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The American Journal of Managed Care May 2019
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Evaluation of Value-Based Insurance Design for Primary Care
Qinli Ma, PhD; Gosia Sylwestrzak, MA; Manish Oza, MD; Lorraine Garneau; and Andrea R. DeVries, PhD
Clarification of References to Medication Adherence Scale
Open Doors to Primary Care Should Add a “Screen” to Reduce Low-Value Care
Betsy Q. Cliff, MS; and A. Mark Fendrick, MD
From the Editorial Board: Daniel B. Wolfson, MHSA
Daniel B. Wolfson, MHSA
Cost-Effectiveness of DPP-4 Inhibitor and SGLT2 Inhibitor Combination Therapy for Type 2 Diabetes
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Improving Provider Directory Accuracy: Can Machine-Readable Directories Help?
Michael Adelberg, MA, MPP; Austin Frakt, PhD; Daniel Polsky, PhD; and Michelle Kitchman Strollo, DrPH, MHS
Electronic Consults for Improving Specialty Care Access for Veterans
David E. Winchester, MD, MS; Anita Wokhlu, MD; Juan Vilaro, MD; Anthony A. Bavry, MD, MPH; Ki Park, MD; Calvin Choi, MD; Mark Panna, MD; Michael Kaufmann, MD; Matthew McKillop, MD; and Carsten Schmalfuss, MD
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Leah L. Zullig, PhD; Bradi B. Granger, PhD; Helene Vilme, DrPH; Megan M. Oakes, MPA; and Hayden B. Bosworth, PhD
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Maria de Jesus Diaz-Perez, PhD; Rita Hanover, PhD; Emilie Sites, MPH; Doug Rupp, BS; Jim Courtemanche, MS; and Emily Levi, MPH
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Laura M. Holdsworth, PhD; Dani L. Zionts, MScPH; Karen Marie De Sola-Smith, PhD; Melissa Valentine, PhD; Marcy D. Winget, PhD; and Steven M. Asch, MD
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Joel F. Farley, PhD; Arun Kumar, PharmD, MS; Benjamin Y. Urick, PharmD, PhD; and Marisa E. Domino, PhD
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Ryan P. Radecki, MD, MS; Kevin F. Foley, PhD; Timothy S. Elzinga, MD; Cynthia P. Horak, MD; Thomas E. Gant, MS; Heather M. Papp, BA; Adam J. Morris, BS; Natalie R. Hauser, BA; and Briar L. Ertz-Berger, MD, MPH

Evaluation of Value-Based Insurance Design for Primary Care

Qinli Ma, PhD; Gosia Sylwestrzak, MA; Manish Oza, MD; Lorraine Garneau; and Andrea R. DeVries, PhD
The removal of cost sharing increased primary care access and did not negatively affect total cost of care.

The decision to implement VBID by removing enrollees’ cost sharing for all PCP visits marked a departure from conventional cost structures at a time when a continually growing portion of healthcare expenditures was being transferred to consumers. Rather than using the blunt tool of a fixed cost-sharing rate with the purpose of decreasing the use of low-value services, our research sought to determine the impact of VBID in encouraging the use of high-value services (primary care). In this study, we examined both children and adults during a 4-year period after implementation of the VBID initiative for primary care in a large employer group.

The VBID cohort in our study experienced a lower total healthcare spending trend relative to the comparison cohort, driven by decreases in medical utilization. In contrast to the results of a prior study of the initiative,17 which was limited to children and found no change in overall medical expenditures, our results speak favorably for the implementation of VBID for primary care. One explanation for the difference is that inclusion of adults, a population expected to have more chronic conditions, generated more opportunity for improved disease management through PCPs. Additionally, our study assessed healthcare spending over a 4-year period compared with 2 years in the previous study, which also allowed for improvements in chronic disease management to affect outcomes to a greater degree.

In our study, the VBID cohort did not experience a statistically significant increase in physician office visits compared with the comparison cohort from the preintervention to the postintervention period (2.6% increase vs 1.7% increase). Given the benefit change, it was expected that office visits might increase to a greater extent than was actually observed. We found that the increase in office visits primarily occurred within individuals aged 51 to 64 years in both cohorts, who may have more ongoing healthcare needs than younger members. For the same age group, we observed that the VBID cohort had a large relative reduction in ED visits for both all-cause and primary care–treatable conditions. One hypothesis about the reduction in ED visits and the relatively small increase in office visits is that removing financial barriers to primary care may have improved timeliness of care, which in turn led to positive health outcomes—reduced need for ED use and for follow-up care office visits.18,24,25 In addition, timely evaluation can result in the treatment of an urgent condition before it turns into an emergent condition, and proper management of chronic conditions tends to decrease morbidity and associated healthcare spending.25,26

