Health Care Reform and Essential Benefits
Posted by Valley Insurance Associates, Inc. on Wed, Oct 05, 2011 @ 02:04 PM
Part I
What is an Essential Benefit? This debate has gone on for decades…
Health Care Reform Essential Benefits (No Lifetime dollar maximums may apply…or can they?)
- Ambulatory Patient Services
- Emergency Services
- Hospitalization
- Maternity and Newborn Care
- Mental Health/Substance Abuse Disorder Services (Behavioral Health inclusive)
- Prescription Drugs
- Rehab Services and Devices
- Laboratory Services
- Preventative and Wellness Services
- Pediatric Services (Oral and Vision Care inclusive)
A Little Historical Perspective:
1970’s HMO Regulation: All HMO’s required to offer consistent categories of benefits. The intention was to offer benefits so close to identical that the member wouldn’t see any change regardless of the HMO they chose. The reality was the categories were too vague and this led to varied interpretation, which led to greater variation, not less.
By the 1990’s there were far more questions about what should or should not be included, as well as who should be making the inclusionary/exclusionary decision and on what basis. This led to myriad lawsuits as providers and consumers jousted with HMO’s about what was, or was not experimental or investigative in nature.
The issue with defining Essential now is that it is becoming increasingly difficult to decide what is “medical” and what is “necessary.” Even if a treatment is essential for some, it is not essential for everyone.
How much is a life worth?
Well, without a doubt it assuredly depends upon your perspective…
For instance, a recent Associated Press story used a new prostate cancer treatment as its focus, which upon information extends the life of the patient an average of four months at a cost of approximately $93,000.00/year.
Medicare currently does not cover this treatment but the Federal Government has it under consideration for 2014.
Another quoted example is a pancreatic cancer drug that added, on average, 12 days to the survival time v. standard chemotherapy (6.5 mos. v. 6 mos.) at an additional cost of $4,000.00/mo. So, on average, these people spent an additional $24,000.00 to gain those 12 days.
It appears to be an easy decision when we look at the cost v. the gain; however, if the patient is someone we know or a member of our family it becomes far more difficult to remain pragmatic.
Next time: Part two in this two-part series.
David Brand writes bi-weekly in his Benefits Blogged column. He can be contacted via email at dbrand@viainsurance.com.