PERSPECTIVES ON ESSENTIAL
HEALTH BENEFITS
WORKSHOP REPORT
Cheryl Ulmer, Bernadette McFadden, and Cassandra Cacace, Rapporteurs
Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans
Board on Health Care Services
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
This study was supported by Contract No. HHSP23320042509XI, Task Order HHSP23337027T between the National Academy of Sciences and the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-21543-5
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ISBN 0-309-21543-9
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Suggested citation: IOM (Institute of Medicine). 2012. Perspectives on Essential Health Benefits: Workshop Report. Washington, DC: The National Academies Press.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
–Goethe
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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COMMITTEE ON DEFINING AND REVISING AN ESSENTIAL HEALTH BENEFITS PACKAGE FOR QUALIFIED HEALTH PLANS1
JOHN R. BALL (Chair), Former Executive Vice President, American Society for Clinical Pathology
MICHAEL S. ABROE, Principal and Consulting Actuary, Milliman, Inc.
MICHAEL E. CHERNEW, Professor of Health Care Policy, Harvard Medical School
PAUL FRONSTIN, Director, Health Research & Education Program, Employee Benefit Research Institute
ROBERT S. GALVIN, Chief Executive Officer, Equity Healthcare, Blackstone Group
MARJORIE GINSBURG, Executive Director, Center for Healthcare Decisions
DAVID S. GUZICK, Senior Vice President for Health Affairs, and President, UF&Shands Health System, University of Florida
SAM HO, Executive Vice President and Chief Medical Officer, UnitedHealthcare
CHRISTOPHER F. KOLLER, Health Insurance Commissioner, State of Rhode Island
ELIZABETH A. MCGLYNN, Director, Kaiser Permanente Center for Effectiveness & Safety Research
AMY B. MONAHAN, Associate Professor, University of Minnesota Law School
ALAN R. NELSON, Internist-Endocrinologist
LINDA RANDOLPH, President and Chief Executive Officer, Developing Families Center
JAMES SABIN, Clinical Professor, Departments of Psychiatry and Population Health, Harvard Medical School, and Director, Harvard Pilgrim Health Care Ethics Program
JOHN SANTA, Director of Consumer Reports Health Ratings Center, Consumer Reports
LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California
JOE V. SELBY, Executive Director, Patient-Centered Outcomes Research Institute
SANDEEP WADHWA, Chief Medical Officer and Vice President of Reimbursement and Payer Markets, 3M Health Information Systems
Study Staff
CHERYL ULMER, Study Director
BERNADETTE MCFADDEN, Consultant
SHADIA BEL HAMDOUNIA, Research Associate
CASSANDRA L. CACACE, Research Assistant
ASHLEY MCWILLIAMS, Senior Program Assistant (through July 2011)
ROGER C. HERDMAN, Board Director
____________________
1 The report summarizes the views expressed by workshop participants, and while the committee is responsible for the overall quality and accuracy of the report as a record of what transpired at the workshop, the views contained in the report are not necessarily those of the committee.
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Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report:
CINDY EHNES, President and CEO, California Children’s Hospital Association
SHANA A. LAVARREDA, Director, Health Insurance Studies, and Research Scientist, UCLA Center for Health Policy Research
ROBERT S. MCDONOUGH, Head, Clinical Policy Research and Development, Aetna U.S. Healthcare
SARA ROSENBAUM, Professor and Chair, Department of Health Policy, George Washington University School of Public Health and Health Services
Although the reviewers listed above have provided constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by CHRISTINE K. CASSEL, American Board of Internal Medicine. Appointed by the Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution.
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Acknowledgments
The committee and staff are grateful to many individuals and organizations who contributed to the success of the two workshops. Many thanks to the individuals who testified before the committee during the workshops as well as to the numerous individuals who submitted materials to the committee throughout the study process. We would like to especially thank the employees of the National Academies who assisted us with the first workshop, coordinating meeting rooms, as well as setting up and controlling the video, audio, and webcast, and providing liaison with the press: Christian Dobbins, Eileen Milner, Patsy Powell, Christine Stencel, and Nicole Stephenson. Thanks too to Jordan Wyndelts for her work on the project website and development of the public input portal. Additional thanks to Institute of Medicine staff, including Abbey Meltzer for preparing the highlights document of this workshop report. Lastly, we would like to thank the sponsoring staff at the Office of Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, including Sherry Glied, Richard Kronick, Caroline Taplin, Lee Wilson, and Pierre Yong, for their financial support and guidance on this project.
