A complaint survey into the death of a 60-year-old patient, who jumped from her 11th floor room at Grady Memorial Hospital, has identified serious deficiencies at the hospital that limit the hospital's "ability to render adequate care" and will require a full survey of the facility, according to the Centers for Medicare & Medicaid Services. The deficiencies also prevent Grady from "being in compliance" with the conditions of participation for the federal Medicare program.
Alston "Pete" Correll, who chairs the Grady Memorial board of directors, was notified of the hospital's deficiencies in a Sept. 28 letter from the Atlanta office of CMS. HealthLeaders Media obtained a copy of the letter and the deficiency report from CMS on Friday following a freedom of information request. Grady Memorial Hospital declined to provide documents or information related to the complaint survey.
At the time Grady Memorial was awaiting the arrival of its new CEO, John Haupert, who arrived on Oct 3. He was formerly COO of Parkland Memorial in Dallas. Parkland and Dallas CMS officials recently signed a systems improvement agreement to permit that hospital to remain open while it works to correct deficiencies that threatened its closure.
A complaint survey can originate from several sources, including patients or their families. Efforts to identify who initiated the complaint survey were unsuccessful. The complaint survey was conducted by an unidentified state survey agency.
A full survey of the 689-bed Grady Memorial will be conducted in the next few weeks, according to the CMS letter. The survey team will arrive unannounced and spend several days looking at all aspects of the hospital facility and operations. If any deficiencies are identified during the survey, Grady Memorial will be required to submit to CMS a corrective action plan that separately addresses each deficiency..
As noted in the 52-page survey report, Grady's current deficiencies fall into three broad categories: patient rights, nursing services, and physical environment. All of the deficiencies are related to the Sept 6 patient death.
According to the report findings the patient was admitted" to receive treatment for seizures and alcohol withdrawal." On the ninth day of the patient's hospitalization physician orders "revealed the patient was to be on 1:1 monitoring." However, on Sept. 6 there were "no available sitters for the 11p.m to 7 a.m. shift." Instead, staff was going to check on the patient "as often as possible." A registered nurse noticed that the patient was missing around 1:50 p.m. and that the patient's room window was open. The RN "looked out the window and saw something on the street." Accompanied by the charge nurse, the RN "went downstairs and found the patient's body on the street."
The survey report noted these issues that contributed to the deficiencies:
The patient's unit was understaffed during 20 of 21 shifts from Sept. 1 to Sept. 7.
No documented evidence of the patient having a sitter in either the nursing notes or the patient's plan of care.
No sitter observation or hand-off forms were included in the patient's records.
No protocol for assessing the safety of patient room windows was in effect.
It also identified steps the hospital has already taken to correct the deficiencies:
Staff has been added to the medical-surgical units.
Overtime has been authorized for unlicensed staff to work as sitters.
Education and training sessions have been implemented for sitters regarding safety and compliance to sitter documentation logs
All 566 of the hospital's operable windows have been inspected and 21 were found unlocked. Standard screws were replaced with tamper-proof screws.
The hospital's media department provided via e-mail this statement, which was dated Oct. 6: "There were some initial findings resulting from the state Department of Human Services review that occurred immediately following the September 6 incident. We are aware of those findings and are implementing corrective actions. At the same time we are preparing for a full unannounced survey by the Centers for Medicare and Medicaid, which is standard in situations like this. We were expecting CMS survey notification and received it on September 28."
How much Medicare or Medicaid funding might be at risk is unknown. A Grady spokesperson would comment only that in 2010 Medicare accounted for 32% of net patient revenue while Medicaid accounted for 40% of net patient revenue.
Methodist Dallas Medical Center continues to face the possibility of termination of its Medicare funding after a second review of the medical center revealed two new problems. At risk is about $208 million in federal funding.
Laura Irvine, the administrator at Methodist Dallas Medical Center, was notified of the medical center's new deficiencies in the areas of nursing services and infection control in an Oct 12th letter from the Dallas office of the federal Centers for Medicare & Medicaid Services.
