Meeting #3 Summary Essential Benefits Set Work Group September 24, 2009 Freeman Building, Minnesota Department of Health St. Paul, MN Work Group Members Present Susan Castellano, Minnesota Department of Human Services Amy Gilbert, Minnesota Medical Association Patrick Herson, Blue Cross Blue Shield of Minnesota 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 Rich Sykora, Medica N. Marcus Thygeson, HealthPartners Bryan Dowd, University of Minnesota, Division of Health Policy and Management Work Group Members Absent Mary Bethke, Minnesota Chamber of Commerce Nathan Moracco, Minnesota Management and Budget Julia Philips, Minnesota Department of Commerce Robert Stevens, Ridgeview Medical Center Diana Williams, The KNW Group Project Team Members Present CIRDAN Health Systems and Consulting John Klein Mike Rieth 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 group and called the meeting to order. 2. Confirm Work Group Charge and Primary Purpose of EBS Reflecting recent clarifications from the Minnesota Department of Health on the charge and outlining the common assumptions of the group, Ellie Garrett and Karen Gervais presented Handout A: Consensus Assumptions and requested feedback and, if possible, assent to the assumptions. 1
Background Assumptions – Handout A ‐ Assumption 1: Affirmed with no changes. ‐ Assumption 2: “High value services” required definition and debate ensued over the legislature’s concern for high deductible plans. This assumption was split into two statements as follows: o Some policymakers are concerned that high‐deductible insurance plans may be preventing people from getting needed services in a timely way, thus undermining individual and population health. o There should be limited or no financial barriers to obtaining high value services, recognizing that what constitutes a financial barrier may be different for different people. ‐ Assumption 3: Affirmed with no edits. ‐ Assumption 4: Discussion centered on the sufficiency of one (“the”) EBS for the entire population or if “an” EBS should be defined for different population segments. Legislative intent, according to Julie Sonier, was for an essential set for Minnesotans in general terms, and minimization of implementation questions of utilization and underwriting (and reliance on actuarial consultants to identify financial impossibilities). The tension around this assumption will likely be revisited as the work group’s work progresses. ‐ Assumption 5: o Modification: Decisions about EBS inclusions, exclusions, and cost‐sharing tiers should be evidence based, where possible. Evidence about clinical‐ and cost‐effectiveness should be the basis of decisions to include, exclude or adjust cost sharing for services in the EBS, where possible. ‐ Assumption 6: Affirmed with no edits. ‐ Assumptions 7 and 8: Both were affirmed with no edits. ‐ Assumption 9: Modification was made in light of Julie Sonier’s clarification that the work group’s charge was not to address whether or the extent to which public subsidies should be available to help pay for the EBS, though considering relative cost‐effectiveness remains part of the work group’s charge. o Modification: Implementation concerns in relation to the Work Group’s EBS and VBID recommendations should not constrain the Work Group’s development of the EBS or the VBID options. The Work Group’s task is to make value judgments about what health services are important to meet individual and population health goals, not to determine whether and how to operationalize them. The Work Group should strive to set a minimum essential standard but not address subsidies or implementation beyond considering cost sharing as part of the Work Group’s charge. Policymakers will address tradeoffs involving affordability and subsidies separately. ‐ Assumption 10: o Modification: Statutory or regulatory changes may be necessary to effect the Work Group’s recommended EBS and VBID options. EBS Assumptions – Handout A, continued ‐ Assumption 1: The EBS should include minimum services to promote the life‐long health needs of Minnesotans. ‐ Assumption 2: Affirmed with no changes. ‐ Assumption 3: 2
Modification: Assumption 3 was REMOVED, because it was premature. The work group would decide, rather than assume from the start, the range of services the EBS should cover. Assumption 4: o Modification: Currently mandated and commonly covered benefits should be reviewed by the Work Group for possible inclusion or exclusion from the EBS. Assumption 5: The term “catastrophic” will have to be defined by the Work Group, but otherwise it was affirmed with no changes. Assumption 6: o DELETED as an unnecessary statement. Assumption 7: o Modification: Customers, employers and other group purchasers and individuals could have the option of covering more than the EBS. Assumption 8 (and EBS Assumption 1): Some work group members argued that insufficient coverage in the private market forced individuals with disabilities to enroll in Medical Assistance to receive needed services. Debate ensued on the appropriate scope for the EBS, particularly the relevant population (all segments—publicly and privately insured and uninsured—or a specific subset of the population). More discussion centered on how to address transportation needs for access to care and inclusion/exclusion of these peripheral but needed health care services in the EBS. Some consensus that the EBS should be for all Minnesotans with benefits available to certain populations to meet special needs. Health promotion services, typically offered by care delivery organizations, not necessarily covered and provided by both licensed and non‐licensed personnel, were also raised and examined for inclusion in the EBS (inconclusive). o Possible modification: The Work Group should craft a benefit set with an eye toward what isn’t covered in the private market but should be because absence drives people into government programs (inconclusive). o These issues were revisited later in the meeting (see below). o
