On May 7, 2020, the final 2021 Notice of Benefit and Payment Parameters rule released by the broad support for the inclusion of V-BID principles in marketplace health plans. This rule includes language and research from the V-BID Center’s own guidelines for the V-BID X health plan, describing the potential for a “value-based model” qualified health plan.
Value-Based Insurance Design (V-BID) serves as a promising solution to the misallocation of underused of high-value care and utilization of care associated with no clinical benefit. V-BID programs selectively reduce financial barriers to evidence-based care that improve patient-centered outcomes. The incremental expenditures incurred by this increased use are paid for by savings incurred by the reduced use of low-value care.
Although V-BID principles have generated multi-stakeholder interest and bipartisan political support over the years, implementation has been slowed by a lack of a model plan that specified high and low-value services, including the cost-sharing changes necessary to result in the same or lower total medical spending. ‘V-BID X’ plan designs look to fill this void.
There is a lot of enthusiasm for the V-BID X model plan, most notably from the Department of Health and Human Services (HHS). On January 31, 2020, in the 2021 Notice of Benefit and Payment Parameters rule, HHS declared broad support for the inclusion of V-BID principles in marketplace health plans. The rule uses language and research directly from The V-BID Center’s own guidelines for V-BID X, noting the potential of “value-based model” qualified health plans.
With support from Arnold Ventures, a group of public and private stakeholders convened to specify the high and low-value services and establish the cost-sharing parameters for a cost-neutral model plan. An independent actuarial firm was engaged to estimate the incremental spending on high-value services and the cost offsets resulting from higher cost-sharing on low-value care.
WEBINAR | V-BID X: A NEW PLAN OPTION FOR THE INDIVIDUAL HEALTH INSURANCE MARKET
After substantial deliberation, services for reduced or eliminated cost-sharing (high-value) and increased cost-sharing (low-value) were selected (Table 1). For select services, cost-sharing was eliminated or reduced and projected additional spending was estimated using actuarial modeling. Out-of-pocket costs were increased on the selected low-value services such that the model plan results in the same level of total spending. If the reduction in spending on services with no clinical benefit exceeds the added expenditures on high-value care, decreased premiums will result.
Table 1. High and Low-Value Services
| High-Value Services and Drugs with Highly Reduced or Eliminated Cost-Sharing | Low-Value Services with No Coverage | |
|---|---|---|
|
Glucometers and testing strips |
Anti-thrombotic/anticoagulants |
Spinal fusions |
|
LDL testing (hyperlipidemia) |
Anti-depressants |
Vertebroplasty and kyphoplasty |
|
Hemoglobin A1C testing (diabetes) |
Statins |
Vitamin D testing |
|
Cardiac rehabilitation |
Antipsychotics |
Proton beam therapy for prostate cancer |
|
INR Testing (hypercoagulability) |
ACE inhibitors and ARBs |
|
|
Pulmonary rehabilitation |
Beta blockers |
|
|
Peak flow meters (asthma) |
Buprenorphine-naloxone |
|
|
Blood pressure monitors (hypertension) |
Anti-resorptive therapy |
|
|
Glucose lowering agents |
Tobacco cessation treatments |
|
|
Rheumatoid arthritis medications |
Naloxone |
|
|
Inhaled Corticosteroids |
Thyroid-related |
|
|
Antiretrovirals |
|
|
| High-Value Branded Drug Classes with Reduced Cost Sharing | Commonly Used Services with Limited Value and Increased Cost-Sharing | |
|---|---|---|
|
Pre-exposure prophylaxis for HIV |
Outpatient specialist services |
X-rays and other diagnostic imaging |
|
Hepatitis C directing-acting combination |
Outpatient labs |
Outpatient surgical services |
|
Anti-TNF |
High-cost imaging |
Non-preferred branded drugs |
Conclusion
V-BID X presents a template to guide organizations interested in incorporating cost-neutral, value-based principles into plan benefit design. Applying targeted cost-sharing based on the clinical value – not price – of a service will allow consumers improved access to high-value care, reduced cost-related non-adherence and decreased exposure to harmful care. Payers meanwhile enjoy the advantage of improved efficiency of their medical expenditures.