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The Work of the Health Services Commission – Prioritizing Benefits

The Work of the Health Services Commission – Prioritizing Benefits. presented by Alison S. Little, MD, MPH. HISTORY. Commission created in 1989

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The Work of the Health Services Commission – Prioritizing Benefits

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  1. The Work of the Health Services Commission – Prioritizing Benefits presented by Alison S. Little, MD, MPH

  2. HISTORY • Commission created in 1989 • Directed to “report to the Governor a list of health services… ranked by priority, from the most important to the least important, representing the comparative benefits of each service to the entire population to be served”

  3. HISTORY, cont. • Commission composed of: • 5 Physicans (one D.O.) • 1 Public Health Nurse • 1 Social Services Worker • 4 Consumer Advocates

  4. HISTORY, cont. • DETERMINING PLACEMENT OF A NEW OR REPRIORITIZED CONDITION/TREATMENT PAIR • Proceed through steps #1-#5 until an appropriate ranking is determined. • 1) Ability of Treatment to Prevent Death • 2) Lifetime Cost of Treatment Per Patient (in case of ties under #1) • 3) Adjustment According to Public Values (if #1 and #2 do not result in an appropriate ranking). • Family Planning Services (place in 10th -15th percentile of List) • Maternity and Newborn Care (place in 10th - 15th percentile) • General Preventive Services (place in 20th - 25th percentile) • Comfort Care (place in 35th - 40th percentile) • Public Health Risk (place in 40th - 45th percentile) • Self-Limiting Conditions (place in 85th - 90th percentile) • Cosmetic Services (place in 90th - 95th percentile) • Medical Ineffectiveness (place in 95th - 100th percentile) • Early Treatment Prevents Progression to Serious Disease (place just above disease being prevented) • Early Treatment Prevents Serious Complications/Future Costs (move up 50 percentile points from the ranking determined by #1 and #2 if the condition is not potentially fatal and 25 percentile points if it is a nonfatal condition) • 4) Place Within Range of 5 Percentile Points from #1-#3 Based On Similarity of Organ System, Etiology, and/or Treatment Outcomes (congruency) • 5) Line Placement Based on Commission Judgment (when #1- #4 do not result in appropriate ranking)

  5. PRIORITIZED LIST OF HEALTH SERVICES • PRIORITIZED LIST OF HEALTH SERVICES • APRIL 14, 2003 • Diagnosis: SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WITH LOSS OF CONSCIOUSNESS • Treatment: MEDICAL AND SURGICAL TREATMENT • ICD-9: 850.1-850.5,851.02-851.06,851.1,851.22-851.26,851.3,851.42-851.46,851.5,851.62- • 851.66,851.7,851.82-851.86,851.9 • CPT: 61108,61313-61316,62140-62141,62148,90471-90472,90780-90799,90901-90937,90945-92060, • 92070-92353,92358-92371,92502-92508,92511-92960,92970-92977,93000-95075,95115-95999, • 96100-96117,96400-97004,97010-97537,97601-97750,97799,99025,99050-99054,99058-99078, • 99175,99185-99362,99374-99375,99379-99440,99499 • Line: 1 • Diagnosis: TYPE I DIABETES MELLITUS • Treatment: MEDICAL THERAPY • ICD-9: 250.01,250.03,250.11,250.13,250.21,250.23,250.31,250.33,250.61,250.63,250.91,250.93, • 251.3 • CPT: 90471-90472,90780-90799,90901-90937,90945-92060,92070-92353,92358-92371,92502-92508, • 92511-92960,92970-92977,93000-95075,95115-95999,96100-96117,96400-97004,97010-97537, • 97601-97750,97799,99025,99050-99054,99058-99078,99175,99185-99362,99374-99375,99379- • 99440,99499 • HCPCS: G0245-G0246,S9145 • Line: 2 • Diagnosis: PERITONITIS • Treatment: MEDICAL AND SURGICAL TREATMENT • ICD-9: 567,569.83,777.6 • CPT: 10180,44120,44602,44626,49021,49040-49061,49080-49081,49420,49423-49424,90471-90472, • 90780-90799,90901-90937,90945-92060,92070-92353,92358-92371,92502-92508,92511-92960, • 92970-92977,93000-95075,95115-95999,96100-96117,96400-97004,97010-97537,97601-97750, • 97799,99025,99050-99054,99058-99078,99175,99185-99362,99374-99375,99379-99440,99499 • Line: 3

  6. ALGORITHM FOR INCORPORATING NEW TECHNOLOGY INTO THE LIST • The HSC will examine pooled data from one of the recognized sources/websites • Exceptions may be made for rare diseases • The HSC will consider new sources/websites as they are identified • Evidence regarding the effectiveness of a treatment will be used according to the algorithm to the right: • The cost of a technology will be considered according to the grading scale below, with “A” representing compelling evidence for adoption, “B” representing strong evidence for adoption, “C” representing moderate evidence for adoption, “D” representing weak evidence for adoption and “E” being compelling evidence for rejection: • A = more effective and cheaper than existing technology • B = more effective and costs less than $25,000/LYS or QALY more than existing technology • C = more effective and costs $25,000 to $125,000/LYS or QALY more than existing technology • D = more effective and costs more than $125,000/LYS or QALY more than existing technology • E = less or equally as effective and more costly than existing technology

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