Meeting Summary Essential Benefits Set Work Group October 2, 2009 Minnesota Department of Health Work Group Members Present Bruce Anderson on behalf of Nathan Moracco, Minnesota Management and Budget Susan Castellano, Minnesota Department of Human Services 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 Mary Maertens, Avera Marshall Regional Medical Center Nancy Nelson, Blue Cross Blue Shield of Minnesota Julia Philips, Minnesota Department of Commerce Robert Stevens, Ridgeview Medical Center Rich Sykora, Medica Bryan Dowd, University of Minnesota, Division of Health Policy and Management Work Group Members Absent Nathan Moracco, Minnesota Management and Budget Diana Williams, The KNW Group Mary Bethke, Minnesota Chamber of Commerce N. Marcus Thygeson, HealthPartners Project Team Members Present CIRDAN Health Systems and Consulting John Klein Mike Rieth Minnesota Center for Health Care Ethics Ellie Garrett Angela Morley Dorothy Vawter Minnesota Department of Health Representative Julie Sonier, Health Economics Program 1. Welcome Ellie Garrett welcomed the group and introductions were made after CIRDAN provided the overview of public input to date. 2. Overview of Public Input to Date Mike Rieth and John Klein presented Handout C: EBS Public Input, summarizing public input received to date. A mixture of condition ‐ or provider‐specific and policy‐level recommendations was provided. CIRDAN will email the comments and supporting documentation to the Work Group. 1
3. MCO Experience with VBID, Barriers to EBM In the previous meeting, the health plans were asked to identify barriers they encountered in making benefits decisions that are grounded in evidence and about their experience, if any, with Value Based Insurance Design (VBID). Blue Cross Blue Shield of Minnesota identified the following trends in commercial products: employers limiting members to generic drugs; step‐therapies for drugs; making brand‐name drugs more expensive; tiering of pharmacies and variation in copayment of drugs; moving to high‐deductible plans and health savings accounts; cost‐differentials between preferred provider networks and other providers; purchase of disease management services as an add‐on; and interest in and use of cost‐comparison tools (e.g., rate bands for relative comparison of procedures and providers). When designing products that begin to incorporate some elements of value‐based insurance, there are significant differences between self‐insured, large employers and smaller, fully insured employers. Suggestions for potential exclusions for commonly included services included: chiropractic services; infertility; maternity; ovarian cancer screening; and lifestyle drugs. Recommendations for potential inclusions for commonly excluded services included: use of medical home, and diabetes and thyroid screening. Medica echoed the experience of Blue Cross Blue Shield and reports that most small, fully‐insured companies are not asking for specific benefit improvements; rather, they are looking to consultants for help cut costs. Trends include offering disease management programs and more high‐deductible plans. Health plans representatives stated that the market does not inhibit them from offering evidence‐based benefits. However, the small group market generally has less capacity for getting involved in complex benefit design issues and, as a result, there is not significant demand for new EBM‐based products. 4. EBS Decision Framework Ellie Garrett and John Klein presented Handout A: EBS Decision Framework, Options and Consultant Team Recommendations for Work Group discussion. They explained the categories on page 1, the three Options Based on Decision Framework on page 2 and the Key Principles for Service/Benefit Inclusion on page 3. The Project Team also offered vulnerability as an additional principle. Substantial discussion centered on how to define the “Evidence of Clinical Evidence” and “Evidence of Cost‐Effectiveness” principles. The Work Group noted that there are different standards for clinical effectiveness and different evidence for cost‐effectiveness. Two aspects of cost‐effectiveness emerged: return on Investment (to whom) and the difference in short and long‐term investment. One suggestion was to add the principle of “Relative Effectiveness between Competing Therapies (including cost)” as an additional principle and to add “Return on Investment (ROI) to whom” to the “Evidence of Cost‐
Effectiveness” principle. The “Population Affected” principle was not discussed at length, and the Work Group chose to retain the “Insurable (Unknown) Event vs. Pre‐Funding of Known Event” (clarification was offered that this “known” events would be pre‐diagnosis) and “Clinical vs. Maintenance” principles. The Work Group agreed that the “Health Impact” principle should be moved to the top of the principles list as the most important principle. “Age‐Appropriate” was suggested as a principle, but later rejected by the Work Group. One suggestion was to find a way to support conservative treatment prior to aggressive treatment, which is generally both clinically and cost effective. Another work group member recommended adding “Plausible Evidence of Market Failure” as a principle, to address time‐horizon 2
