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Prioritization of Health Services PRIORITIZATION OF HEALTH SERVICES A Report to the Governor and the 72nd Oregon Legislative Assembly Oregon Health Services Commission Office for Oregon Health Policy and Research Department of Administrative Services 2003 TABLE OF CONTENTS List of Tables . iii Health Services Commission and Staff . .v Acknowledgments . .vii Executive Summary . xi CHAPTER ONE: HISTORY OF THE OREGON HEALTH PLAN Legislative Framework . 3 Implementation of the Medicaid Demonstration . .. 5 Accomplishments . 7 CHAPTER TWO: PRIORITIZATION OF HEALTH SERVICES Charge to the Health Services Commission . .. 21 Prioritization Methodology . 22 Biennial Review . 23 Interim Modifications . 31 Technical Changes . 32 Advancements in Medical Technology . .33 Solid Organ Transplantation . 34 Intrathecal Baclofen Therapy . 36 CHAPTER THREE: CLARIFICATIONS TO THE PRIORITIZED LIST OF HEALTH SERVICES Practice Guidelines . 39 Hysterectomy for Benign Conditions . 40 Adenomyosis . 42 Comfort Care . 44 Spinal Deformities . 45 Cancer of the Esophagus, Liver, Pancreas, and Gallbladder . 45 Intrathecal Baclofen Therapy . 46 Prevention Guidelines . 47 Coding Specifications . 48 Seminoma . 48 Breast Reconstruction Post-Mastectomy for Breast Cancer . 49 Statements of Intent . 49 Medical Codes Not Appearing on the Prioritized List . 50 CHAPTER FOUR: SUBCOMMITTEES, TASK FORCES, AND WORKGROUPS Health Outcomes Subcommittee . 55 Mental Health Care and Chemical Dependency Subcommittee . 56 Workgroup on Public Outreach . 57 Oncology Task Force . 58 CHAPTER FIVE: RECOMMENDATIONS . .61 i TABLE OF CONTENTS (Cont’d) APPENDIX A: COMMISSION AND SUBCOMMITTE MEMBERSHIP Health Services Commission . .. A-3 Commission Staff . A-6 Mental Health Care and Chemical Dependency Subcommittee . .. A-7 APPENDIX B: BIENNIAL REVIEW CHANGES APPENDIX C: INTERIM MODIFICATIONS APPENDIX D: ACTUARIAL REPORT APPENDIX E: OHP STANDARD Reprinting of the Health Services Commission’s July 2002 Report “Prioritized List of Benefit Packages for OHP Standard: Interim Report to the Governor and Legislative Leadership” PricewaterhouseCoopers December 20, 2002 Report “Average Costs and Capitation Rate Development for the OHP Standard Benefit Package, Federal Fiscal Year 2003, February 2003 Benefit Level” PricewaterhouseCoopers April 15, 2003 Memo OHP Standard and OHP Plus Statewide Per Capita Costs” APPENDIX F: PRIORITIZED LIST OF HEALTH SERVICES Frequently Asked Questions: A User’s Guide to the Prioritized List . F-5 April 29, 2003, Prioritized List of Health Services . F-15 Statements of Intent . F-121 Practice Guidelines . F-125 Prevention Tables . F-135 Ancillary Services . F-155 APPENDIX G: INDEXES TO THE APRIL 29, 2003, PRIORITIZED LIST OF HEALTH SERVICES Condition Index . G-5 Treatment Index . G-59 ii LIST OF TABLES Table 1. Chronology of Oregon’s Health Care Reform Initiatives . 9 Table 2. Subjective Criteria . 24 Table 3. New Line . 27 Table 4. Deleted Line . 27 Table 5. Lines Moved From Previous Ranking . 27 Table 6. Merged Lines Previously Found on Separate Lines . 29 Table 7. Previously Existing Lines Divided Into Two Separate Lines . 29 Table 8. Transplant Algorithm . 35 Table C1 Line Items on 10/1/01 List Which Include Radiation Therapy as Treatment . C-36 Table C2 Line Items on 10/1/01 List Which Include Medical Therapy as Treatment . C-82 iii HEALTH SERVICES COMMISSION COMMISSIONERS AND STAFF COMMISSIONERS: Andrew Glass, Chair David Arnold Donalda Dodson Jono Hildner Alison Little (retired) Ellen Lowe Daniel Mangum Kathleen Savicki Bryan Sohl Eric Walsh Dan Williams STAFF: Darren Coffman, Director Kathleen Weaver, Medical Director Laura Lanssens, Program Specialist v 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 2001-2003 biennial review of the Prioritized List of Health Services by reviewing information pertaining to the ranking of services for their indicated specialty: Gary Allen, DDS Dentistry Diane Baker, MD Dermatology David Balmer, MD Medical Director, MVIPA James Beggs, MD