The Essential Benefit Package

1. The Essential Benefit Package Recommendations of the Oregon Health Fund Board’s Benefits Committee July 2, 2008

2. Features of the Essential Benefit Package • Based on the Prioritized List of Health Services • Promotes use of the integrated health home • Incentivizes use of preventive care and chronic disease management • Cost sharing can be modified to make it more affordable to individual or state

3. Guiding Principles I. Is the set of essential health services established by this committee: + a. essential to the public health of Oregonians?  b. based upon a proven benefit model? + c. reflective of the values of Oregonians? + d. easy to adjust in response to new information on cost and effectiveness? + e. affordable (to the individual, employer, and state) and economically sustainable? + f. developed in a transparent manner?

4. Guiding Principles (cont’d) II. Does the set of essential health services place emphasis on the following services identified in SB 329? + a. Preventive care + b. Chronic disease management + c. Primary care medical homes + d. Dignified end-of-life care + e. Patient-centered care + f. Provision of care in the least restrictive environment

5. Guiding Principles (cont’d) III. Does the set of essential health services help promote: + a. wellness? + b. patient engagement (including education towards self-management)? + c. coordination and integration of care? + d. population health? + e. cost-effective care? + f. cost-control/reductions in over-utilization? + g. access to timely and appropriate diagnosis and treatment?

6. Guiding Principles (cont’d) IV. Have the following issues been addressed by this committee? + a. Use of evidence-based medicine + b. Efficacy of treatments  c. Reduction of health disparities + d. Personal responsibility + e. Impact on vulnerable populations (including but not limited to pregnant women, infants and small children) + f. Incentives to encourage appropriate use of effective services  g. Acute and tertiary care needs of the population

7. The Prioritized List • Prioritized condition-treatment pairs • Created and maintained by 11 member Health Services Commission • First implemented in February 1994 • New methodology resulting in reprioritized list went into effect January 2008 • State legislature currently provides funds for services on lines 1-503 (out of 680)

8. The Prioritized List Condition: TYPE I DIABETES MELLITUS Treatment: MEDICAL THERAPY ICD-9-CM: 250.01,250.03,250.11,250.13,250.21, 250.23,250.31,250.33,250.61,250.63, 250.71,250.73,250.91,250.93,251.3, V53.91,V65.41 CPT-4: 90918-90997,93990-95250,99024,99051, 99060,99070,99078,99201-99362,99374- 99375,99379-99440 HCPCS: G0245,G0246,G0308-G0327,S9145 Line: 10

9. Prioritized List – Categories of Care 1) Maternity/Newborn Care (100) 2) Primary & Secondary Prevention (95) 3) Chronic Disease Management (75) 4) Reproductive Services (70) 5) Comfort Care (65) 6) Fatal Conditions – Disease Modification/Cure (40) 7) Nonfatal Conditions – Disease Mod./Cure (20) 8) Self-limited Conditions (5) 9) Inconsequential Care (1)

10. Prioritized List - Individual/ Population Impact Measures • Impact on Health Life Years (0 to 10) plus • Impact on Suffering (0 to 5) plus • Population Effects (0 to 5) plus • Vulnerability of Population Affected (0 to 5) plus • Tertiary Prevention (0 to 5) • Total then multiplied by • Effectiveness (0 to 5) and • Need for Medical Services (0 to 100%) and • Category weight (1 to 100) • Net Cost (0 to 5) considered as a tie-breaker

11. The Essential Benefit Plan • High deductible (adjustable for income) • Significant copays for many services • Cost sharing tiers based on the Prioritized List • Cap on out-of-pocket maximum (adjustable for income) • Current Medicaid population would see no reductions in current benefits and have cost sharing no higher than current levels

12. Services Not Subject to DeductibleOut-Of-Pocket Max Applies Essential Benefit Package Sample Supplemented EBP

13. Value-Based Services • Seen primarily in the integrated health home • Shown to prevent illness progression and/or disease complications • Avoids preventable hospitalizations or ED visits • Patient incentives to follow treatment recommendations

14. Value-Based Services (cont’d) Examples • Evidence-based preventive care • Chronic disease management • regular provider visits • selected medications • self-treatment education • care coordination • Prenatal care • Preventive dental exams & cleanings

15. Services Subject to DeductibleOut-Of-Pocket Max Applies Essential Benefit Package Sample Supplemented EBP

16. Services Subject to DeductibleOut-Of-Pocket Max Applies Essential Benefit Package Sample Supplemented EBP

17. Tier I Conditions Life-threatening newborn conditions Life-threatening chronic diseases Imminently life-threatening conditions Trauma Acute illness Public health concerns Examples of Conditions in Tiers Tier II Conditions • Cancers with effective treatments • Chronic diseases with less impact on health • Potentially life-threatening conditions • Trauma • Acute illness

18. Examples of Conditions in Tiers Tier III Conditions • Cancers with less effective treatments • Non-life-threatening chronic diseases • Other non-life-threatening conditions • Trauma • Acute illness Tier IV Conditions • Conditions with no effective treatment or no treatment necessary • Self-limited conditions • Conditions with limited effects on health Non-covered services: cosmetic procedures, infertility, etc.

19. Non-emergent health care Doesn’t substantially avert downstream costs/adverse consequences of condition Subject to annual maximum and other possible limitations Restorative dental care Eyeglasses Certain dermatologic conditions Discretionary Services

20. Emergency Department copayments/ coinsurance Well person visits Lifetime maximum Prescription drug cost sharing Mandated services Ancillary services Issues of Note

21. For additional information Darren Coffman, Director Health Services Commission 1225 Ferry St. SE, 1st floor Salem, OR 97301 (503) 373-1616 Darren.D.Coffman@state.or.us