kim bailey health action 2014 january 23, 2014
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Kim Bailey Health Action 2014 January 23, 2014. Consumer-Friendly Value Based Insurance Design. Roadmap: Four Key Questions. Families USA 2014. What is the policy context in which VBID is emerging? What is VBID? How can VBID programs be designed in a consumer-friendly way? - PowerPoint PPT PresentationTRANSCRIPT
Kim Bailey
Health Action 2014
January 23, 2014
Consumer-Friendly Value Based Insurance Design
Families USA2014
• What is the policy context in which VBID is emerging?
• What is VBID?• How can VBID programs be designed in a
consumer-friendly way?• What are the key differences between
VBID and wellness programs?
Roadmap: Four Key Questions
Families USA2014
1) Health care expenditures are high and rising
Policy Context
Families USA2014
Health Spending as a Share of GDP, Select OECD Countries, 2000-2010
U.S.
OECD Avg.
Source: Health at a Glance 2013: OECD Indicators, available online at: http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf.
Families USA2014
1) Health care expenditures are high and rising
2) As a result, premiums continue to grow, too
Policy Context
Families USA2014
Premiums for Employer-Based Coverage, 1999-2013
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013.
Families USA2014
1) Health care expenditures are high and rising
2) As a result, premiums continue to grow, too
3) Employers and other purchasers are looking for ways to contain the cost of coverage
Policy Context
Families USA2014
Two Models:1) Tiered cost-sharing based on clinical value2) Tiered cost sharing by quality and
efficiency of providerGoal: To control costs and improve access to
effective, evidence-based care and providers
Value-Based Insurance Design
Families USA2014
Key Elements to Effective VBID
Families USA2014
How it works– Reduces/waives cost-sharing for services with
evidence of strong clinical benefit relative to cost– May increase cost-sharing for services that are not
clinically effective
Requirements for consumer-friendly design– Robust, reliable evidence base– Accessible exceptions and appeals– Consumer education and the availability of tools
and resources to aid consumers– Paired with policies that address provider pricing
and behavior
VBID: Tiered Cost-Sharing
Families USA2014
Value-Based CareHigh Value Services Low Value Services•Age appropriate cancer screenings
•Eye and foot exams for diabetics
•Medications for chronic heart disease, asthma, diabetes and hypertension
•Transplant drugs
•Defribillators for certain patients with congestive heart failure
•Early Elective C-Sections
•MRI for low back pain (w/ no red flags)
•Sleep studies
•Annual EKG/cardiac screening for low risk patients
•Bone density test for low-risk women under 65
Families USA2014
Pitney Bowes ExperienceDesign: Reduced/waived co-pays for medications
for heart disease, asthma, diabetes and hypertension
Results: • Improved medication adherence for statins and
blood clot inhibitors• Reduced ER visits by 26% in diabetics• Slowed rate of cost growth
VBID in Practice: Tiered Cost-Sharing
Sources: Choudhry NK, Rosenthal MB and Milstein A. Assessing the evidence for value-based insurance design. Health Affairs. 2010 Nov; 29(11): 1988-94 and Choudhry NK et al. At Pitney Bowes Value-Based Insurance Design Cut Co-payments and Increased Drug Adherence. Health Affairs 2010 Nov.; 29(11): 2028-31.
Families USA2014
How it works– Providers placed into tiers based on performance
data and other factors– Cost-sharing varied based on tier within which
provider falls
Requirements for consumer-friendly design– Robust, reliable quality metrics and measures of
provider performance– Sufficient availability of providers to meet the needs
of all plan enrollees– Consumer education on plan design– Accessible exceptions and appeals
VBID: Tiered Provider Networks
Families USA2014
Aetna Aexcel Performance Network
Design: Designates doctors and provider groups in 12 specialties (e.g. cardiology and orthopedics) as high-performing with a blue star
Factors considered:1)Volume
2)Clinical Performance
3)Efficiency
VBID in Practice: Tiered Provider Networks
Sources: http://www.aetna.com/docfind/pdf/aexcel_understanding.pdf and http://www.aetna.com/insurance-producer/document-library/aexcel-member-brochure.pdf
Families USA2014
VBID vs. Wellness Penalties
Value-Based Insurance Wellness Penalties
Evidence Based Not-Evidence Based
Cost-sharing based on clinical value
Cost-sharing based on participation in program or health status
Never alters premiums Higher premiums for enrollees with health risks/who cannot participate
Lowers cost-sharing for high value care for enrollees with related health risks
Raises cost-sharing for enrollees with health risks/who cannot participate
Families USA2014
Families USA2014
• Principles for Consumer Friendly Value-Based Insurance Design: http://familiesusa2.org/assets/pdfs/VVBID-Brief.pdf
• Key Difference between Wellness Reward/Penalty Programs and Value-Based Insurance Design: http://familiesusa2.org/assets/pdfs/health-system-reform/VBID-Wellness-Programs.pdf
Additional Resources
