Meeting Summary Essential Benefits Set Work Group October 16, 2009 Mississippi Room, Snelling Office Park Minnesota Department of Health Work Group Members Present Susan Castellano, Minnesota Department of Human Services Bryan Dowd, University of Minnesota, Division of Health Policy and Management Amy Gilbert, Family Physician Patrick Herson, Blue Cross Blue Shield of Minnesota Roger Kathol, Cartesian Solutions, Inc. Steve Larson, The Arc of Minnesota N. Marcus Thygeson, HealthPartners Work Group Members Absent Bruce Anderson, Minnesota Management and Budget Tom Hesse, Minnesota Chamber of Commerce Mary Maertens, Avera Marshall Regional Medical Center Diana Williams, The KNW Group Nancy Nelson, Blue Cross Blue Shield of Minnesota Julia Philips, Minnesota Department of Commerce Robert Stevens, Ridgeview Medical Center Rich Sykora, Medica Project Team Members Present CIRDAN Health Systems and Consulting John Klein Mike Rieth John Stiglich Minnesota Center for Health Care Ethics Ellie Garrett Karen Gervais Angela Morley Minnesota Department of Health Stefan Gildemeister 1. Welcome Ellie Garrett welcomed the Work Group to the meeting. 2. Overview of Final Report Outline John Klein presented and explained the EBS Report Outline and requested feedback from the Work Group. The Work Group suggested that the emphasis on evidence based medicine (EBM) should be broadened to note that, while it is a major factor in improving health and lowering cost, it is only one component. Discussion also centered on the definition of EBM, and Work Group members felt 1
it should be a more nuanced explanation, expanded beyond ”guidelines” to also include clinical and health services research. The group also suggested that the report highlight that there are many services without applicable guidelines. There was discussion about the impact of high deductible plans on healthcare quality and utilization, as compared to comprehensive plans. Several Work Group members stated that their health plans had seen no significant difference in access to recommended services based on higher member cost sharing, but noted that studies on high‐deductible plans may not have controlled for socio‐economic status. One member noted that significant literature exists on this issue which could be cited in the report. A list of important considerations for the EBS was offered by a member of the Work Group, including: (1) design the insurance benefits to optimize the use of EBM, (2) protect against catastrophic loss, (3) protect against unreasonable cash flow challenges that may limit access to care, (4) note that benefit design is only one part of the solution, and (5) include a statement on the minimum administrative capabilities (e.g., a procedures for providing disease management and discuss administrative services). Discussion ensued. The Work Group recommended that a set of assumptions be included at the beginning of the applicable section of the final report including: (1) an assumption about whether the legislature will provide subsidies to make the essential benefit set affordable for low income individuals, (2) an assumption that current plans will be allowed to remain in the market, causing potential risk selection issues; and (3) whether risk adjustment measures will be used. 3. Revised and Expanded EBS Conclusions and Observations John Klein presented and explained in detail the Conclusions‐Discussion Draft Handout and requested feedback from the Work Group. The Work Group agreed to focus its discussions on substantive issues and to email suggestions for more minor annotations electronically after the meeting. Conclusion 1 – Dimensions of Essential: A member of the Work Group recommended also referencing that richer coverage also increases exposure to potential harm from excess care. Conclusion 2 – Applicability of EBM to Insurance Benefits: Work Group members suggested that the situation where multiple evidence based treatments are available and how to choose between them should also be addressed. They recommended that additional distinctions between situations of “no evidence” and “evidence of harm” be included. In response to Work Group suggestions, the project team will distinguish between “conclusions” and “background information” or “findings,” and that Conclusion 3 would be described as background information. Conclusion 5 – Health Plan Activities Related to EBM: One Work Group member suggested adding, “and health plans also adjust benefits to promote evidence based medicine (i.e., promote use of services that are good for health using first dollar coverage, such as pay for performance)” to the first sentence of this conclusion. Conclusion 6 – Experience to Date in Applying EBM to Benefit Design: One Work Group member suggested that the conclusion should not focus exclusively on drugs, and that it should be 2
highlighted that value based insurance design is about how to design benefits that promote high value and quality services. It was also suggested that conservatism was needed in statements around the utility of value based insurance design and pharmacy, as studies have examined specific benefit designs in isolation and not the overall impact on cost. Conclusions 7 and 8 – Barriers to EBM Initiatives and Barriers to EBM‐Recommended Care: A Work Group member suggested adding that another barrier is lack of consumer awareness of EBM, and resistance to applying EBM to their unique situation. It was pointed out the direct‐to‐consumer marketing adds to this barrier. The Project Team will highlight some of the barriers currently stated as “factors other than cost‐sharing differentials.” 4. Revised and Expanded Recommendations­ EBS Qualified Plan and EBS Market Adjustments John Klein presented and explained in detail the Recommendations‐‐Discussion Draft handout and requested feedback from the Work Group. Recommendation 2 – Basic/Comprehensive Coverage: Extensive discussion centered on defining and clarifying the interaction between the comprehensive and affordable criteria for EBS certified plans. In general, the Work Group recommended that the discussion of the criteria and tensions between them should be expanded. One member felt it was inappropriate to say that the current market is “affordable” and that these premiums should be used as a benchmark for affordability. Concern was also expressed about affordability of an essential benefit set for individuals who typically purchase less comprehensive products in the market. Another member stated that comprehensiveness and affordability were not mutually exclusive, and that health plans should try to meet this challenge. In part (b) it was suggested that (1) one goal of the Work Group was to prevent financial calamity, so out‐of‐pocket costs and coinsurance should be considered in addition to “the prevalent premium,” and (2) that the discussion of comprehensiveness should also address geographic access. The Project Team will expand and clarify these elements in light of this discussion. Recommendation 3 – EBM Emphasis: Based on Work Group discussion, the Project Team will add a statement on coverage for evidence development to address coverage for emerging technologies and new applications of existing technology. An independent entity to conduct or sponsor randomized clinical trials of the technology was suggested as a means to evaluate the technology and determine the appropriateness of coverage in terms of added cost and quality, and to build capacity for the state. Additional issues for the Project Team to address included: (1) developing a cost effectiveness threshold to manage services that are not clearly cost‐effective or not cost‐
effective, focusing on alternative services with comparable outcomes, but not on a “QALY‐based” standard, and (2) defining a minimum set of administrative services for the essential benefit set (e.g., care coordination and utilization). The Work Group suggested adding “standard or lower coverage” to sections 3c and 3d to underscore that a low level of coverage was not being recommended. 3
5. Remaining Open Questions or Work Group Concerns Interpreter coverage was again discussed, specifically addressing who should pay for interpreters, how much should be covered and implementation (e.g., who is a permissible interpreter). Arguments in favor of covering non‐family member interpreters included fulfilling the state mandate on interpreter availability and minimizing the adverse impact on healthcare quality that can stem from family member interpreters. The Project Team will solicit additional comments from the Work Group. 6. Next Steps The Project Team will circulate a revised set of handouts from today’s meeting that incorporates the changes made during the meeting. The team will solicit additional feedback from the work group and will communicate deadlines for comments and potential dates for completion of the final report. Final Meeting Thursday, October 29, 2009, 9:00 a.m. – 12:00 noon MDH Snelling Office Park, Mississippi Room 1645 Energy Park Drive St. Paul, MN 55108 4