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The Essential Benefit Package Recommendations of the Oregon Health Fund Board’s Benefits Committee July 2, 2008 Features of the Essential Benefit Package Based on the Prioritized List of Health Services Promotes use of the integrated health home

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The Essential Benefit Package

Recommendations of the

Oregon Health Fund Board’s

Benefits Committee

July 2, 2008


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Features of the Essential Benefit Package

  • Based on the Prioritized List of Health Services

  • Promotes use of the integrated health home

  • Incentivizes use of preventive care and chronic disease management

  • Cost sharing can be modified to make it more affordable to individual or state


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Guiding Principles

I. Is the set of essential health services established by this committee:

+ a. essential to the public health of Oregonians?

 b. based upon a proven benefit model?

+ c. reflective of the values of Oregonians?

+ d. easy to adjust in response to new information

on cost and effectiveness?

+ e. affordable (to the individual, employer, and

state) and economically sustainable?

+ f. developed in a transparent manner?


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Guiding Principles (cont’d)

II. Does the set of essential health services place emphasis on the following services identified in SB 329?

+ a. Preventive care

+ b. Chronic disease management

+ c. Primary care medical homes

+ d. Dignified end-of-life care

+ e. Patient-centered care

+ f. Provision of care in the least restrictive

environment


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Guiding Principles (cont’d)

III. Does the set of essential health services help promote:

+ a. wellness?

+ b. patient engagement (including education towards self-management)?

+ c. coordination and integration of care?

+ d. population health?

+ e. cost-effective care?

+ f. cost-control/reductions in over-utilization?

+ g. access to timely and appropriate diagnosis and treatment?


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Guiding Principles (cont’d)

IV. Have the following issues been addressed by this committee?

+ a. Use of evidence-based medicine

+ b. Efficacy of treatments

 c. Reduction of health disparities

+ d. Personal responsibility

+ e. Impact on vulnerable populations (including but not limited to pregnant women, infants and small children)

+ f. Incentives to encourage appropriate use of effective services

 g. Acute and tertiary care needs of the population


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The Prioritized List

  • Prioritized condition-treatment pairs

  • Created and maintained by 11 member Health Services Commission

  • First implemented in February 1994

  • New methodology resulting in reprioritized list went into effect January 2008

  • State legislature currently provides funds for services on lines 1-503 (out of 680)


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The Prioritized List

Condition: TYPE I DIABETES MELLITUS

Treatment: MEDICAL THERAPY

ICD-9-CM: 250.01,250.03,250.11,250.13,250.21,

250.23,250.31,250.33,250.61,250.63,

250.71,250.73,250.91,250.93,251.3,

V53.91,V65.41

CPT-4: 90918-90997,93990-95250,99024,99051,

99060,99070,99078,99201-99362,99374-

99375,99379-99440

HCPCS: G0245,G0246,G0308-G0327,S9145

Line: 10


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Prioritized List – Categories of Care

1) Maternity/Newborn Care (100)

2) Primary & Secondary Prevention (95)

3) Chronic Disease Management (75)

4) Reproductive Services (70)

5) Comfort Care (65)

6) Fatal Conditions – Disease Modification/Cure (40)

7) Nonfatal Conditions – Disease Mod./Cure (20)

8) Self-limited Conditions (5)

9) Inconsequential Care (1)


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Prioritized List - Individual/ Population Impact Measures

  • Impact on Health Life Years (0 to 10) plus

  • Impact on Suffering (0 to 5) plus

  • Population Effects (0 to 5) plus

  • Vulnerability of Population Affected (0 to 5) plus

  • Tertiary Prevention (0 to 5)

    • Total then multiplied by

  • Effectiveness (0 to 5) and

  • Need for Medical Services (0 to 100%) and

  • Category weight (1 to 100)

  • Net Cost (0 to 5) considered as a tie-breaker


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The Essential Benefit Plan

  • High deductible (adjustable for income)

  • Significant copays for many services

    • Cost sharing tiers based on the Prioritized List

  • Cap on out-of-pocket maximum (adjustable for income)

  • Current Medicaid population would see no reductions in current benefits and have cost sharing no higher than current levels


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Services Not Subject to DeductibleOut-Of-Pocket Max Applies

Essential Benefit Package

Sample Supplemented EBP


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Value-Based Services

  • Seen primarily in the integrated health home

  • Shown to prevent illness progression and/or disease complications

  • Avoids preventable hospitalizations or ED visits

  • Patient incentives to follow treatment recommendations


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Value-Based Services (cont’d)

Examples

  • Evidence-based preventive care

  • Chronic disease management

    • regular provider visits

    • selected medications

    • self-treatment education

    • care coordination

  • Prenatal care

  • Preventive dental exams & cleanings


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Services Subject to DeductibleOut-Of-Pocket Max Applies

Essential Benefit Package

Sample Supplemented EBP


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Services Subject to DeductibleOut-Of-Pocket Max Applies

Essential Benefit Package

Sample Supplemented EBP


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Tier I Conditions

Life-threatening newborn conditions

Life-threatening chronic diseases

Imminently life-threatening conditions

Trauma

Acute illness

Public health concerns

Examples of Conditions in Tiers

Tier II Conditions

  • Cancers with effective treatments

  • Chronic diseases with less impact on health

  • Potentially life-threatening conditions

    • Trauma

    • Acute illness


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Examples of Conditions in Tiers

Tier III Conditions

  • Cancers with less effective treatments

  • Non-life-threatening chronic diseases

  • Other non-life-threatening conditions

    • Trauma

    • Acute illness

Tier IV Conditions

  • Conditions with no effective treatment or no treatment necessary

  • Self-limited conditions

  • Conditions with limited effects on health

Non-covered services: cosmetic procedures, infertility, etc.


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Non-emergent health care

Doesn’t substantially avert downstream costs/adverse consequences of condition

Subject to annual maximum and other possible limitations

Restorative dental care

Eyeglasses

Certain dermatologic conditions

Discretionary Services


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Emergency Department copayments/ coinsurance

Well person visits

Lifetime maximum

Prescription drug cost sharing

Mandated services

Ancillary services

Issues of Note


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For additional information

Darren Coffman, Director

Health Services Commission

1225 Ferry St. SE, 1st floor

Salem, OR 97301

(503) 373-1616

[email protected]


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