Marge Ginsburg

What Matters MostIdentifying medical problems as priorities

for healthcare coverage

April 24, 2010

Bringing the public’s voice to healthcare policy

when we do what we do

When there are no easy answers

When a new issue is on the horizon

When the public has not been involved

Using CHAT: 2002 - 2010

“ “You want Viagra…

buy it yourself!”

CHAT project participant

Sacramento, 2002

January 2, 2007

Three most acceptable limitations:(N=779)

percent who pickedPts. pay more for health care 10 %Longer waiting times 35Limit choice of MDs and hospitals 36Pts. pay more if not following med. advice 41 Limit costly tx that provides small benefit 50Not critical for basic functioning/long life 57Doesn’t meet national standards 61

What Matters Most project (2008-09)

• Do people distinguish high and low priority when not “required” to do so?

• RSS: 1,019 Californians, 80+ vignettes. Each responder asked 19 random vignettes.

1 – 10 ratingYes/no for coverage

• 15 diverse discussion groups statewide to interpret the results

Assessing perceptions of medical need

63%5.6

A 32 year-old man has had problems with his left knee…. with knee surgery, he will be able to play in weekend soccer games. (n=161)

90%7.9

A 32 year-old man has had problems with his left knee…..with knee surgery, he will be able to walk without pain. (n=167)

% approvalMean rating

scale 1-10 Vignettes

Assessing views on treatment effectiveness

75%6.5A 50 year-old man has severe nerve pain in his shoulder…. The only medication for this type of pain is very expensive and often doesn’t work very well. (n=107)

91%7.8A 50 year-old man has severe nerve pain in his shoulder…. There is a medication that works well for this type of pain but it is very expensive. (n=117)

% approvalMean ratingscale 1-10Vignettes

mean ratings of 7.5 – 9.2

Vignettes with the HIGHEST mean ratings

Potentially fatal condition that could be cured

Disabling problem affecting core functions of living

Catastrophic event requiring intensive medical care

Effective treatment for prevention or meaningful life-extension

Results: Tier 1

mean ratings of6.0 – 7.2

Vignettes in the MIDDLE range

Behavioral health problems (e.g., substance abuse)

Obesity problems

Dental care problems

Reproduction and sexuality

Results: Tier 2

mean ratings of 3.9 – 5.9

Vignettes with the LOWEST ratings

Problems which are unsightly but not harmful

Treatments for restoring or improving recreational abilities

Problems that could be remedied through non-medical or less expensive interventions

Problems that would resolve over time without treatment

Treatments requested by patients but are not medically necessary

Results: Tier 3

Coverage approvals

All vignettes: 69% mean coverage approval

Life-threatening/major impairment: 94 %

Questionable medical treatment: 54 %

Women compared to men: aver. 7 points higher

15 discussion groups statewide

When ratings/values conflict

–> Personal fulfillment –> Personal responsibility–> Prevention

Coverage for lower priority situations(N=168)

• Patients pay full cost 14 %• Patients pay at least half the cost 36• Patients pay somewhat higher

co-payment 30• No additional payment 20

80% pay more

Value-based insurance design (VBID)

• Low cost-sharing for high value treatment

• High cost-sharing for low value treatment

public engagement

Tell me, I’ll forget.Show me, I may remember.But involve me and I’ll understand.

Chinese proverb