Alert: Comments Due on Essential Health Benefits (12/06) and CMS "Innovations"/Accountable Care Organizations (12/03)

Summary: Readers inform that 2 additional comment deadlines are coming up on key health reform developments. Of most importance: What are processes in clarifying the "Essential Health Benefits" package under the new law? Will this reflect the non-discrimination language in Section 2706? Will historic, discriminatory practices prevail? The IOM seeks comment for this study requested by US Health & Human Services. Then, for those of you who wish to get integrative practice/medicine/CAM into thinking on Medicare "innovation" and Accountable Care Organizations (ACO), a comment period on preliminary standards for ACOs ends December 3, 2010. Here is summary background on each of these and information about how and where to respond. 

Charged by HHS to set benefit guidelines

"Activity Description

"The Patient Protection and Affordable Care Act (PPACA), signed into law on March 23, 2010, will allow individuals and businesses to purchase health insurance directly through exchanges-competitive marketplaces where buyers can compare coverage. These exchanges will offer a choice of qualified health plans (QHPs) that vary in coverage levels but meet certain standards in categories of care and limits on patient cost sharing. The PPACA stipulates that these QHPs will cover the general categories of: 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; and pediatric services including oral and vision care. Further details of an "essential health benefit" package are to be defined by the Secretary of Health and Human Services (HHS) based on the scope of benefits offered by a typical employer plan. 

"At the request of the Secretary of HHS, the IOM is undertaking a study that will make recommendations on the criteria and methods for determining and updating the essential health benefits package. The IOM will not define specific service elements of the benefit package. Instead, the IOM will review how insurers determine covered benefits and medical necessity and will provide guidance on the policy principles and criteria for the Secretary to take into account when examining QHPs for appropriate balance among categories of care; the health care needs of diverse segments of the population; and nondiscrimination based on age, disability, or expected length of life. 

"Additionally, the IOM will offer advice on criteria and a process for periodically reviewing and updating the benefits package. To provide public comment, please use our online form . Please submit your comments by December 6 to ensure that your perspective and the evidence base you provide can be examined before the committee's first meeting."

"On November 17, CMS issued a notice inviting people to submit comments by December 3 that will be used in the development of regulations on Accountable Care Organizations (ACOs).  ACOs are groups of providers that will manage and coordinate the care of Medicare beneficiaries. If an ACO can demonstrate that it is able to reduce Medicare costs (e.g. by decreasing hospital admissions, emergency room use, etc.), the ACO will share in the cost savings. 

"Under the same request for information, CMS is also accepting comments on the new Center for Medicare and Medicaid Innovation (CMMI), which was established to test innovative payment and service delivery models that improve quality of care and reduce costs. 

"Both the ACOs and the CMMI were established in Sections 3021 & 3022 of the Affordable Care Act to improve quality and lower costs by creating integrated health care delivery systems that are patient-centered and foster the participation of physicians and other clinicians in solo or small practices.

"While nothing here explicitly addresses Integrative Health Practitioners or Integrative Health Care, these initiatives are simply too big and too important to ignore.  ACOs are going to want to show that they have saved Medicare money through things such as fewer inpatient hospitalizations, ER visits, invasive procedures, visits to high priced specialists, etc. by the beneficiaries that are assigned to them. 

• Shouldn't they be able to offer acupuncture, yoga, or any other CAM modality to patients? 
  
• Even though most IPs would not be eligible to be part of the ACO and share directly in the cost savings, wouldn't it be helpful if the regulations specifically allowed, or even encouraged, the ACOs to include CAM as part of their strategy to improve quality and reduce cost? 
  
• When the data is evaluated, wouldn't it be interesting if the ACO with a strong CAM component was successful in reducing costs and improving care?
• Perhaps even more critical is to submit comments on how the CMMI is defining integrated health care delivery systems: Shouldn't they include all licensed health professionals in the health care delivery system, not just those currently recognized by Medicare? 
  
• If CMS wants to tests new delivery models, shouldn't they look at some of the Integrative Clinics that are already providing a range of both conventional and CAM services?
  

"This is a rare opportunity to provide formal input on something when it is still in its developmental stage.  Even though most IPs are not Medicare providers, the new CNNI may have more flexibility to consider innovative approaches that improve quality of care and outcomes, and reduce overall costs, than any previous initiatives.  If nothing else, this is an opportunity to start a dialogue and educate the new leadership at CMS that Integrative Health is more than just conventional practitioners talking to each other, and could be an important component of changing the way health care is delivered and paid for."   

Surgeon General Benjamin: Comments sought on draft framework