Priority Area 5: Attend to Benefit Design
Benefit design has a powerful effect on access to and utilization of services—particularly for the low and moderate income people most affected by health reform. Traditional design features such as copayments, deductibles, and benefit limits are blunt instruments. Newer concepts of evidence-based benefit design are more sophisticated. For example, some plans have eliminated cost-sharing for medications designed to treat chronic conditions on the basis that use of these drugs should be encouraged, not discouraged through copayments. At the same time, new benefit designs under development increase cost-sharing for procedures that do not have an evidence base to support their effectiveness.
While the federal law establishes parameters for insurance coverage, and those standards may be further explicated through regulations, a significant number of benefit design issues remain with the states. For example, the new Medicaid coverage for people with incomes below 133 percent of the federal poverty level is for so-called “benchmark” coverage, which can be designed more akin to a commercial plan than to the traditional Medicaid benefit structure. The broad authority states have to select plans to participate in the insurance exchange could be used to affect benefit design. Many states operate premium assistance programs for workers who have access to employer-sponsored insurance, and the standards for those programs could include certain criteria regarding benefit design. States retain control over their benefit mandates in the individual and small group markets—although they must reimburse the federal government for some subsidy expenses associated with those benefits. And, of course, states continue to purchase coverage for their own workers and retirees.
While benefit design initially affects how the enrollee interacts with the health care system, when considered across purchasers, effective benefit design can push the entire health care system toward an emphasis on prevention and coordination and away from services and procedures that have limited value.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
