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The experiences of plan sponsors show a common theme: the investment in workforce health is founded on variability in cost sharing based on value to the individual and the organization.1 1. Mahoney J. Value-based designs. Presented to the Health Care Service Corporation, May 2009; Richardson, TX. 4 4

The experiences of plan sponsors show a common theme: the investment in workforce health is founded on variability in cost sharing based on value to the individual and the organization.1 1. Mahoney J. Value-based designs. Presented to the Health Care Service Corporation, May 2009; Richardson, TX. 5 5

The experiences of plan sponsors show a common theme: the investment in workforce health is founded on variability in cost sharing based on value to the individual and the organization.1 1. Mahoney J. Value-based designs. Presented to the Health Care Service Corporation, May 2009; Richardson, TX. 6 6

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Reductions in medications supplied were also noted for1: ● NSAIDS, 45% High copays have been shown to reduce adherence to medication use. Research has shown that decreased adherence can increase long-term costs and have a negative impact on productivity. Researchers looked at pharmacy claims data and health benefit designs for more than 500,000 privately insured beneficiaries from 1997 to 2000. The analysis indicated that doubling of drug copays was linked to a marked reduction in the use of medications for 8 common chronic disease categories, including diabetes, high cholesterol, and hypertension. For patients with diabetes, asthma, and gastric disorders, reductions in medication use were associated with a 17% increase in annual emergency department (ED) visits and a 10% increase in hospital days.1 Reductions in medications supplied were also noted for1: ● NSAIDS, 45% ● Antihistamines, 44% ● Antiulcerants, 33% ● Antiasthmatics, 32% ● Antidepressants, 26% 1. Goldman DP et al. JAMA. 2004;291(19):2344–2350. 9 9

Trivedi et al obtained data from the Medicare Health Plan Employer Data and Information Set (HEDIS®) from 2001 through 2004 through the Centers for Medicare and Medicaid Services and reviewed 2,143,566 observations from enrollees in 174 Medicare-managed plans. The study sample included 550,082 observations that were assessed for the HEDIS mammography measure, representing 366,475 women between the ages of 65 and 69 years.1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). 1. Trivedi AN et al. N Engl J Med. 2008;358(4):375–383. 10

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In this controlled trial, the intervention reduced copayments for the 5 chronic medication classes seen here. Results demonstrated the potential for copayment reduction to increase medication adherence above the effects of an existing disease-management program.1 1. Adapted from Chernew ME et al. Health Aff. 2008;27(1):103–112. 12

Carle Clinic Association, a 342-physician multispecialty group practice in east central Illinois, is the owner of Health Alliance Medical Plans in Illinois. Carle Clinic tested a value-based design for use with its employees being treated for asthma and diabetes. In this slide, you can see the replication of their results against those of Pitney Bowes; after 1 year, the number of people with diagnosed asthma who were on controller medications increased, the exclusive use of rescue drugs decreased, and the number of people who achieved a medication possession ratio (MPR) of 80% or more increased by 33%.1 1. Better health, better bottom line. Case study: Health Alliance Medical Plans value-based benefits for diabetes and asthma. Center for Health Value Innovation. vbhealth.org/papers/CarleClinic.pdf. Accessed September 21, 2009. 13

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This study by Gibson et al looked at the effect of a value-based insurance design (VBID) pharmacy program for diabetes that lowered out-of pocket costs for antidiabetic medications in 2 units of a large, multiindustry firm. The comparison group was a matched cohort from the remainder of the firm’s units, which had a traditional 3-tier pharmacy plan: 10% copayments for generic drugs, 20% for preferred brand-name drugs, 35% for nonpreferred brand-name drugs.1 All of the participants had the option to enroll in a disease management program consisting of targeted mailings, a workbook about the disease, telephone outreach by a nurse, coaching, and periodic monitoring. Additional communications reinforced diabetes management goals.1 Merck provided funding for this study and one of the coauthors is a Merck employee. 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 15

This diagram illustrates the breakdown of the study design This diagram illustrates the breakdown of the study design. The post-intervention period included 3 years: 2006, 2007, and 2008. All enrollees aged under 65 years with at least 4 consecutive quarters of enrollment were included in the study.1 Enrollees in the value-based program and the disease management (DM) program were matched with similar enrollees in the DM program alone. Similarly, enrollees in the value-based program alone were matched with diabetes patients who were not in either the value-based program or the DM program.1 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 16

