PRIORITIZATION OF HEALTH SERVICES A Report to the Governor and the 73rd Oregon Legislative Assembly Oregon Health Services Commission Office for Oregon Health Policy and Research Department of Administrative Services March 2005 PRIORITIZATION OF HEALTH SERVICES A Report to the Governor and the 73rd Oregon Legislative Assembly Oregon Health Services Commission Office for Oregon Health Policy and Research Department of Administrative Services March 2005 TABLE OF CONTENTS List of Figures . iii Health Services Commission and Staff . .v Acknowledgments . .vii Executive Summary . xiii CHAPTER ONE: HISTORY OF HEALTH SERVICES PRIORITIZATION UNDER THE OREGON HEALTH PLAN Legislative Framework . 3 Implementation of the Medicaid Demonstration . 5 CHAPTER TWO: PRIORITIZATION OF HEALTH SERVICES Charge to the Health Services Commission . .. 23 Prioritization Methodology . 24 Biennial Review . 30 Interim Modifications . 38 Technical Changes . 39 Advancements in Medical Technology . .40 Evidence-Based Reviews . 42 Physical, Occupational and Speech Therapy. 42 Transplantation . 43 CHAPTER THREE: CLARIFICATIONS TO THE PRIORITIZED LIST OF HEALTH SERVICES Practice Guidelines . 49 Therapies . 50 Erythropoietin and Colony Stimulating-Factors . 51 PET Scans . 52 Breast and Colon Cancer Surveillance . 53 Cataract Extraction . 54 Cochlear Implants . 54 Sinus Surgery . 55 Sleep Apnea . 56 Psoriasis . 56 Radiation Therapy for Benign Conditions . 57 Transplant Guidelines . 57 Spinal Guidelines . 58 Fetoscopic Surgery . 58 Comfort Care . 59 Prevention Guidelines . 59 Coding Specifications . 60 Pediatric Solid Malignancies and Seminoma . 60 Breast Reconstruction Post-Mastectomy for Breast Cancer . 61 Statements of Intent . 61 Medical Codes Not Appearing on the Prioritized List . 62 CHAPTER FOUR: SUBCOMMITTEES AND TASK FORCES Health Outcomes Subcommittee . 65 Mental Health Care and Chemical Dependency Subcommittee . 65 HSC Actuarial Advisory Committee . 66 Evidence-Based List Task Force . 67 Line Zero Task Force . 68 i TABLE OF CONTENTS (Cont’d) CHAPTER FIVE: RECOMMENDATIONS . .71 APPENDIX A: HOUSE BILL 3624 of 2003 APPENDIX B: COMMISSION AND SUBCOMMITTEE MEMBERSHIP Health Services Commission . .. B-3 Commission Staff . B-6 Mental Health Care and Chemical Dependency Subcommittee . B-7 HSC Actuarial Advisory Committee . B-10 APPENDIX C: BIENNIAL REVIEW CHANGES APPENDIX D: INTERIM MODIFICATIONS APPENDIX E: PRIORITIZED HEALTH SERVICES Frequently Asked Questions: A User’s Guide to the Prioritized List . E-5 2005-07 Prioritized List of Health Services . E-13 Statements of Intent . E-93 Practice Guidelines . E-97 Prevention Tables . E-109 APPENDIX F: INDEXES TO THE 2005-07 PRIORITIZED LIST OF HEALTH SERVICES Condition Index . F-5 Treatment Index . F-59 ii LIST OF FIGURES Figure 1.1 Chronology of Oregon’s Health Care Reform Initiatives . 7 Figure 2.1 Determining Placement of a New or Reprioritized Condition/ Treatment Pair . 25 Figure 2.2 Process for Incorporating Evidence-Based Health Technology Assessment and Cost-Effectiveness . 27 Figure 2.3 Overview of the Health Services Commission’s Prioritization Process . 29 Figure 2.4 Deleted Lines . 34 Figure 2.5 Newly Merged Lines Previously Found on Separate Lines . 34 Figure 2.6 Significant Changes in Line Contents . 36 Figure 2.7 Medical Advancements Reviewed . 41 Figure 2.8 Solid Organ Transplant Algorithm . 45 Figure 2.9 Bone Marrow Transplant Algorithm . 46 Figure D.1 Line Items on 4/1/04 List Which Include Medical Therapy as Treatment . D-102 Figure D.2 Line Items on 4/1/04 List From Which Physical Therapy is Being Removed as Treatment . D-104 Figure D.3 Line Items on 4/1/04 List From Which Speech Therapy is Being Removed as Treatment . D-106 Figure D.4 Line Items on 4/1/04 List From Which Cardiac Rehabilitation is Being Removed as Treatment . D-108 Figure D.5 Line Items on 4/1/04 List From Which Vascular Disease Rehabilitation is Being Removed as Treatment . D-110 Figure D.6 Line Items on 10/1/04 List Which Include Acute Therapies as Treatment . D-112 Figure D.7 Line Items on 10/1/04 List Which Include Cardiac Rehabilitation as Treatment . D-112 Figure D.8 Line Items on 10/1/04 List Which Include Oncology Diagnoses . D-114 iii iv HEALTH SERVICES COMMISSION AND STAFF COMMISSIONERS: Eric Walsh, Chair Donalda Dodson Andrew G. Glass Jono Hildner (retired) Ellen Lowe Daniel Mangum Susan McGough Kathleen Savicki Somnath Saha Bryan Sohl Dan Williams STAFF: Darren Coffman, Director Alison S. Little, Medical Director Laura Lanssens, Program Specialist v vi Acknowledgements The Health Services Commission extends a sincere “thank you” to all those organizations and individuals who assisted the Commission in its development and refinement of the Prioritized List of Health Services. These organizations have given generously of their time and support for Commission activities: DHS, Children, Adults, and