Dr. Morrison called “extremely limiting.” He advocated for insurers to cover palliative care “sooner than hospice” (i.e., at the time of diagnosis).
A recent study indicates that when palliative care is provided in concert with curative care at the time of diagnosis, palliative care results in better patient outcomes and survival. Lung cancer patients receiving early palliative care lived 23.3 percent longer than those who delayed palliative treatment, and median survival for “early” palliative care patients was 2.7 months longer than for those receiving standard care (Temel et al., 2010). Additionally, a 2007 study found hospice patients had a 29-day longer mean survival than patients not receiving hospice (Connor et al., 2007).
Furthermore, Dr. Morrison noted, hospice and palliative care services can lower health care costs. A study conducted at Duke University demonstrated that hospice services reduce Medicare expenses by an average of $2,309 per hospice patient while improving the quality of care provided to patients with life-limiting illness (Taylor et al., 2007). Moreover, the study found that Medicare costs would be further reduced for seven out of 10 hospice recipients if hospice was used for a longer period of time. For cancer patients, up to 233 days of hospice care decreased Medicare costs, while for non-cancer patients, up to 154 days of hospice care decreased Medicare costs. Palliative care programs in hospitals also provide “substantial savings.” In a recent study comparing Medicaid beneficiaries in four New York State hospitals, provision of palliative care reduced hospital costs by $4,098 per admission for patients discharged alive and $7,563 for patients who died in the hospital. Consistent with the goals of a majority of patients and their families, palliative care recipients spent less time in intensive care, were less likely to die in intensive care units, and were more likely to receive hospice referrals than usual care patients (Morrison et al., 2011).
Ms. Dhillon, a staff attorney with NHeLP, outlined several principles for the EHB package, including flexibility to allow for the best treatment options. She advised the committee to rely on Medicaid for guidance on developing the EHB package. The standards of care for children and adolescents in Medicaid, for example, provide an array of important services, including early and periodic screening, diagnostic, and treatment services (EPSDT). NHeLP believes Medicaid EPSDT “can be an instructive model for these packages to ensure a comprehensive and robust set of services for very low-income and/or special needs children.”
Ms. Dhillon suggested that the standards of care recognized by the professional academies be used to determine the scope of coverage in EHB packages. This criterion, she said, should apply both to the U.S. Department of Health and Human Services’ (HHS’) initial determination of the EHB package as well as to the coverage policies of insurers offering EHB packages. Relying on approved standards of care, she said, would address regional variation in implementation and prohibit plans from “providing piecemeal coverage to insured individuals where a more comprehensive scope of covered services would be more appropriate, both in saving costs and improving health.” NHeLP believes that health care providers should provide information about all treatment options in accordance with the proper standards of care, based on the individual’s needs, and with the overall goal of maximizing wellness. Furthermore, insurers should not be allowed to base the scope of coverage on non-clinical reasons, such as moral or religious grounds. Insurers should not be permitted to limit coverage of reproductive health services, for example.
NHeLP recognizes that in some cases, an individual may require services outside the scope of covered benefits. Therefore, NHeLP recommends that all EHB packages have a clinical exceptions process that is timely, not overly burdensome, and easily navigable by patients and providers. Medicaid can be instructive in this context; while Medicaid allows for higher cost sharing for non-preferred drugs, it also provides an exception whereby if the prescribing provider determines the preferred drug would not be as effective or if the patient would have an adverse outcome, the Medicaid enrollee can then gain access to the non-preferred drug. In some cases, Ms. Dhillon said, step therapy may be an effective strategy for providing safe, cost-effective care. However, because step therapy policies may encourage insurers rather than providers to “have the final word in treatment options,” there must be “special oversight” when this policy is used. The potential negative effects of step therapy can be mitigated,