COMPARATIVE EFFECTIVENESS RESEARCH
AND THE CALIFORNIA
MEDI-CAL PROGRAM
Len Finocchio, Dr.P.H
Associate Director
California Department of Health Care Services
1
Income Limits for Eligibility
4
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
Scope of Benefits
± - Covered for those under 21 and in nursing homes
5
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
$45 billion Total
2010-2011
Expenditures
7
California HealthCare Foundation. Medi-Cal Facts & Figures. September 2009
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
9
Proposed Reductions FY2102-13
Health & Human Services
CalWorks $946.2
Medi-Cal $842.3
In-Home Supportive Services $163.8
Other HHS Programs $ 86.9
Education
Prop 98 $544.4
Child Care $446.9
Cal Grants $301.7
Other Education $ 28.0
All Other Reductions
State Mandates $828.3
Other Reductions $27.3
Total Expenditure Reductions $4,215.8
10
Governor’s Proposed 2012-2013 Budget. Health & Human Services. http://www.ebudget.ca.gov/pdf/BudgetSummary/HealthandHumanServices.pdf
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
11
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
12
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?
14
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.
15
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.
16
Ranking Interventions
HazardousHigh-volumeExpensive
EffectiveHigh-volumeCost-saving
Questionable effectivenessModerate-volumeModerate expense
UNDESIRABLE DESIRABLE
17
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
18
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
19
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.
20
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
21
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
22