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Contents
Exchanges and Essential Health Benefits
2 THE POLICY CONTEXT FOR ESSENTIAL HEALTH BENEFITS
Presentation by Dr. Sherry Glied, Assistant Secretary for Planning and Evaluation (ASPE), HHS
Presentation by Mr. Mark Hayes, Greenberg Taurig, LLP
Presentation by Mr. David Schwartz, Staff, Senate Finance Committee
Presentation by Dr. David Bowen, The Bill & Melinda Gates Foundation
Department of Labor (DOL) Surveys on Employer-Sponsored Insurance
Presentation by Dr. Joseph Piacentini, EBSA, and Mr. William Wiatrowski, BLS
3 PURCHASER PERSPECTIVES ON THE EHB
Presentation by Ms. Jerry Malooley, U.S. Chamber of Commerce
Presentation by Mr. Michael Turpin, USI Insurance Services
Presentation by Ms. Helen Darling, National Business Group on Health
4 STATE EXPERIENCES WITH DEFINING A MINIMUM BENEFIT STANDARD
Presentation by Dr. Jon Kingsdale, Wakely Consulting
Presentation by Dr. Beth Sammis, Maryland Insurance Administration (MIA)
Presentation by Dr. Rex Cowdry, MHCC
Presentation by Representative James Dunnigan, State of Utah House of Representatives
Presentation by Mr. Matthew Salo, The National Governors Association
5 MEDICAL NECCESSITY AND USE OF EVIDENCE
Presentation by Dr. Alan Garber, VA Palo Alto Health Care System and Stanford University
Presentation by Dr. Barbara Warren, Consumers United for Evidence-Based Healthcare (CUE)
6 INSURER DECISIONS OF BENEFIT COVERAGE AND MEDICAL NECESSITY
Presentation by Dr. Louis Jacques, Centers for Medicare & Medicaid Services (CMS)
Presentation by Dr. Jeffrey Kang, CIGNA Corporation
Presentation by Dr. Virginia Calega, Blue Cross and Blue Shield Association (BCBSA)
Presentation by Dr. Robert McDonough, Aetna
Presentation by Ms. Carmella Bocchino, America’s Health Insurance Plans (AHIP)
7 EXAMINING TWO CATEGORIES OF CARE IN SECTION 1302
Presentation by Dr. Kenneth Wells, David Geffen School of Medicine, UCLA
Presentation by Dr. Kavita Patel, UCLA Semel Institute
Presentation by Mr. Paul Samuels, Legal Action Center (LAC) and the Coalition for Whole Health
Presentation by Mr. Peter Thomas, Consortium for Citizens with Disabilities (CCD)
Presentation by Dr. Gary Ulicny, The Shepherd Center
Presentation by Ms. Marty Ford, The Arc and United Cerebral Palsy Disability Policy Collaboration
8 NON-DISCRIMINATION IN THE REQUIRED ELEMENTS FOR CONSIDERATION
Presentation by Ms. Sara Rosenbaum, The George Washington University
9 ADDITIONAL STAKEHOLDER PERSPECTIVES
Presentation by Dr. R. Sean Morrison, National Palliative Care Research Center (NPCRC)
Presentation by Ms. Jina Dhillon, National Health Law Program (NHeLP)
Presentation by Mr. Stuart Spielman, Autism Speaks
Presentation by Ms. Meg Booth, Children’s Dental Health Project (CDHP)
Presentation by Dr. Andrew Racine, American Academy of Pediatrics
Presentation by Dr. Gerald Harmon, Council on Medical Service, American Medical Association (AMA)
Presentation by Dr. Robert Murphy, American Society of Plastic Surgeons (ASPS)
Presentation by Ms. Linda Fishman, American Hospital Association (AHA)
Presentation by Mr. John Falardeau, American Chiropractic Association
Presentation by Dr. Arnold Cohen, American Congress of Obstetricians and Gynecologists (ACOG)
Presentation by Mr. Thomas Sellers, National Coalition for Cancer Survivorship (NCCS)
Presentation by Mr. Troy Zimmerman, National Kidney Foundation (NKF)
Presentation by Mr. Richard Smith, Pharmaceutical Research and Manufacturers of America (PhRMA)
Presentation by Mr. Brian Gallagher, American Pharmacists Association
Presentation by Mr. Bruce Wolfe, Obesity Care Continuum (OCC)
10 TWO PRIVATE-SECTOR APPROACHES TO BENEFIT COVERAGE AND DESIGN
Presentation by Dr. Samuel Nussbaum, WellPoint, Inc.
