Essential Health Benefits Balancing Coverage and Cost Public - PowerPoint PPT Presentation

Essential Health Benefits Balancing Coverage and Cost Public Briefing, October 7, 2011

Committee Members JOHN R. BALL ( Chair ), Former Executive Vice President, American Society for Clinical Pathology MICHAEL S. ABROE , Principal, Consulting Actuary, Milliman, Inc. MICHAEL E. CHERNEW , Professor of Health Care Policy, Harvard Medical School PAUL FRONSTIN , Director, Health Research & Education Program, Employee Benefit Research Institute ROBERT S. GALVIN , Chief Executive Officer, Equity Healthcare, Blackstone Group MARJORIE GINSBURG , Executive Director, Center for Healthcare Decisions DAVID S. GUZICK , Senior Vice President for Health Affairs, and President, UF&Shands Health System, University of Florida SAM HO , Executive Vice President and Chief Medical Officer, UnitedHealthcare CHRISTOPHER F. KOLLER , Health Insurance Commissioner, State of Rhode Island ELIZABETH A. MCGLYNN , Director, Kaiser Permanente Center for Effectiveness & Safety Research AMY B. MONAHAN , Associate Professor, University of Minnesota Law School ALAN R. NELSON , Internist-Endocrinologist LINDA RANDOLPH , President and Chief Executive Officer, Developing Families Center JAMES SABIN , Clinical Professor, Departments of Psychiatry and Population Health, Harvard Medical School, and Director, Harvard Pilgrim Health Care Ethics Program JOHN SANTA , Director of Consumer Reports Health Ratings Center, Consumer Reports LEONARD D. SCHAEFFER , Judge Robert Maclay Widney Chair and Professor, University of Southern California JOE V. SELBY , Executive Director, Patient-Centered Outcomes Research Institute SANDEEP WADHWA , Chief Medical Officer and Vice President of Reimbursement and Payer Markets, 3M Health Information Systems

Committee’s Charge • To develop policy foundations, criteria and methods for defining and updating Essential Health Benefits (EHB). • Not to develop a specific list of categories and services for inclusion.

Approaching the Study • Solicited public input via the web on questions relevant to EHB determination. • Established online mailbox for the public to send other comments or materials. • Held two public workshops with 59 speakers; published workshop summary: Perspectives on Essential Health Benefits . • Conducted additional research and analysis. • Held 4 in-person committee meetings and numerous conference calls.

Key Issues That Emerged • Setting a balance between comprehensiveness and affordability • Defining what typical should mean for typical employer and benefits • Determining whether state mandates should be automatically included • Considering how specific HHS guidance should be when defining the EHB package and whether state to state variation might be allowable • Developing criteria and methods that address calls for use of evidence, protection of patients, innovation, and fair processes

