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COMPARATIVE%20EFFECTIVENESS%20RESEARCH%20AND%20the%20California%20MEDI-CAL%20Program

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Title: disinvestment: an evidence-based approach to health care budget cuts Author: Neal D. Kohatsu Last modified by: Piontkowski, Cynthia Created Date – PowerPoint PPT presentation

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Title: COMPARATIVE%20EFFECTIVENESS%20RESEARCH%20AND%20the%20California%20MEDI-CAL%20Program


1
COMPARATIVE EFFECTIVENESS RESEARCH AND the
California MEDI-CAL Program
  • Len Finocchio, Dr.P.H
  • Associate Director
  • California Department of Health Care Services

2
background
3
Beneficiary Profile
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
4
Income Limits for Eligibility
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
5
Scope of Benefits
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
- Covered for those under 21 and in nursing
homes
6
Managed Care Fee-for-Service
7
Expenditures
45 billion Total 2010-2011
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
8
Highest Expenditures
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
9
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

10
Proposed Reductions FY2102-13
Health Human Services CalWorks 946.2
Health Human Services Medi-Cal 842.3
Health Human Services In-Home Supportive Services 163.8
Health Human Services Other HHS Programs 86.9
Education Prop 98 544.4
Education Child Care 446.9
Education Cal Grants 301.7
Education Other Education 28.0
All Other Reductions State Mandates 828.3
All Other Reductions Other Reductions 27.3
Total Expenditure Reductions Total Expenditure Reductions 4,215.8
Governors Proposed 2012-2013 Budget. Health
Human Services. http//www.ebudget.ca.gov/pdf/Budg
etSummary/HealthandHumanServices.pdf
11
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

12
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

13
Value-based service design
14
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?

15
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.

16
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.

17
Ranking Interventions
DESIRABLE
UNDESIRABLE
Hazardous High-volume Expensive
Effective High-volume Cost-saving
Questionable effectiveness Moderate-volume Moderat
e expense
18
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

19
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

20
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.

21
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

22
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

23
thanks
  • Len Finocchio, DrPH
  • len.finocchio_at_dhcs.ca.gov
  • 916.440.7400
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