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The exact nature of the new problems is unknown. In an e-mail exchange, Bob Moos, a spokesperson for the Dallas office of CMS, said the deficiency specifics will not be made public until Oct 24th when Methodist Dallas files with CMS its required corrective action plan. Once CMS accepts the CAP another survey will be scheduled before Dec. 13th, which is the date when CMS could terminate the medical center's Medicare agreement if the deficiencies aren't corrected.
The new problems were discovered during a follow-up review undertaken to confirm that the facility had corrected certain immediate jeopardy problems identified during an August review of the medical center. That review identified 10 broad areas of deficiencies, involving medical screening, emergency services, handwashing, medication administration, and medical records.
In a statement e-mailed to Healthleaders Media, officials at Methodist Dallas said the 10 previous deficiencies had been "acceptably addressed" but new problems were discovered during the recent seven-day survey.
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Methodist's statement noted that the 515-bed hospital "follows national standards regarding nurse staffing and infection control protocols." It said the hospital has already taken action to correct the problems, including "instituting additional nursing education, strengthening surveillance to ensure adherence to policies and protocols, and reinforcing adherence through annual education and performance reviews."
Methodist Dallas Medical Center, which is part of the five-hospital Methodist Health System, is the second Dallas hospital in recent months to face the potential loss of its Medicare funding. Last month officials at Parkland Memorial Hospital signed an agreement with CMS that allows the hospital to retain more than $417 million in Medicare and Medicaid funding while it attempts to correct deficiencies that threatened its closure.
Officials at Martin's Point Health in Portland, ME learned Wednesday that its Medicare Advantage health plans scored two five-star ratings from the Centers for Medicare & Medicaid Services.
A five-star designation is a rarity; only 12 out of 446 plans rated achieved it in 2011. The rating means that Martin's Point's Value and Prime Medicare Advantage plans will qualify in 2012 for a cut of an estimated $3 billion in bonus payments. Also, the two plans will be able to enroll members throughout the year rather than only during the seven-week Medicare enrollment period.
The other Medicare Advantage plans with a five-star ratings for 2011 are Advocare in Wisconsin; Dean Health Plan in Wisconsin; Group Health Cooperative in Washington; Gunderson Lutheran Health Plan in Iowa and Wisconsin; Health New England in Massachusetts; and Kaiser Permanente in California, Colorado, Hawaii, Oregon and Washington.
Larry Henry, vice president of Medicare at Martin's Point, said the rating will provide a strategic advantage for the small plan, which has only 12,500 Medicare Advantage members. "Now we'll be able to tell our story and market our plans year-round. We'll be able to separate ourselves from the other Medicare Advantage health plans that can sell their products for only a short time each fall."
He said the plans were close last year –they were received 4.5 stars—and some tweaking helped kick them into star status. The plans posted important gains in preventive services thanks to a campaign to increase flu shots among its Medicare Advantage members.
The ratings program, created to help CMS monitor plan performance, has been around for four years, but it only began to generate real interest among health plans when the bonus payments were added as part of the Affordable Care Act.
The CMS star rating system is based on more than 40 quality measures, including preventive screenings, managing chronic conditions, and customer service.
Now the star rating system plays a strategic role in the development and growth of Medicare Advantage business.
During a recent conference call with stock analysts, Angela Braly, the president and CEO of WellPoint Inc., said the insurer's acquisition of CareMore, a Medicare Advantage plan, would "lead to higher quality star ratings that will be an increasingly important part of the Medicare program in the future."
During a similar call, Michael McCallister, Humana's chair of the board and CEO, said Humana "plans to reinvest heavily in improving our stars' processes, procedures and infrastructure to position us for further improvements in star metrics."
In addition to the dozen plans at the five-star level, another 97 achieved at least a four-star rating, which is the minimum number of stars needed to qualify for a bonus.
