1 / 23

COMPARATIVE EFFECTIVENESS RESEARCH AND the California MEDI-CAL Program

COMPARATIVE EFFECTIVENESS RESEARCH AND the California MEDI-CAL Program. Len Finocchio, Dr.P.H Associate Director California Department of Health Care Services. background. Beneficiary Profile. California HealthCare Foundation. Medi-Cal Facts & Figures . September 2009.

rollin
Download Presentation

COMPARATIVE EFFECTIVENESS RESEARCH AND the California MEDI-CAL Program

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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 Governor’s Proposed 2012-2013 Budget. Health & Human Services. http://www.ebudget.ca.gov/pdf/BudgetSummary/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 Questionable effectiveness Moderate-volume Moderate expense Effective High-volume Cost-saving

  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@dhcs.ca.gov 916.440.7400

More Related