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Essential Health Benefits: Balancing Costs, Coverage, And Necessity

Sep 1, 2018

By KAVITA PATEL, MD

The much anticipated Institute of Medicine Report on essential health benefits (EHB) was released last week with a series of recommendations that answered some questions and raised many more. The report offers a very important opportunity for researchers, policymakers, providers and patients to fill in some of the white space between the recommendations.

Background on EHB in the Affordable Care Act and some Legislative History

The Affordable Care Act (ACA) tasked the IOM to make recommendations on the methods for determining and updating the essential health benefits that must be offered by qualified health plans seeking to participate in exchanges as defined in section 1301 of the statute. The ACA identified ten categories of items and services that must be included in a package of benefits:

Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care

The Affordable Care Act did not have a conference committee report, which is the product of the House and Senate working to resolve differences between the two chambers’ versions and also helps to highlight legislative intent. So the long history of the decisions behind the language and legislative intent is not as apparent. Briefly, Congress looked at many design models and previous bills, such as HR 3600 — one of the health reform bills put forward during the Clinton administration — which contained 61 pages of details on benefits. This approach was was felt to be too detailed and prescriptive. Staff from Senator Kennedy’s Health, Education, Labor and Pensions Committtee used the Massachusetts language on exchange benefits and its promulgated regulations and then made important additions such as habilitative services (educational or long term services, often associated with long terms disabilities or conditions such as autism).

A Doctor Thanks His Mentor – Steve Jobs

Aug 1, 2018

By DAVIS LIU, MD

I’ve been reading A Game Plan for Life: The Power of Mentoring written by famed UCLA basketball coach John Wooden. Wooden spends half of his book thanking the people who had a powerful influence on his life, coaching, philosophy, and outlook on life. Important people included his father, coaches, President Abraham Lincoln, and Mother Theresa.

Yes, President Abraham Lincoln and Mother Theresa.

Though clearly he could have never met the former and didn’t have the opportunity to meet the latter, Wooden correctly points out that as individuals we can be mentored by the writings, words, and thoughts of people we have never and will likely never meet.

Which seems like the most opportune time to thank one of my mentors, founder and former CEO of Apple, Steve Jobs.

Now, I have never met nor will I ever meet Steve Jobs. Lest you think I’m a devoted Apple fan, I never bought anything from Apple until the spring of 2010. Their products though beautifully designed were always too expensive. I’m just a little too frugal. I know technology well enough that people mistaken me for actually knowing what to do when a computer freezes or crashes. Yet, the value proposition was never compelling enough until the release of the first generation iPad. Then the iPhone 4. Finally the Macbook Air last Christmas.

No, thanking Steve Jobs isn’t about the amazing magical products that have changed my life as well as millions of others. It’s more than that. What he has mentored me on is vision, perspective, persistence, and leadership.

Shielding My Daughter’s Heart

Aug 1, 2018

By LYGEIA RICCIARDI

A couple of years ago, I gave birth to a baby girl, Ada. She looked perfect, but the doctors told me she had a significant heart murmur. When I held her in my arms at night I could hear blood rushing through a hole in her heart that shouldn’t have been there.

My husband and I took Ada to a pediatric cardiologist, who said she would probably need surgery to close that hole. For an entire year of tests and hospital visits, we lived in fear that open heart surgery was just around the corner. And then one day it was. “It’s time,” the cardiologist declared, “That hole is dangerously impeding her growth.”

Was Open-Heart Surgery Necessary?

I am grateful to live in a time and place in which surgery—even surgery on a heart the size of a golf ball—is an option. This kind of procedure has undoubtedly saved many lives. But it’s not without risks. More than 100,000 people die in this country every year from preventable medical errors. And hospital infections are a serious problem, too. We didn’t like the idea of subjecting a life so new, so tenuous, to a procedure of such magnitude unless there was a clear case for it. I’m not going to sugar coat this: We were talking about sawing open my baby’s ribs and stopping her heart and lungs.

The Individual Mandate, a Brief History — Part I Conservative Origins

Aug 1, 2018

By BRADLEY LATINO

In recent years, politicians of every stripe have eaten their words about the wisdom of requiring all Americans to possess health coverage. This hasn’t been real news since the 2007 Democratic primary debates, when candidate Obama claimed his reasons for opposing the mandate were similar to those expressed by Hillary some 15 years ago.