Unlike previous years when health plans were allowed to maintain their Medicare Advantage status despite poor quality ratings, CMS has proposed a rule that will give it the authority to terminate poor-performing Medicare Advantage and Part D sponsors that fail to achieve at least a three-star rating for three consecutive years.
Hospitals, health plans, and healthcare reform advocates all talk a lot these days about the engaged healthcare consumer—the one with skin in the game who approaches healthcare purchases with the same money-saving zeal as a coupon clipper in a supermarket.
But how hard will the average consumer work to trim a healthcare bill? It’s one thing to save money by purchasing a less expensive brand of tuna fish, quite another to score a deal on a mammogram.
For more than a decade, consumer- directed health plans (CDHPs) have been touted as a way to give the consumer some control over healthcare spending decisions. How effective has this model been?
A group of researchers at RAND Health has been looking at how CDHPs affect healthcare spending. They’ve released three reports so far, and each one has provided another piece of the puzzle to help understand how healthcare dollars are spent. While their research shows that CDHPs reduce healthcare spending, there is also evidence that those cuts have come at the expense of necessary care, not from consumers shopping more prudently for healthcare services.
The first report, released in March 2011, looked at the effect of high-deductible plans on spending. In a study of more than 800,000 families, the researchers found that people in high deductible plans spend less money on healthcare. That’s the good news. But they spend less money because they forgo preventive healthcare such as childhood shots and cancer screening. Oops, there’s the bad news.
The second report, released in April 2011, looked at the effect of high-deductible plans on the medically vulnerable. It found that people with chronic health problems or low incomes are no more at risk to reduce needed healthcare than anyone else.
The third report, out this month, looks at the effect of high-deductible plans on spending for an episode of care—the set of services required to manage a specific medical condition over a certain period of time. The good news from this study is that people always look for ways to conserve their healthcare dollars. The bad news is that, once again, one of the ways they save is by avoiding preventive care.
The episode of care for a broken wrist includes the ER, x-rays, doctors, and rehabilitation services. The researchers discovered that once care is initiated—the ER visit for that broken wrist, for instance—patients still have some control over how much they spend on healthcare services and they still find ways to save money on that episode of care.
How? Amelia Haviland, the study’s lead author and a senior statistician at RAND, explains that patients trim costs in three ways: they use fewer name-brand drugs, see fewer specialists, and limit their hospital stays.
“Unfortunately,” said Haviland in a telephone interview, “that only happened about one-third of the time. Usually patients achieved a savings during an episode of care by receiving less care.” So, in the case of that broken wrist, maybe a patient would go for five sessions of physical therapy instead of 10.
Haviland says more studies are planned to determine the extent to which necessary medical care is sacrificed for cost savings. But for now this CDHP research project presents troubling news for the triple aim of healthcare reform—better care, better health, and lower cost. Everyone, especially employers and health plans, should stop and think about such lofty expectations. Is the fabled consumer who will use the power of the marketplace to reduce his healthcare bill in fact a myth?
It’s important that all parties take a hard look at how cost-cutting and care-cutting play out in high-deductible health plans. Healthcare reform is expected to further encourage enrollment in these plans, which will probably be among the key offerings in health insurance exchanges. That could translate into millions of new enrollees who might not receive the medical care they need.
Consider the example of the episode of care for a broken wrist once more. Assuming that each physical therapy session is billed at $120, then the patient could save $600 by forgoing five sessions. But what are the long-term costs? Nerve damage? Limited use of that hand? Maybe health insurers, lawmakers and employers need to stop talking about lower healthcare costs to the exclusion of the other two parts of the triple aim. Better care and better health offer a sustainable way to control healthcare costs. That’s the message consumers need to hear.
The pillars of an essential health benefits package are medical effectiveness, safety, and their relative value compared with alternatives, the Institute of Medicine suggested last week. Working out the details, however, is up to the Department of Health and Human Services, which has announced that it will seek public opinion on what health insurance exchanges must offer.
