Stretching Scarce Resources: State Strategies to Design Effective, Affordable Benefit Packages John Santa, M.D. Administrator Office for Oregon Health Policy and Research

Oregon 2001 Pre 9/11 Uninsurance rising Economy in recession Post 9/11 800M deficit Highest unemployment in US

OHP2 Benefits/eligibility flexibility Maximize leverage—access all $$ sources possible Use resources—expand eligibility Cap enrollment for expansion populations

Making Tough Choices Ration services rather than people Explicit, public decision process Oregon data for reference and relevance Rely on evidence when available

Prioritized List – Lessons Learned Priorities made explicit—prevention high on list. Futile and inefficient care lowest Overall rankings make sense Less valued services excluded—about 3% more than usual exclusions Difficult to administer Still complex and emotional process

Listening to the Public Multiple public sessions—over 2000 participants Oregonians understand tradeoffs Prefer cost-sharing to benefit elimination Prescription drugs highest valued Dental and mental health similar

Dental—”on the cusp” Dental—first benefit with substantial resources “on the cusp” Motivated managed dental plans Data shows minimal preventive, substantial high cost use Focus on maintaining function 6 month $ limit, copays on restorative

Importance of Research Good research on low income, churning, subsidy for ESI Lack of research on cost-sharing at lowest incomes other than Rx Using evidence-based analysis done by Oregon Evidence Based Practice Center for high cost prescription drugs

Lessons Learned Taking benefits away is tough work Uninsured have little leverage Keep presenting options, keep participants talking, be a catalyst Identify basic services Identify less valued, less effective services Pursue every option until you get pushed back

Important Questions Cost sharing in poor adults What works, what doesn’t? How can delivery systems and communities help? Effect of premiums on poor adults Does trading off benefits for expansion of eligibility result in net benefits to the population as a whole?

Resources for Poor/Low Income Focus on adults—no premium/nominal copays for children No discretionary income Family/friends/other sources Financing options Other resource help—food, housing

Strategies to Moderate Impact Premium subsidy Premium financing Copay financing Continuous enrollment Medical culture Community culture

Alternatives to Cost-sharing Eliminate coverage for specific treatments—return to list Site of service strategies—individual visit to group, subacute detox Limits on visits Guidelines