| 2006 Biennial Review of the Prioritized List |
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In the summer of 2005, as the HSC began to prepare for the biennial review of the list. The Commission was encouraged to ask themselves whether the basic structure of the list represented what they truly considered to be the most important to the least important. It was suggested that a higher emphasis on preventive services and chronic disease management would ensure a benefit package that provides the services necessary to best keep a population healthy, not waiting until an individual gets sick before higher cost services are offered to try to restore good health again.
The HSC believed that placing a higher value on prevention and chronic disease management was a good idea on its face and could be crucial in maintaining a sustainable program as we face an aging population. The Commission put together a task force that included HSC members, stakeholders, and health policy experts to study the issue further. This task force reviewed the principles on which the OHP was based, the values expressed in the four sets of public forums held by the HSC since 1990, and the results of the biennial public surveys on health care conducted by Oregon Health Decisions. The task force found evidence in all of these sources that supported such a shift in health care priorities and recommended the HSC pursue a reprioritization of the list to reflect this new emphasis.
New Methodology
In December 2005 the HSC embarked on the developing a new prioritization methodology for the first time since the list was first implemented in February 1994. First the HSC developed the framework of what they thought the new list should look like by defining a rank ordered list of nine broad categories of health care (see Table 1).
Next, each of the 710 on the 2005-07 list were assigned to one of the nine health care categories. During this process, as has occurred with all biennial reviews, lines were merged or split in an attempt to where appropriate. For example, all superficial abscesses where combined into one line as outcomes and costs are similar regardless of where the abscess is located. In contrast, the Commission found relatively minor birth traumas lumped together with imminently life-threatening conditions and split these into two separate lines. As more lines were merged together than split, the new list is 680 lines long compared to the current list of 710. As most of these mergers involved currently funded condition-treatment pairs, new line 503 best equates to the benefit package represented in lines 1-530 of the current list.
Once the condition treatment pairs were assigned to one of the nine health care categories, a list of criteria was developed to sort the line items within the categories (see Table 2).
These measures were felt to best capture the impacts on both the individual’s health and the population health that HSC thought were essential in determining the relative importance of a condition-treatment pair. The HSC Medical Director and HSC Director worked with two HSC physician members to established ratings for the criteria for over 100 lines in order to establish a general scale to follow for each of the criteria. The HSC Medical Director (and in most cases HSC Director) then met with individual HSC physician members and other volunteer physicians with OHP experience.
After ratings were established for all 710 lines, they were reviewed by the HSC Medical Director and HSC physician members for accuracy and consistency. A total score was then calculated for each line using the following formula to sort all line items within each of the health care categories, with the lowest net cost used to break any ties:
| Impact Healthy Life Years |
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+ Impact on Suffering
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Need for |
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+ Population Effects
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X |
Effectiveness |
X |
Service |
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+ Vulnerable of Population Affected
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+ Tertiary Prevention (categories 6 & 7 only)
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A workgroup of the HSC members then met to explore the best method for intermixing condition-treatment pairs across health care categories. While the nine health care categories were meant to establish the framework of the new list it was always clear that not every service in Category 1 was more important than every service in Category 2 and so on. In the methodology used to develop the initial prioritized list implemented in February 1994, approximately 75% of the line items where hand adjusted after an initial computer sort on the treatment’s prevention of death and cost of the treatment. The workgroup found that applying a weight to each category that was then multiplied by the total criteria score for each condition-treatment pair achieved an appropriate adjustment in the majority of the cases. The full commission agreed with the conclusions of the workgroup and approved the weights shown in parentheses after the title for each category in Table 1. Hand adjustments were applied where the application of this methodology did not result in a ranking that reflected the importance of the service, which was the case in fewer than 5% of the line items.
The following two examples illustrate line items that were given a very high score and a very low score as a result of this process.
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Schizophrenic Disorders
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Grade I Sprains of Joints and Muscles
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(Old line: 159, New line: 27)
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(Old line: 626, New line: 628)
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Impact on Healthy Life Years: 8
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Impact on Healthy Life Years: 1
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Impact on Suffering: 4
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Impact on Suffering: 1
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Effects on Population: 4
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Effects on Population: 0
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Vulnerability of Population Affected: 0
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Vulnerability of Population Affected: 0
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Effectiveness: 3
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Effectiveness: 2
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Need for Service: 1
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Need for Service: 0.1
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Net Cost: 5
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Net Cost: 4
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Category 3 Weight: 75
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Category 8 Weight: 5
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Total Score: 3600
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Total Score: 2
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[(8+4+4+0) x 3 x 1] x 75 = 3600
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[(1+1+0+0) x 2 x 0.1 x 5 = 2
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Some of the services moving towards the top of the list as a result of this reprioritization include maternity care and newborn services, preventive services found to be effective by the US Preventive Services Task Force, and treatments for chronic diseases such as diabetes, major depression, asthma, and hypertension, where ongoing maintenance therapy can prevent exacerbations of the disease that lead to avoidable high-intensity service utilization, morbidity, and death.
Public Input
The HSC solicited public and stakeholder input throughout the process. As always, all commission meetings are open to the public and time is set aside for public testimony. When the HSC was initially considering reprioritizing the list, they sent out a survey to over 200 stakeholders. This included physicians randomly selected from the Board of Medical Examiners mailing list, specialty societies, hospitals, safety net clinics and school-based health centers. Thirty-one responses were received and, of these, thirty were supportive of a new emphasis on prevention and chronic disease management.
