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ACR disappointed by CMS final rule on essential health benefits
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The American College of Rheumatology has issued a statement expressing concern over a CMS final rule that, among other provisions, would allow individual states to select their own benchmark plans for essential health benefits on federal exchanges under the Affordable Care Act.
According to the ACR, the change threatens health care access for many patients with complex rheumatologic conditions by creating a “race to the bottom,” in which states seek cheaper, less comprehensive coverage.
“While we are pleased to see that CMS is using this rule to reduce regulatory burdens and promote drug price transparency, we are disappointed that the agency did not heed the advice of the ACR and other health groups regarding essential health benefits coverage,” David Daikh, MD, PhD, president of the ACR, said in the statement. “It is absolutely critical that people living with rheumatic diseases are able to access insurance coverage on the federal exchanges without having to worry about whether the treatments they need to manage their conditions will be covered.”
CMS issued the final rule, titled “HHS Notice of Benefit and Payment Parameters for 2019,” on April 9. In a statement, CMS said the rule will “mitigate the harmful impacts of Obamacare and empower states to regulate their insurance market.”
According to CMS, the rule will accomplish this by increasing state flexibility, improving affordability, empowering consumers and reducing “unnecessary regulatory burdens” it says were imposed by the Affordable Care Act (ACA).
“Too many Americans are facing skyrocketing premiums that they can’t afford and every year consumers are faced with the threat of fewer choices,” Seema Verma, CMS administrator, said in a press release. “This rule gives states new tools to stabilize their health insurance markets and empower citizens to find coverage that fits their families’ needs and budgets.”
However, the ACR, as well as a collection of various patient and consumer groups, have responded to the rule with alarm and disappointment. In a letter submitted last November to then-acting CMS Administrator Eric Hargan, Daikh said that although the ACR understands the desire for increased flexibility, allowing states to set their own process for soliciting comments on proposed benchmarks, the rule as written could spark a “race to the bottom,” and hurt patients in the process.
“Historically, most states have chosen the default benchmark plan set by HHS,” Daikh wrote in the letter. “Therefore, we have concerns that that this will create a race to the bottom, wherein states will seek the least acceptable coverage at the lowest cost, further restricting patient access to care. Rheumatologists constitute a specialty that provides ongoing care for patients with complex chronic and acute conditions that can be difficult to diagnose and treat, and having a wide range of benefits available to patients is of utmost importance.”
In addition, the Arthritis Foundation, the National Psoriasis Foundation, American Heart Association and American Lung Association have joined with 16 other patient and consumer health groups in criticizing the new rule.
In a joint statement, the groups said the final rule will “severely weaken key benefits that underpin core consumer protections for Americans with pre-existing conditions,” and will lead to increased costs for coverage that will still fail to meet their needs.
“The administration’s 2019 Notice of Benefit and Payment Parameters final rule will lower standards for the 10 essential health benefits that by law must be covered in the individual and small-group markets,” read the joint statement. “Subject to state approval, the rule will allow insurance plans to cover fewer benefits and services, meaning individuals with pre-existing conditions will have to pay more in out-of-pocket costs for their care. The rule could also let insurers in some states substitute out services that people with high-cost conditions badly need, bringing back another backdoor form of discrimination against those in less than perfect health.”
Despite the criticisms regarding essential health benefits, the ACR also praised CMS for opting to scuttle another proposed rule that would have designated Children’s Health Insurance Program (CHIP) buy-in programs that provide identical coverage to state Title XXI CHIP programs as “minimum essential coverage” — all without first undergoing an application process. The ACR urged CMS to abandon the proposal, arguing it would leave children who suffer from rheumatic diseases in a “dangerous medical limbo,” with no guarantee that coverage provided under these programs would be the same.
“We remain committed to ensuring that all rheumatic disease patients are able to access high quality, affordable care and will continue to serve as a resource for CMS as it works to extend coverage, reduce barriers, and expand patient choice,” Daikh said in the press release. – by Jason Laday
Perspective
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Gary S. Hoffman, MD, MS, MACR
I believe all judgments as to appropriate therapies for any disease should be data-driven in regard to reduction in suffering, disability and mortality. Looked at in this fashion, data can be derived for jobs and societal roles maintained, financial costs for hospitalizations and advanced care interventions and disability avoided. This data is far more meaningful than the up-front costs of medications.
When such metrics are taken into account, the guidance for treatments “covered” should be the same for all Americans. Deferring to the individual states is inappropriate, and appears to be a strategy for the federal government to avoid its responsibilities. If blame is later to be assigned for inappropriate judgments, it will be assigned to the states. Until this is corrected, our patients will pay the price regarding dollars and their health.
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