Monday, December 05, 2011

"It's going to be very, very exciting." Not.

I don't mince words, mostly because I lack time to do so and secondarily because I lack interest in political correctness. Let's talk straight about the Patient Protection and Affordable Care Act of 2010.

For some background and additional reading on the debacles that occur when government intrudes into health care decision making click on the 'health insurance' topics in this blog.

At the 2010 Legislative Conference for National Association of Counties, Nancy Pelosi made her now famous remarks
You've heard about the controversies within the bill, the process about the bill, one or the other. But I don't know if you have heard that it is legislation for the future, not just about health care for America, but about a healthier America, where preventive care is not something that you have to pay a deductible for or out of pocket. Prevention, prevention, prevention -- it's about diet, not diabetes. It's going to be very, very exciting. But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.
Well we passed the bill and still nearly two years later we are waiting to find out what is in it.

The November 14th edition of OT Practice included an article by Jennifer Hitchon who is AOTA's regulatory counsel. Her article neatly summarizes the recently released Institute of Medicine report Essential Health Benefits: Balancing Coverage and Cost. The purpose of the IOM report was to survey stakeholders (aka insurance companies) about what products and services were deemed 'essential.' In other words - what is the bare minimum that these insurance companies are covering?

Now this is where I start to scratch my head a little - because the government determines that we need a new law to replace/supplement the 'evil profiteering health insurance companies' with government sponsored 'exchanges.' So, the government commissions the IOM to study the issue and the results of the study will go to the policy wonks who write the actual regulations that dictate what is in it. So then the IOM goes and asks the 'evil profiteering insurance companies' for their input so they can tell the policy wonks how to write better regulations than what is currently being done... oh... um.... hm.......

The IOM is non-governmental and advisory to the government and normally the IOM is a source to have faith in - but why survey/invite the fox to the hen house to determine what benefits should be considered 'essential?' I understand that the charge to the IOM was to come up with some package that was 'comparable' to what is being offered by most small business insurance plans - but how is the Affordable Care Act going to improve anything if all we do is base decisions on the cheapest available plans being offered by some small company that is already being squeezed by costs and is now choosing bargain basement health plans for its employees.

The lack of percipience into this issue is stunning, even for a government.

For fun I searched the IOM report for mentions of occupational therapy - you can view the mentions here. Most of the mentions relate to various inclusion/exclusion criteria of selected insurance plans.

The study includes some interesting statements that essential benefits should be medically oriented and not social or educational - which has rather large potential impact on all of pediatric occupational therapy practice. This same issue is being fought out state by state regarding insurance coverage for autism interventions and it will be interesting to see what the federal government does with the issue. I am curious how there will be reconciliation between exchange mandates and statutory requirements that have been written into state law about this coverage.

There are other notable exclusion points in the document related to some chronic conditions like intellectual disabilities and low vision. There is enough controversy for all. This doesn't mean that these will be automatically removed from 'essential' coverage determinations - but this all represents writing on the wall that people need to attend to.

Occupational therapists need to be watching this issue closely. Actually, the entire American public needs to watch this closely - but the complexities are beyond what many people have time or energy to follow, track, and decipher.

I encourage professional associations like AOTA to continue publishing about this issue as events unfold. However, we need straight analysis and not generic 'we will provide formal comments when the opportunity arises.' Practitioners and the public need to know the following:

  1. The government may plan to model their exchange off of the cheapest possible plan that is offered by a small business.
  2. Habilitation services could be on the proverbial chopping block, particularly if they can be labeled as 'educational' or 'social'
  3. The plan may cover things like if your eyeballs fall out of your head, because that is a medical problem. However, if you need therapy or equipment to help you function you might be out of luck because that would be a personal problem and not a medical problem.

Many professional groups (MDs, etc.) are getting out IN FRONT of these issues by publishing position papers about what needs to be covered and why. The OT community needs to do more than simply respond during the comment period. AOTA needs to publish similar position papers about including a wide range of OT services in the act and increase visibility and lobbying about these issues. Practitioners have to start by educating themselves on what they are actually facing.

For the record, I would not characterize this as very exciting. I think it may be the largest boondoggle ever perpetrated on the American public.

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