The Institute of Medicine unveiled last week the processes and procedures it recommends that HHS follow in the development of the health benefits package that will be offered by health insurance exchanges (HIX). That effort involved an 18-member committee comprised primarily of representatives from organized stakeholder groups.
Keith Maley, an HHS spokesperson, said in an interview that the agency will focus for the time being on getting public input on the development of essential health benefits. The IOM has recommended a public process for both defining and updating the EHB package.
In its report, Essential Health Benefits: Balancing Coverage and Cost, the IOMsaid the public deliberation process "would enable individuals? working in small group meetings around the country?to participate in a prioritization process, where different elements of coverage?specific services, types of cost-sharing, degree of provider choice, approval requirements, etc.?are discussed and debated."
In a press statement Secretary Kathleen Sebelius stressed the importance of the "listening sessions where Americans from across the country will have the chance to share their thoughts on these issues but offered no commitment to the structure of the sessions themselves or their locations.
Maley said the department faces "no statutory deadline" for creating the list of essential benefits. However, the Affordable Care Act requires that HIX be up and running in 2014. Health plans have already expressed concern that they will face a tight timeline to develop, test and market a health insurance product that can be ready for HIX. Off the record, insurers have suggested that a six- to 18-month timeline is not out of question.
IOM has recommended that the list be developed by May 1, 2012.
Walt Cherniak, a spokesperson for Aetna, noted that the rollout for an essential health benefits product could be different from how the large insurer usually introduces a new product. "We usually work from customer demand. This time we'll be putting together mandated benefits and mandated design."
Congressional support to repeal the sustainable growth rate (SGR) program is growing. Some 114 members of Congress, including 21 Republicans, have signed a bipartisan letter to the Joint Select Committee on Deficit Reduction, asking the committee to repeal the unpopular Medicare physician payment system.
“We urge you to include a full repeal of the SGR, to stabilize current payment rates to ensure beneficiary access in the near-term, and set out a clear path toward comprehensive payment reform,” says the letter, which the signatories sent on Thursday to the 12-member “super committee.” “Failure to take advantage of this opportunity to permanently address the SGR means that the cost of a remedy over five years could double to nearly $600 billion.”
The letter notes that “for a decade, the fundamentally flawed Medicare physician payment system has created uncertainty and instability not only in the healthcare system but in the larger economy. Through this deficit reduction process, Congress has an historic opportunity to implement sound fiscal policy in the Medicare program in the context of broad economic reforms.”
It closes with a call for “bipartisan Congressional action to put an end to the fiscal irresponsibility that has defined Medicare payment policies for a decade. True deficit reduction cannot be achieved without addressing the significant debt in our nation’s largest health program.”
Rep. Allyson Schwartz (D-PA), a House leader on healthcare issues and the second-highest ranking Democrat on the House budget committee, organized the letter signing.
Members of Congress who added their name to the letter include Rep. Todd Akin (R-MO), Rep. Barney Frank (D-MA), Rep. Dennis Kucinich (D-Ohio), and Rep. Phil Roe, MD (R-TN).
The letter was sent on the very day that the Medicare Payment Advisory Commission voted to repeal the SGR and replace it with a plan that will include cutting reimbursements by $335 billion over 10 years. MedPAC, which advises Congress on Medicare payment matters, proposed that specialist reimbursement be reduced by 17.7% over three years and then frozen for seven years. PCP reimbursements would remain unchanged for the next 10 years. The remaining $235 billion in reductions would come from a combination of payment cuts to providers and health plans, including hospitals, Medicare Advantage plans, and durable medical equipment.
While asking for the repeal of the SGR, the Congressional letter offered only a vague statement on what might replace SGR: “The sustainable growth rate must be repealed and replaced by a payment system that promotes efficiency, quality, and value, and ensures access to medical services for Medicare beneficiaries.”