Medical Director, Cascade Comprehensive Care Robert Bentley, MD Oregon Academy of Ophthalmology Lester Bergeron, MD Medical Director, Tuality Health Alliance Tanveer Bokham, MD Medical Director, ODS Harold Boyd, MD Orthopedics John Campbell, MD Pediatric Surgery David Candelaria, MD Medical Director, Mid-Rogue IPA Colin Cave, MD Otolaryngology William E. Connor, MD Hyperlipidemia David B. Couten, MD Oregon Society of Allergy and Immunology Bruce Dana, MD Oncology Joel Daven, MD Medical Director, DCIPA Henry DeMots, MD Cardiology Robert George, MD Psychiatry Rupert Goetz, MD Medical Director, Dept. of Mental Health Services Bruce Goldberg, MD Medical Director, CareOregon Elizabeth Goldblatt,PhD Acupuncture Alan R. Hay, MD Oregon Urological Association John Hoppack, MD Hyperbaric Oxygen Roger Illingsworth, MD Hyperlipidemia Lyle Jackson, MD Medical Director Mid-Rogue Health Plan Steve Jones, MD Adult Infectious Disease F. Leonard Johnson, MD Pediatric Oncology viii Nathan Kemalyan, MD Burn Care Chris Kirk, MD Medical Director, Marion-Polk Community Health Plan Tina Kitchin, MD Developmental Disabilities Mary Jane Kuhar, MD Medical Director, COIHS David Labby, MD Medical Director, CareOregon James Lace, MD Pediatrics Brian Lauer, MD Pediatric Infectious Disease Robert Law, MD Family Practice Allison Little, MD Medical Director, COIHS William Long, MD Trauma Mark Loveless, MD HIV Disease Carla McKelvey, MD Medical Director, DOCS Victor Menashe, MD Pediatric Cardiology Thomas Morris, MD Medical Director, Grants Pass IPA Mark D. Nichols ACOG, Oregon Section Brian O'Halloren, MD Urology Kevin Olson, MD Oncology Connie Powell, MD Oregon Psychiatric Association Sidney Prescott, MD Obstetrics and Gynecology Peter Regan, MD Family Practice Hector Rodriquez, DO Internal Medicine, Osteopathy Arthur Rott, DO Medical Director, FamilyCare Miles Seeley, MD Obstetrics and Gynecology Mike Shirtcliff, DMD Dentistry Ronald S. Sklor, MD Neonatology Thomas Syltebo, MD Medical Director, Kaiser Permanente NW Cornelia Taylor, MD Medical Director, Regence HMO Oregon Thomas Turek, MD Medical Director, OMAP Fredrick Waller, MD Neurosurgery Douglas C. Walta, MD Gastroenterology Robert Wheeler, MD Medical Director, LIPA Ronald F. Wolf, MD General Surgery Richard Wopat, MD Medical Director, Intercommunity Health Care ix x Executive Summary The Health Services Commission fulfilled its legislative mandates during the 2001-03 biennium through its maintenance and comprehensive review of the Prioritized List of Health Services. Additionally, the Commission continues to play a key role in the stabilization of the Oregon Health Plan through its development of the Prioritized List of Benefit Packages for OHP Standard. The Commission began its most recent biennial review of the Prioritized List of Health Services in the fall of 2001. The Commission requested that providers from all specialties comment on the ways in which savings to the Oregon Health Plan could be achieved through the elimination of obsolete treatments, redundant diagnostic tests, or ineffectively treated conditions. In addition, the Commission solicited the help of the Medical Directors of the contracted fully capitated managed care plans to help identify those conditions which are ineffectively treated or for which treatment is effective for only a defined subset of patients that could be characterized in a practice guideline. The Commission then reviewed this information during public meetings held from January through June of 2002. The biennial review process resulted in the Prioritized List of Health Services dated April 29, 2003 that appears in Appendix F. Please see Chapter Five for the Health Services Commission’s recommendations accompanying this list. The Commission is hopeful that the recent decision of the Centers for Medicare and Medicaid Services (CMS) to allow Oregon to reduce funding of the Prioritized List of Health Services by eight line items is a signal that further reductions are possible should
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