* Mr. Speaker, in my capacity as co-chair of the Congressional Brain Injury Task Force, I would like to share my understanding of the intent of the provisions of H.R. 3590, the Patient Protection and Affordable Care Act regarding coverage of the treatment continuum for persons with brain injury. I believe that health care reform should address the unique health care needs of individuals with brain injury by recognizing that brain injury is the start of a lifelong disease process requiring access to a full continuum of medically necessary treatment, including rehabilitation and chronic disease management, furnished by accredited programs in the most appropriate treatment setting as determined in accordance with the choices and aspirations of the patient and family, in concert with an interdisciplinary team of qualified and specialized clinicians.
* News reports of returning veterans and recent high profile brain injury stories indicate what researchers have been reporting for years--brain injury is a leading public health problem in U.S. military and civilian populations. Brain injury is not an event or an outcome but is the beginning of a lifelong disease process that impacts brain and body functions resulting in difficulties in physical, communication, cognitive, emotional, and psychological performance that undermines health, function, community integration and productive living. Brain injury is also disease causative and disease accelerative in that it predisposes individuals to re-injury and the onset of other conditions (e.g., brain injury impacts neurologic disorders such as epilepsy, vision and hearing impairments, psychiatric disorders, and orthopedic, gastrointestinal, urologic, sexual, neuroendocrine, cardiovascular and musculoskeletal dysfunction).
* The Brain Injury Association of America, BIAA, has developed a series of guiding principles for assessing any health reform bill from a brain injury perspective. I am pleased to conclude that the Patient Protection and Affordable Care Act reflects and is consistent with these principles.
* One principle identified by BCIAA is that an individual with brain injury should have access to the full treatment continuum to manage the disease that includes early, acute treatment to stabilize the condition followed by acute and specialized post-acute brain injury treatment and rehabilitation, including inpatient, outpatient, day treatment and home health programs, to minimize and/or prevent medical complication, recover function and cope with remaining physical or mental disabilities, and achieve durable outcomes that maintain an optimal level of health, function and independence following brain injury. The Patient Protection and Affordable Care Act authorizes the Secretary of Health and Human Services to define the details and limits of the essential health benefits package but establishes certain general categories of benefits that must be covered. The bill specifically lists, among other things, hospitalization, outpatient hospital and outpatient clinic services, professional services of physicians and other health professionals, and prescription drugs. In addition, I am pleased that the list includes the following benefits that are of particular importance to persons with brain injury:
* Rehabilitative and habilitative services and devices,
* Mental health and substance use disorder services, including behavioral treatment, and
* Chronic disease management.
* I believe that for individuals with disabilities such as brain injury, rehabilitation and habilitation is equivalent to the provision of antibiotics to a person with an infection--both are essential medical interventions. The term ``rehabilitative and habilitative services'' includes items and services used to restore functional capacity, minimize limitations on physical and cognitive functions, and maintain or prevent deterioration of functioning as a result of an illness, injury, disorder or other health condition. Such services also include training of individuals with mental and physical disabilities to enhance functional development.
* The term ``rehabilitative and habilitative devices'' includes durable medical equipment, prosthetics, orthotics, and related supplies. It is my understanding that the Patient Protection and Affordable Care Act requires the Secretary of HHS to develop, through regulation, standard definitions of many terms, including durable medical equipment for purposes of comparing benefit categories from one private health plan to another. It is my expectation ``prosthetics, orthotics, and related supplies'' will be defined separately from ``durable medical equipment'' and the Secretary is not to define durable medical equipment for purposes of ``in-home'' use only.
* I defining the list of categories of essential health benefits, I am particularly pleased that the bill states that the Secretary shall:
* Ensure that such benefits reflect an appropriate balance among the categories so that benefits are not unduly weighted toward any category;
* Not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;
* Take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups; and
* Ensure that essential benefits not be subject to denial on the basis of the individual's present or predicted disability, degree of medical dependency, or quality of life.
* Taken together, these are strong protections that will help ensure that the essential health benefits package--that must be offered by all health plans that participate in the new Health Insurance Exchanges--will take into account the needs of people with brain injury and other disabilities and chronic conditions and not impose value judgments about disability and quality of life. This legislative language makes clear that Congress understands the subtle discrimination that can occur against people with brain injury and other disabilities in the area of benefit design.
* A provision in the bill allows insurance companies to sell insurance products across State lines. It is my understanding that the new federal standards regarding essential benefits are meant to act as a floor, not a ceiling, for these essential benefits, giving room for plans within states to offer more generous coverage to their constituents. Thus, it is also my understanding that all state benefit and consumer protection laws will be accorded full force and effect when multi-state compacts are organized under one state's laws but sell insurance across state lines.
* A second principle identified by BIAA is that an individual with a brain injury should have an individualized medical treatment plan that documents specific diagnosis-related goals when the person has a reasonable expectation of achieving measurable functional improvements in a predictable period of time through the provision of treatment of sufficient scope, duration and intensity. As described above, I am pleased to report that under the bill, payment for items and services included in the essential benefits package should be made in accordance with generally accepted standards of medical and other appropriate clinical or professional practice. In addition, under the bill, a qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health items and services included in the essential benefits package. Consistent with medical, clinical, and professional practice, appropriateness should be determined based on the unique needs of the individual with brain injury and treatment should be of sufficient scope, duration, and intensity.
