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The Essential Work of Defining Essential Healthcare Benefits

Margaret Dick Tocknell, for HealthLeaders Media, October 5, 2011

The IOM is tight-lipped about what its final report will say, so I turned to the Institute’s workshop report to glean information about the committee’s focus. I quickly found that the IOM has tackled a seemingly impossible task. In many cases, there is no clear path to an unquestionably right decision. The devil is indeed in the details.

Expect the IOM report to weigh in on several key areas:

Balancing coverage and affordability. As you can imagine, opinions on how to reconcile benefits and price run the gamut. What benefits make a health insurance policy meaningful? Does essential mean “basic” or should comprehensive coverage be included? The IOM will have to balance the desires of consumer groups for comprehensive coverage with concerns that small businesses will not be able to offer more expensive benefit packages for their employees.

Defining a typical employer plan. According to a Department of Labor survey that the IOM used to help it decide what constitutes a typical plan, 99% of health plan participants currently have inpatient coverage, 67% have hospice care, and the median deductible is $500 per person. Should essential coverage be consistent with the generous plans offered by large firms or match the benefit packages of smaller companies – because they will be most affected by the ACA?

Defining medical necessity of care. Medical necessity can mean a lot of things: Is it the care provided in accordance with generally accepted standards? Is it evidenced-based intervention? Is a certain medical intervention appropriate for a specific patient? How should medical necessity be applied to chronic diseases? In addition to care for healthy adults, the IOM must consider the definition of medical necessity for care to children, the elderly, and the chronically ill.

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1 comments on "The Essential Work of Defining Essential Healthcare Benefits"


Matthew Bassett (10/7/2011 at 4:37 PM)
You were spot on when pointing out that the devil is in the details. The White House will carefully watch the response to the IOM report which will likely not satisfy anyone and only raise politically difficult questions. HHS is already saying that the final rule will not be out until May of next year at the earliest. This would be in the heat of the Presidential election and right around when the Supreme Court could rule on the constitutionality of the ACA. No one should be surprised if this is not settled definitely until after the election. At least this means that providers have time to express their views to state and federal officials. Payors' views are already well established and it seems the provider community is very late to the game. Providers need to make their voices heard now to help shape this important rule. Matthew Bassett, Revive PR