Download Establishing New York`s Essential Health Benefits Package (EHB

Establishing New York’s Essential Health Benefits Package (EHB):
What Policymakers Can Do to Ensure Access, Quality & Affordability for Cancer Patients
The health care needs of cancer patients are of those with serious and life-threatening illnesses,
as well as chronic health care issues. Treating cancer involves accessing a complex and
exhaustive set of health care services including prevention, early detection, chemotherapy,
radiation therapy, surgery, diagnostic and biomarker evaluation, prescription drugs, cancer
treatment planning and survivorship care, among others. These long-term treatment plans often
put patients at great financial risk due to the cost sharing burdens associated with care, even if
they are insured.
New York cancer patients and survivors, alike, who are currently uninsured and underinsured,
are among those who will benefit greatly from the establishment of the state’s Health Exchange,
as part of implementation of the federal Affordable Care Act (ACA). After much anticipation,
the U.S. Department of Health and Human Services (HHS) released a bulletin, on December 16,
2011, to provide guidance to states when determining the essential health benefits (EHB) for
state health exchanges, the small group market inside and outside the exchange, benchmarks for
Medicaid and Basic Health Programs.
Instead of providing a detailed list of criteria and services that states must cover in 2014, the
bulletin was vague, leaving in depth coverage decisions to states, proposing unnecessary
flexibility for insurers, and creating confusion on how state policymakers move forward.
Unless New York policymakers follow the state’s rich tradition of providing affordable access to
comprehensive care, the promise of the ACA will not become reality for cancer patients or
survivors. If the state’s essential health benefit (EHB) package leans too heavily toward
maximizing flexibility at the expense of ensuring access to comprehensive and quality cancer
care, cancer patients may find themselves having insurance that is inadequate to meet their health
care needs, while being saddled with crippling financial responsibility for their care.
In order to get it right the first time and meet the needs of cancer patients, New York
policymakers must take a comprehensive approach when setting the standard for the state’s
Health Exchange and EHB package. Creating a benchmark plan that is broad in scope, while
offering affordable coverage, is key. We, the undersigned, offer the following road map to use
when making these critical choices:
A Road Map to Comprehensive Cancer Care for New Yorkers
PREVENTION AND RISK REDUCTION
 Provide coverage without cost-sharing for preventive services rated “A” and “B” by the
U.S. Preventive Service Task Force, as required by the Affordable Care Act, including
evidence-based tobacco-cessation treatments and various cancer screening services.
http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm
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Coverage for the use of tamoxifen and raloxifene as preventive measures for women at
high risk for breast cancer, as determined by their physicians. Coverage for patient/doctor
discussion of environment and life-style for prevention and risk reduction plan.
Coverage for primary care physician role in coordination of patient preventive care. All
health benefits plans must cover cancer screening and FDA-approved and CDCrecommended cancer vaccines (Gardasil and/or Cervarix) either at no cost to employees or
their covered dependents or at a reasonable cost-sharing level defined as at a level that does
not present an impediment to being screened or obtaining an appropriate vaccination.
SCREENING & EARLY DETECTION
 Evidence-based screening and early detection services based on risk profile, to facilitate
early diagnosis and prompt treatment.
 Risk assessment services, including genetic counseling and testing in high risk situations
to determine risk of developing cancer and facilitate development of risk-based options
for screening and intervention.
 Ensure that health benefit plans cover, at either no cost or at a reasonable cost-sharing
level, evidence-based screening services for breast, colorectal, cervical, lung, and prostate
cancer, and all FDA-approved vaccines for the prevention of cancer.
 Provide coverage for enrolled employees and their covered dependents for cancer screenings,
and coverage for vaccines that have been approved by the FDA, and recommended by the
CDC, for the prevention of cancer.
 All health benefit plans must cover the following specific tests and cancer screenings:
o Evidence-based screening ultrasound, magnetic resonance imaging and/or other
screening tests for breast cancer based on doctor/patient assessment of benefit and
harms of screening as well as on a woman's preference and risk profile.
DIAGNOSTIC
 Comprehensive diagnostic services to ensure accurate diagnosis and staging using all
available evidence based technologies.
 Coverage for a second opinion regarding diagnosis and/or treatment choices and plan.
