choose to submit bills for.” This is very different, Dr. Jacques said, from prioritizing health care technologies that are of the most public benefit.

Precedents. Do you want to rely on the rulings or regulations of federal agencies as benchmarks for EHB coverage policy? The committee could, for instance, say that EHB are directly tied to U.S. Food and Drug Administration (FDA) approval, or the withdrawal of FDA approval, of a particular drug. He cautioned the committee, though, to consider that because the Department of Defense (DOD) TRICARE, U.S. Deparment of Veterans Affairs (VA), and Medicare serve special populations (DOD, 2011; VA, 2011), specific covered benefits under their benefit plans may not necessarily align with the needs of the population insured under an EHB package.

Reactivity vs. pro-activity. Will your coverage policies be used for medical review or audit? The committee’s definition of medical necessity, he noted, will impact the ability of individuals to appeal for “individual consideration” of a specific benefit.

Administrative agility vs. formalized consistency. Developing policies that try to anticipate every eventuality may not be feasible, he said. Rather, the system might need to naturally evolve. The committee will need to consider, he said, whether the U.S. Department of Health and Human Services (HHS) wants “pre-written policies established to enhance transparency” or if it wants the capacity to provide individual consideration for coverage decisions. Whatever decisions are made will require balance among different features as outlined in the grid across the four dimensions of being reactive versus proactive and having formalized consistency versus administrative agility (see Figure 6-1).

Dr. Jacques implored the IOM and ultimately HHS to “design a system that keeps in mind a more long-term view.” All of the early decisions will be precedents for what happens later, he said. Therefore, decisions about EHB

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FIGURE 6-1 Defining benefit plans requires balancing administrative agility or consistency with the need to proactively or reactively define benefits. SOURCE: Jacques, 2011.



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