Value-Based Insurance Design
Authors: Eric C. Stecker, John Z. Ayanian, A. Mark Fendrick
Journal: Circulation (2015)

HomeCirculationVol. 132, No. 16Value-Based Insurance Design Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBValue-Based Insurance DesignAligning Incentives to Improve Cardiovascular Care Eric C. Stecker, MD, MPH, John Z. Ayanian, MD, MPP and A. Mark Fendrick, MD Eric C. SteckerEric C. Stecker From Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (E.C.S.); Institute for Healthcare Policy and Innovation, Division of General Medicine, Medical School and Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI (J.Z.A., A.M.F.); Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI (J.Z.A.); and Center for Value-Based Insurance Design, School of Public Health and Medical School, University of Michigan, Ann Arbor, MI (A.M.F.). , John Z. AyanianJohn Z. Ayanian From Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (E.C.S.); Institute for Healthcare Policy and Innovation, Division of General Medicine, Medical School and Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI (J.Z.A., A.M.F.); Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI (J.Z.A.); and Center for Value-Based Insurance Design, School of Public Health and Medical School, University of Michigan, Ann Arbor, MI (A.M.F.). and A. Mark FendrickA. Mark Fendrick From Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR (E.C.S.); Institute for Healthcare Policy and Innovation, Division of General Medicine, Medical School and Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI (J.Z.A., A.M.F.); Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI (J.Z.A.); and Center for Value-Based Insurance Design, School of Public Health and Medical School, University of Michigan, Ann Arbor, MI (A.M.F.). Originally published20 Oct 2015https://doi.org/10.1161/CIRCULATIONAHA.114.012584Circulation. 2015;132:1580–1585Over the past 50 years, the costs of American medical care have increased dramatically. Although these high costs have been accompanied by substantial reductions in morbidity and mortality, Americans could derive significantly more value from healthcare expenditures.1 For many policy makers, the major focus of healthcare reform has centered on methods to improve economic efficiency – the outcomes achieved relative to per capita healthcare spending. A more recent emphasis on patient-centered care has added growing awareness of the importance of accommodating individual patients' preferences, needs, and beliefs into health care.2 Value-based insurance design (V-BID) describes a system of health insurance that varies patients' cost sharing to maximize the use of high-value services while maintaining a focus on patient centeredness. This review addresses aspects of V-BID that are relevant to cardiovascular medicine: fundamental features, evidence for effectiveness, real-world applications, novel ways to build on strengths, relevance in future health policy landscapes, and known limitations.V-BID FundamentalsPatient CenterednessThe premise of V-BID is that patients should be placed at the center of reform efforts by incentivizing their behavior through modulation of out-of-pocket healthcare costs. V-BID is distinct from – yet complementary to – many other health policy constructs because it directs financial incentives toward patients rather than providers. At the same time, it promotes economic efficiency by allowing payers to subsidize care in a manner proportionate to its societal cost-effectiveness. Although patients are required to incorporate value-based financial incentives into their decision-making process, financial considerations are neither the only factor nor a coercive factor. A wide range of services can be covered, with varying contributions from the patient and the payer based on how much relative value is provided for each party. This focus on noncoercive patient incentives respects and reinforces the reality that medical decisions should incorporate patients' preferences as a central factor.Cost-sharing incentives are designed to maximize the use of high-value care, but patient autonomy is respected by permitting the selection of lower-value care by patients who are willing to pay more of the cost. In a departure from the covered/noncovered dichotomy of conventional insurance designs with fixed copayments, partial coverage through the selective use of higher patient cost sharing can be incorporated into V-BID. V-BID incentives are determined by using the concept of clinical nuance, which supports value-based patient choice by recognizing that: (1) different medical services contribute variably to improving health, and (2) the clinical benefit and economic efficiency derived from a specific service depends on context (ie, where it is used, when it is used, and for which patients it is used).Cost SharingPatient cost sharing in the form of copayments and coinsurance strongly influences healthcare use,3–5 yet it is not overtly