Transcript disinvestment: an evidence-based approach to health care

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COMPARATIVE
EFFECTIVENESS RESEARCH
AND
THE CALIFORNIA
MEDI-CAL PROGRAM
Len Finocchio, Dr.P.H
Associate Director
California Department of Health Care Services
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BACKGROUND
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Beneficiary Profile
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
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Income Limits for Eligibility
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
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Scope of Benefits
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
± - Covered for those under 21 and in nursing homes
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Managed Care & Fee-for-Service
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Expenditures
$45 billion
Total
2010-2011
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
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Highest Expenditures
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
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Managing Medi-Cal Expenditures
• Better delivery of existing services
• Care coordination & management, focus on prevention
• Reduce the number of beneficiaries
• Scale back income eligibility thresholds
• Reduce scope of benefits
• Curtail or eliminate optional benefits (e.g. dental, chiropractic)
• Reduce provider reimbursements
• Value-based purchasing
• Delegate financial risk & measure performance
• Non-payment for health care-acquired conditions
• Evidence-based service design
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Proposed Reductions FY2102-13
Health & Human
Services
Education
All Other
Reductions
CalWorks
$946.2
Medi-Cal
$842.3
In-Home Supportive Services
$163.8
Other HHS Programs
$ 86.9
Prop 98
$544.4
Child Care
$446.9
Cal Grants
$301.7
Other Education
$ 28.0
State Mandates
$828.3
Other Reductions
$27.3
Total Expenditure Reductions
$4,215.8
Governor’s Proposed 2012-2013 Budget. Health & Human Services. http://www.ebudget.ca.gov/pdf/BudgetSummary/HealthandHumanServices.pdf
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Cost Saving Proposals in Budget
• Improved care coordination for senior & disabled
beneficiaries
• Federally Qualified Health Center payment
reform
• Managed care expansion to rural areas
• Align open enrollment with commercial plan
policies
• Value-based service design
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Reasons for Better Purchasing
• Buy better value with limited public resources
• State budget shortfalls: $26 billion last year & $9 billion this year
• “Bend the cost curve”
• Improve quality of care & health of beneficiaries
• Maintain income eligibility and benefit levels
• Prepare for large program expansion in 2014
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VALUE-BASED
SERVICE DESIGN
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Key Issues & Questions
• Medical interventions often adopted without rigorous
evidence
• New interventions are more effective than the previous
standard of practice
• Can we perform technology assessment retrospectively?
• Can we selectively purchase health services using
evidence?
• Can we selectively purchase health services in a
systematic & transparent, not haphazard, way?
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Value-Based Service Design
• Assure beneficiary access to necessary health care services
• Identify and reduce services that:
• Do not improve health outcomes
• May cause harm to patients
• Are overused & should only be provided under limited
conditions.
• Not synonymous with addition or removal of benefits covered
under the State Plan.
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Systematic Evidence Review
• Evidence-based treatment guidelines from organizations
whose primary mission is to conduct objective analyses of
the effectiveness of medical interventions:
• National Institute for Health and Clinical Excellence (NICE)
• Agency for Healthcare Research and Quality
• US Preventive Services Task Force
• Patient-Centered Outcomes Research Institute
• Individual studies in peer reviewed literature
• Clinical practice guidelines published by medical and
scientific societies.
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Ranking Interventions
DESIRABLE
UNDESIRABLE
Hazardous
High-volume
Expensive
Questionable effectiveness
Moderate-volume
Moderate expense
Effective
High-volume
Cost-saving
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Examples of Candidates
Where evidence shows little or questionable value:
• Vertebroplasty
• Implantable cardioverter difibrillators
• Arthroscopic surgery for knee osteoarthritis
• Exercise electrocardiogram for angina
• Lumbar imaging for lower back pain
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Determine Costs & Feasibility
• Determine potential costs and savings from modifying,
curtailing or eliminating targeted services.
• Determine feasibility of implementation:
• Evaluate the cost and timeframe for computer system changes
• Staffing & expertise needed to craft policies that effectively limit
inappropriate use of a service without interfering with appropriate
(i.e., scientifically justified) use of that same service
• Ability to use utilization management staff to effectively manage the
targeted services
• Identify services requiring prior authorization for any particular
beneficiary
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Transparency & Stakeholder Engagement
• Consult with stakeholders
• Including health professionals, Medi-Cal providers, and consumer
advocacy organizations prior to modifications to targeted services
• Notification about proposed changes
• To targeted services, rate methodologies and payment policies
• Receive, review and respond to written input
• Regarding changes and provide a public stakeholder meetings
• Provide for an appropriate and meaningful response
• Notify the legislature
• Of the action taken and reasons for the action.
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Issues with Implementation
• Systematizing evidence review
• Consumer preferences, fear, knowledge
• Managing stakeholder engagement
• Lobbying by professional and advocacy groups
• Push me – Pull You of expanding coverage while
contracting services/benefits
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For Research Community
• Build body of related research – comparative effectiveness
of services and:
• Consumer perceptions
• Practitioner behaviors
• Deepen working relationships with major payers
• Communicate effectively and strategically about findings
• Take the long view
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THANKS
Len Finocchio, DrPH
[email protected]
916.440.7400