Briefs

Cost-Sharing for Immunizations in Medicare: Impacts on Beneficiaries and Recommendations for Policymakers Introduction Vaccine-preventable diseases affecting adults cost the US nearly $9 billion per year, including $5.9 billion in inpatient costs alone.1  Yet rates of vaccination among adults remain stubbornly low, with a 2012 report suggesting more than 20 million Medicare beneficiaries have not received vaccinations in accordance with evidence-based guidelines.2  Specifically, in 2014: • 28 percent of Americans age 65 and older were not vaccinated for influenza, • 38 percent of Americans age 65 and older were not vaccinated for pneumococcal disease, and • 69 percent of Americans age 65 and older were not vaccinated for herpes zoster.3 Given the high-value of immunizations and the substantial room for improvement with vaccine compliance, the Healthy People 2020 goals include numerous objectives dedicated to increasing receipt of evidence-based immunizations – including the percentage of adults vaccinated [...]

V-BID in Action: A Profile of Connecticut’s Health Enhancement Program Value-Based Insurance Design (V-BID)—hailed as a “game changer” by the National Coalition on Health Care— refers to insurance designs that vary consumer cost-sharing to distinguish between high-value and low-value health care services and providers.  V-BID entails (1) reducing financial barriers that deter use of evidence-based services and high-performing providers, and (2) imposing disincentives to discourage use of low-value care.  Through the incorporation of greater clinical nuance in benefit design, payers, purchasers, taxpayers, and consumers can attain more health for every dollar spent.  The University of Michigan Center for V-BID leads in research, development, and advocacy for innovative health benefit plans and payment reform initiatives. Connecticut Seeks to Improve Health and Contain Costs The State of Connecticut faced a projected budget gap of $3.8 billion in fiscal year 2012, and state employees were asked to help address the [...]

A 'Dynamic' Approach to Consumer Cost-Sharing for Prescription Drugs Access to, and levels of spending on, prescription drugs has become an important public policy issue.  Given the significant individual and population health gains that result from the appropriate use of prescription drugs, as well as the fiscal concerns pertaining to the escalation of health care expenditures, the development and implementation of patient-centered solutions that allow access to medications at an affordable cost are of critical importance. One common strategy that health care purchasers employ to control pharmaceutical spending is to increase consumer cost-sharing.  This trend -- seen for nearly all drugs across all formulary tiers -- has proceeded regardless of the clinical benefit provided by a specific drug, with cost-sharing increasing as rapidly for high-value drugs (e.g., included in evidence-based guidelines) as for drugs deemed unnecessary or potentially harmful. 1  As consumers are asked to pay a [...]

V-BID in Action: The Role of Cost-Sharing in Health Disparities The existence of health disparities among specific populations has long been recognized; substantial variations in health insurance coverage, access to providers, use of specific clinical services, and patient-centered outcomes among different groups are well documented.  Differences in levels of medical knowledge  and information sources, trust and skepticism, participation, social support, and resources can vary significantly by population demographic.  Adverse effects on health care equity have also been shown to be the result of clinician judgment, healthcare facility characteristics, and cultural milieu. A robust evidence base has determined that the causes of these disparate outcomes are multifactorial; including race, ethnic group, income, education, and age.  It is difficult to attribute blame to any single factor, as many of the predictors are inextricably linked.1 A systematic review of extensive published research documenting the scope of disparities and summary of proposed potential [...]

Health Information Technology & V-BID: A Synergistic Combination IntroductionValue-Based Insurance Design (V-BID) is an innovative approach that can improve clinical outcomes and contain costs.  The basic premise of V-BID is to align consumer incentives with value by reducing barriers to high-value health services and providers (‘carrots’) and discouraging the use of low-value health services and providers (‘sticks’).  When ‘carrots’ are coupled with ‘sticks’ in a clinically nuanced manner, V-BID improves health care quality and controls spending growth.  The concept of clinical nuance recognizes that:  1) medical services differ in the benefit provided; and 2) the clinical benefit derived from a specific service depends on the patient using it.  This brief examines how the incorporation of V-BID principles into health information technology (HIT) can enhance the potential for HIT to improve quality and increase efficiency.Interoperable HIT systems, meaning systems with the capability to “talk to each other” by exchanging [...]

Supporting Consumer Access to Specialty Medications through Value-Based Insurance Design Originally Produced:  June 2014   Updated:  February 2017 Introduction Specialty pharmaceuticals are medications that consist of complex molecules, are often complicated to deliver, and/or carry high costs.  These medications are frequently used in the treatment of rheumatoid arthritis (RA), HIV, multiple sclerosis (MS), cancer and a variety of other serious health conditions.  For many patients, specialty medications represent the most appropriate clinical recommendation.  However, the benefit delivered by any given medication may vary markedly depending on the particular circumstances around its use.  Today, approximately a quarter of total pharmaceutical spend-ing in the commercial market is devoted to specialty medications.  If current trends in utilization hold, it is estimated that spending on specialty medications will comprise half of all pharmaceutical expenditures by 2018.1 To constrain the rapid rate of increased spending, many payers have established high consumer cost-sharing requirements [...]

Consumer Operated and Oriented Plans:  A Potential Role for V-BID Implementation [1] Originally Produced: January 2014. Updated: July 2016 Introduction Value-Based Insurance Design (V-BID) aligns consumer incentives with value by reducing barriers to high-value clinical services and providers (“carrots”) and by discouraging the use of low-value services and providers (“sticks”).  V-BID is driven by the concept of clinical nuance which recognizes that:  1) medical services differ in the benefit provided; and 2) the clinical benefit derived from a specific service depends on the patient using it, who provides it, and where the service is delivered.  V-BID is included in the Affordable Care Act (ACA) and a 2013 CMS rule which permits State Medicaid programs to alter co-payments for provider visits and prescription drugs.  Currently, hundreds of public and private organizations utilize V-BID principles to enhance health outcomes and constrain cost growth.  This brief offers an overview of Consumer Operated [...]