* A third principle identified by BIAA is that individuals with brain injury should receive treatment in the most appropriate treatment setting by accredited programs including acute care hospitals, inpatient rehabilitation facilities, residential rehabilitation facilities, day treatment programs, outpatient clinics and home health agencies as determined in accordance with the choice and aspirations of the patient and family in concert with an interdisciplinary team of qualified and specialized clinicians. I am pleased that the bill includes important patient protections that are designed to permit providers to fully discuss treatment options with patients and their families and permit the patient to render an informed choice as to their course of rehabilitation or other treatment. These patient protections are also designed to ensure that the patient receives appropriate medical care and that the health care treatment is available for the full duration of the patient's medical needs.
* More specifically, the bill restricts the Secretary in a number of important ways from creating rules that potentially restrict access to certain benefits or settings of care. The bill states that the Secretary shall not promulgate any regulation that:
* Creates any unreasonable barriers to the ability of individuals to obtain appropriate medical care;
* Impedes timely access to health care services;
* Interferes with communications regarding the full range of treatment options between the patient and provider;
* Restricts the ability of health care providers to provide full disclosure of all relevant information to patients making health care decisions;
* Violates the principles of informed consent and the ethical standards of health care professionals; or
* Limits the availability of health care treatment for the full duration of the patient's medical needs.
* In addition, the bill specifies that a group health plan and a health insurance issuer shall not discriminate with respect to participation in the group or individual health insurance plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law. The bill also specifies that health plans to be considered ``qualified'' by the Secretary must ensure ``a sufficient choice of providers (in a manner consistent with applicable network adequacy provisions under section 2702(c) of the Public Health Services Act) and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers'' in order to ensure enrollee access to covered benefits, treatments and services under a qualified health benefits plan. Thus, rehabilitative and habilitative services and chronic disease management services must be available from a full continuum of accredited programs and treatment settings at a level of intensity that is consistent with the needs of the patient.
* A fourth principle identified by BIAA is that the bill should prevent private insurance systems from delaying or denying treatment as a means of transferring the burden of brain injury care to taxpayers at federal, state and local levels; ensure that both public and private health insurance systems meet the health care needs of people with brain injury; and avoid using Medicaid and Medicare as the first option for coverage of people with brain injury. I am pleased to report that the bill includes numerous requirements reforming the health insurance marketplace that should prevent private insurance systems from delaying or denying treatment for individuals with brain injury. These reforms include: prohibiting pre-existing condition exclusions; requiring guaranteed issue and renewal; requiring nondiscrimination in health benefits or benefit structure in terms of factors such as health status, medical condition, medical history, disability or any other health status-related factor; limits cost-sharing, and prohibits the imposition of lifetime limits or unreasonable annual limits on the dollar value of benefits for any individual. I believe that these provisions should help prevent private insurance from delaying or denying treatment to persons with brain injury.
* The Patient Protection and Affordable Care Act includes provisions rewarding quality through market-based incentives, including consideration of payment structures that provide increased reimbursement or other incentives for, among other things, improving health outcomes through the implementation of activities that include effective case management, care coordination, and chronic disease management. The bill also includes numerous provisions designed to encourage the development of new patient care models that address the needs of persons requiring comprehensive rehabilitation and chronic care management, including models that facilitate the maintenance of close relationships between care coordinators, primary care physicians, specialist physicians, community-based organizations, and other providers of services and suppliers.
* Separate provisions are included in the Patient Protection and Affordable Care Act regarding post-acute care (PAC) bundling under Medicare. The bill provides for the establishment of a national pilot program for integrated care around a hospitalization in order to improve coordination, quality, and efficiency of health care services. Under the bill, the Secretary will select 1 or more of 8 conditions, taking into consideration, among other things, whether a condition is high volume and most amenable to bundling. Applications to participate in the pilots may be made by ``participating providers'' consisting of providers of services and suppliers, including but not limited to hospitals.
* BIAA, in a submission to the chair of the Senate Finance Committee commented that post-acute payment systems must facilitate, not impede, improvements in functional status of individuals with brain injury and their ability to return to their homes and communities. BIAA supports a deliberative planning process and rigorous pilot testing. The deliberative process should determine, among other things, whether PAC bundling should exempt diagnoses such as brain injury, which are of low predictability and highly complicated; and test innovative payment methods that make payments directly to nonhospital-based treatment centers, including residential rehabilitation facilities specializing in the treatment of brain injury that have earned accreditation by the Joint Commission on Accreditation of Healthcare Facilities and/or the Commission on Accreditation of Rehabilitation Facilities.
* I agree with the comments presented by BIAA. I am pleased that the Patient Protection and Affordable Care Act is consistent with BIAA's comments and addresses their concerns. I have some reservations regarding the bundling of post-acute care that require the ``bundle'' be earmarked to an acute care hospital for patients with complex and highly unpredictable diagnosis and health outcomes, as is the case for individuals with brain injury and other catastrophic conditions. I agree with BIAA that such payment systems may impede, rather than facilitate, improvements in functional status and may result in premature return to homes and undue levels of preventable disability without adequate facilitation of progression through necessary step down levels of treatment.
* In closing, I believe the Patient Protection and Affordable Care Act addresses the unique health care needs of individuals with brain injury by recognizing that brain injury is the start of a lifelong disease process requiring access to a full continuum of medically necessary treatment, including rehabilitation services and devices and chronic disease management, furnished by accredited programs in the most appropriate treatment setting as determined in accordance with the choices and aspirations of the patient and family in concert with an interdisciplinary team of qualified and specialized clinicians.