Presentation by Dr. Sharon Levine, The Permanente Medical Group
11 DECIDING WHAT IS ESSENTIAL AND EVIDENCE-BASED IN TWO STATES FOR PUBLIC INSURANCE PROGRAMS
Presentation by Ms. Carolyn Ingram, CHCS
Presentation by Dr. Jeffery Thompson, Washington State Department of Social and Health Services
Presentation by Ms. Leah Hole-Curry, Washington State Health Technology Assessment (HTA) Program
12 LESSONS FROM CALIFORNIA’S BENEFIT REVIEW PROCESSES
Presentation by Ms. Susan Philip, California Health Benefits Review Program (CHBRP)
Presentation by Mr. Anthony Wright, Health Access California
13 PRIORITY SETTING AND VALUE-BASED INSURANCE DESIGN
Presentation by Dr. Somnath Saha, Portland VA Medical Center and the Oregon HSC
Presentation by Dr. Jeanene Smith, Office for Oregon Health Policy and Research
Presentation by Ms. Jean Fraser, San Mateo County Health System
14 ASSESSING AFFORDABILITY AND THE POTENTIAL FOR UNDERINSURANCE
Presentation by Dr. Jessica Banthin, Agency for Healthcare Research and Quality (AHRQ)
Presentation by Ms. Cathy Schoen, The Commonwealth Fund
APPENDIXES
A Patient Protection and Affordable Care Act, Section 1302
B Web-Based Questions for Public Input on Determination of Essential Health Benefits
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Boxes, Figures, and Tables
Summary
Box
S-1 Statement of Task for the IOM Committee
Chapter 1
Boxes
1-1 Essential Health Benefits Categories in ACA
1-2 Statement of Task for the IOM Committee
Chapter 2
Box
2-1 Characteristics of the National Compensation Survey
Chapter 3
Figures
3-1 Insurance premiums can rise as state-mandated health benefits accumulate
3-2 Insurers use a continuum of patient risk factors to guide consumer engagement efforts
Chapter 4
Figure
4-1 The benefit categories in the ACA could vary in breadth and depth of coverage
Table
4-1 The Marginal Cost of Maryland’s State-Mandated Benefits Is Less Than the Full Cost Per Benefit
Chapter 6
Box
Figure
Table
6-1 Scope of Included Benefits: ACA vs. CIGNA’s Standard Employer Plan
Chapter 10
Figures
10-2 Prostate cancer treatments vary in cost but not necessarily in outcomes
Chapter 11
Box
Figures
Table
Chapter 12
Tables
12-2 Independent Medical Reviews (IMRs) by Treatment 2008-2010
12-3 Comparison of 2010 Independent Medical Review (IMR) Results
12-4 Comparison of Grievance and Appeals Processes Under the Knox-Keene Act and the ACA
Chapter 13
Boxes
13-1 Example of Oregon’s Criteria for Line Item Scoring: Type II Diabetes Mellitus
13-2 Hypothetical Example of Costs and Benefits Under a Silver-Level Plan
Tables
13-2 Oregon Health Services Commission’s Prioritized Categories of Care and Associated Weights
13-3 Oregon’s Proposed Value-Based Benefit Tiers Vary in Benefits and Patient Cost Sharing
Chapter 14
Figures
14-1 Percent of families spending 10 percent or more of family income by insurance status
Table