‐
‐
‐
‐
‐
John Klein presented and explained Handout C (Related Issues/Parking Lot) and the project team reminded the work group of the provider profiling group and potential overlap. 3. Decision Tools/Framework for EBS Development Karen Gervais introduced and explained Handout D: MCHCE Decision Making Model as a possible tool for the work group, necessitated by EBS Assumptions 1 and 2 and informed by information from the Minnesota Department of Health. How to compare clinical‐ and cost‐ effectiveness, and whether clinical effectiveness should mirror ICSI guidelines, remain unanswered questions. The work group agreed that a general statement asking the legislature to avoid preventing health plans from covering comparatively less expensive services ought to be drafted. John Klein presented and explained Handouts E (Conditions or Service Needs: Pregnancy Example), F (Cost/Clinical Effectiveness Tiers), G (EBS Value Tiers), H (EBS Basic Design Options – also provided at 9.18.09 EBS Meeting), and I (Mandated Benefits under Minnesota Law). With respect to Handout I, Ellie Garrett noted that the list of mandated benefits was provided so that work group members could explicitly choose to recommend against covering one or more of them. 3
John Klein presented and explained Handout J (MCO Tools and Initiatives to Manage Costs Based on Service Value, Quality or Necessity). Work group members expressed appreciation for the list of tools in Handout J, highlighting the complexity of determining appropriate care in specific cases and the need to adjudicate similar claims similarly. New technology was offered as an area of coverage concern, with the need for some entity to examine efficacy, beyond simple safety. Consequently, the additional limiting tool of coverage predicated on evidence development was suggested as a means to improve the volume of clinical and cost‐effective research and reduce the use and coverage of ineffective or wasteful interventions. Handout K (ICSI Health Care Redesign Project, Guidelines and Other Resources) and Handout L (ICSI Evidence Grading System) were both presented and summarized by John Klein, accompanied by a question on the appropriate threshold for evidence‐based medicine. Additional discussion centered again on EBS Assumptions 1 and 8, and whether to develop an EBS for “all” Minnesotans. Some discussion that the work group should start with the private market but include those benefits for which some would have to spend down and use Medical Assistance, and exclude benefits with little positive effect. Some were concerned that preventing spend‐down is micromanagement and at odds with improving access to affordable health care coverage in the private market. Ellie Garrett shifted the conversation to determining which categories should be covered and how extensively they should receive coverage. Categories identified included lifestyle benefits, services related to accessing health services (and other key determinants of health status), and services directly related to improving health. One work group member suggested that the group’s focus should be on the coverage of clinical services provided by licensed health care providers. Also, the work group recommended broad statements ensuring plans are not precluded from excluding coverage for unproven or harmful services as well as not prevented from covering services with a positive return on investment. Coverage of new and unproven technology was also revisited, and the work group discussed a provision to review services for medical necessity to limit use of and claims for inefficacious and non‐medically necessary services. Utilization management process review was highlighted as a related example, and preservation of professional judgment was identified as important. Members noted the insufficiency of ICSI quality guidelines for administering a health plan. ICSI’s guidelines and protocols are for quality improvement in a health care setting, and are not readily applicable in many cases to a benefit design. Additional comments revolved around the concept of “essential,” with one suggestion that “essential” refer to what providers would be expected to provide in the situation of global capitation. Some common opinion indicated that clinical consensus might be too low a bar for the EBS purposes. 4. Next steps Members agreed that it would be useful to understand what barriers, whether regulatory or market‐
based, may be inhibiting health plans from embracing an evidence‐based approach to coverage design. Also, what are helpful models or approaches, and where is the evidence strongest or weakest? Regulators, too, could speak to these issues. 4
One member suggested that a good starting point with be to agree on what should be excluded (not covered) in the EBS, and the conversation around exclusions could help the group refine its principles and decision‐making tools. Another suggested that handouts D, E and F would be good starting points, along with ICSI’s evidence grading system. Another suggested that the project team should be charged with deciding which decision‐making tool(s) should be used, and help the work group go through the exercise(s) to begin fleshing out an EBS at its next meeting. Next meeting: Friday, October 2, 2009 Noon ‐ 4p.m. Snelling Office Park (MDH) Mississippi Room 1645 Energy Park Drive St. Paul MN 55108 5