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

Gregory A. Freeman, May 17, 2017

She cites Oregon as a state already taking the right approach, one that she says could be implemented nationwide rather than having other states reinvent the wheel, and make some wobbly wheels in the process.

Oregon's Health Evidence Review Commission (HERC) determines what healthcare services will be covered by the Oregon Health Plan, which operates under a Medicaid waiver granted in 1993.

An Evidence-Based Strategy

The 13 members of the HERC consists are mostly healthcare professionals.  Each year they prioritize several hundred treatments using a formula that considers the impact on healthy life years, suffering, population health, and other factors. The HERC uses the annual state budget to determine the cut off point for which services will be covered by the health plan.

The prioritized list currently has 665 items. Coverage is provided for items 1 (pregnancy) through 475 (repair for acquired ptosis and other eyelid disorders with vision impairment) but not for items 476 (medical and surgical treatment for keratoconjunctivitis) through 665 (evaluation for miscellaneous conditions with no or minimally effective treatments or no treatment necessary).

The same concept can be applied on the federal level, she says, to establish which essential benefits health plans would be required to cover.

"I'm concerned with the current version of the AHCA because a lot of what it is trying to do is not based on evidence. It's based on politics, and that is not the right way to determine what healthcare benefits are the most essential and worthwhile," she says.

"The current essential benefits may not be the best answer, but neither is deferring to 50 states to determine something that should be uniform for all consumers. The rationale behind evidence-based care doesn't change just because you crossed a state border."

Gregory A. Freeman

Gregory A. Freeman is a contributing writer.

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