Providers, business groups spar on need for flexibility in essential benefits
Flexibility at issue in essential benefits
READ The “Window to Washington” blog at modernhealthcare.com/washington
Ahead of HHS’ final word on essential health benefits, tension is emerging between provider groups that say giving states and health plans too much flexibility could render the coverage meaningless, and business groups that argue more flexibility is needed to make coverage affordable. Industry experts expect HHS to release its final regulation on the critical piece of the healthcare reform law this quarter, with one source
The results were so striking that the trial was halted because of concerns that it was unethical to prevent patients in the control group from receiving fecal transplants.
“That study will definitely trigger a lot of inquiries,” said Dr. Robert Orenstein, an infectious disease specialist at the 244-bed Mayo Clinic Hospital, Phoenix.
Orenstein and a few of his colleagues began doing fecal transplants in early 2011, after a patient with a severe, recurrent case of C. diff begged for the procedure. “We were in awe of the results,” he said. “The patient was near death and was probably going to have to have most of his colon removed. Twenty-four hours later, he was walking out of the hospital.”
Galvanized by that first case, they began working out the details of a long-term program. Like Boca Raton Regional Hospital, the Mayo Clinic Hospital relies on colonoscopies, covered by insurers, to administer the donated samples. The hospital bills the donor about $1,000 for the screenings that aren’t covered, and then bills the patient about $600 for the cost of processing the stool.
Like many who perform the procedure, Orenstein predicts it won’t be long until insurers begin reimbursing directly for fecal transplants, especially now that promising data from a randomized trial is available. “It is so effective, it makes you wonder why we do anything else,” he said, adding that the hospital has done between 35 and 40 transplants. Still, he acknowledged that evidence-based guidelines for donor selection, infection control, handling and administration are sorely needed. Such guidelines are likely to be clearer after future trials, he said.
In the meantime, providers are designing widely varying approaches to performing the procedure. At 301-bed Meriter Hospital, Madi-
“We were in awe of the results. The patient was near death and was probably going to have to have most of his colon removed. Twenty-four hours later, he was walking out of the hospital.”
—Dr. Robert Orenstein Mayo Clinic Hospital, Phoenix
son, Wis., Dr. Gary Griglione, the gastroenterology division chief, has performed 33 fecal transplants since launching Meriter’s program less than a year ago. But unlike many other physicians who perform the procedure, he uses enemas instead of colonoscopies, a decision he says saves money without sacrificing effectiveness. “If we don’t get patients cured with an enema, which costs $1.99, then we do a colonoscopy,” said Griglione, who’s been performing fecal transplants for more than 25 years.
Meriter charges donors roughly $1,300 for lab tests, most of which is covered by insurers, he said. Patients pay a $140 fee for processing the sample, plus a $60 office-visit fee. “I lose money, the hospital loses money, but look what the patient saves,” Griglione said.
Dr. Colleen Kelly, a clinical assistant profes- sor of medicine at Brown University’s Alpert Medical School and a leader in the field of fecal transplantation, said the next crossroads will be regulatory. The U.S. Food and Drug Administration has expressed an interest in overseeing the procedure and ensuring it’s done safely, said Kelly, who is leading another randomized trial of fecal transplantation. She fears government oversight will include “overly burdensome regulations.”
Another obstacle is one of perception, said Dr. Clifford McDonald, a medical epidemiologist and C. diff expert at the CDC. He worries the “eww” factor could hinder the progress of a promising treatment that he says could prove effective for treating other drugresistant organisms. One solution? A name change. The term “fecal transplant” places too much emphasis on the donated material, he says. A new term—his suggestions include “intestinal microbiota restoration”—could help people to better accept the procedure.
“We need to get over the fact that these good bacteria live in our bodies and are necessary,” McDonald said.
Dental trade groups are concerned HHS will require that insurers offer pediatric dental coverage without making enrollees buy.