Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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9 Additional Stakeholder Perspectives
9 Additional Stakeholder Perspectives
Pages 91-108
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From page 91... ...
. Under the current health insurance model, he said, the only reimbursement for palliative care is for hospice,2 which some insurers do not cover.
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From page 92... ...
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.
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From page 93... ...
Booth advocated in favor of the inclusion of pediatric dental care in the EHB package and promoted a comprehensive, robust, affordable, and evidence-based package. She began by noting that the ACA failed to include oral health as an essential benefit necessary for individuals of all ages, but that it
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From page 94... ...
The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) 4 defined a dental benefit that was specific to the needs of children and could be used by state programs: coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.
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5 Section 1001 of the Affordable Care Act, amending the Public Health Service Act by inserting Section 2713 outlines specific preventive services each health plan must provide without any cost sharing, including specific services for children, like screenings and immunizations supported by CDC and HRSA.
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coupled with HSAs, will enable patients to select health plans that meet their health care needs and budgetary realities. Medical Necessity In response to the committee's inquiry about how insurers apply medical necessity, Dr.
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Harmon argued, interfere with the patient-physician relationship and prevent patients from getting needed medical care. To determine medical necessity, health plans should develop formal protocols that distinguish between when in-house medical expertise is sufficient and when outside consultation is necessary.
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From page 98... ...
. He proceeded to argue that the EHB package should cover reconstructive surgery when the surgery meets the AMA definition of reconstructive surgery: surgery performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease.
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From page 99... ...
By requiring plans to use a template certificate of coverage, HHS and health insurance exchanges could more easily determine if the benefits offered by the plan meet the requirements of the law. Additionally, the template would be helpful to consumers as they compare coverage and would ensure plans are clearly communicating to patients that the services listed under "essential benefits" must be made available to them (provided the patient is receiv 9Patient Protection and Affordable Care Act of 2010 as amended.
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From page 100... ...
He began by asking the committee to look to ACOG's clinical and practice guidelines when determining the EHB related to women's health. He also remarked that defining the EHB as specifically as possible "is the surest way to protect our patients against potential conflict or debate regarding medical necessity." Every pregnant woman should have the ability to determine for herself whether first-trimester ultrasounds or screening for Down syndrome, for instance, are appropriate.
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From page 101... ...
Clinical Trials The ACA includes a provision requiring the coverage of routine patient care costs for patients enrolled in clini cal trials for cancer or other life-threatening diseases or conditions.
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From page 102... ...
Annual Report notes that because a patient with chronic kidney disease is more likely to have a cardiovascular event and die than to reach end-stage renal disease, it is imperative to identify chronic kidney disease among individuals who have been diagnosed with diabetes and/or hypertension, the two leading causes of chronic kidney disease and end-stage renal failure. This identification would allow patients and their providers to monitor risk factors for cardiovascular events and address the progression of kidney disease (USRDS, 2010)
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From page 103... ...
"Simply put," he said, "severely and/or chronically ill patients should not bear a disproportionately high share of the cost of care." Additionally, he said, increasing cost sharing transfers a financial burden from the health plan to the patient and does little to reduce overall health care spending (Goldman et al., 2006)
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. APhA developed the definition and core elements service model for MTM by convening diverse stakeholder groups (including physicians and other health care providers, policy makers, health plans, and quality organizations)
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Dr. Wolfe argued that bariatric surgery is safe, citing a mortality rate of 0.3 percent and a complication rate of 4.3 percent among all patients undergoing laparoscopic gastric bypass, open surgery, and laparoscopic adjustable gastric banding (LABS, 2009)
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2005. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999.
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2008. Relationship of body mass index with demographic and clinical characteristics in the Longitudinal Assessment of Bariatric Surgery (LABS)
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2010. Annual data report: Atlas of chronic kidney disease in the United States.
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