Essential Benefits Could Be Replaced by an Evidence-based Care Framework

Gregory A. Freeman, May 17, 2017

The AHCA would eliminate essential benefits in favor of letting each state decide, but why reinvent the wheel? Oregon has already developed a system that works.

Archelle Georgiou, MD
Archelle Georgiou, MD

It's time to get serious about assessing the value of health services, says a former health plan executive, and Oregon is a good place to look for a structure that works.,

The American Health Care Act (AHCA) or a new reform bill should replace the Affordable Care Act's 10 Essential Health Benefit (EHB) categories with evidence-based basic health services that deliver the best possible care and value, says Archelle Georgiou, MD.

Between 1995 and 2007, she was a senior executive and chief medical officer of UnitedHealthcare, where she dismantled many of the company's legacy policies in order to minimize the bureaucratic hassles imposed on patients and physicians.

For policies sold to individuals and employers with 50 or fewer employees, the ACA requires health plans to include 10 EHBs:

  1. Emergency services
  2. Habilitative and rehabilitative services
  3. Inpatient care
  4. Outpatient care
  5. Maternity and newborn care
  6. Mental health and addiction treatment
  7. Lab tests
  8. Preventive care
  9. Prescriptions
  10. Pediatric services, including oral and vision care

Plans sold to larger employers are exempt from the requirement, but if they cover any EHBs, the health plan cannot have lifetime or annual limits for that care.

Potential for Chaos

The Republican bill would eliminate the ACA's mandate on EHBs, allowing states to determine what health plans must cover. Not the right move, Georgiou says.

"That would mean we have 50 different legislatures determining independently what basic services are needed by a population, but the biology and the needs of people don't vary that much across the country. Why are we figuring this out 50 times?" she says.

"The risk is that states are going to be influenced by lobbying, lack of knowledge, and then you have situations where people in Minnesota don't have some type of care that people in Wisconsin get. What kind of effect will that have on people deciding where to live and work?"

Related: Population Health Management Strategies, Explained

The notion of allowing states to decide runs counter to what the healthcare community knows about population health and evidence-based care, Georgiou says.

Gregory A. Freeman

Gregory A. Freeman is a contributing writer.

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