1. An Evaluation of a Value-Based Health Plan Design at Group Health David Grossman, MD, MPH Group Health Research Institute Seattle, Washington

2. Disclosures and Funding PI is employee and shareholder, Group Health Permanente medical group Funding from AHRQ (R01 HS018913-01) and Group Health Cooperative

3. Improving Value of US Healthcare Expenditures Increased purchaser focus on: Improving value of expenditures Reducing waste Improving health outcomes for beneficiaries Preventing chronic illness and complications Two main levers Health plan design Delivery system design

4. Cost-Sharing and Health Impact of larger cost-shares on chronic disease self- management Chronic disease the major driver in health care costs Re-consideration of indiscriminate cost-sharing Consumer holds the early short term risk Purchaser/health plan holds the longer term risk

5. Value-based Cost-Sharing First iterations: Preventive service coverage Tiered pharmacy benefits Generics Brand-name Non-preferred and non-formulary Most recent efforts focused on pharmacy cost-sharing: reducing cost-shares Pitney Bowes University of Michigan employees

6. Science of Value-Based Design Large body of evidence on impact of increased cost- shares Tends to be focused on discrete services Much smaller literature on impact of reducing cost shares Even smaller literature on impact of cost-sharing on health outcomes and productivity Tiny literature using control group with multiple outcomes

7. Worksite Wellness Another approach to reducing costs and improving health Focus on lifestyle change Incenting health behavior Healthy work environments Change of work culture Outcomes of interest Health status and utilization Absenteeism and presenteeism Productivity 77% of large employers offer these services Health risk assessments are entry portal for engagement

8. Group Health’s Total Health Plan for Employees Employer Aims Improve productivity through Better health of staff Decreased absences Improved on-the-job productivity Decrease health expenditure trend rate Mechanism Incent healthy behaviors and improved chronic disease control through monetary incentives and value-based health benefit pricing Reinforce culture of self-awareness, accountability and reporting of health and health behaviors through monetary incentives and culture change

9. Specific Aims To assess the impact of the new value-based insurance design on: PRIMARY: changes over time in employee self-reported: health status absenteeism due to illness and disability presenteeism (i.e. lost productivity time at the workplace) SECONDARY: clinical quality scores for chronic illness care and preventive screenings, lifestyle behavioral risk factors, employee satisfaction with health benefits, health services utilization by employees, and employer-paid health costs for the employee population.

11. Total Health Design Overview Value-based copayments Preventive services (already 1 st dollar): no change Chronic disease cost-sharing decreased for Selected Visits Pharmacy Worksite wellness and health promotion activities Engagement tied to premium stabilization for 3 years Health risk assessment annually, AND Achievement of point threshold Points aimed at both healthy and chronically ill staff

12. Visit Cost-Sharing Waiver of co-pay for 2 visits/year for chronic care Coronary Artery Disease Diabetes Hypertension Congestive Heart Failure Asthma Mental Health (first ten visits) Waiver of copay for chemical dependency visits and lactation service visits

13. Pharmacy Co-payments Copayments reduced to zero for: generic, mail dispensed meds for same diseases plus depression Copayment reduced for brand name drugs for same diseases

14. Devices Wavier of cost-sharing for: Home BP monitors Diabetic glucose monitors Spaces for inhaled asthma meds

15. Obesity Management Programs 50% discount for enrollment 100% coverage (50% rebate) for diabetics that lose five percent of body weight

16. Cost-Shares Increased Outpatient surgery High cost imaging procedures CT, MRI, PET

17. Total Health Website

18. Total Health Evaluation Design Study Design Quasi-experimental 2 group before/after design Repeated measures Control group: Kaiser Permanente Colorado employees

19. Survey Tool Survey invitation to employees Web survey tool Paper survey on request Domains: Instrument Functional Status:(SF-12) Workplace productivity: Work Health Interview

20. Outcomes Primary Health status change: Survey Absenteeism due to illness: Survey +HR data Productivity at work: Survey Secondary Care Quality scores Chronic illness:HEDIS scores Preventive servicesHEDIS scores Lifestyle behavioral risk factorsSurvey E.g. smoking, activity Employee satisfactionSurvey Costs and service utilizationClaims data Health Risk Behaviors BRFSS, other »Tobacco »Alcohol »BMI »Physical Activity »Satisfaction w/ plan

21. Administrative Data Health utilization/cost/quality Group Health Research Institute data warehouse Claims Pharmacy EMR data Employee characteristics Human Resources administrative data

22. Data Collection Sample of 5000 employees invited to take e-survey tool Active opt-out Implied consent with survey completion Separate permissions to link claims and HR data 3 follow-up emails No telephone follow-up

23. Statistical Power

25. Total Health – participation >80% of all staff and spouses/domestic partners on the TH medical plan have taken the HRA 73% are earning points on the wellness website

26. Progress to Date Baseline survey completed early 2010 Group Health: 70% response rate KPCO: 60% response rate Permissions to link survey data Approximately 60-64% agree to linkage with HR and/or medical data

27. Challenges and Strengths Privacy issues/concerns Employer is also provider of care Key engagement of organized labor units Validity of self-reported data Study design and potential for confounding Use of highly similar control group external to Group Health

28. GHRI/UWKPCO Paul FishmanArne Beck Nora HenriksonDebra Ritzwoller Rebecca HubbardNancy Brace Diane Martin Rob Reid Ellen Schartz Aaron Scrol Kay Theis Research Team