Tali Israeli, a spokesperson for Rep. Schwartz, says the congresswoman is concerned that MedPAC’s cuts are too severe. “There needs to be a smoother transition and more certainty in the future for the providers,” Israeli told HealthLeaders Media.
Schwartz is developing legislation to provide for an SGR alternative, but no details concerning what might be included in the potential bill are available. Israeli says it is doubtful that the legislation will be presented before the end of the year.
Time is of the essence. Congress has until October 14 to provide its recommendation on how to reduce the deficit to the debt committee. The super committee must vote on its debt reduction proposal by November 23, and Congress must vote on the debt committee proposal by December 23. If SGR is not repealed, a 29.4% cut in physician reimbursements will go into effect at the beginning of 2012.
The criteria used to define essential health benefits should include medical effectiveness, safety, and their relative value compared with alternatives, according to a report released Thursday by the Institute of Medicine.
Essential Health Benefits: Balancing Coverage and Cost sets forth the methods and criteria that the IOM recommends be used to develop the actual list of essential benefits. That big job will fall to the Department of Health and Human Services.
As required by Patient Protection and Affordable Care Act, beginning in 2014, health insurance exchanges, as well as individual and small group health insurance policies must offer these essential benefits.
To balance cost and affordability of the essential benefits package, the IOM recommends that the essential benefits reflect "the scope and design of packages offered by small employers today." Consumer groups had hoped that the IOM would opt for a more robust list of benefits.
The 300-page report provides recommendations in five areas:
Developing a premium target. The report recommends that HHS determine what the national average premium of typical small employer plans would be in 2014 and match the benefits to that premium cost.
Defining priorities. The report recommends a series of small group meeting be held around the country to discuss the benefits and costs of different plan designs, including coverage-specific services and cost-sharing.
Ensuring appropriate care. Only medically necessary services should be covered and the definition of "medically necessary" should depend on individual circumstances.
Promoting state-based innovations. HHS should grant states' requests to adopt alternatives to the EHB package only if the alternatives are consistent with ACA requirements and the criteria specified in this report, and they do not vary significantly from the federal package.
Updating the EHB. HHS should update the EHB package annually, beginning in 2016. Advances in medical science and cost should define the updates. A National Benefits Advisory Council should be appointed to offer external advice.
Stakeholders began weighing in on the IOM report Thursday.
America's Health Insurance Plans CEO Karen Ignagni said she is encouraged by the report's attention to balancing affordability and coverage. "We agree that this balance is critical to ensuring that individuals, working families and small employers can afford health insurance. The recommendation that the initial EHB package reflect the scope of benefits and design provided under a typical small employer plan is an important step toward maintaining affordability."
The final rule on essential benefits is expected in 2012.
The Medicare Payment Advisory Commission on Thursday voted to repeal the contentious sustainable growth rate formula and replace it with a controversial plan that would include reimbursement cuts to specialists and pay freezes for primary care physicians.
MedPAC is charged with advising Congress on Medicare payment policy issues, including reimbursements to physicians, hospitals, labs and imaging centers. SGR was put in place as part of the Balanced Budget Act of 1997 to help control Medicare spending. It soon became apparent that significant cuts in physician reimbursements would be required to help reduce spending.
Typically Congress has ignored MedPAC's payment reduction recommendations. It's been 10 years, for instance, since Congress has actually enacted any cuts to physician reimbursements.
Now the proverbial chickens are coming home to roost. Unless some action is taken before Jan. 1, 2012, Medicare payment rates for physicians will drop by 29.4%. In the current political climate, however, Congress and President Obama are unlikely to intercede and delay the cuts as they have in the past.
Details
MedPAC has proffered a plan that calls for $335 billion in reimbursement reductions over 10 years. The so-called "doc fix" will account for $100 billion. Specialist would see their reimbursement rates reduced by 5.9% each year for three years and then frozen for seven years. PCP reimbursements would remain unchanged for the next 10 years.
