The list of providers who are trying to make the case that their services are essential — and cost-effective, and cost-preventing — includes psychologists, dentists, optometrists, social workers, urgent care clinic managers, acupuncturists, chiropractors, and more.
Insurers and the providers have been fighting the battles with each other and in state legislatures for decades.
Now the national effort to develop the new “essential health benefits” (EHB) package is forcing the country to engage in a new, intense, wonky round of debate about what health care matters, and why.
One group in the EHB battle includes rehab therapists — the providers of physical, occupational and speech therapy who help patients overcome everything from broken legs to strokes, and who, in some cases, may provide similar, “habilitative” services to children with autism, mental retardation and other disorders who are not on track to develop typical life abilities in a typical way.
PTPN — a network that represents about 3,500 rehab and habilitative therapists — has been trying to help the therapists deliver the message that spending money on the therapists’ services up front can help hold down the total cost of care and improve overall outcomes.
“There’s a lot of return on investment to be had with a robust rehab benefit,” said Dr. Michael Weinper, PTPN’s president.
The EHB cometh
Congress sparked the current wave of provider group outreach campaigns by making the EHB package provision part of the Patient Protection and Affordable Care Act of 2010 (PPACA).
PPACA calls for all non-grandfathered individual and small group plans sold after Jan. 1, 2014, to offer the EHB package, to help consumers shop for coverage on an apples-to-apples basis and reduce the chances that some plans will try to outcompete others by watering down their benefits.
The U.S. Department of Health and Human Services has just released an advance version of EHB final regulations. It’s not clear whether the final EHB regulations will really represent the last word, or just the official start of the EHB debate fireworks.
Most states still have not yet defined their EHB packages, but regulators have talked about modeling the EHB package standard on commercial small-group benefits packages.
Critics have sometimes argued that the evidence supporting the cost-effectiveness of some types of rehab therapy is weak.
The rehab therapists contend that their services can help lower acute care, disability and long-term care (LTC) costs by helping patients get the most out of what they have. PTPN has been citing a study on primary care referrals of patients with low back pain that showed that referring patients quickly saved about $2,700 per case.
In addition to the EHB package provision, PPACA includes, for example, a provision that is supposed to punish hospitals when too high a percentage of patients return to the hospital soon after leaving.
Therapists say they can help prevent the preventable readmissions, and also prevent the need for patients to enter the hospital in the first place.
“Therapists can provide preventive and wellness care often more cost effectively than other types of providers, and our training in body mechanics, musculoskeletal issues and other areas make us well-suited to helping the aging population in particular stay active and healthy,” Weinper said.