CARE PLANNING & DOCTOR-PATIENT COMMUNICATION
 A written plan for the patient to keep that:
o Outlines all elements of treatment, including surgery, chemotherapy, radiation
therapy, and supportive care, including management of the symptoms of cancer
and cancer care and appropriate psychosocial services.
o Provides adequate detail of resources to assist the patient’s caregiver and family
members.
o Includes a plan for fertility preservation, if appropriate for the patient.
o Include discussion of genetic counseling and biomarker testing, if appropriate, to
support treatment decisions and make risk assessment.
o Is provided at the beginning of diagnosis when there are significant changes in the
patient’s condition or care and throughout the survivorship continuum from
treatment thru post-treatment aftercare.
o Is directly communicated to the patient by his/her doctor orally and in writing.
o Provides adequate detail to assist the patient in managing care and making
treatment decisions.
o Is provided to the patient in culturally appropriate language.
o Facilitates the coordination of multidisciplinary care provided by all health care
providers to support integrated patient centered care.
TREATMENT
 All elements of multi-disciplinary treatment, as recommended by the patient’s care team
and supported by available evidence, including:
o Surgery
o Appropriate reconstructive surgery, such as reconstruction after mastectomies.
o Radiation therapy.
o Drugs and biologicals, whether physician-administered or self-administered.
o Drugs and biologicals for off-label uses, according to the evidence-based
standards utilized in the Medicare program.
o Bone marrow and umbilical cord blood transplants.
 Diagnostic and biomarker testing.
 Pharmacy Benefit That Includes:
o Prescription drug coverage with full coverage of the six protected classes, offering
more than one drug per class and as defined in the Medicare Part D program.
o Patient appeals process.
o Formulary standards that require inclusion of multiple drugs in a range of
therapeutic categories and comprehensive coverage for therapies needed by the
most vulnerable patients.
o Independent Pharmacy and Therapeutic (P&T) Committees that review the drugs
included on those formularies, as well as the utilization management requirements
for such drugs, and consider newly approved treatments and indications for
inclusion in formularies within certain timeframes.
o Includes a mechanism for incorporating new therapeutic categories or classes in
order to protect patients’ access to innovative therapies as they become available.
 Equal treatment of out-of-pocket expense to patient between I.V. & oral chemotherapy
treatments.
 Supportive and psychosocial care including treatment for pain, nausea and vomiting,
fatigue, depression, and other side effects of cancer and cancer treatment.
 Care by out-of-network physicians and other health care providers, if in-network care
does not meet the medical needs of the patient.
 Prohibit the use of excessive cost-sharing required by prescription drug benefit designs
that utilize specialty tiers; out-of-pocket costs for prescription drug coverage should be
transparent and included in the out-of-pocket limits pursuant to the ACA requirements
ACCESS TO NATIONAL CANCER INSTITUTE (NCI) CANCER CENTERS
 Ensure access to cancer treatment at Commission on Cancer-accredited programs and/or
NCI-designated cancer centers.
ACCESS TO CANCER CLINICAL TRIALS
 Ensure that New York cancer patients continue to have affordable access to cancer
clinical trials, via accelerated decision making, within the state’s external appeals
process, until 2014, when stand alone benefit covering clinical trials goes into effect.
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Plans should be required to establish and make available informational materials and
programs to ensure that providers are encouraged to make referrals to oncologists and
other cancer specialists who can provide individuals with access to clinical trials.
SURVIVORSHIP CARE
 A written and orally communicated treatment summary & survivorship care plan.
 Monitoring of late & long-term effects of cancer treatment.
 Long-term follow up care, as defined in evidence-based survivorship care standards.
 Access to ongoing, evidence-based cancer screening, counseling and other preventive
services, according to standards articulated for cancer survivors.
 Comprehensive rehabilitation services for the period of time required to address the
effects of cancer and cancer treatment, including prosthesis & restorative.
 Full lymphedema treatment coverage including lymphedema sleeves, bandages, among
others.
 Coverage for primary care physician guidance in coordination of survivorship care.
PALLIATIVE CARE ACROSS THE CONTINUIM OF CARE
 Supportive care, symptom management, and palliative care from the time of diagnosis
and across the continuum of care, including but not limited to services provided through
hospice.
 Comprehensive support resources for the caregiver and family.
 Discussion of palliative care options with the patient and inclusion of options for care in
the written care plan provided to the patient by the care team.
 Coverage of alternative palliative care services.
STRUCTURAL
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Designate representatives with cancer perspective to New York’s Health Exchange board
including two consumer advocate/ survivors who are actively involved with a community
based grass roots cancer organization to New York’s Health Exchange board.
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Establish point of contact, or patient navigator, within the Department of Financial
Services/Department of Health specifically for cancer patients & advocates.
HARNESS TECHNOLOGY
 Establish a standard/universal prior authorization process for drugs.
 Use Exchange information technology to assure rapid access to appropriate drugs.
 Ease burden on prescribers & pharmacists.