Evaluations of VBID initiatives for medical services are relatively limited. The existing evidence suggests that increased cost sharing leads to reduced use of low-value services, but encouraging use of high-value services—and establishing a corresponding return on investment—is harder to demonstrate. For example, the Mayo Clinic study reported a decrease of 0.7 visits per person to specialists in response to increased cost sharing for specialty care services; however, no change in PCP visits was associated with the removal of cost sharing.6 Although the 2008 Oregon Medicaid Experiment did not report the impact on expenditures, the study found that beyond the improved receipt of primary care and preventive services at community health centers, use of other health services increased with Medicaid expansion.27 In the 2011 Connecticut experience, participants had used more preventive services within 2 years of receiving incentives; however, the impact on expenditures was inconclusive, and researchers concluded that longer-term follow-up was needed.28

Strengths and Limitations

Our study contributes to the existing evidence on the impact of VBID initiatives in the area of primary care. There are several unique features of this study. First, our study, building on recommendations from earlier studies, covered a time period spanning several years, which might be required to see benefits from improved PCP care. Second, prior implementations focused on patients who had chronic diseases or were previously uninsured, whereas this initiative targeted, other than those with severe health issues, employees and their family members regardless of their underlying risks. Making primary care more accessible increases the potential to prevent development of chronic conditions and to avoid subsequent treatment expenses. Additionally, aspects of primary care, such as care continuity and the patient–provider relationship, have considerable clinical benefits above and beyond simple disease management in patients with chronic conditions. Examples include higher vaccination rates and higher utilization of recommended screening services, which have been shown to decrease under the pressure of increases in cost sharing.10,17,29,30 This raises some worthy ideas for future research: Evaluating quality of care in subsets of individuals with chronic conditions, or age groups eligible for certain cancer screenings, will complete understanding of the impact of the initiative; directly assessing patient satisfaction and perception will help understand how the initiative works.

The results of this study were subject to several limitations. First, study subjects were affected by other changes in the marketplace. One major change was the enactment in March 2010 of the Affordable Care Act (ACA), which requires insurers to offer free preventive services to all members.31 This may contribute to the observed improvement of the comparison cohort during the postintervention period driven by the preventive services provision of ACA, and it potentially attenuates the impact of the VBID intervention. Second, there were some unobserved characteristics within the 2 matched cohorts, such as marital status, income, and primary care site–level information, which might affect members’ healthcare behaviors. Third, the VBID cohort consisted of a relatively young and healthy employed population, so the results may not apply to complex chronically ill populations who would consume more healthcare resources. The VBID cohort also had good access to care at baseline and continuous healthcare coverage for a long time, which may affect the study generalizability. In the aforementioned 2008 Oregon Medicaid Experiment, the uninsured population sought more primary care services after receiving insurance coverage; however, they also had more ED visits and hospitalizations and little change in overall health measures after 2 years of participation.27,32-35 The type of VBID intervention demonstrated in our study may offer additional potential for populations with limited provider access and higher price sensitivity, but as seen with the Oregon Medicaid study, it is difficult to predict the impact.


This real-world analysis, using quasi-experimental design, demonstrates the potential for favorable spending trends with carefully crafted benefit design. Removing cost sharing for PCP care was associated with a moderate favorable trend in total medical expenditures through reduced use of healthcare services relative to a matched comparison group. Preserving and promoting access to care while keeping expenditure trends stable is an attractive outcome for all participants in the healthcare system. The favorable results for spending are encouraging. Further investigations of this VBID initiative are needed to understand patient perceptions and evaluate its impact on quality of care and on populations with different socioeconomic factors and levels of access to care.

Author Affiliations: HealthCore, Inc (QM, GS, ARD), Wilmington, DE; Anthem, Inc (MO, LG), Indianapolis, IN.

Source of Funding: The funding for this project was provided entirely by Anthem, Inc. All the authors are employed by Anthem, Inc, or by HealthCore, Inc, a wholly owned subsidiary of Anthem, Inc.

Prior Presentation: The preliminary results of our study were presented at the AcademyHealth Annual Research Meeting (June 26-28, 2016; Boston, MA) under the title “Members’ Behavioral Response to Elimination of Primary Care Cost Share.” Our results have not been published by any journal, nor are they currently under consideration for publication.

Author Disclosures: Dr Oza and Ms Garneau are employees of Anthem, which administrates the health insurance for the employer studied in the manuscript. Drs Ma and DeVries and Ms Sylwestrzak are employees of HealthCore, which is a subsidiary of Anthem.

Authorship Information: Concept and design (QM, GS, MO, LG, ARD); acquisition of data (QM, GS, LG, ARD); analysis and interpretation of data (QM, GS, MO, ARD); drafting of the manuscript (QM, GS, ARD); critical revision of the manuscript for important intellectual content (QM, GS, MO, ARD); statistical analysis (QM); obtaining funding (GS, ARD); administrative, technical, or logistic support (LG, ARD); and supervision (GS, ARD).

Address Correspondence to: Qinli Ma, PhD, HealthCore, Inc, 123 Justison St, Ste 200, Wilmington, DE 19801. Email:

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