What is an essential health benefit? I suppose that is a health or medical action, product, or process that should be paid for by someone other than the patient, in a society that provides so-called “third party coverage.”
Many very smart people and strong organizations have struggled with this issue for many decades.
Prior answers, such as they are, have come from staff model HMOs like Kaiser Permanente, the Veterans Health Administration, the Department of Defense, and the Oregon Health Plan.
But American medicine has become mostly a business, with some three trillion dollars a year up for grabs. So, an awful lot of people — few disinterested or non-conflicted — have a stake in giving and getting theirs.
Who would you trust with payment decisions for your health?
Nobody? Yeah, me too.
How about who to trust to create a contextualized framework for making those decisions? In the U.S., probably only the Institute of Medicine of the National Academy of Sciences.
Prompted by the upcoming need to implement the Affordable Care and Patient Protection Act, and commissioned in response to a request, and payment by (I don’t know how much money, but I assume a lot; IOM reports don’t come cheap) the Department of Health and Human Services, an IOM Committee has just completed such a report.
My old friend Dr. John Ball chaired a diverse committee of 18 members who are thought, data, and opinion leaders who, with able IOM staff support, produced this report. Here is another summary of it.
The 300-page report is heavy on use of evidence, cost effectiveness, inclusiveness, transparency, and value. I, for one, am happy with the range and nature of the report, but disappointed by lack of specifics.
The Secretary of HHS plans open hearings for feedback as HHS attempts to convert the framework into action.
Sadly, I think HHS will fail.
The money involved is so massive and the ownership of the U.S. Congress by special interests so dominant, I cannot imagine how this, or any, administration could write and implement the specifics, devoid of political domination.
I dearly hope that the IOM will be invited and paid to take the next and final (plus ongoing) steps.
And, one would hope that any subsequent IOM reports along those lines follow the procedures espoused in the IOM’s most recent report on Conflicts of Interest in crafting Clinical Guidelines.
George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.
Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.