California Health Benefits
Review Program
Providing the State Legislature independent analyses of
health insurance benefit mandate or repeal bills
Susan Philip, MPP
Director, California Health Benefits Review Program
University of California,
California Office of the President
Academy Health Annual Research Meeting
June 30, 2009
Who are we?
 Created by law to provide timely, independent,
evidence-based information to the Legislature to
assist in decision making
 Administered by the University of California, but
i tit ti
institutionally
ll independent
i d
d t
 Charged
g to analyze
y medical effectiveness, cost,
and public health impacts off health insurance
benefit mandates or repeals
 Requested to complete each analysis within 60
days
2
Who are we ?(cont.)
(
)
Task Force Members
Task Force Contributors
Helen Halpin, PhD, Vice Chair,
Wade Aubry, MD
University of California, San Francisco
Public Health Impact
University of California, Berkeley
Gerald Kominski, PhD, Vice Chair, Cost Impact
(Outgoing)
Nicole Bellows, PhD
University of California, Berkeley
Robert Kaplan PhD, Vice Chair, Cost Impact (Incoming)
University of California, Los Angeles
Janet Coffman, PhD
University of California, San Francisco
Ed Yelin,
Yelin PhD,
PhD Vice Chair,
Chai Medical Effectiveness
Effecti eness
University of California, San Francisco
Mi-Kyung
Mi
Kyung Hong
Hong, MPH
University of California, San Francisco
Wayne Dysinger, MD, MPH
Loma Linda Medical Center
Stephen McCurdy, MD, MPH
University of California, Davis
Susan Ettner, PhD
University of California, Los Angeles
Sara McMenamin, PhD
University of California, Berkeley
Theodore Ganiats, MD
University of California, San Diego
Ying-Ying Meng, DrPH
University of California, Los Angeles
Sheldon Greenfield, MD
University of California, Irvine
Nadereh Pourat, PhD
University of California, Los Angeles
Kathleen Johnson,, PharmD,, MPH,, PhD
University of Southern California
Dominique
q
Ritley,
y, MPH
University of California, Davis
University of California, Los Angeles
Joy Melnikow, MD, MPH
University of California, Davis
Thomas MaCurdy, PhD
Stanford University
3
Who are we?
Task Force
Actuarial firm:
Milliman, Inc
Librarians
Content Experts
National Advisory
Council
CHBRP staff at UC
Office of the
President
(cont.)
What are mandates and repeals?
Mandates require that health plans or insurers:
1 Off
1.
Offer or provide
id coverage for
f th
the screening,
i
diagnosis,
di
i or
treatment of a disease or condition.
2. Offer or provide coverage of a type of health care
t t
treatment
t or service,
i
or off medical
di l equipment,
i
t supplies,
li
or drugs used in a treatment or service.
3. Offer or provide coverage permitting treatment or
services from a type of health care provider
provider.
Repeal
p
bills would delete mandate law or allow
development of health insurance products that
are not subject to all or a subset of benefit
mandate laws.
5
State Benefit Mandate Laws:
National Context
1,505
1
505 state laws mandating benefits (BCBSA
2008) as part of “managed care backlash”
Since late 1990s
1990s, growing concern about
the impact of mandates on
 Cost of health insurance
 Employers’ decisions to offer coverage
Mandate review laws enacted to help
legislators’ make more informed decisions
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State Mandated Benefit Review Laws
29 states require mandate reviews:
AZ, CA, CO, FL, GA, HI, IN, KS, KY, LA, MA, ME,
MD, MN, NV, NH, NJ, NY, NC, ND, OH, OR, PA,
SC TN,
SC,
TN TX,
TX VA,
VA WA,
WA WI
19 mandate review laws enacted since 2000,
1 sunsetted in 2007
Most reviews are conducted prior to state
legislatures’ consideration of mandate bills
Sources: BCBSA, 2008; Bellows et al., 2006; CHBRP, Forthcoming
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60-Day Timeline: Days 0-20
•Identify analytic teams, faculty/staff leads,
reviewers
•Identify potential conflicts of interest
•Determine scope
p of services
• Receive request; post on web site
• Clarify intent of bill in writing (work w/bill author)
• Send out CHBRP coverage survey
• Contact various groups re public demand
• Review drafts (e.g. bibliography, baseline tables)
• Compile carrier coverage data and
• Compile info from the interested parties
• Compile coverage info for public programs
• Screen
S
andd select
l t content
t t expertt per protocol
t l
• Identify search terms and scope of search
• Librarians conduct literature search under
direction of effectiveness team
• Librarians
Lib i
prepare final
fi l abstract
b t t ddatabase
t b
• Team analyzes literature & prepares draft medical
outcomes summary tables
• Conduct cost
cost-related
related literature search
• Identify codes for claims pull of baseline
utilization
• Develop baseline coverage
coverage, utilization tables
tables.
