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Computer Program Used To Define Basic Coverage

To provide coverage to the uninsured, it is essential to determine how to provide “enough coverage” affordably, Marjorie Ginsburg — executive director of the Sacramento Healthcare Decisions, a not-for-profit group that aims to include the public in efforts to improve health care policy and practice — said on Tuesday at a Health Affairs briefing in Washington, D.C. Sacramento Healthcare Decisions designed a project, called Just Coverage, using a computer-based program to solicit public input on what basic coverage should include.

The computer-based program called CHAT – Choosing Healthplans All Together – was developed by the University of Michigan and the NIH. The Just Coverage version of the program focuses on health care needs, such as chronic illness and episodic care.

Ginsburg said that while policymakers use the term “basic coverage” liberally, it is unclear what it actually entails. She added that in order to create a sustainable program to reduce the number of uninsured residents, it is important to focus on the needs and wants of the public rather than policymakers and providers.

The study, which was supported by a California HealthCare Foundation grant, included 798 Northern California residents and was conducted from June 2005 through April 2006.

Study Methods

Participants used the CHAT program to consider 14 categories, each of which offered three different tiers. Higher tiers were more costly but included better benefits and fewer restrictions.

Participants were asked to design a coverage plan that represented the “floor below which no one should fall,” Ginsburg said. They were instructed to look at the task from a policy perspective rather than a personal perspective and were informed that the basic coverage plan would most likely be used by lower-income, working-class individuals and families. It would not apply to those who are covered under Medicare or Medicaid, and more comprehensive coverage would be available to those who could afford it.

Groups of 10 to 12 participants met for two-and-a-half hour sessions that were divided into the following rounds:

  • Participants used the program to individually design a basic plan;
  • Groups of three designed a consensus plan;
  • The entire group worked with a facilitator to design a uniform plan; and
  • Individuals created their own plan again after their group discussions.

An article, called “(De)constructing ‘Basic’ Benefits: Citizens Define The Limits of Coverage,” which appears in the current issue of Health Affairs, highlights the findings of the SHD study. Participants put an emphasis on designing a plan that was neither too costly nor a “free ride,” according to Ginsburg. The participants sought to create a plan that was “fair and reasonable” and as “comprehensive as possible,” she said.

Participants did not view all needs equally, according to the study. The highest priority was put on coverage for:

  • Responding to life-threatening situations;
  • Preventing or delaying illness, disease or disability; and
  • Enabling or restoring vital capabilities.

Most participants excluded quality-of-life care – such as infertility treatment – from basic coverage. However, while just 15% of participants included quality-of-life care during the group discussion round, the number increased to 40% during the final round where participants designed individual plans.

Participants found it acceptable to provide tighter coverage criteria and excluded coverage for treatment:

  • That will not bring meaningful benefit;
  • When established guidelines are not followed; and
  • When expensive interventions are used instead of equivalent, less costly ones.

For example, when the entire group discussed plans, only 4% of the groups included in their plans catastrophic care “treatments that are not likely to help but are the ‘only hope left.'”

Participants during the group discussions said it was reasonable to restrict the provider network by eliminating excess physician capacity, limiting specialist referrals and utilizing cost-efficient alternative providers, such as nurse practitioners. Participants noted that restricting providers was acceptable only if the quality of providers was satisfactory, if patients could change physicians when necessary and if specialty care was not completely inaccessible, according to the study.

The Just Coverage project looked at health care needs, so actuarial estimates of the costs were less precise than if the project had focused on health care services, according to the Health Affairs article. In addition, if the project had included more participants who would be likely recipients of basic coverage — such as the uninsured, those with less education and Hispanics — the findings would better represent the wants and values of those utilizing basic coverage, according to the article.

The study’s authors said they hope the project’s findings will provide a starting point for “long overdue” discussions on designing effective basic coverage plans.

“I don’t think we’re even close to the tipping point” of significant health care reform, Ginsberg said. She estimated that such reform is “easily five to 10 years away,” unless there is strong political leadership that is able to change the course.

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