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The Work of the Health Services Commission – Prioritizing Benefits presented by Alison S. Little, MD, MPH.

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Presentation on theme: "The Work of the Health Services Commission – Prioritizing Benefits presented by Alison S. Little, MD, MPH."— Presentation transcript:

1 The Work of the Health Services Commission – Prioritizing Benefits presented by Alison S. Little, MD, MPH

2 HISTORY Commission created in 1989 Directed to report to the Governor a list of health services… ranked by priority, from the most important to the least important, representing the comparative benefits of each service to the entire population to be served

3 HISTORY, cont. Commission composed of: –5 Physicans (one D.O.) –1 Public Health Nurse –1 Social Services Worker –4 Consumer Advocates

4 HISTORY, cont. DETERMINING PLACEMENT OF A NEW OR REPRIORITIZED CONDITION/TREATMENT PAIR Proceed through steps #1-#5 until an appropriate ranking is determined. 1) Ability of Treatment to Prevent Death 2) Lifetime Cost of Treatment Per Patient (in case of ties under #1) 3) Adjustment According to Public Values (if #1 and #2 do not result in an appropriate ranking). –Family Planning Services (place in 10th -15th percentile of List) –Maternity and Newborn Care (place in 10th - 15th percentile) –General Preventive Services (place in 20th - 25th percentile) –Comfort Care (place in 35th - 40th percentile) –Public Health Risk (place in 40th - 45th percentile) –Self-Limiting Conditions (place in 85th - 90th percentile) –Cosmetic Services (place in 90th - 95th percentile) –Medical Ineffectiveness (place in 95th - 100th percentile) –Early Treatment Prevents Progression to Serious Disease (place just above disease being prevented) –Early Treatment Prevents Serious Complications/Future Costs (move up 50 percentile points from the ranking determined by #1 and #2 if the condition is not potentially fatal and 25 percentile points if it is a nonfatal condition) 4) Place Within Range of 5 Percentile Points from #1-#3 Based On Similarity of Organ System, Etiology, and/or Treatment Outcomes (congruency) 5) Line Placement Based on Commission Judgment (when #1- #4 do not result in appropriate ranking)

5 PRIORITIZED LIST OF HEALTH SERVICES APRIL 14, 2003 Diagnosis: SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WITH LOSS OF CONSCIOUSNESS Treatment: MEDICAL AND SURGICAL TREATMENT ICD-9: 850.1-850.5,851.02-851.06,851.1,851.22-851.26,851.3,851.42-851.46,851.5,851.62- 851.66,851.7,851.82-851.86,851.9 CPT: 61108,61313-61316,62140-62141,62148,90471-90472,90780-90799,90901-90937,90945-92060, 92070-92353,92358-92371,92502-92508,92511-92960,92970-92977,93000-95075,95115-95999, 96100-96117,96400-97004,97010-97537,97601-97750,97799,99025,99050-99054,99058-99078, 99175,99185-99362,99374-99375,99379-99440,99499 Line: 1 Diagnosis: TYPE I DIABETES MELLITUS Treatment: MEDICAL THERAPY ICD-9: 250.01,250.03,250.11,250.13,250.21,250.23,250.31,250.33,250.61,250.63,250.91,250.93, 251.3 CPT: 90471-90472,90780-90799,90901-90937,90945-92060,92070-92353,92358-92371,92502-92508, 92511-92960,92970-92977,93000-95075,95115-95999,96100-96117,96400-97004,97010-97537, 97601-97750,97799,99025,99050-99054,99058-99078,99175,99185-99362,99374-99375,99379- 99440,99499 HCPCS: G0245-G0246,S9145 Line: 2 Diagnosis: PERITONITIS Treatment: MEDICAL AND SURGICAL TREATMENT ICD-9: 567,569.83,777.6 CPT: 10180,44120,44602,44626,49021,49040-49061,49080-49081,49420,49423-49424,90471-90472, 90780-90799,90901-90937,90945-92060,92070-92353,92358-92371,92502-92508,92511-92960, 92970-92977,93000-95075,95115-95999,96100-96117,96400-97004,97010-97537,97601-97750, 97799,99025,99050-99054,99058-99078,99175,99185-99362,99374-99375,99379-99440,99499 Line: 3

6 ALGORITHM FOR INCORPORATING NEW TECHNOLOGY INTO THE LIST The HSC will examine pooled data from one of the recognized sources/websites Exceptions may be made for rare diseases The HSC will consider new sources/websites as they are identified Evidence regarding the effectiveness of a treatment will be used according to the algorithm to the right: The cost of a technology will be considered according to the grading scale below, with A representing compelling evidence for adoption, B representing strong evidence for adoption, C representing moderate evidence for adoption, D representing weak evidence for adoption and E being compelling evidence for rejection: A = more effective and cheaper than existing technology B = more effective and costs less than $25,000/LYS or QALY more than existing technology C = more effective and costs $25,000 to $125,000/LYS or QALY more than existing technology D = more effective and costs more than $125,000/LYS or QALY more than existing technology E = less or equally as effective and more costly than existing technology

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