The remaining $235 billion would come from
Cuts to Medicare Part D drug plans (32%)
Post–acute care facilities (21%)
Medicare beneficiaries (14%)
Hospitals (11%), labs (9%)
Durable medical equipment (6%)
Medicare Advantage plans (5%)
Other providers (2%)
MedPac first unveiled the proposal in September and it was greeted with a resounding thud.
Industry Reaction
MedPAC's proposal brought howls of protests from the American Medical Association.
"The recommendation voted on today by MedPAC flies in the face of their previous recommendations to stop harmful physician cuts that threaten access to care for patients," AMA President Peter W. Carmel, MD, said in prepared remarks.
"There is already a 20% gap between Medicare payment updates and the cost of providing healthcare to seniors. Many physicians may also face upcoming payment penalties related to electronic prescribing, health information technology and quality reporting programs. Adding additional physician payment cuts to this mix will leave many physicians unable to care for Medicare patients or make the investments needed to participate in new models of care that can increase coordination and reduce costs."
The American Hospital Association this week told MedPAC that it should stop punishing hospitals – which are already facings cuts of $155 billion in reimbursement cuts over 10 years under the Affordable Care Act.
Instead, AHA gave MedPAC a list of 40 recommendations that the hospital lobby said could generate savings, including medical malpractice reform, and budget reduction proposals from both the Obama Administration and from House Republicans.
AHA said it would even support raising the Medicare eligibility age and eliminating first-dollar coverage on MediGap plans if that would help the nation's hospitals avoid additional reimbursement cuts over the next decade.
In a letter this week to MedPAC Chairman Glenn M. Hackbarth, AHA President/CEO Richard Umbdenstock said he supports eliminating the SGR, but not at the expense of hospitals.
"Offsetting the cost of the repeal with Medicare cuts to hospitals and other providers is merely 'robbing Peter to pay Paul' and is the wrong approach," Umbdenstock said in the letter. "Making cuts to providers, such as hospitals, that, according to MedPAC itself, are already seeing negative Medicare margins, could endanger beneficiary access to those providers."
Instead of passing the costs onto other providers, Umbdenstock said MedPAC could pass the costs onto seniors by considering "offset suggestions, such as eliminating first-dollar coverage for MediGap plans or raising the Medicare eligibility age."
Umbdenstock says MedPAC and the federal government should consider tort reform, which he said adds between $50 billion and $100 billion each year to the nation's healthcare bill.
"Across the nation, access to healthcare is being negatively impacted as physicians move away from states with high insurance costs or stop providing services that may expose them to a greater risk of litigation," he said.
"The increased costs that result from the current flawed medical liability system not only hinder access to affordable health care, they also threaten the stability of the hospital field, which employed 5.3 million people in 2009, and continues to be one of the largest sources of private-sector jobs."
The Washington, D.C.-based Blue Cross and Blue Shield Association wants to share some how-to knowledge with the federal government to help improve healthcare quality and rein in costs. Citing best practices implemented by many of BCBSA's 39 plans, president and CEO Scott P. Serota said the government should "encourage the private sector to innovate. Let us figure out what works."
He added that the federal government should "learn from our experiences and then communicate those experiences to speed adoption" of the practices.
At a press conference Tuesday, Serota announced a roll-up-your-sleeves action plan that he estimates could produce $319 billion in Medicare and Medicaid savings over the next decade by replicating a number of innovations underway at various Blue Cross and Blue Shield companies across the country.
The plan presents 20 recommendations to improve healthcare quality and tackle rising costs. It focuses on what it says are four actionable steps the government can take: reward safety, do what works, reinforce front-line care, and inspire healthy living.
The plan matches policy steps Blues plans across the country are taking, such as investing in the primary care workforce, coordinating care to better manage chronic conditions, and designing incentive programs to drive safety, with examples of how the policies are being implemented at Blues plans:
The foundation at Blue Cross and Blue Shield of North Carolina awarded a $1.2 million grant to increase the number of North Carolina-trained medical students who elect family medicine residency programs and practice in the state.
