Briefs

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 [...]

Originally Produced:  November 2013   Updated:  July 2019 Protecting Preventive Care Coverage in the Post-ACA Era Preventive Care Coverage in the ACA: Section 2713 of the Public Health Service Act as amended by the Patient Protection and Affordable Care Act (ACA) requires that issuers offering group or individual health insurance plans must provide coverage for specified preventive services without a beneficiary copayment or a contribution toward a deductible.  This elimination of consumer cost-sharing applies only when these services are delivered by a network provider. Determining Covered Preventive Services: Congress selected three organizations to determine covered preventive services with the intent to include all segments of the population.  These organizations are the United States Preventive Services Task Force, the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices, and the Health Resources and Services Administration.  The current list of preventive services includes a variety of counseling [...]

Originally Produced:  August 2013   Updated:  February 2014V-BID in Action:  Michigan Medicaid ExpansionIntroductionValue-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” and “sticks” are used 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, as well as when and where the service is provided.  By Incorporating greater clinical nuance into benefit design, payers, purchasers, taxpayers, and consumers can attain more health for every dollar spent.Federal Government Allows V-BID in [...]

New Regulations Permit Use of Value-Based Insurance Design in State Medicaid Programs Originally Produced: July 2013   Updated: June 2016. Introduction Value-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” and “sticks” are used 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, as well as when and where the service is provided. Incorporating greater clinical nuance into benefit design, payers, purchasers, taxpayers, and consumers can attain more health [...]

Originally Produced: April 2013   Updated: July 2016. V-BID and Grandfathered Health Plans: Promoting High Value Services and Controlling Costs Introduction Value-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” and “sticks” are used in a clinically nuanced manner, V-BID improves healthcare 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, as well as when and where the service is provided. Maintaining Grandfathered Health Plan Status Allowing Americans to keep their existing health insurance was a critical element of [...]

Originally Produced: February 2013   Updated: July 2016. V-BID in Action: Driving Value through Clinically Nuanced Incentives Introduction Value-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.i Dangers of a Blunt Approach It has been shown that when patients are faced with increases in cost-sharing applied to all services regardless of clinical benefit, they reduce their use of both high-value and low-value services.  While this blunt approach potentially lowers expenditures in the short-term, the cost-related noncompliance with high- value services leads to inferior health outcomes and higher [...]

Originally Produced:  September 2012   Updated:  June 2016Communicating with Consumers about Value-Based Insurance DesignValue-Based Insurance Design (V-BID) is one of the most innovative and widely implemented approaches to enhance clinical outcomes and control the cost of health care.  V-BID programs lower financial barriers to specific preventive services, diagnostic tests, treatments, and providers demonstrated to be of high value across the entire continuum of clinical care.  Studies show that when barriers to high-value care are reduced, patient compliance with recommended treatments increasesii and potential cost savings result.iii  V-BID programs may also impose higher out-of-pocket cost-sharing for consumers to discourage the use of services of marginal or unproven value.iv  Restructuring health insurance plans to provide patient incentives for evidence-based care can help refocus the health care system on quality outcomes rather than volume.Public and private employers have been implementing V-BID programs for more than a decade, and the use [...]

Originally Produced: August 2012  Updated: July 2016.  Wellness and Value-Based Insurance Design: Better Outcomes Together  Value-Based Insurance Design (V-BID) is a method of improving individual health and controlling the cost of healthcare.  In the case of employer wellness programs, V-BID helps align the amount of health produced with the cost to the consumer.  V-BID can integrate existing wellness and health management programs to more wisely invest in those employees, regardless of age, who most need care and to expand preventive services to those at risk of developing a health condition. Evolution of Wellness Programs Employers have long cited unhealthy employee behaviors as a major challenge to maintaining affordable health care benefits.  Workplace wellness programs emerged as a natural way to encourage and incentivize healthy behaviors, and these programs have evolved considerably over the last decade.  Prompted by increasing costs, chronic disease rates, and absenteeism, numerous programs and interventions [...]

Patient-Centered Medical Homes and V-BID: A Highly Synergistic Approach to Achieve More Health for the Moneyi Originally Produced:  July 2012.  Updated:  July 2016 The past several decades have produced remarkable technological and therapeutic innovations in the prevention and treatment of disease resulting in impressive reductions in morbidity and mortality.  These enhanced clinical outcomes coincide with a time of significant stress within our healthcare system – namely with the burden of costs of care.  Although expenditure growth is the principle driving force behind health care reform, concerns remain regarding access to, and quality of, medical services.  The challenge, therefore, is to enable continued improvements in care while containing expenditure growth. Unfortunately, few reform initiatives simultaneously address the issues of quality improvement and cost containment.  As a result, “value” –the clinical benefit achieved for the money spent–is frequently excluded from the dialogue on how to manage spending. Currently popular payment [...]

Originally Produced: May 2012   Updated: July 2016“Will V-BID Save My Company Money?” A Guide To Thinking About V-BID ImplementationValue-Based Insurance Design (V-BID) is one of the most innovative and widely implemented approaches to enhance clinical outcomes and control the cost of health care.  The goal of V-BID is to align patients’ out-of-pocket costs, such as copayments and premiums, with the “clinically nuanced” value of health services.  Restructuring wellness programs and health insurance plans to provide consumer incentives for evidence-based care can help refocus health care expenditures on value rather than volume, especially if provider payments are restructured along similar lines.There are multiple approaches to V-BID, which may include “carrots” or “sticks,” targeting specific clinical services, and identifying patients with particular clinical diagnoses.i  V-BID uses incentives to encourage the following:Use of high-value services, including preventive services and certain prescription drugs, often covered at low / no co-payment levels [...]

Value-Based Insurance Design: Contributions to Consumer Health in Consumer-Directed Health Plans1 Originally Produced: April 2012. Updated: June 2016 A consumer-directed health plan (CDHP) is an insurance product that offers lower premiums in exchange for higher patient deductibles than traditional plans.  People who use CDHPs are responsible for paying for most of their routine care.  The goal of CDHPs is to make customers more cost-conscious about the care they use, theoretically saving money on foregone services and lowering prices for consumers.  In 2010, 28 million people were enrolled in a CDHP; in the same year nearly half of all employers reported that they planned to offer a CDHP to their employees within five years.2 CDHPs have faced criticism because the higher deductibles may cause patients to use less care. Research shows that when cost sharing is increased, consumers will forgo needed as well as unneeded care, and are likely to have [...]