Prioritization Methodology

Prioritized List of Health Services Methodology
Developed by the Health Services Commission (HSC)

Updated 10/25/13

As of January 1, 2008, the Prioritized List reflects a ranking of health services based on a new methodology that places a higher emphasis on preventive services and chronic disease management. The new methodology ensures a benefit package that provides the services necessary to best keep a population healthy rather than waiting until an individual gets sick before higher cost services are offered to try to restore good health.

The prioritization methodology first defines a rank ordered list of nine broad categories of health care to establish a basic framework for the list (See Figure 1.1). Next the methodology calls for each of the line items on the Prioritized List to be assigned to one of these health care categories. Once the line items have been assigned to one of the nine categories, a list of criteria is used to sort the line items within the categories (See Figure 1.2). These measures are felt to best capture the impacts on both the individual's health and the population health that is essential in determining the relative importance of a condition-treatment pair.

Since not every service in Category 1 is more important than every service in Category 2 and so on, a weight is applied to each category that is then multiplied by the total criteria score for each condition-treatment pair, achieving an appropriate adjustment in the majority of the cases. The category weights are shown in parentheses after the title for each category in Figure 1.1. A total score is then calculated for each line using the following formula to sort all line items within each of the health care categories, with the lowest net cost used to break any ties:

Hand adjustments were applied by the Commission where the application of this methodology did not result in a ranking that reflected the importance of the service, which was the case in fewer than 5% of the line items (compared to over 70% of cases using the previous methodology).

Figure 1.1 – Rank Order of Health Care Categories

1. Maternity & Newborn Care(100) - Obstetrical care for pregnancy. Prenatal care; delivery services; postpartum care; newborn care for conditions intrinsic to the pregnancy.
2. Primary Prevention and Secondary Prevention (95) -
   Effective preventive services used prior to the presence of disease and screenings for the detection of diseases at an early stage. Immunizations; fluoride treatment in children; mammograms; pap smears; blood pressure screening; well child visits; routine dental exams.
3. Chronic Disease Management (75) - Predominant role of treatment in the presence of an established disease is to prevent an exacerbation or a secondary illness. Medical therapy for diabetes mellitus, asthma, and hypertension. Medical/psychotherapy for schizophrenia.
4. Reproductive Services (70) - Excludes maternity and infertility services. Contraceptive management; vasectomy; tubal occlusion; tubal ligation.
5. Comfort Care (65) - Palliative therapy for conditions in which death is imminent. Hospice care; pain management.
6. Fatal Conditions, Where Treatment is Aimed at Disease Modification or Cure (40) -
   Appendectomy for appendicitis; medical & surgical treatment for treatable cancers; dialysis for end-stage renal disease; medical therapy for stroke; medical/psychotherapy for single episode major depression.
7. Nonfatal Conditions, Where Treatment is Aimed at Disease Modification or Cure (20) -
   Treatment of closed fractures; medical/psychotherapy for obsessive-compulsive disorders; medical therapy for chronic sinusitis.
8. Self-limiting conditions (5) - Treatment expedites recovery for conditions that will resolve on their own whether treated or not. Medical therapy for diaper rash, acute conjunctivitis and acute pharyngitis.
9. Inconsequential care (1) - Services that have little or no impact on health status due to the nature of the condition or the ineffectiveness of the treatment. Repair fingertip avulsion that does not include fingernail; medical therapy for gallstones without cholecystitis, medical therapy for viral warts.

Figure 1.2 – Population and Individual Impact Measures

• Impact on Healthy Life - What is the magnitude of the benefit to the patient from the treatment as compared to no treatment for the condition, after factoring in harms associated with the treatment. Range of 0 (no impact) to 10 (high impact).
• Impact on Suffering - To what degree does the condition result in pain and suffering? Effect on family members (e.g. dealing with a loved one with Alzheimer's disease or needing to care for a person with a life-long disability) should also be factored in here. Range of 0 (no impact) to 5 (high impact).
• Population Effects - The degree to which individuals other than the person with the illness will be affected. Examples include public health concerns due to the spread of untreated tuberculosis or public safety concerns resulting from untreated severe mental illness. Range of 0 (no effects) to 5 (widespread effects).
• Vulnerability of Population Affected - To what degree does the condition affect vulnerable populations such as those of certain racial/ethnic descent or those afflicted by certain debilitating illnesses such as HIV disease or alcohol & drug dependence? Range of 0 (no vulnerability) to 5 (high vulnerability).
• Tertiary Prevention - In considering the ranking of services within new categories 6 and 7, to what degree does early treatment prevent complications of the disease (not including death)? Range of 0 (doesn't prevent complications) to 5 (prevents severe complications).
• Effectiveness - To what degree does the treatment achieve its intended purpose? Range of 0 (no effectiveness) to 5 (high effectiveness).
• Need for Medical Services - The percentage of time in which medical services would be required after the diagnosis has been established. Percentage from 0 (services never required) to 1 (services always required).
• Net Cost - The cost of treatment for the typical case (including lifetime costs associated with chronic diseases) minus the expected costs if treatment is not provided — including costs incurred through safety net providers (e.g., emergency departments) for urgent or emergent care related to the injury/illness or resulting complications. Range of 0 (high net cost) to 5 (cost saving)

The following two examples illustrate line items that were given a very high score and a very low score as a result of this process.

Services near the top of the list as a result of this reprioritization include maternity care and newborn services, preventive services found to be effective by the U.S. Preventive Services Task Force, and treatments for chronic diseases such as diabetes, major depression, asthma, and hypertension, where ongoing maintenance therapy can prevent exacerbations of the disease that lead to avoidable high-intensity service utilization, morbidity, and death.