problems and inadequacy of risk adjustment. “Vulnerability” was also retained with the understanding that it might be removed if determined unhelpful in subsequent discussions. The Minnesota Department of Health representative confirmed that the Medicare population could be removed from discussion of the EBS such that the focus would be on the under 65 population. The Work Group proceeded to examine whether dental services should be included in the essential benefit set in light of the principles discussed. After some discussion, the Work Group voted to exclude dental services from the essential benefit set. Rationales included the existence of robust dental insurance market which the health insurance market may not be well suited to replace and the concept that dental care expenditures are predictable, not catastrophic. 5. EBS Clinical Categories Discussion The Project Team shifted the discussion to the services that should be included in the essential benefit set premium. Both providers and health plans can provide services listed in category X on Handout A (e.g., care coordination). Some discussion addressed whether providers should be separately compensated when they provide care coordination, consumer education and health promotion services, and how much of these services should be included in the premium. The project team asked if separate services, such as smoking cessation, that are not included in the bundled group should be in the premiums. The Work Group decided that the essential benefit set should focus on services in category A in Handout A (page 1) and include care coordination by providers. The project team explained Handouts B (EBS Design Options for “Evidence Based Medicine” Standards) and D through L (ICSI Guidelines and design options). The Work Group was asked to apply the key principles to preventive services for adults (assuming an ROI within 10 years), and focused on the ICSI Guidelines in Handouts J, J2 and J3. The Work Group assessed preventive services for adults according to the key principles chart (as modified in previous discussion). An “X” was placed halfway between the center and the right of the “Cost‐Effectiveness” principle, to the right of the “Population Affected” and “Health Impact” principles, and to the left of the “Insurable (Unknown) Event vs. Pre‐Funding of Known Event” principle. The “Maintenance/Clinical” and “Relative Effectiveness” principles were not applicable and an “X” was placed halfway between the center of the “Market Failure (Discrepancy in ROI)” and the right. Mike Rieth noted the automatic inflationary effect of adding a known or predictable event to the benefit set. Discussion centered on the relationship between market failure, time horizon problems and return on investment to health plans and society. The “Plausible Evidence of Market Failure” principle was changed to “Plausible Evidence of Market Failure (Discrepancy in ROI to Whom),” distinguishing health plan cost effectiveness (related to health plan financial benefit) and individual or societal financial detriment (Market Failure Discrepancy in ROI to Whom). Additional suggestions included changing the “Evidence of Cost‐Effectiveness” principle to “Short‐term Cost‐Effectiveness” and “Plausible Evidence of Market Failure (Discrepancy in ROI to Whom)” to “Long‐term Cost‐Effectiveness.” Some members of the Work Group expressed concern that this approach was not helpful, and suggested that the Work Group make a judgment based on current policies and give general guidelines for coverage. For example, it was suggested that preventive care based on the best evidence should be included in the essential benefit set with the least amount of cost‐sharing (minimize barriers). 3
The team shifted the group’s attention to Handout J2 and asked which levels of preventive services should be included in the essential benefit set, and if so, the level of cost‐sharing for each. One Work Group member recommended that the costs of PSA screening and THS/thyroxine should be borne by the consumer. The issue of how much of the cost should be incorporated into the premium was again raised. Examining outcomes, rather than payment incentives, was also recommended. The Work Group agreed to preferential cost sharing for Level 1 and Level 2 preventive services, with cost sharing to incentivize members to see providers who agree to practice according to evidence‐based guidelines. Agreement was expressed that Level 4 services should be excluded. The Work Group also agreed that Level 3 services should be included to some degree in the essential benefit set. Concern was expressed about the applicability of cost‐sharing determinations for Level 3 services and the applicability to clinical settings, so the Work Group chose to avoid specifying the extent of cost sharing for these services. For Level 3 services, the Work Group recommended a proxy: using cost‐sharing to incentivize consumers to see physicians practicing according to evidence‐based guidelines. The team turned the Work Group’s attention to Handout D: EBS Benefit Category Work Up (Type 2 Diabetes) to discuss care management and proxies. The Work Group readily agreed that an essential benefit set should include treatment for diabetes. Concern was expressed that some types of case management that can provide societal return on investment are not paid for by health plans, and recommended incentives to patients to choose appropriate sites of services for care. One idea was to recommend complete coverage for care delivery in group settings, incentives – but to a lesser extent, for treatment in physician offices and disincentives for preventable ER visits. 6. Next Steps Work Group members requested more clarification on what the end product should look like, specifically the level of detail needed (i.e., do we want health plans to be able to determine if they meet the threshold for the minimum plans). Work Group members requested information on the impact on cost if physicians are required to practice according to ICSI guidelines, or if Level 1 and 2 services were required for health plans. One option discussed was analysis of commonly excluded benefits in a sample contract or a summary benefit design and determine what should be excluded or included, and provide justification for its determinations. 4