state can afford for the covered population. This latter decision of where to draw the line is primarily made using actuarial analysis of the cumulative costs of services. Currently, Dr. Saha said, approximately 75 percent of the over 600 lines of condition-treatment pairs are covered (Table 13-1) (Oregon Health Services Commission, 2011). The HSC’s prioritization methodology was “reinvented” in 2006. The HSC first ranks nine categories of care based on healthy life years and impact on suffering, among other criteria. Each category of care is given a weight, ranging from maternity care with a weight of 100 to inconsequential care with a weight of 1 (see Table 13-2). The category list does not mean that all maternity care is prioritized over preventive care; rather, these category rankings are one component in an overall scoring formula. Dr. Saha pointed out that these categories of care are based on Oregon’s priorities and not on organ systems or type of provider. As a result of this distinction, dental and mental health care are integrated in the category list. Second, the HSC goes “line by line” and scores each condition and treatment within these categories of care based on eight impact measures: impact on health life years, impact on suffering, population effects beyond the affected patient (e.g., contagious diseases), vulnerability of the population affected, prevention of downstream complications, treatment effectiveness, the need for medical services, and net cost. The comprehensive list of conditions and treatments is built using diagnostic codes and procedure codes (i.e., ICD-9, CPT, and HCPCS [Healthcare Common Procedure Coding System] codes). Thus, a procedure without a CPT code is not included on the list, and prescription drugs and DME apply to many different lines on the list. To address this latter shortcoming, these products are called “ancillary services” and are “blanketly covered for conditions that fall within the covered range of the list.” Additionally, the list is used to determine the coverage of treatments only after the necessary diagnostic services establish the condition.
|Ranking||Category of Care||Weight|
|2||Primary and secondary prevention||95|
|3||Chronic disease management||75|
|6||Fatal conditions-acute care||40|
|7||Nonfatal conditions-acute care||20|
|SOURCE: Oregon Health Services Commission, 2007.|