Meeting Summary Essential Benefits Set Work Group September 18, 2009 Wilder Center 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 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 Robert Stevens, Ridgeview Medical Center N. Marcus Thygeson, HealthPartners Bryan Dowd, University of Minnesota, Division of Health Policy and Management Work Group Members Absent Nathan Moracco, Minnesota Management and Budget Rich Sykora, Medica Diana Williams, The KNW Group Mary Bethke, Minnesota Chamber of Commerce Julia Philips, Minnesota Department of Commerce (?) 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 Dorothy Vawter Minnesota Department of Health Representatives Julie Sonier, Health Economics Program 1. Welcome and Introductions Ellie Garrett welcomed the group and introductions were made after proposed parking lot issues were discussed. 2. Proposed parking lot issues Ellie Garrett reviewed the charge of the group and proposed parking lot issues. Discussion centered around whether the work group’s charge was to develop an essential benefit set for the private market or the public market. Considerations of cost‐shifting and use of the public market for supplemental 1
insurance for individuals with disabilities were raised as rationales for focusing on the complexities of both markets, with primary emphasis on the private market. Ellie Garrett clarified that Minnesota Department of Health’s charge was to focus on the private market. The work group concluded that it would focus on the private market with an eye to understanding the breadth and complexity of the private market and the population in that market, as well as the areas of overlap between markets such as implications of cost‐shifting to the private market. Sentiment was again expressed that an essential benefits set would constitute a floor or a minimum. General consensus was expressed that the work group should focus on the private market, as what is essential for the private market would be essential for the public market, albeit possibly insufficient. Confirmation that low‐hanging fruit of evidence‐based medicine would be addressed in the plan (at both extremes) was made. 3. Proposed decision points: guidelines and principles for developing the EBS; scope John Klein presented five categories touched on by the work group as considerations for developing the EBS and asked the work group for guidance on balancing: (alphabetical order): (1) better value, (2) financial protection, (3) individual health, (4) lower costs and (5) population health. Discussion centered around defining “value” and suggestions included evidence‐based medicine and outcomes. Consensus emerged that “value” should be defined as improving health positively, considering cost over time. Four primary categories of clinical services arose in discussion: (1) “positive return on investment” including some preventive services for which the health plan saves money for every dollar spent, (2) cost‐effective services, defined as the cheaper means of achieving the same outcome, (3) services with medical benefit (effectiveness) but substantial cost and (4) services with no medical benefit. Value “to whom” was highlighted as a potential concern for the third category and discussion arose around the appropriate value at the system level and quality as a possible value. Difficulty of defining the threshold for cost‐effectiveness was expressed. John Klein presented the potential points of agreement and clarifications of the charge of the work group. The work group identified different ways of addressing the services in the “middle ground,” categories 2 and 3. Some discussion occurred on using benefits design rather than coverage to incent healthy behavior. (i.e. differential benefits for individuals using a medical home). The project team will develop additional handouts with examples. 4. ICSI presentation, Kathy Cummings, RN, MA, Director of Clinical Products & Systems Improvement Kathy Cummings presented information about the Institute for Clinical Systems Improvement. She outlined and the development and use of evidence‐based guidelines and highlighted ICSI’s Diamond Transformation program. Discussion and questions centered around the evidence grading system, and the advantage of ICSI’s recommendations (e.g., ICSI guidelines consider the strength of the studies). ICSI has not yet established guidelines for alternative medicine. Member organizations commit to project improvement. Cummings also discussed her experience implementing a rapid response system. 5. Background and discussion on commercial benefits designs currently in use, including common design elements John Klein presented and summarized material on examples of standard plans available in the market for individuals. Premium changes and benefit trends were highlighted. The availability of Health Savings Accounts in high deductible plans, eligibility requirement and questions about the incomes and assets of individuals with HSAs were raised and discussed. Mike Rieth summarized an additional handout comparing structures and benefits of private and public health plans, ranging from relatively basic plans to plans rich in benefits. He highlighted the medical necessity exclusion of the MCHA plan and its comparability to private plans. Concern over usability of benefits was expressed, particularly for Medicaid recipients and shortages of available providers due to limited reimbursement. 2
John Klein presented and explained the “EBS Basic Design Options” handout as a means to facilitate discussion. Situations where a health plan would be incentivized not to comply with disease management guidelines were highlighted as an area of focus for the work group. The issue of which services, beyond catastrophic care and basic preventive services, should be provided was revisited. Additional discussion centered around defining catastrophic care, with consensus that catastrophic care should be covered. The propriety, and specific limits on income, lifetime and annualized maximums were debated. Some consensus that limits should accord with health plan definitions of catastrophic levels. A sliding scale, lifetime maximum of 4‐6 million dollars and an out of pocket expenditure of 10‐
15k, were all suggested as potential limits. Expenditures leading to medical bankruptcy could serve as the threshold for catastrophic care. Ellie Garrett shifted the discussion to the preventive services and the costs of health maintenance and promotion benefits. One member advised that the state should not intervene in a health plan’s choice either to cover preventive services with a positive rate of return or deny coverage for services of no medical benefit. Debate ensued on whether preventive services with positive rate of return should be included in premium payments or require co‐insurance payments, and the advantages and disadvantages of offering a defined and discrete set of preventive services outside the purview of the deductible and copayments. An additional category of non‐covered discretionary services (cosmetic surgery) was suggested. John Klein presented the remainder of the EBS options (i.e. Services Alone) to the work group. The Medical Home option elicited some discussion on the state’s advantage plans and cost differentials, and concerns about the provider‐centric focus and of the medical home model emerged. Restrictive conditions such as requiring purchase into the multiple health plan pool to receive subsidy were also discussed. 6. Other Items Consensus emerged among the group that written public input, both on the draft recommendations and the final benefit set should be sought (from members of the Minnesota Department of Health email list and other interested parties). Email to follow as soon as possible. Next meeting: Thursday, September 24, 2009 Noon‐4 p.m. Minnesota Department of Health Freeman Building Room B‐144 625 Robert St. N St. Paul, MN 55164‐0975 3