After the methodology had taken shape, the HSC conducted five focus groups with specialty society presidents, members of the Oregon Academy of Family Practice, representatives from service providers (hospitals, physicians, OHP managed care plans, mental health, chemical dependency, dentistry and home health), consumers, and consumer advocates. There was no objection to the direction that the HSC was taking.
Medical directors and administrators for the contracted managed care plans were kept up to date on the HSC’s work and also were supportive of the reprioritization effort.
Next Steps
A group of stakeholders brought together by the Governor’s office in 2006 examined whether this new list could be used to expand coverage to a larger segment of Oregon’s population living under the federal poverty level who don’t meet categorical Medicaid eligibility criteria (through OHP Standard). Over the last three years, OHP Standard has seen its enrollment decrease from over 100,000 to under 24, 000 as revenues became tighter. This group, called the OHP Standard Benefit Design Workgroup, considered trade-offs in benefit coverage should additional revenues not be available for an expansion, potential issues involved in implementing such a benefit package, and whether the principles of the Oregon Health Plan would be followed under such a scenario. To note, the present cost of covering the much reduced OHP Standard population is currently higher at a per-person level due to higher chronic disease prevalence and service utilization. Therefore, after detailed analysis, the workgroup concluded that the over 200 line items that would need to be eliminated from coverage in order to increase enrollment in OHP Standard from a baseline level of 24,000 for the 2007-09 biennium to approximately 28,000 individuals was not justifiable at this time. Health Services Commission members continue to believe that it is preferable to provide a reduced benefit package focused on preventive services and chronic disease management to the OHP Standard population and encourage the legislature to consider ways to use the new Prioritized List as a means to achieve expanded access.
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| Table 1 |
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Rank Order of Health Care Categories
1) Maternity & Newborn Care (100) - Obstetrical care fo r pregnancy. Prenatal care;
delivery services; postpartum care; newborn care for conditions intrinsic to the
pregnancy.
2) Primary Prevention and Secondary Prevention (95) - Effective preventive services
used prior to the presence of disease and screenings for the detection of diseases at an
early stage. Immunizations; fluoride treatment in children; mammograms; pap
smears; blood pressure screening; well child visits; routine dental exams.
3) Chronic Disease Management (75) - Predominant role of treatment in the presence of
an established disease is to prevent an exacerbation or a secondary illness. Medical
therapy for diabetes mellitus, asthma, and hypertension. Medical/psychotherapy for
schizophrenia.
4) Reproductive Services (70) - Excludes maternity and infertility services. Contraceptive
management; vasectomy; tubal occlusion; tubal ligation.
5) Comfort Care (65) - Palliative therapy for conditions in which death is imminent.
Hospice care; pain management.
6) Fatal Conditions, Where Treatment is Aimed at Disease Modification or Cure (40) -
Appendectomy for appendicitis; medical & surgical treatment for treatable cancers;
dialysis for end-stage renal disease; medical therapy for stroke; medical/psychotherapy
for single episode major depression.
7) Nonfatal Conditions, Where Treatment is Aimed at Disease Modification or Cure (20) -
Treatment of closed fractures; medical/psychotherapy for obsessive-compulsive
disorders; medical therapy for chronic sinusitis.
8) Self-limiting conditions (5) - Treatment expedites recovery for conditions that will
resolve on their own whether treated or not. Medical therapy for diaper rash, acute
conjunctivitis and acute pharyngitis.
9) Inconsequential care (1) - Services that have little or no impact on health status due to
the nature of the condition or the ineffectiveness of the treatment. Repair fingertip
avulsion that does not include fingernail; medical therapy for gallstones without
cholecystitis, medical therapy for viral warts.
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| Table 2 |
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Population and Individual Impact Measures
Impact on Health Life Years - to what degree will the condition impact the health of the individual if left untreated, considering the median age of onset (i.e., does the condition affect mainly children, where the impacts could potentially be experienced over a person’s entire lifespan)? Range of 0 (no impact) to 10 (high impact).
Impact on Suffering - to what degree does the condition result in pain and suffering? Effect on family members (e.g. dealing with a loved one with Alzheimer’s disease or needing to care for a person with a life-long disability) should also be factored in here. Range of 0 (no impact) to 5 (high impact).
Population Effects - the degree to which individuals other than the person with the illness will be affected. Examples include public health concerns due the spread of untreated tuberculosis or public safety concerns resulting from untreated severe mental illness. Range of 0 (no effects) to 5 (widespread effects).
Vulnerability of Population Affected - to what degree does the condition affect vulnerable populations such as those of certain racial/ethnic decent or those afflicted by certain debilitating illnesses such as HIV disease or alcohol & drug dependence? Range of 0 (no vulnerability) to 5 (high vulnerability).
Tertiary Prevention - in considering the ranking of services within new categories 6 and 7, to what degree does early treatment prevent complications of the disease (not including death)? Range of 0 (doesn’t prevent complications) to 5 (prevents severe complications).
Effectiveness - to what degree does the treatment achieve its intended purpose? Range of 0 (no effectiveness) to 5 (high effectiveness).
Need for Medical Services - the percentage of time in which medical services would be required after the diagnosis has been established. Percentage from 0 (services never required) to 1 (services always required).
Net Cost - the cost of treatment for the typical case (including lifetime costs associated with chronic diseases) minus the expected costs if treatment is not provided -- including costs incurred through safety net providers (e.g., emergency departments) for urgent or emergent care related to the injury/illness or resulting complications. Range of 0 (high net cost) to 5 (cost saving).
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