A few years later it was President Obama’s turn. And by 2010, the entire Republican party performed a synchronized heel-face turn, virulently opposing the solution they advocated decades earlier. All of this culminated with the recent passage of the “Repealing the Job-Killing Health Care Law Act” in the House, by which point the mandate had become a 21st century Intolerable Act.

The media have dutifully reported each foible as if such strategic backpedaling were something new under the sun. But the 22-year path to ACA § 1501(b) is a story in its own right, a sort of philosophical history of American health reform policy.

Part I – The think-tank solutions (1989 – 1992)

Back in the late 1980s, the individual mandate wasn’t controversial at all–just another idea being kicked around in conservative think tanks. Although economist Mark V. Pauly, an adviser to the first Bush administration, is often cited as the mandate’s creator, conservative thinkers Stuart M. Butler and Edmund F. Haislmaier were dreaming up similar proposals at the Heritage Foundation as early as 1989.Continue reading…

Single Payer Health: It’s Only Fair

Oct 5, 2012• 134

By SENATOR BERNIE SANDERS

The United States is the only major nation in the industrialized world that does not guarantee health care as a right to its people. Meanwhile, we spend about twice as much per capita on health care and, in a wide number of instances, our outcomes are not as good as others that spend far less.

It is time that we bring about a fundamental transformation of the American health-care system. It is time for us to end private, for-profit participation in delivering basic coverage. It is time for the United States to provide a Medicare-for-all, single payer health coverage program.

Under our dysfunctional system, 45,000 Americans a year die because they delay seeking care they cannot afford. We spent 17.6% of our GDP on health care in 2009, which is projected to go up to 20% by 2020, yet we still rank 26th among major, developed nations on life expectancy, and 31st on infant mortality. We must demand a better model of health coverage that emphasizes preventive and primary care for every single person without regard for their ability to pay.

It is certainly a step forward that the new health reform law is projected to cover 32 million additional Americans, out of the more than 50 million uninsured today. Yet projections suggest that roughly 23 million will still be without insurance in 2019, while health-care costs will continue to skyrocket.Continue reading…

Are Doctors Shifting to the Left?

Aug 9, 2012• 44

By DAVID E. WILLIAMS

A recent story in the New York Times (As Physicians’ Jobs Change, So Do Their Politics) highlights the political shift underway within the physician community. While doctors used to be mainly male small businessmen, who were a natural fit with the Republican Party, they’re now much more likely to be female and employed by larger organizations. According to the Times, that’s making doctors more likely to be out of sync with the GOP, and the article cites examples from around the country. The American Medical Association came out in support of the Patient Protection and Affordable Care Act, which was a surprise to many. State medical societies find themselves increasingly allied with liberal activist groups, and even historically “red meat” issues like malpractice reform aren’t that big a deal for those whose malpractice premiums are paid by their employers.

It seems to me there’s an important facet missing from the article. When I was growing up in the 1970s, being a doctor was viewed as one of the surest ways for an ambitious person to make money. That started to change as the advent of managed care made medicine less lucrative and the explosion of the financial services industry provided opportunities to make a lot more money in investment banking, hedge funds, private equity and venture capital. As I observe my own generation and those somewhat younger than me, it seems that those intent on making a lot of money aren’t as drawn to the physician path.

My father in law, of blessed memory, used to compliment certain physicians by saying, “he’s not a money doctor.” That really boiled it down to the essence.

On the whole, younger doctors –and older ones who are sticking with the profession– seem to have the patients’ interest increasingly at heart. And that’s no bad thing.

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma, biotech, and medical devices. Formerly with BCG and LEK. He writes regularly at Health Business Blog, where this post first appeared.

Employers and Health Reform

Jul 21, 2012• 70

By MICHAEL TURPIN

“Change, before you have to…” Jack Welch

We live in a society that loathes uncertainty – particularly the unintended consequences that sometimes result from a catastrophic event or in the case of PPACA, landmark legislation. Wall Street and the private sector crave predictability and find it difficult in uncertain times to coax capital off the sidelines when the overhang of legislation or geopolitical unrest creates the potential for greater risk. Despite our best energies around forecasting and planning, some consequences, particularly unintended ones – only reveal themselves in time.

In the last decade, employers have endured an inflationary period of rising healthcare costs brought on by a host of social, political, economic and organizational failures. There was and remains great anticipation and trepidation as Congress continues to contour the new rules of the road for this next generation’s healthcare system. Optimists believe that reform is both a way forward and a way out of a mounting public debt crisis and a bypass for an economy whose arteries are clogged by the high cost of medical waste, fraud and abuse. Cynics argue reform is merely a Trojan Horse measure that offers an open invitation for employers to drop coverage and for commercial insurers to “hang themselves with their own rope” as costs continue to spiral out of control — leading to an inevitable government takeover of healthcare.