• Review evidence for projecting impacts (utilization
assumptions, cost offsets, long-term impacts)
• Conduct literature search for PH analysis (e.g.
prevalence racial disparities)
prevalence,
• Develop baseline tables for public health and review
evidence to for projecting impacts on subpopulations
0
10
20
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60-Day Timeline: Days 21-60
• Review drafts (e.g.
medical effectiveness
outcomes, impact tables)
• Complete 1st internal
review full draft
• Address
NAC
comments
•Final Vice
Chair & EVP
of Health
Transmit
NAC
• 1st Draft of ME section
• Address all comments on 1st
Affairs
Final
•Update
and appendices due
draft
Committee
Review
tables,
Bill
finalize
•Address
any
Review
• Finalize approach to
• Finalize approach
Analysis
appendices final
determine utilization & cost • Actuaries produce draft
and finalize comments by Report
impacts
tables
each section Vice Chairs
• Actuaries produce draft
• 1st draft Cost section,
and EVP
•Editor
Editor
tables
tables due & address VC
completes • Final
• 1st draft of Cost section
comments
review
production
due
• Finalize approach to
• 1st draft of PH section due
determine PH impacts
& address VC comments
• Draft post-mandate
section
• Review drafts, coordinate • Integrate all sections; 1st
internally and NAC reviews draft full report
21
30
40
50
60
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What have we done?
 58 Reports, 9 letters since 2004
 55 mandate bills, 3 repeal bills introduced
 Current session: 11 pending in the Legislature
 Prior sessions:
• 24 died in the Legislature
• 17 vetoed by Governor
• 6 enacted into law
 Public briefings and workshops with Legislative staff
 Special Issue of Health Services Research 41:3,
41:3 Part II
(June 2006) Informing Legislative Decisions on Health Benefit
Mandates: The California Health Benefits Review Program
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Programmatic Impacts
Methods of determining impacts




Key informant interviews
Review of legislative analyses
Review of stakeholders’ summaries
Review of Governor’s veto/signing messages
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Impacts
Health Committee Staffer:
“The question to assess the value of the
program should be ‘Do
Do the reports elevate the
level of debate?’ To which the answer is
‘Yes.’”
 Committee staff no longer need to rely on bill sponsors
for evidence, cost estimates or public health impacts.
 Reports are trusted by stakeholders and both political
parties
D
Debates
b t can ffocus on political
liti l and
d resource trade-offs
t d ff
rather than nuts and bolts (e.g. how much would it cost?
is it effective?)
12
Impacts
p
((cont.))
Appropriations Committee Staffer:
“CHBRP
CHBRP analyses help the committee have
more certainty about a fiscal impact
analysis…they feel comfortable quoting it
directly in the legislative analysis.”
 The analytic process helps identify bill language issues
and potential for unintended consequences
C
Costt section
ti iis very heavily
h
il used
d by
b Legislative
L i l ti Staff,
St ff
insurers (often opponents), Governor’s Office and other
stakeholders
13
Impacts
(cont.)
Consumer Advocate:
“Since
Since CHBRP, there seems to be a decrease in
the number of manufacturer-sponsored bills.
CHBRP’s process is useful in helping to flag
such bills.”
Health plan/insurer lobbyist:
“These mandates cost something. Now we’re
not the only ones saying that
that.”
14
Bill Outcomes
 Bill introduction rates have not changed
 Bills have been re-worked (amended, reintroduced) to address issues identified via
CHBRP analytic process
 Bills with weak evidence base have been
dropped by Bill Author or failed
f
passing the
Legislature
 Bills with substantial costs or which limit market
flexibility are vetoed by the Governor
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 60-day timeline
Challenges
g
 Limited time for research translation that can be done directly
g
staff
with Legislative
 Turnover and term limits of the California Legislature
 Bill language ambiguity
 Communicating findings especially when literature
regarding the benefit, services, technologies, addressed
by the bill is limited of if the evidence is ambiguous
 Longer term impacts
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www.chbrp.org
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California Health Benefits Review Program
University of California Office of the President
1111 Franklin Street,
Street 11th Floor
Oakland CA 94607
Tel: 510-287-3876
Fax: 510-763-4253
www.chbrp.org
Email: chbrpinfo@chbrp.org
The California Health Benefits Review Program is administered by the Division of Health Sciences and
Services at the University of California, Office of the President, under John Stobo, Senior Vice
President for Health Sciences and Services. Susan Philip is the CHBRP Director.
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