addressed in many other health policy constructs. Discretionary patterns of use are thought to be critical modifiable factors that can improve quality and control healthcare costs.6,7 On the other hand, indiscriminate increases in cost sharing can lead to reductions in the use of preventive and essential care, which may worsen health disparities.4,8–10 V-BID uses clinical nuance to create a carrot-and-stick approach to mitigate concerns regarding cost-related nonadherence, and to reduce potentially harmful and wasteful health expenditures. Services across the entire spectrum of care that are deemed to be high value may be incentivized by lowering or eliminating cost sharing (carrot). Services without evidence of benefit can be discouraged through increases in cost sharing (stick). V-BID can shift the focus of patients, doctors, and payers away from a one-size-fits-all cost-sharing system that fails to acknowledge the differences in clinical value among medical interventions, and instead toward maximizing value in health care. It can steer stakeholder interactions away from the challenges of a reductionist, binary coverage decision model (covered/noncovered) or a cost-driven tiered model (generic/branded/noncovered drugs). Evidence-based services that are valued by patients and considered clinically indicated by physicians can be covered by using V-BID principles as long as value-based incentives are appropriately aligned by using carrots and sticks of variable cost sharing.Evidence for V-BID's EffectivenessV-BID programs have thus far demonstrated moderate effectiveness for increasing patient demand for high-value care and for improving outcomes. Application of V-BID to medication benefits has been associated with an average 3% absolute increase in adherence (ranging up to 10% in individual studies)11 and moderate improvement in cardiovascular outcomes (Table 1)12–14 in an expected dose-response manner.16 There has been one, large randomized trial testing V-BID techniques for patients with high-risk cardiovascular disease. In the Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI-FREEE) study, commercially insured patients experiencing acute myocardial infarction were randomly assigned to either usual prescription coverage or prescription coverage without cost sharing for any generic or brand-name angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, β-blocker, or statin.12 A V-BID coverage strategy that eliminated copayments for these medications led to improved medication adherence. The rate of full adherence with all 3 classes of evidence-based cardiovascular medications increased 3.2% (37% relative increase) in the V-BID group. Individual medication full adherence increased between 4.8% and 7.0% (relative increases of ≈20%). Improved adherence was associated with lower rates of additional major vascular events and decreased patient spending, with no increase in overall health costs.Table 1. Studies Evaluating Effects of Variable Medication Cost Sharing on Cardiovascular End Points or Healthcare UseStudyYearDesignSizePatient CharacteristicsObserved EffectKeeler et al141985RCT3495Stable outpatient↓ Blood pressurePilote et al152002ITS22 066>65 yo after AMINoneChoudhry et al122011RCT5855<65 yo after AMI↓ First major vascular event (secondary end point)Choudhry et al132012CBA2830 cases/49 801 controlsStable outpatient↓ Hospitalizations and emergency department admissionsAMI indicates acute myocardial infarction; CBA, controlled before-after study; ITS, interrupted time series study; RCT, randomized, controlled trial; and yo, years old.A secondary analysis was performed to examine the effect of the V-BID program on racial and ethnic disparities.17 At baseline, nonwhite patients enrolled in the MI-FREEE study were less adherent with prescribed medications and had higher healthcare spending than their white counterparts. After cost sharing was eliminated for the intervention group, adherence to β-blockers and statins significantly improved for nonwhite enrollees. In comparison with nonwhites with standard cost sharing, those for whom copayments were eliminated experienced a 35% lower risk of readmission for a major vascular event or coronary revascularization, and a 70% reduction in total healthcare spending, as well.Existing Applications of V-BIDV-BID has been used to incentivize both drug and nondrug health services and adoption has increased over time. In a 2007 survey of large employers, 20% reported using V-BID and 80% reported being interested or very interested in incorporating it.18 With passage of the Affordable Care Act, V-BID incentives were extended to millions of Americans to promote preventive care. The Affordable Care Act mandated the elimination of copayment and coinsurance for US Preventive Services Task Force level A and B recommendations, including screening for several cardiovascular risk factors and tobacco cessation interventions.19 V-BID has also been used to encourage a broader array of