Health Insurance Managed Care P4P Quality


Value-based insurance design looks to be expanding. As the American Journal of Managed Care reports:

The bill calls for a pilot demonstrating the feasibility of incorporating VBID by “reducing co-payments or cost shares for targeted populations of covered beneficiaries in the receipt of high-value medications and services and the use of high-value providers” no later than January 1, 2018.

The pilot will assess how implementing VBID concepts impacts adherence to medication, quality measures, health outcomes, and patient experience. TRICARE currently implements cost sharing in a “one-size-fits-all” way, similar to Medicare. Beginning January 1, 2017, Medicare Advantage is implementing its own VBID demonstration, which will run for 5 years.

The demonstration will only be available in 7 states in 2017 (Arizona, Iowa, Indiana, Massachusetts, Oregon, Pennsylvania, and Tennessee) with 3 additional states (Alabama, Michigan, and Texas) being added in 2018. In the first year, plans can offer varied benefit design for enrollees who fall into certain clinical categories: diabetes, congestive heart failure, chronic obstructive pulmonary disease, past stroke, hypertension, coronary artery disease, and mood disorders. In 2018, the demonstration will expand to include dementia and rheumatoid arthritis.

Tying copayments to care value seems like a good thing, as long as value is measured well.  For instance, consider an extreme case where an individual is allergic to a high-value treatment.  Would they be required to pay the higher-copay?  There are a number of nuances to be ironed out, but tying copayments to value without restricting patient choice does seem like a win-win for patients and payers.

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