4 Policy Foundations with Principles 6

Criteria to Guide Content of the Criteria to Guide Content of the Criteria to Guide EHB Content on Criteria to Guide EHB Content on Criteria to Guide Methods for Defining Criteria to Guide Methods for Defining Aggregate EHB Package Aggregate EHB Package Specific Components Specific Components and Updating the EHB and Updating the EHB In the aggregate, the EHB must: In the aggregate, the EHB must: The individual service, device, drug for the EHB The individual service, device, drug for the EHB Methods for defining, updating, and prioritizing Methods for defining, updating, and prioritizing must: must: must be must be • Be affordable for consumers, employers, and • Be affordable for consumers, employers, and • Be safe — expected benefits should be • Be safe — expected benefits should be taxpayers. taxpayers. • Transparent. The rationale for all decisions • Transparent. The rationale for all decisions greater than expected harms. greater than expected harms. about benefits, benefit design, and changes is about benefits, benefit design, and changes is made publicly available. made publicly available. • Maximize the number of people with • Maximize the number of people with • Be medically effective and supported by a • Be medically effective and supported by a insurance coverage. insurance coverage. • Participatory. Current and future enrollees • Participatory. Current and future enrollees sufficient evidence base, or in the absence of sufficient evidence base, or in the absence of evidence on effectiveness, a credible standard evidence on effectiveness, a credible standard have a role in helping define the priorities for have a role in helping define the priorities for • Protect the most vulnerable by addressing • Protect the most vulnerable by addressing of care is used. of care is used. coverage. coverage. the particular needs of those patients and the particular needs of those patients and populations. populations. • Demonstrate meaningful improvement in • Demonstrate meaningful improvement in • Equitable and consistent. Enrollees should • Equitable and consistent. Enrollees should outcomes over current effective outcomes over current effective feel confident that benefits will be developed feel confident that benefits will be developed • Encourage better care practices by • Encourage better care practices by services/treatments. services/treatments. and administered fairly. and administered fairly. promoting the right care to the right patient in promoting the right care to the right patient in the right setting at the right time. the right setting at the right time. • Be a medical service , not serving primarily a • Be a medical service , not serving primarily a • Sensitive to value. To be accountable to • Sensitive to value. To be accountable to social or educational function. social or educational function. taxpayers and plan members, the covered taxpayers and plan members, the covered • Advance stewardship of resources by • Advance stewardship of resources by service must provide a meaningful health service must provide a meaningful health focusing on high value services and reducing focusing on high value services and reducing benefit. benefit. • Be cost effective , so that the health gain for • Be cost effective , so that the health gain for use of low value services. Value is defined as use of low value services. Value is defined as individual and population health is sufficient to individual and population health is sufficient to outcomes relative to cost. outcomes relative to cost. justify the additional cost to taxpayers and justify the additional cost to taxpayers and • Responsive to new information. EHB will • Responsive to new information. EHB will consumers. consumers. change over time as new scientific information change over time as new scientific information • Address the medical concerns of greatest • Address the medical concerns of greatest becomes available. becomes available. importance to enrollees in EHB-related plans, importance to enrollees in EHB-related plans, as identified through a public deliberative as identified through a public deliberative Caveats: Caveats: process. process. • Attentive to stewardship. For judicious use • Attentive to stewardship. For judicious use of pooled resources, budgetary constraints are of pooled resources, budgetary constraints are Failure to meet any of the criteria should result Failure to meet any of the criteria should result necessary to keep the EHB affordable. necessary to keep the EHB affordable. • Protect against the greatest financial risks • Protect against the greatest financial risks in exclusion or significant limits on coverage. in exclusion or significant limits on coverage. due to catastrophic events or illnesses. due to catastrophic events or illnesses. • Encouraging to innovation. The EHB • Encouraging to innovation. The EHB Each component would still be subject to the Each component would still be subject to the should allow for innovation in covered services, should allow for innovation in covered services, criteria for assembling the aggregate EHB criteria for assembling the aggregate EHB service delivery, medical management, and service delivery, medical management, and package. package. new payment models to improve value. new payment models to improve value. Inclusion does not mean that it is appropriate Inclusion does not mean that it is appropriate • Data-driven. An evaluation of the care • Data-driven. An evaluation of the care for every person to receive every component. for every person to receive every component. included in the EHB is based on objective included in the EHB is based on objective clinical evidence and actuarial reviews. clinical evidence and actuarial reviews.

Balancing Act in Defining Benefits Comprehensiveness Affordability Statute Statute: • Breadth of typical employer • Equal in “scope” to TEP plan (TEP) — learn from plan • Subsidies, no annual and documents and surveys lifetime caps on EHB • Add to fulfill the 10 broad • Insurers can continue to use categories if missing from TEP utilization management Select Committee Criteria Select Committee Criteria • Protect the most vulnerable • Use average small employer • Address medical concerns of premium as a measure of “scope” and as a budgeting tool greatest importance • Encourage better care • Be evidence-based, medically practices effective, and cost effective