high-value care by directing patients toward high-quality clinicians or health systems. For example, the Oregon Public Employees Benefit Board has prioritized the use of high-quality primary care providers by lowering copayments for services at recognized primary care medical homes.20 Similarly, the home improvement retailer Lowes has prioritized high-value cardiovascular care at the Cleveland Clinic by eliminating deductibles and travel costs associated with treatment there.21V-BID has garnered significant multistakeholder support, which has enabled its implementation at both the state and national levels.22 Several state employee programs, such as those in Connecticut, Maine, Oregon, and Virginia, have implemented V-BID principles. In addition, the V-BID concept has been incorporated into state Medicaid programs, including those in Michigan, Oregon, and New Mexico. Advanced V-BID designs that include both carrots and sticks for a variety of services (medications, office visits, imaging services, and procedures) are being offered and studied by innovators such as Group Health Cooperative and the Mayo Clinic.Building on V-BIDA novel insurance design has been proposed that would expand V-BID reach and flexibility by shifting patient incentives from cost sharing at the episode-of-care level to value-based indexing of monthly insurance premiums. Relative value health insurance describes policies with premium levels set based on how closely coverage matches proven, cost-effective health care.23,24 Policies covering primarily cost-effective drugs, devices, and services would be offered at the lowest premium level. Policies covering health care that is unproven or not cost-effective would be offered at higher premium levels. Again, patients could choose coverage that matches their personal preferences by using principles analogous to V-BID. An advantage of the relative value health insurance construct is that it allows for general decisions about cost-sharing preferences at the time of policy selection. As a result, it distributes the costs (sticks) of low-value care preferred by some patients, and the savings (carrots) from high-value care preferred by others, across the duration of the insurance policy, rather than concentrating them at the episode-of-care level.Another alternative to conventional V-BID approaches could be created by bundling high-value services across episodes of care. Health care goods and services could be combined based on several different rubrics including clinical indication, patient diagnosis, and patient risk level.25 For example, a V-BID bundle could be constructed that pools post–myocardial infarction medications, clinician visits, laboratory testing, cardiac rehabilitation sessions, cardiac imaging, and an implantable cardioverter-defibrillator (if indicated) into a single package that is well defined and free for patients. Such an arrangement could simplify and make affordable what would otherwise be a daunting, unpredictable array of services and out-of-pocket costs for the average patient convalescing from a myocardial infarction. In another setting, patients at high risk for hospital admission for heart failure could enjoy free medications, clinician encounters, home telemonitoring, and cardiac rehabilitation encounters to promote adherence and close follow-up. Finally, if desirable from a value standpoint or if other forms of bundling would be excessively complex, patients could be incentivized to receive care from select high-quality clinicians or health systems.V-BID's Future RolesV-BID could be an important method for aligning incentives in the complex array of programs that are available to policy makers (Figure 1, Tables 2 and 3). Two features of V-BID make it a natural complement to existing healthcare reforms: (1) patient-focused incentives can be aligned with provider-focused incentives to better match supply and demand, and (2) episode-of-care level incentives can be used to enhance the effects of global payments. These features could be used in new ways to improve the value of cardiovascular care. Although V-BID has historically been tested mostly as a motivating incentive (carrot), there is increasing interest in using its demotivating features (stick) to discourage the use of low-value/overused services.Table 2. Incentive Programs That Span Multiple Episodes of CareProgramPrimary Targeted EntityDescriptionRelative value health insurance22Patients, physicians, and health systemsTheoretical system that shifts patient cost-sharing incentives from episodes of care to fixed monthly premiums. In the same manner as conventional V-BID programs, it uses lower pricing to incentivize high-value care and higher pricing to disincentivize low-value care.Global payments26Health systemsCapitation or partial-capitation system with quality and efficiency incentivesBundled payments27Health systemsHybrid system that incorporates multiple episodes of care by multiple providers into a single