Determining 'essential' health benefits

If health insurance plans aren’t structured to deal with these facts, our quest for a high-quality, cost-effective healthcare system will be a futile one. In order to contain escalating healthcare costs, we have to find a way to better diagnose, better treat and better prevent the symptoms associated with diabetes, heart disease, cancer and other chronic diseases.
 

ADVERTISEMENT
With that in mind, there are certain steps HHS should take in defining Essential Health Benefits. Here are three critical ones:
 
First, define “preventive and wellness services and chronic disease management” within the Essential Health Benefits regulation to include evidence-based programs that have demonstrated progress in attacking chronic disease. Health insurance plans should cover intervention-focused programs designed to prevent obesity, help people stop smoking and avoid the lifestyle choices that lead to diabetes and other preventable chronic diseases. Employers have proven that these programs work, as demonstrated by their labor forces that are more productive and spending less on healthcare services. It makes cost-effective sense for insurance plans to cover them.
 
Second, maintain a strong commitment to mental health parity.  For the tens of millions of Americans coping with serious physical illnesses, mental and behavioral health becomes even more important and often, more endangered. Essential Health Benefits must include the mental and substance abuse disorder services that are just as important as coverage for regular physical checkups and diagnostic care.
 
And that leads us to one more vital step that HHS must take in defining Essential Health Benefits. Give physicians the flexibility they need to provide their patients with the most effective treatments for their conditions.
 
This is a matter of real concern. A preliminary bulletin issued by HHS provided an indication that the federal government may allow insurance companies to sharply restrict the range of prescription drugs they would have to cover. The bulletin previewed a minimum of “one drug” per class approach in which, in six different therapeutic classes affecting tens of millions of patients, there may be a single medication that has the federal seal of approval and the blessing of insurance coverage.
 
This unnecessarily restrictive regulation would be catastrophic. Medicines are not interchangeable.  One patient with a health condition may get better results from a particular drug than another with the same illness. Physicians regularly try different medications and dosages with their patients to find the best solution to treat their symptoms, sometimes even turning to a “cocktail” comprised of multiple medicines. That would no longer be feasible if the federal government allow health plans to only pay for one prescription medicine. Instead the Essential Health Benefit should consider patient protections similar to those in Medicare that allow for broader drug coverage.
 
We already have a chronic disease crisis in this country, and illnesses like diabetes are rapidly escalating. We need to give healthcare providers every tool they need to prevent illnesses and stop symptoms from occurring. Doing so will save money in the long run because, well, healthy people cost society a lot less than sick people who aren’t receiving the treatment they need.
 
When HHS issues regulations on Essential Health Benefits, let’s hope they adequately define the meaning of ‘essential.’ For the sake of our societal well-being and the financial sustainability of our healthcare system, federal policymakers can’t exclude the provisions that are vital to the millions of us waging war against chronic disease.
 
Kenneth Thorpe, Ph.D., is chairman of the Partnership to Fight Chronic Disease and the Robert W. Woodruff professor and chair of the Department of Health Policy & Management at the Rollins School of Public Health, Emory University. He is also the former Deputy Assistant Secretary for the U.S. Department of Health and Human Services (HHS).