Man and woman speaking with doctor There is still unrealized opportunity to use value-basedinsurance design to impact the utilization of a wider array of highvalue, and low value, clinical services. (Photo:Shutterstock)

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Do consumers really value items that cost money more than thosethat are free? One leading benefit design strategy hopes that whenit comes to essential health care services, the answer is no.Value-based insurance design (VBID) removes or lowers financial barriers to high-value clinicalservices in hopes that this will make consumers more likely to seekthem.

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First theorized by University of Michigan faculty in 2005, theconcept underpins much of what consumers may take for granted intheir covered benefits, such as free annual physicals, but it hasthe potential to do so much more. Thus far, VBID programs havelargely focused on waiving or lowering out-of-pocket costs forpreventive services. The most prominent example is Section 2713 ofthe Affordable Care Act, which requires health plans to coverrecommended primary preventive services (e.g., screening fordepression, flu shots, all FDA-approved contraceptives) with nocost sharing.

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Related: A secret weapon in our march toward value-basedcare

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The VBID model has also had measurable success on the pharmacy side, wherepayers and purchasers alike have prompted consumers to fillgeneric prescriptions over brand names bysignificantly lowering out-of-pocket costs for the former.

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Because of these examples, VBID has been on employers' radar fora while, but the concept appears to be experiencing a second wind.That's because there is still unrealized opportunity to use VBID toimpact the utilization of a wider array of high-value and low-valueclinical services.

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Consider secondary preventive services: these encompass all ofthe care patients with chronic conditions need to keep theirconditions under control and to stay out of the hospital. Patientsmanaging chronic conditions, such as diabetes, congestive heartfailure or hypertension may be the most impacted by financialbarriers to care. That's why Congress introduced a bi-partisan bill in 2018 proposing that chronicdisease prevention and treatment be covered for pre-deductiblepatients with health savings accounts (HSA)-eligiblehigh-deductible health plans (HDHPs) per the VBID model.

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Some employers have sidestepped this obstacle by setting uphealth reimbursement accounts instead of HSAs.The Innovation Center at the Centers for Medicare and MedicaidServices also launched the Medicare Advantage (MA) VBID Model inJanuary 2017 in an attempt to improve access to high value servicesfor patients with a long list of chronic conditions.

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These efforts focus on expanding access to high-value clinicalservices, but this only represents half of the VBID equation. VBIDcan also be used to discourage consumers from seeking services thatare not proven to generate value. In 2017, the Task Force on Low-Value Care identified fiveservices that are commonly paid for but shouldn't be, eating upabout $25 billion in annual health expendituresnationally. The list includes imaging for acute low-backpain in the first six weeks after onset, population-based vitamin Dscreening, and diagnostic testing and imaging for low-risk patientsprior to low-risk surgery.

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Figuring out how to limit the provision of these services willrequire thoughtful benefit design and communications strategies, aswell as alignment with providers. To that end, an Employer Task Force in Virginia has stepped upto the challenge.

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These specific examples represent a troubling but solvablephenomenon: significant health care spending may be going towasteful services that have little to no positive impact on health,while some high-value services that do provide meaningful clinicalbenefit may be under-utilized. If you are a benefit managerobserving this trend, consider asking your health plandirectly—what VBID programs do you have in place today? What aboutfor 2020? Those committed to high value health care should have aready answer.

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Suzanne Delbanco is executive director atCatalyst forPayment Reform.Suzanne Delbanco CPR


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