
•
and at point-of-care) to help plan participants make informed decisions about their health. These tools
OCR for page 34
34 PERSPECTIVES ON ESSENTIAL HEALTH BENEFITS
include customized comparison and financial modeling to help people choose among plan options;
hospital and physician report cards to assess provider performance against evidence-based standards; and
nurse lines, self-care guides, self-study modules, online information, health coaches, health advocates,
and consumer medical information services. Some employers require that plan participants use decision-
support services before nonemergency surgery.
Pay-for-performance: Employers link plans’ provider payments to health care quality, paying more for
•
better outcomes, greater efficiency, and better performance on prevention, chronic care management, and
patient satisfaction measures. Employers also provide financial incentives to plan participants who choose
better performing providers, for example, by offering a preferred tier of medical groups and hospitals
with differential co-pays based on performance in quality and costs.
High-performance networks: Employers use high-performance networks to reduce costs and improve
•
quality by offering specialized services through facilities that meet criteria for volume and clinical
outcomes, patient and family-oriented services, and evidence-based medicine.
Health information technology (HIT): Employers require health care vendors to use interoperable HIT
•
wherever possible or provide personal health records for plan participants.
Transparency (cost and quality): Employers require plans and providers to publicly disclose information
•
about the price and quality of care.
The focus on primary care prompted committee member Dr. Santa to ask Ms. Darling to comment on the
degree to which the effectiveness of primary care vs. more specialty care is considered by employers as a part of
benefit design. This emphasis on primary care, she said, is based on evidence comparing systems with primary
care as the foundation (Starfield et al., 2005) and evidence showing that primary care encourages ongoing patient-
provider relationships, which may, among other things, decrease duplicative testing. Ms. Darling said that NBGH
has been working with employers and plans to “build in more reasons for starting with primary care” such as
having the employee pay less for primary care visits. IBM, for example, has eliminated co-pays for primary care.
Limiting State Mandates
Ms. Darling concluded by suggesting that because state mandates are often driven “by forces that sometimes
have very little to do with evidence and very little to do with cost considerations,” the committee should not con -
sider state mandates as a criterion for the EHB package. There is a lack of awareness of the collective costs of
mandates. It is important for the committee to “fully grasp the significant cost impact of overly comprehensive
or open-ended coverage.”
In sum, she said, the EHB package has to be something that rules some things out; something between every -
thing under the sun and a very narrow, limited package. Thus, she said, the committee and the U.S. Department
of Health and Human Services should aim to ensure affordable but comprehensive coverage.
REFERENCES
AHIP (America’s Health Insurance Plans). 2008. Ensuring quality through appropriate use of diagnostic imaging. Washington, DC: America’s
Health Insurance Plans.
Brenner, D. J., and E. J. Hall. 2007. Computed tomography—an increasing source of radiation exposure. New England Journal of Medicine
357(22):2277-2284.
Bunce, V. C., and J. P. Wieske. 2010. Health insurance mandates in the states 2010. Alexandria, VA: The Council for Affordable Health
Insurance.
CAHI (The Council for Affordable Health Insurance). 2010. Trends in state mandated benefits, 2010. Alexandria, VA: The Council for Afford-
able Health Insurance.
Chernew, M., D. M. Cutler, and P. S. Keenan. 2005. Increasing health insurance costs and the decline in insurance coverage. Health Services
Research 40(4):1021-1039.
Compass Professional Health Services. 2011. Compass Professional Health Services: Tools and support for healthcare consumers. Dallas, TX:
Compass Professional Health Services.
OCR for page 35
35
PURCHASER PERSPECTIVES ON THE EHB
Dehn, T. G., B. O’Connell, R. N. Hall, and T. Moulton. 2000. Appropriateness of imaging examinations: Current state and future approaches.
http://www.imagingeconomics.com/issues/articles/2000-03_02.asp (accessed April 22, 2011).
Engdahl-Johnson, J., and L. Mayne. 2010. 2010 Milliman Medical Index: 2010 healthcare costs increase $1,303 for family of four. New York,
NY and Salt Lake City, UT: Milliman, Inc.
Goldman, D. P., A. A. Leibowitz, and D. A. Robalino. 2004. Employee responses to health insurance premium increases. American Journal of
Managed Care 10(1):41-47.
ICMA (International City/County Management Association) and CIGNA. 2008. Creating a culture of health. Washington, DC: International
City/County Management Association.
IOM (Institute of Medicine). 2001. Coverage matters: Insurance and health care. Washington, DC: National Academy Press.
______. 2010. Project information: The learning health care system in America. http://www8.nationalacademies.org/cp/projectview.
aspx?key=IOM-EO-10-06 (accessed April 20, 2011).
Kelley, R. 2009. Where can $700 billion in waste be cut annually from the U.S. healthcare system? http://img.en25.com/Web/ThomsonReuters/
WASTEWHITEPAPER_FINAL11_3_09.pdf (accessed August 15, 2011).
Malooley, J. 2011. Purchaser decision-making on benefit design. PowerPoint Presentation to the IOM Committee on the Determination of Essen-
tial Health Benefits by Jerry Malooley, Director, Benefit Programs Health Policy, State of Indiana, Personnel Department and Member, U.S.
Chamber of Commerce, Washington, DC, January 13.
NADP (National Association of Dental Plans). 2009. 2009 dental benefits report: Premium trends. Dallas, TX: National Association of Dental
Plans.
Starfield, B., L. Shi, and J. Macinko. 2005. Contribution of primary care to health systems and health. Milbank Quarterly 83(3):457-502.
Towers Watson. 2009. Towers Perrin 2010 Health Care Cost Survey. http://www.towersperrin.com/hcg/hcc/TPHCCS2010srvycharts.pdf (accessed
August 11, 2011).
Turpin, M. 2011. Building affordable and sustainable essential benefits. PowerPoint Presentation to the IOM Committee on the Determination
of Essential Health Benefits by Michael Turpin, Executive Vice President and National Health and Benefits Practice Leader, USI Insurance
Services, Washington, DC, January 13.
U.S. Chamber of Commerce. 2010. Small businesses and Washington regulation, U.S. Chamber of Commerce, September 2010. http://www.
uschamber.com/sites/default/files/press/1009pollregulation.pdf (accessed April 20, 2011).
U.S. Corporate Wellness. 2011. The ROI of employee wellness at a glance. Littleton, CO: U.S. Corporate Wellness, Inc.
OCR for page 36
