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Tuesday, November 15, 2011

Guest Blogger Kathy Cerminara: Coverage of Hospice Care as an Essential Health Benefit

Kathy CermineraLast week’s post was about the IOM’s focus on relative value in its report on crafting the essential benefits package under ACA.  In formulating its recommendations, the IOM considered the goals of ACA in interpreting Congress’s instruction that “the Secretary shall ensure that the scope of the essential health benefits . . . is equal to the scope of benefits provided under a typical employer plan.”  (Emphasis added.)  Balancing ACA’s desires to increase access to care and to ensure that benefits are affordable, the IOM recommended that HHS begin designing the essential benefits package by attempting to reflect the benefits packages covered by small employers before ACA.  Generally, as the IOM noted, differences between small and large employer plans tend to coalesce around design features (such as amount of patient cost-sharing) rather than around listed benefits.   Beginning with packages previously covered by small employers may not, however, result in the best relative value in end-of-life care because doing so may leave one essential end-of-life health care benefit by the wayside.

As discussed last week, determining relative value of benefits involves balancing cost-effectiveness and medical necessity.  Traditionally, society has shied away from discussions of cost-effectiveness of care at the end of life, but last week I argued, at the risk of sounding like former Governor Richard Lamm, that costs should be part of the conversation.  Now let’s think about medical necessity.

For patients near the end of life, there can be no dispute that good palliative care is medically necessary, regardless of how one defines that term.  Many patients facing a diagnosis of terminal illness wish, first and foremost, that they be spared physical pain, and palliative care physicians specialize in pain relief.  Advance directive statutes and other legislative and regulatory guidance of medical care near the end of life universally advocate the provision of “comfort care” or other, similarly titled palliative measures.  In Cruzan, the U.S. Supreme Court (or at least some of the justices) came close to stating that patients have a constitutional right to adequate palliative care.  Palliative measures are covered when part of a course of treatment that leads to a patient’s death.

But, medically necessary or not, some private insurers do not cover one tremendously important piece of palliative care.  Hospice care, or the provision of multi-disciplinary services through a team-based approach of caregivers and counselors, is primarily funded through Medicare in the United States.  Employer-provided plans certainly do not universally cover hospice care.  For example, the IOM included in its report a summary of WellPoint small employer benefits packages  that did not list hospice care as a covered benefit.  While some health insurers, such as Anthem Blue Cross Blue Shield, predicted that hospice care would be included on the list of essential benefits, such predictions occurred before the IOM recommended small employer health plan coverage packages as a starting point for design.  Data regarding whether there is a difference in this respect between large-employer benefits and small-employer benefits seems unclear, indicating a need for further study.

Hospice care provides patients with an opportunity to prepare for death in a low-intensity setting, foregoing treatments that merely postpone the moment of death,  Primarily provided at home, most of the insurers covering it, and Medicare and Medicaid, pay on a per diem rate.  Through hospice providers, in other words, patients and their families and caregivers receive multi-disciplinary counseling, assistance, nursing, doctoring, and therapy in the comfort of their own homes for relatively low per diem payments, providing for more peaceful journeys unto death.

As HHS convenes public meetings to discuss the contours of the essential benefits package, it should be wary of becoming too tied to the small-employer package starting point the IOM has recommended.  Whether part of the typical small employer package already or not, hospice care is high-value treatment for patients at the end-of-life, on a relative or an absolute scale.

- Kathy Cerminara

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