episode.Medicare value-based purchasing program28Health systemsFee-for-service–based system that incentivizes efficient, quality care over multiple patients/encounters.Medicare physician group demonstration projects29Physician groupsFee-for-service–based system that incentivizes efficient, quality care over multiple patients/encounters.Medicare physician quality reporting system30Individual physicians and physician groupsFee-for-service–based system that incentivizes care based on self-selected quality measures to be assessed over multiple patients/encounters.V-BID indicates value-based insurance design.Table 3. Incentive Programs That Target Individual Episodes of CareProgramPrimary Targeted EntityDescriptionV-BID31PatientsVariable patient cost-sharing system (usually at episode-of-care level) to incentivize high-value careShared decision making32PatientsInformation system to ensure that medical decision making is consistent with patient preferences. Not value targeted in a strict sense, but often leads to less costly care.Value-based payments33Individual physicians and physician groupsTheoretical system for providers that is analogous to V-BID; providers receive greater remuneration for highly cost-effective care. Based in a fee-for-service environment.Value-based RVUs34Individual physicians, physician groups and health systemsTheoretical system for providers that is analogous to both V-BID and value-based payments; clinician productivity metrics are weighted to favor high-value care. Could be used in either fee-for-service or capitated environments, and any form of healthcare organization.RVUs indicates relative value units; and V-BID, value-based insurance design.Download figureDownload PowerPointFigure 1. Example of various patient- and provider-focused incentive systems across a continuum of care for acute myocardial infarction. For more detailed descriptions see the text and Tables 2 and 3. HF indicates heart failure; MI, myocardial infarction; PGDP, physician group demonstration project; PQRS, physician quality reporting system; RVUs, relative value units; SCD, sudden cardiac death; V-BID, value-based insurance design; and VBP, value-based purchasing (for hospitals).Aligning Supply and DemandMaximizing the value of health care at a societal level requires that value-driven patient choices (demand) are well matched with available services (supply).35 Because multiple factors are at play, supply and demand for high-value services may become unbalanced. For example, supply distortions can arise from a shortage of primary care providers36 or geographic clustering of invasive cardiac services,37 whereas demand distortions can arise from poor patient participation in cardiac rehabilitation38 or excessive enthusiasm for routine ECG or echocardiography in preparticipation athletic screening.39 V-BID can be used to help match supply and demand by functioning as a complement to provider-based value incentives.40 For example, the MI-FREEE study described above (see Evidence for V-BID's Effectiveness above) showed that a V-BID program helped to move demand (patient medication adherence) closer to supply (provider medication prescription) for evidence-based cardiovascular therapy. It is unknown whether additional incentives, such as paying patients to take selected medications, would increase adherence further. Such a strategy has proven effective for smoking cessation pharmacotherapy.41 It is also unknown whether matching episode-of-care–based V-BID incentives with episode-of-care–based clinician incentives33,42 could have affected adherence.Aligning Patient Behavior With Global BudgetsEven the broadest of health policies must ultimately affect decisions made by individual patients and clinicians at discrete moments in time, particularly outpatient episodes of care. Thus, explicitly addressing patient preferences and incentives at the episode-of-care level could complement global payment priorities directed at health systems (Figure 2). Although many incentive systems attempt to influence providers by using a variety of leverage points, few established programs aside from V-BID are available to influence patient behavior (Tables 2 and 3).Download figureDownload PowerPointFigure 2. Flow diagram of the potential alignment of patient and provider incentives across a continuum of care. Provider-facing programs such as annual global payment, bundled payments, and value-based relative value units (RVUs) are paired with patient-facing programs such as value-based insurance design (V-BID) strategies and relative value health insurance policies. Note: V-BID bundled care, relative value health insurance (RVHI), and relative value RVUs are all theoretical constructs. For more detailed descriptions of each strategy see the text and Tables 2 and 3.Accountable care organizations and even individual health systems could be motivated to use V-BID principles independent of payers if patient behavior is incorporated into global payment