COMPARATIVE%20EFFECTIVENESS%20RESEARCH%20AND%20the%20California%20MEDI-CAL%20Program

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COMPARATIVE EFFECTIVENESS RESEARCH AND the
California MEDI-CAL Program

• Len Finocchio, Dr.P.H
• Associate Director
• California Department of Health Care Services

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background
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Beneficiary Profile
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
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Income Limits for Eligibility
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
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Scope of Benefits
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
- Covered for those under 21 and in nursing
homes
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Managed Care Fee-for-Service
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Expenditures
45 billion Total 2010-2011
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
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Highest Expenditures
California HealthCare Foundation. Medi-Cal Facts
Figures. September 2009
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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

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Proposed Reductions FY2102-13
Health Human Services CalWorks 946.2
Health Human Services Medi-Cal 842.3
Health Human Services In-Home Supportive Services 163.8
Health Human Services Other HHS Programs 86.9
Education Prop 98 544.4
Education Child Care 446.9
Education Cal Grants 301.7
Education Other Education 28.0
All Other Reductions State Mandates 828.3
All Other Reductions Other Reductions 27.3
Total Expenditure Reductions Total Expenditure Reductions 4,215.8
Governors Proposed 2012-2013 Budget. Health
Human Services. http//www.ebudget.ca.gov/pdf/Budg
etSummary/HealthandHumanServices.pdf
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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

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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

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Value-based service design
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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?

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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.

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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.

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Ranking Interventions
DESIRABLE
UNDESIRABLE
Hazardous High-volume Expensive
Effective High-volume Cost-saving
Questionable effectiveness Moderate-volume Moderat
e expense
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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

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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

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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.

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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

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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

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thanks

• Len Finocchio, DrPH
• len.finocchio_at_dhcs.ca.gov
• 916.440.7400