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.
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:
- Emergency services
- Habilitative and rehabilitative services
- Inpatient care
- Outpatient care
- Maternity and newborn care
- Mental health and addiction treatment
- Lab tests
- Preventive care
- Prescriptions
- 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?"
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The notion of allowing states to decide runs counter to what the healthcare community knows about population health and evidence-based care, Georgiou says.
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 is a contributing writer for HealthLeaders.