Meanwhile, leading economic indicators are flashing crimson warning signs as recent stop-gap stimulus wears off and long overdue private/public sector deleveraging results in reduced corporate hiring, lower consumer confidence and increased rates of savings. The symptoms of a prolonged economic malaise can be felt in unemployment stubbornly lingering around 9.2% and a stagnating US economy that is struggling to come to grips with the rising cost of entitlement programs. Across the Atlantic, the Euro-Zone is teetering as Italy and Spain (which represent more credit exposure than Greece, Portugal and Ireland combined) stumble toward default. Despite these substantial head winds, US healthcare reform is forging ahead – – right into the teeth of the storm.

Monopoly Anyone? The Battle To Control Health Care

Jul 21, 2012• 137

By DAVID COWLES

Like children gathered around a card table, America’s special interests are engaged in a high stakes game of Monopoly. But the winner of this game gets more than a day or two of bragging rights; this time the spoils are nothing less than control of our health care delivery system for the foreseeable future.

Let’s meet the players: on one side, Big Medicine; across the table, Big Insurance; and between them, Big Government. There’s room at the table for a 4^th player…but we’ll get to that later.

Introducing Big Medicine

To compete in this high-stakes game, Big Medicine is reforming itself into large, multi-disciplinary organizations. Independent hospitals are merging into hospital systems. Hospitals and doctors are coming together as self-regulating Accountable Care Organizations (ACOs).

Cost-consciousness and clinical decision-making

Jul 6, 2012• 45

By IAN METZLER

With computerized health systems, physicians can place orders as easily as they can shop online at Amazon.com. Just a few clicks and your physician can purchase a panel of blood tests, futuristic imaging and diagnostic procedures that will hopefully guide their path to solving your ailments.

Search. Click. Submit. Repeat.

Except, unlike online shopping, physicians don’t see the price tags and they never get the bill. Doctors are the true consumers of health care dollars, but the rules of economics falter when the consumers aren’t the ones that pay up. This disconnect is a fundamental cause of the uncontrollable inflation of health care costs in the US. Ignorance about cost fuels spiraling inflation in healthcare because without cost-related restraint in utilization there is no incentive for suppliers of healthcare services to get any cheaper.

But the system’s stuck. While physicians ultimately control the tap of healthcare costs, exerting that control can contradict their primary objectives. Physicians feel a responsibility to do the most they can to make the patient in front of them better. If young doctors don’t order a test, a superior may berate them for not considering it in their differential. Malpractice always lingers as a consequence for a diagnosis missed. Some claim that it is irresponsible or unethical for physicians to consider cost in their clinical decision making. Perhaps good doctoring should be blind to finances. And after all, it’s no skin off the doc’s back to just click a little more, some of that money may even end up back in their own pockets.Continue reading…

Microsoft Bows Out of the Clinical Market

Dec 9, 2011

By JOHN MOORE

Today, GE and Microsoft announced a joint venture (JV) that will lead to the formation of a new company (NewCo) targeting the clinical healthcare market sector. The NewCo will be located near Microsoft HQ in Redmond, WA, start with roughly 700 employees and combine the remaining Microsoft clinical products, Amalga UIS and the former Sentillion products Vergence and expreSSO with GE’s eHealth and Qualibria suite. NewCo’s new CEO will be GE’s Michael Simpson, who has been heading up the combined Qualibria-eHealth group since earlier this year after a re-org at GE. Along with this announcement, Microsoft’s Health Solutions Group (HSG) leader, Peter Neupert stated that he’ll be retiring.

Combine the above announcement with Microsoft’s long anticipated sale of Amalga HIS, which went to Orion Health in October, and you are left with Microsoft completely pulling out of the clinical market. Sure, they’ll claim to be still in healthcare by directly selling their horizontal products (e.g., SharePoint, MS Office, various server products, etc.) into this sector and having a stake in this JV, but it is also exceedingly clear that Microsoft will no longer have any direct involvement in this market, that will be left to GE. That being said, Microsoft did state that they’ll hang onto HealthVault, but even here, that is more likely a by-product of no one wanting to take on HealthVault rather than Microsoft’s strong desire to continue to try and build a viable, revenue generating entity out of it. Do not be too surprised if, in a year’s time, HealthVault falls to the wayside much like Google Health did this year.