Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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13 Priority Setting and Value-Based Insurance Design
13 Priority Setting and Value-Based Insurance Design
Pages 141-148
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From page 141... ...
Additionally, they discuss developing value-based insurance design across the public and private sector in Oregon. Jean Fraser, the current chief of the San Mateo County Health System and the former CEO of the San Francisco Health Plan, built on these points by discussing her experience "making hard choices" when developing benefit plans for two California coverage programs.
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From page 142... ...
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. TABLE 13-1 Selected Elements and Rankings from the Oregon Health Services Commission's Prioritized List for Medicaid Line Number Examples of Services Coverage 1 Maternity care 101 Medical treatment of acute lymphocytic leukemia 201 Surgical treatment of brain hemorrhage 301 Treatment for rheumatic heart disease 401 Laser therapy to prevent retinal tear 501 Treatment for noninflammatory vaginal disorders Covered Not Covered 551 Treatment for back pain without neurologic impairment 651 Treatment for calcium deposits SOURCE: Oregon Health Services Commission, 2011.
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From page 143... ...
, the service's total impact score (derived from the set of scaled impact measures) , the effectiveness of the service, and the need for the service.
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From page 144... ...
Using the Prioritized List to Develop EHB In 2007, during a push for a universal coverage plan in Oregon, the state legislature directed the development of "recommendations for defining a set of essential health services that would be available to all Oregonians under a comprehensive reform plan."1 The legislature, Dr. Saha said, recommended using Oregon's prioritized list of health services as the basis for developing the state's essential benefits package.
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From page 145... ...
Smith. The actuaries used "judgment, rules of thumb, and many assumptions," she said, to "tease out" the first estimates of the cost implications of tiered, evidence-based benefit design; initial analysis suggests that a 3 to 5 percent premium reduction would be pos sible compared to a traditional commercial plan.
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From page 146... ...
In addition to the cost implications of tiered benefit design, the OHPR has explored the expected utilization offset by changes in cost sharing. As shown in Table 13-4, use of value-based services (those that are highly effective, low cost, and have strong evidence supporting their use)
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From page 147... ...
Fraser. While the exclusions and limited provider network impose significant limits, they also allow the program to cover a "limited set of core services," including prevention and treatment for "most medical conditions for tens of thousands of people who did not have coverage before." Thus, the "choice" the developers made in benefit design "was not between the perfect and the good.
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From page 148... ...
Fraser noted that regardless of whether states do it or the federal government tells the states what to, the committee should develop mechanisms to ensure some level of consistency. She suggested that if the federal government delegates this work to states, states ought to be given the option of following federal rules and/or joining regional consortia to take advantage of economies of scale and data.
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