Meeting Summary Essential Benefits Set Work Group October 8, 2009 Minnesota Department of Revenue Work Group Members Present Bruce Anderson, Minnesota Management and Budget 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 Tom Hesse, Minnesota Chamber of Commerce Roger Kathol, Cartesian Solutions, Inc. Steve Larson, The Arc of Minnesota Nancy Nelson, Blue Cross Blue Shield of Minnesota Julia Philips, Minnesota Department of Commerce Robert Stevens, Ridgeview Medical Center Rich Sykora, Medica N. Marcus Thygeson, HealthPartners Work Group Members Absent Mary Maertens, Avera Marshall Regional Medical Center Diana Williams, The KNW Group 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 Representative Julie Sonier, Health Economics Program 1. Welcome Ellie Garrett welcomed the Work Group to the meeting and introductions were made around the table. 1
2. EBS Recommendations and Conclusions‐ Discussion Draft Conclusions ‐ Discussion Draft John Klein presented and summarized the Conclusions – Discussion Draft handout and requested feedback from the Work Group. C‐3 “Barriers to EBM Initiatives”: One Work Group member requested that this conclusion emphasize that when health plans make exceptions in some cases to expand standard coverage, they make patient‐
specific decisions, where the additional benefit must be clinically indicated or cost‐effective. Another Work Group member requested additions to the conclusions to highlight market barriers or areas of concern with respect to EBM products. The Work Group recommended the following observations accompany the final report: (1) an observation relating to time‐horizon and inadequate risk‐adjustment problems, and (2) a comment on the scope of the Work Group’s discussions and areas it wanted to address but were outside the scope of its charge. Recommendations ‐ Discussion Draft John Klein presented and summarized the following handouts, “Recommendation – Discussion Draft, EBS Content Recommendations and Market Adjustment Recommendations – Coverage Requirement,” ”Public Comments,” and “Definitions,” and requested feedback from the Work Group. Lifestyle drugs were added to the E‐7 “Excluded Categories of Services” list. There was discussion and agreement about changing the phrase “EBS Certified Plans will not cover” to “EBS Certified Plans will not be required to cover” in the E‐4, E‐6, and E‐7 EBS Content Recommendations. Other suggestions included removing “comprehensive” in E‐1 “EBS Certification” to avoid confusion and in E‐3b “EBM Programs and Networks” changing the phrase from “Services with limited EBM basis” to “Services with limited EBM basis or a lower level of cost‐effectiveness,” to account for situations where health plans cover at a lower level services that are comparably clinically effective, but less cost effective. E‐3 “EBM Emphasis”: One Work Group member felt that higher cost sharing for lack of evidence was in some cases inappropriate, since much of clinicians’ practice is not evidence‐based, and suggested adding clinical effectiveness and strength of standard practice as additional considerations. Alternative means of controlling costs beyond benefit structure design were suggested, including flagging efficient providers and rewarding patients accessing those providers. M‐1 “ROI Period and Scope”: In the context of this recommendation, additional discussion was held on the suggested definition of “cost‐effective.” One Work Group member preferred to remove the second facet of the cost‐effective definition relating to the return on investment of a given service or sequence of services. Discussion ensued over whether “secondary impacts” (e.g., productivity) should be considered, especially for services where the cost‐effectiveness stems solely from the impact on productivity or other secondary effect. Some Work Group members felt that secondary benefits to the population should be considered, and others suggested that they should be excluded and/or distinguished in an essential benefit set as services better provided by public health. 2
M‐3 “EBS Price Differentials”: Clarification on EBM Certification was requested by the Work Group, specifically, on how it would be applied. Discussion also centered on the rationale and appropriateness of a risk adjustment mechanism. John Klein responded that the cost‐effectiveness charge was the rationale. He clarified that risk adjustment would be needed to maintain premium affordability for plans that offer certain services that may attract a higher‐cost population, and in small business situations where premiums can be unaffordable due to a high‐risk member. One Work Group member objected to including the provision as unnecessary, while another Work Group member objected to deleting the provision as potentially important to correct market failures related to EBM initiatives. E‐5 “Clinical Emphasis”: The Project Team will add “disability,” to the first sentence so it would read “prevent illness, injury, disability, disease or related symptoms.” E‐1 “EBS Certification”: Some Work Group members argued that there should be only one EBS plan, (i.e. remove the notion of a “minimum” plan). (The last sentence of E‐1 was removed later in discussion.) E‐2 “Basic/Comprehensive Coverage”: Discussion revolved around how to define the “member total cost threshold” and the budget question in general. Some Work Group members highlighted the added cost of recommending a richer benefit set than is typically offered in the private market. One member recommended against denying coverage for services that fail to meet a QALY threshold in dollars. Some consensus was expressed on leaving the budget issue unresolved in the interim and rephrasing E‐2 in more open‐ended language. E‐3 “EBM Emphasis”: The Project Team will, per the Work Group’s recommendations, spotlight prevention in E‐3 and add additional distinctions or categories to the list in E‐3 to prevent overlap of certain services with categories. Concern was expressed about using the “standard of care” as the baseline measure as it does not necessarily reflect the best care. The Project Team will redesign the E‐3 categories to reflect this concern and incorporate more distinctions related to evidence and standards of care to this recommendation. One Work Group member recommended excluding ICSI level 4 screening from the essential benefit set, and ensuring that health plans would not be open to litigation for refusing to cover the level 4 screening services. E‐1 “EBS Certification”: Discussion centered on the definition of “actuarially equivalent,” and the Work Group noted that the concept could allow for significant variations in covered health benefits. The Work Group voted to strike this last sentence of E‐1: “A health insurance product that provides coverage that is comprehensive and actuarially equivalent to an EBS Certified Plan, but does not meet the specified EBM parameters, will be designated as an “Essential Benefit Set Minimum Plan.” In response to discussion on whether the Work Group should design a tiered (high, medium and low cost) plan, the representative from the Minnesota Department of Health (MDH) clarified that the legislature did not expressly request three essential benefit sets, but that MDH intended that the Work group consider the tradeoffs between the extent of coverage and plan affordability. Some discussion also addressed the task of a state agency to evaluate whether products satisfy the essential benefit set expectations. One Work Group member wanted to highlight health plans’ continuing ability to do medical assessment reviews in order to reduce costs and keep care appropriate. Including mental health services as part of one budget was also suggested, and a question about whether interpreters should be included in E‐7b was raised (the issue of interpreters will be revisited at the next meeting). 3
3. Actuarial Pricing Issues John Stiglich summarized the actuarial strategies that could be employed to analyze the work group’s recommendations at a high level of generality, and further explained some of the potential pricing issues that may need to be addressed. 4. Next Steps – Meeting #6 The project team will revise the conclusions and recommendations based on today’s discussion, and frame an agenda around the outstanding issues. 4