quality metrics. In such a scenario, the same rationale by which accountable care organizations create disease management programs could drive them to create and fund their own V-BID programs. This issue could become relevant sooner than many realize. The Center for Medicare and Medicaid Services recently proposed a quality measure for the National Quality Foundation's Cardiovascular Measures Project that would target an 80% adherence benchmark for statin use among patients with cardiovascular disease.43 V-BID could be an important tool to improve performance for this metric.Increasing Appropriateness of Cardiovascular CareImproving the appropriateness of cardiovascular care (reducing overuse and underuse) is an important focus. However, many interventions, such as the use of radiology benefits managers, create administrative inefficiencies and focus one-sidedly on overuse. In the future, V-BID approaches could be used to more efficiently align patient demand incentives for appropriate care with provider quality metrics and supply incentives at both the episode-of-care and global-payment levels. For example, if guided by a marker of clinical value such as appropriateness criteria,44,45 echocardiography could be completely subsidized in certain high-value contexts such as guiding treatment when new signs and symptoms of heart failure are present (high appropriateness; 0% patient/100% payer). On the other hand, echocardiography in less valuable settings, such as routine surveillance of established heart failure without a change in clinical status, could be partially subsidized if done less often than yearly (moderate appropriateness; 50% patient/50% payer) or minimally subsidized if done more often than yearly (low appropriateness; 90% patient/10% payer). In any of these scenarios, V-BID allows patients, providers, and payers to partner in a manner that is more clinically nuanced than binary covered/noncovered decisions.LimitationsClinically nuanced payment models or benefit designs are not a panacea to substantial gaps in quality of care or variations in costs. However, patient engagement initiatives that provide incentives based on efficiency and health benefits – not absolute cost or profit – can complement ongoing provider-facing programs with similar goals. Nonetheless, V-BID applications may be challenging in some domains. Clinical scenarios for which patient discretion is unrealistic, such as emergency care for acute myocardial infarction or cardiac arrest, may not be readily addressed with V-BID. Similarly, when high-cost diagnostics or procedural treatments are embedded in complex episodes of care, such as prolonged hospitalizations or outpatient treatment protocols, isolating them for V-BID incentives can be difficult. In the most challenging scenarios, influencing provider behavior is likely to provide the maximum impact, and incentivizing patients to choose centers of excellence may be the only practical patient-directed approach.Another limitation is that V-BID has generally proven cost neutral rather than cost saving. Reductions in event-related costs among V-BID medication adherence programs have been counterbalanced by associated increases in prescription drug costs. This is not surprising, given that the underlying clinical trials of these medications have generally demonstrated them to be cost effective but not cost reducing. It is also important to recognize that the overall goals of health reform are to reduce the rate of growth of healthcare spending while increasing the value derived from that spending. Thus, many strategies included in health reform will improve cost efficiency without reducing absolute costs. Nonetheless, as the stick aspect of V-BID programs is tested to reduce overuse of low-value services, cost may more often be targeted as the primary goal of interventions. One important exception is for clinical services with simultaneous underuse and overuse. In such cases, reductions in the use of overused services may subsidize the use of underused services in a manner that is cost neutral yet value promoting.ConclusionsV-BID is a multifaceted approach that aligns consumer cost sharing to promote high-value care and discourage low-value care. Cardiovascular medicine is an ideal setting for using V-BID, given the breadth and depth of studies that evaluate the effect of medications, devices, procedures, imaging, and clinician services on clinical outcomes. When aligned with provider-facing quality initiatives, a clinically nuanced approach such as V-BID could improve cardiovascular care by mitigating cost-related nonadherence to evidence-based services, reducing disparities, and minimizing potential conflicts between patients, physicians, and payers.Sources of FundingThis work was funded by National Heart, Lung, and Blood Institute (NHLBI) grant K12 HL108974 supporting Dr Stecker.DisclosuresNone.FootnotesCorrespondence to Eric C. 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