This diagram illustrates the breakdown of the study design This diagram illustrates the breakdown of the study design. The post-intervention period included 3 years: 2006, 2007, and 2008. All enrollees aged under 65 years with at least 4 consecutive quarters of enrollment were included in the study.1 Enrollees in the value-based program and the disease management (DM) program were matched with similar enrollees in the DM program alone. Similarly, enrollees in the value-based program alone were matched with diabetes patients who were not in either the value-based program or the DM program.1 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 17

Enrollees were given an estimated propensity score based on sociodemographic variables, plan type, health status, and length of enrollment by number of quarters. They were then matched with enrollees in the relevant comparison group according to propensity score.1 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 18

Multivariate generalized estimating equations were used to estimate the effects of the VBID program on health care use and spending in each quarter vs the comparison group.1 The medication possession ratio was calculated based on the percentage of days that an enrollee had the prescribed medication available (determined by when the prescription was filled and how many days were supplied). Adherence was assessed by the percentage of patients who had medication available for at least 80% of the days per quarter. This is generally accepted as a threshold for clinical benefits to occur.1 The effects on medication use for enrollees in the VBID program who participated in disease management were higher in each year than for patients not in the VBID group. The difference was statistically significant. For patients without disease management, these effects were mostly not significant.1 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 19

1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. This graph shows the estimated program effect on medication possession ratios for the study enrollees with the value-based program plus disease management compared with those with disease management alone.1 For patients in the VBID-plus-DM group, in the first year after implementation the medication possession ratio for oral medications rose 3.7% above the ratio for those not in the value-based program. In the second year this increase was 4.8%, and in the third year it was 5.8% above the ratio for patients not in the value-based program.1 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 20

1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. Results were similar to those found in medication use when assessing the receipt of medical services recommended in guidelines. The rates for HbA1c testing, lipid tests, primary care physician visits, and urinalysis were higher in the group with the value-based program plus disease management. These effects increased with time compared to the baseline year without the VBID intervention. However, the rate of retinal exams was not affected.1 Generally, rates of medical services among the group not in the DM program did not significantly change. 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 21

This graph shows the estimated program effect on diabetes guidelines measures for the study enrollees with the value-based program and disease management vs those with disease management alone.1 The program effect reflects the difference in increase of these measures between the group with VBID and the group without VBID. 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108. 22

Diabetes-related prescription spending in the value-based insurance design plus disease management (VBID + DM) group increased due to higher adherence to medications. This increased medication adherence was evident in the first year and persisted throughout all study years. Significant decreases in diabetes-related medical spending offset prescription increases to produce an overall decrease in diabetes-related costs. Diabetes-related medical costs decreased in the first study year and showed further decrease in each subsequent year. Program impact on all-cause total medical + prescription spending was minimal and not statistically significant. 1. Gibson TB et al. Health Affairs. 2011;30(1):100–108.

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VBID can be applied across a spectrum of choices, from a strategy limited to reducing copays for specific drugs to one that incorporates a comprehensive worker-specific benefit design.1,2 The VBID spectrum displayed in this slide demonstrates the range of complexity that with which this system may be used. There are 2 basic VBID approaches3: Reducing copays for specific drugs Reducing copays for services related to a diagnosis; this approach can be expanded beyond pharmaceutical therapy to include other management-related services, such as behavioral counseling and advice and support for lifestyle modifications The approach with the greatest potential for a positive financial impact is one that is employee-specific. The better the system is at identifying which services are high value for which patients, the higher the financial return will be.1 1. Fendrick AM et al. Aligning Incentives and Systems: Promoting Synergy Between Value-Based Insurance Design and the Patient Centered Medical Home. National Business Coalition on Health. http://www.pcpcc.net/valuebasedinsurancedesign. Accessed August 19, 2010. 2. Chernew ME et al. Value based insurance design: restoring health to the health care cost debate. Society of Actuaries Web site. http://www.soa.org/library/essays/health-essay-2009-chernew.pdf. Accessed August 19, 2010. 3. Fendrick AM et al. Am J Manag Care. 2006;12:SP5-SP10. 25

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