Is Choice of Physician and Hospital an Essential Benefit

IN THE 1970S, HEALTH CARE WAS SIMPLER. THE FIELDS OF transplant surgery, clinical pharmacology, and clinical oncology, among others, were just emerging. The proportion of the gross national product spent on health care was in the low single digits. There were no preferred provider organizations, no publicly available data indicating which surgeon was better than another, no evidencebased medicine movement, or any other kind of information designed to help individuals make treatment choices. In the 1970s, it was reasonable for health insurance to cover the entire gamut of health care, from what currently would be called complementary and alternative medicine to traditional medicine. For those with health insurance, no matter what kind of service a physician and patient agreed to, the service was covered without either evidence that it was effective or prior authorization. Forty years later, the Patient Protection and Affordable Care Act requires that the federal government define an essential benefit package for those individuals who will obtain insurance through the new health insurance exchanges. The Secretary of the Department of Health and Human Services has asked the Institute of Medicine to assist in this activity. What is an essential benefit package? One definition is a package that covers anything a physician and patient want, regardless of whether there is clinical evidence to support its use. Patients might be asked to share some portion of the cost of the package benefit, which would help to control use. Cost sharing is effective in reducing the amount of care used. But as the RAND Health Insurance Experiment of the 1970s demonstrated, cost sharing neither changed the quality of care that was delivered, nor did it change whether patients went to physicians for conditions that really required medical care. Stated another way, cost sharing exerted some control on the amount of care used, but it did not change the mix of appropriate or inappropriate care that was used, or improve the quality of care that was provided. Even free care did not affect the mix of care or quality. So how should an essential benefit be designed in an era when health care is far more expensive, the number of tests and procedures is significantly greater, and evidencebased medicine is the slogan of the day? In addition, consumers have access, at least in theory, to data describing the quality of hospitals, physicians, and health care facilities, complicating discussions regarding what is an essential benefit. What do individuals want in health care? Obviously, they want to receive the treatment or procedure that can best help to improve their health status. Individuals do not want medical services that are not needed, but they do want those that are. Most individuals probably prefer not to travel very far to obtain needed care. Furthermore, many may ask whether, if given the opportunity, they should seek care from the physician they know or are referred to, or whether they should choose a “better” physician in their local area, or even travel to a health facility such as one of the top-rated hospitals in the country to receive the required procedure, operation, or treatment. Whatever their choice, patients want to be treated humanely—to be respected as individuals and dealt with equitably and compassionately. This is the complicated context in which health care reform is being implemented and an essential benefit plan is being defined. As the definition process moves forward, answers will be needed for questions that may be uncomfortable to discuss openly, such as whether expensive but marginally effective procedures or medicines should be covered. Another issue is whether an essential benefit package should allow patients to choose where and from whom they receive care with no financial consequences of their decision. Should an essential benefit plan allow this choice only if evidence shows that more expensive physicians and hospitals improve health status and outcomes more than those that are less expensive? What will happen if a patient has reliable information that a particular hospital provides a specific treatment better, or perhaps even far better, than the hospital covered in the patient’s essential benefit plan? Will the patient have any recourse? How can patients be empowered and costs be controlled at the same time? What are the precedents set elsewhere for essential health care benefits? Some countries that provide citizens with basic health care packages do not include choice of either physician or hospital as part of the essential benefit plan. In Israel, for example, a patient has to pay more for the privilege of choosing a specific surgeon.