Marge Ginsburg
Citizens’ priorities
for healthcare coverage
AcademyHealth
June 29, 2009
Bringing the patient,
consumer, citizen voice
to healthcare policy
Center for Healthcare Decisions
• When there are no easy answers.
• Obama: ….. to reverse our “collective failure to
make hard choices.”
• Citizen voice
What is fair? What is reasonable?
What trade-offs can we live with?
What values take priority?
Coverage priorities: project questions
Just Coverage
What should ‘basic’ healthcare coverage look
like?
What Matters Most
What are the characteristics of medical problems
that are essential for coverage?
Funding support:
California HealthCare Foundation
Just Coverage project (2005-07)
Basic coverage: the best use of limited resources
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71 meetings No. California
Most well-educated, insured
798 participants
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11 meetings statewide
Uninsured for > one year
100 - 300% of FPL
121 participants
The process: CHAT® (choosing healthplans all together)
Four rounds of CHAT
Health event “lottery”
Catastrophic
While trying out his son’s skate board, Joe crashed into a wall
and knocked unconscious. Rushed to the hospital, he spent a
week in the ICU that cost $100,000. Though his life was saved,
he lost his eyesight in the accident.
____________________________________________
Tier 1: His health plan paid the $100,000. But it will NOT
pay for a $20,000 surgery that has only a 2% chance of
recovering his eyesight.
Tier 2: His health plan paid the $100,000. It will also pay
$20,000 for surgery even though it only has a 2% chance
of recovering his eyesight.
Challenges to CHAT as a process
• Labor- and resource intensive
2 ½ hours for each session, 9-18 people
Customizing the board, actuarials
• Hardware/software needs
• Recruiting diverse participants
Results from Just Coverage
Identifying priorities
– Reasonable cost-sharing
– Wide choice of providers
– Many categories of coverage
– Minimal restrictions
What Matters Most:
Does the public distinguish essential from ‘less’ essential?
Process, part 1:
1,000 person phone survey, 19 vignettes each
Q. 1: On a scale of 1 to 10….
Q. 2: Should it be included….
– A 24-year-old woman has long-standing asthma that prevents her
from being active. With an inhaler and medications, she can live a
more normal life.
– A 32-year-old man is very active with sports and his glasses often get
in the way. Laser surgery would correct his vision so he wouldn’t need
glasses anymore.
What Matters Most, cont.
Process, part II:
15 discussion groups statewide, diverse groups
• Do you agree these vignettes should be rated
highly? Why/ why not?
• What distinguishes higher and lower rated vignettes?
• How should health plans deal with lower-priority
situations?
Challenges to this mixed approach
• Phone surveys are costly, “snapshot”
opinions
• Do not know the reasoning behind the
ratings; no opportunity for deliberation
• Discussion groups: Cannot easily reach
large numbers or measure demographic
differences.
Results from What Matters Most
What matters most
saves lives, restores function, prevents illness
What matters some
physical discomfort/distress (but not ADLs)
What matters least
unsightly but not harmful
ineffective / marginally effective treatment
maximizes recreational abilities
civic engagement in health policy
Tell me, I’ll forget.
Show me, I may remember.
But involve me and I’ll
understand.
Chinese proverb