Meeting Summary Essential Benefits Set Work Group September 9, 2009 Minnesota Department of Revenue Building Work Group Members Present Mary Bethke, Minnesota Chamber of Commerce 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 Julia Philips, Minnesota Department of Commerce Robert Stevens, Ridgeview Medical Center Diana Williams, The KNW Group Bruce Anderson, Minnesota Management and Budget Work Group Members Absent Bryan Dowd, University of Minnesota, Division of Health Policy and Management Nathan Moracco, Minnesota Management and Budget Rich Sykora, Medica N. Marcus Thygeson, HealthPartners 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 Dorothy Vawter Minnesota Department of Health Representatives Scott Leitz, Assistant Commissioner Julie Sonier, Health Economics Program 1. Welcome and Introductions On behalf of the project team and the Minnesota Department of Health, respectively, Ellie Garrett and Scott Leitz welcomed work group members and thanked them for agreeing to participate. Introductions were made around the table. 1
2. Work Group Charge and Scope of the Project Scott Leitz reviewed the charge for the work group. He explained that the work group is one of several called for by 2008 health care reform legislation. The Legislature has no single reform agenda into which the work group’s efforts will fit. The notion of an essential benefits set can fit within many different approaches to health care reform. 3. Presentation and Questions regarding the Background Paper John Stiglich and Mike Rieth summarized salient points from the background paper. Discussion ensued and centered on the work group’s charge and the legislative context for the work. Leitz clarified that there could be many potential uses for the essential benefits set (EBS). It could be folded into many different approaches to health care reform and universal coverage proposals. The Department of Commerce currently evaluates a limited number of proposed benefits each year, but doing so is complex, time‐consuming and difficult. The issue of mandates presents a choice for the work group. The group could decide to confine its recommendations to what is possible under current laws and regulations, or it could decide to make recommendations without that constraint and to let the work highlight areas where legal or regulatory changes might be advisable. The work group members leaned toward not being constrained by existing laws and regulations. Julie Sonier from the Minnesota Department of Health clarified later in the meeting that it is within the scope of the work group’s charge to recommend regulatory or statutory changes. 4. Preliminary Work Plan Ellie Garrett summarized the preliminary work plan to show how the following, general discussion about EBS goals and of value‐based insurance design fit with making progress toward generating an EBS. 5. Preliminary Discussion: EBS Goals and Value‐Based Insurance Design Work group members were asked to offer the goal(s) they felt should guide the development of an EBS and for implementing value‐based insurance design. During discussion, several different ideas and principles began to take shape, but no single set of goals emerged. The following were offered at various times during discussion:  The goal should be cost containment, e.g., o People should be protected from the catastrophic costs of serious medical problems. o People should have financial incentives to use cost effective treatments. For many conditions, there is a range of clinically equivalent treatments that have very different costs. For these “preference sensitive” treatments, the patient should pay a significant amount of the additional cost for the more expensive options.  The goal should be promoting individual health, because health care is experienced as a series of individual patient encounters with health care providers.  The goal should be promoting population health, or the health of all Minnesotans.  Whether the goal is individual or population health, the benefits set should be comprehensive enough to offer services like mental and dental health care if they can be proven to support overall health and reduce costs in the long run.  There should be reductions to financial barriers for important preventive services or disease screening.  Patients with serious chronic conditions should have access to services that enable them to manage their conditions and avoid medical crises. For example, diabetics should have access to physician, testing and dietary counseling with minimal cost. 2
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People should take personal responsibility for keeping themselves healthy. For example, there should be financial incentives for diabetics to manage their care. People should have the option of “buying up” from the basic minimum benefit. Employers and other group purchasers should have the option to purchase a larger benefit set. Various potential procedures for evaluating the scope of services from the meeting emerged that include the following:  Pick off the low‐hanging fruit. Start by ruling out the services or groups of services that are deemed to be discretionary. This may be done by removing services that do not improve health or are possibly detrimental to health.  Start with the science. Focus on coverage of therapies that have strong scientific evidence of effectiveness. The downside is that many conditions and therapies are under‐studied, and limiting coverage to that which is scientifically proven is too high a bar in many aspects of medicine.  Focus on areas of largest concern to the population as a whole. Concentrate on specific targeted areas that correspond to those who are the high users of health services. This may be done by identifying what services have the largest practice variation, highest cost procedures, or significant areas of under‐treatment. Some of the conversation concerned issues with how a benefits set is implemented and how benefits design intersects with design of provider networks, reimbursement and contracting. The work group discussed the various audiences that could find the EBS useful and whether and to what extent they should narrow the focus. Should be it relevant to both public programs and private insurers? Some suggested that a narrow focus on the private, regulated market would be most useful; others suggested that a more statewide approach would be relevant. The populations covered by public programs and by the private, regulated market are different in important ways, and some benefits have greater relevance for some subpopulations than others. If the focus is on the private market, it will still be useful to understand the reach of government programs so as to smooth the transition from private to public. Following the break, three questions were asked of the group: 1. Is there a sense that existing benefit sets are sufficient and that that the real issue is administration, despite evidence that ineffective treatments like arthroscopic knee surgery for osteoarthritis are still provided? Is the EBS the appropriate tool for addressing that problem, or is that a matter for patient education and provider contracting? 2. What is the purpose of insurance for which we are designing an EBS: is it catastrophic care or health maintenance? 3. Can we begin to identify issues that will be lower priority or off‐topic for the group? One member observed that there is no single, common benefits set in use so the group can’t start talking about what to exclude without a sense of which set among many we are using as a basis for the group’s discussions. Another suggested that we should start from a minimal set in use in the private market. In regard to the second question, some support was offered for focusing on health maintenance, which would include preventive services, would be appropriate. Other support was offered for catastrophic coverage. No clear consensus emerged. 3
Ellie Garrett offered another complexity to consider, and that is that the high, medium and low cost options for the EBS reflect different covered benefits and not just cost‐sharing options. 6. An ethical framework for coverage decision‐making Karen Gervais walked the group through the framework for coverage decision‐making that was described in the article handed out at the meeting. The framework, designed to help an insurer evaluate whether to cover a particular therapy, drug or procedure for a given condition, is the product of a public/private project led by the Minnesota Center for Health Care Ethics a few years ago. The group was asked to consider the utility of such a framework for its work and also to consider how it could be modified to apply to the decisions the work group will be facing regarding designing an EBS. 7. Refine Work Plan; Identify Action Items/Next Steps John Klein walked the group through the preliminary work plan in some detail, outlining how the meetings might progress. In response to a question about what kinds of presentations the group might find useful, the following were identified:  A presentation by ICSI about how it makes its recommendations, how it chooses which areas to focus on, how it rolls out recommendations and how they are received  A presentation by Medica about its approach to value‐based insurance design  A presentation about the actuarial analysis that is encompassed in this project and how actuaries do their work Work group members who are interested in circulating particular articles to the group can send them to Mike Rieth at Cirdan. The project team will begin developing a list of parking‐lot issues for the group to consider. Next meeting: Friday, September 18, 2009 10:30 a.m.‐2:30 p.m. Wilder Center 451 Lexington Parkway N North, St Paul, MN 55104 4