Families DHS, Office of Medical Assistance Programs DHS, Office of Mental Health and Addiction Services Oregon Association of Hospitals and Health Systems Oregon Dental Association Oregon Health Action Campaign Oregon Health Decisions Oregon Medical Association Meridian Park Hospital Many agencies have provided meeting space for Commission related activities, and many individuals have given freely of their time and knowledge. The Commission gratefully acknowledges the commitment of all the volunteer members of the Commission's subcommittees and task forces. The process was improved by, and benefited from, their hard work. The Commission appreciates the many hours of work and thoughtful recommendations of the provider groups who initially supplied the information making it possible to rank the condition/treatment pairs. This work continues to be carried out by their successors who have willingly reviewed line items in their area of expertise. For this community spirit, the Commission offers its gratitude and thanks. Finally, the Commissioners wish to thank their spouses, significant others, business partners, employers, and friends for their support and patience during this arduous process. vii The following individuals provided assistance to the Health Services Commission during their 2003-2005 biennial review of the Prioritized List of Health Services by reviewing information pertaining to the ranking of services for their indicated specialty: Gerald Ahmann, MD Hematology Oncology Assoiciates, Medford Natalie Arndt, LAc Oregon Acupunture Association Stephen Bader, MD Oregon Clinic Grover Bagby, MD Oregon Cancer Institute James Beggs, MD Medical Director, Cascade Comprehensive Care Robert Bentley, MD Oregon Academy of Ophthalmology Lester Bergeron, MD Medical Director, Tuality Health Alliance Robert Bohnen, MD Cancer Treatment Center, Merle West Medical Center Nancy Boutin, MD Radiation Therapy Consultants, Salem Harold Boyd, MD Orthopedics, Salem Mark Berg Providence Health System Joanna Cain, MD Center for Women’s Health, OHSU David Candelaria, MD Medical Director, Mid-Rogue IPA Linyee Chang, MD Central Oregon Cancer Treatment Center Bradley Coffey, OD Optometry James Cohen, MD Otolaryngology, OHSU Scott Collins, MD Oregon Dermatology Society Brendan Curti, MD Oregon Clinic Joel Daven, MD Medical Director, DCIPA Charles Dibb, MD Hematology Oncology Associates, Medford Robert Djergaian, MD Oregon Society of Physical Medicine and Rehab Deborah Dotters, MD Northwest Gynecology Oncology, Eugene Will Foran, PT CDRC David Fryefield, MD Willamette Valley Cancer Center viii Robert Gluckman, MD Oregon Chapter, American College of Physicians Matthew Gordon, MD Radiation Therapy Consultants, Salem Bill Guest Cascade Comprehensive Care Alan Hay, MD Oregon Urological Association Cedric Hayden, DDS Hayden Family Dentistry Joseph Henke, MD Medical Director, DOCS Arnella Hennig, MD Radiation Therapy Consultants, Salem Michael Huntington, MD Samaritan Regional Cancer Center, Corvallis Lyle Jackson, MD Medical Director Mid-Rogue Health Plan Kraig Jacobson, MD Oregon Society of Allergy and Immunology Mark Jensen, DMD Oregon Dental Association Bruce Johnson, MD Willamette Ear, Nose, Throat and Facial Plastic Surgery, Salem Tom Johnson, MD Radiation Oncology Stephen Jones, MD Oregon Chapter, American College of Physicians Matthew Kang, MD Radiation Therapy Consultants, Salem Nathan Kemalyan, MD Oregon Burn Center Chris Kirk, MD Medical Director, Marion-Polk Community Health Plan Tina Kitchin, MD Medical Director, Seniors and People with Disabilities Kathryn Kolibaba, MD Northwest Cancer Specialists, Vancouver Peter Kovach, MD Willamette Valley Cancer Center, Eugene David Labby, MD Medical Director, CareOregon Keith Lanier, MD Oregon Hematology Oncology Associates Gary Lee, MD Willamette Valley Cancer Center, Eugene Ken Lindsey, MD Medical Director, COIHS ix Barry McKenzie, MD Willamette Valley Cancer Center, Eugene Jeffrey Menashe, MD Northwest Cancer Specialists, Portland John Molendyk, MD Oregon Clinic Thomas Morris, MD Medical Director, OHMS Craig Nichols, MD Hematolgoy Oncology Division, OHSU H. Stacy Nicholson, MD Pediatric Oncology, OHSU Russ Omizo, MD Radiation Oncology Gregory Patton, MD Northwest Cancer Specialists Mark Peterson, MD Oregon Association of Orthopedists William Pierce, MD Hematology Oncology of Salem Brett Poisson, MD Hematology Oncology Associates, Medford David Pollack, MD Medical Director, Oregon Mental Health and Addiction Services Nancy Reyes-Molyneux, Radiation Therapy MD Consultants, Salem Gerald Rich, MD Sleep Disorders Medicine Rob Richardson, DO Medical Director, Family Care Margaret Rowland, MD Medical Director, Providence Health Plan Erik Schoenberg, MD Otolaryngology Gerald Segal, MD Northwest Cancer Specialists Brett Sheppard, MD Oregon Chapter, American College of Surgeons.