In partnership with a major account, Regence Blue Shield developed a patient-centered medical home for highest risk employees—the ones who account for 65% of the company's healthcare costs. The program resulted in a 20% reduction in healthcare costs.
Highmark Blue Cross Blue Shield's QualityBLUE hospital pay-for-performance program aligns reimbursements with high-quality care and improved outcomes. In 2011 the program results in $48 million in savings.
The 20 recommendations for the federal government include:
Expand value-based payments in Medicare.
Make care coordination available to all Medicare beneficiaries.
Ensure that government payment policies recognize the value of primary care.
Align federal delivery system reform initiatives with private sector best practices to promote primary care.
Expand government initiatives to reduce healthcare disparities.
Promote safe deliveries and improve maternal care.
Kenneth Thorpe, PhD, a professor and chair of the department of health policy & management at Emory University in Atlanta, who produced the program's economic analysis, said the BCBSA program stresses proven actions. "I have pilot fatigue. We don't need another pilot where we wait 12 to 15 years for the results. We know what works and we need to do it now."
Tucked away in section 1302 of the behemoth Patient Protection andAffordable Care Act (ACA) is the requirement that the Department of Health and Human Services define the essential healthcare benefits that must be offered – beginning in 2014 – by health insurance exchanges and health insurance policies, both individual and small-group.
This work is fundamental to the future state of healthcare. It will directly affect the medical benefits of many Americans, and therefore the functioning of hospitals and healthcare systems.
The ACA specifies 10 broad categories of medical care for which essential benefits must be defined: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, lab services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.
The idea is that the essential services will reflect the benefits provided in a typical employer health insurance package. Medical care that isn’t deemed essential can be excluded from coverage.
A committee at the independent Institute of Medicine has been hard at work since January on the first step in the process of creating the list of services to be deemed essential benefits. On Friday the IOM will unveil the methods and criteria that HHS will then use to develop the actual list. “IOM provides the guidance and HHS will define the benefits,” explains IOM spokesperson Christine Stencel.
The IOM committee has hosted two public workshops and heard from hundreds of stakeholders, including employers, insurers, healthcare providers, consumers, and healthcare researchers. These groups and individuals hope that benefits affecting their part of the medical world will be included.
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.
Applying evidence to benefit coverage. Stakeholder comments to the IOM committee were united in support of using medical evidence to decide what benefits should be covered in an essential healthcare package. But what evidence should be standardized? Should there be flexibility so as not to limit access to care? How should evidence be used to assess new technologies? Age and chronic illnesses also come into play. The IOM has it hands full here.
I asked a few stakeholder groups what they would like to see from the IOM’s review.
Ethan Rome, executive director of Health Care for America Now, a grassroots group affiliated with the Obama administration’s healthcare reform efforts, says a specific list of essential medical benefits would be a bad idea. “The final rules must ensure that consumers get good benefits, not mini-med plans that burden families and businesses with outrageous medical costs and force them into bankruptcy,” he told HealthLeaders Media.
Dave Lemmon, director of communications for Families USA, a nonprofit advocating for consumers, says the organization would like an essential benefits package to “recognize the importance of coverage for disease management services that can help people stay healthy, save money, and avoid more expensive interventions.”
And Robert Zirkelbach, press secretary for America's Health Insurance Plans, the trade association for the health insurance industry, says his organization would like to see coverage remain affordable, and that “when you add benefits, the health insurance will cost more.” AHIP also recommends that any definition of essential benefits embrace the federal employee’s health plan model, which provides a variety of cost-sharing levels so consumers can pay for what they want.
The IOM report will help (I hope) define and narrow some of the broad issues that must be considered. When the report is released, the IOM’s work will be done but the debate will just be starting.