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AJMC® Study Finds Removing Cost Sharing in Primary Care Reduces Cost, Emergency Visits


Accompanying editorial calls for further refinements in value-based insurance design to reduce unintended use of low-value care, reports the latest issue of The American Journal of Managed Care®.

(CRANBURY, N.J.) When a large national employer removed cost sharing for primary care visits, medical utilization fell, as did monthly costs, driven mostly by reduced emergency department (ED) visits. The findings on this value-based insurance design (VBID) model, coming as the nation grapples with rising healthcare spending, putting pressure on payers, employers, and consumers, are reported in the May issue of The American Journal of Managed Care® (AJMC®).

The Clinical research article, “Evaluation of Value-Based Insurance Design for Primary Care,” looked at healthcare spending in two cohorts between 2008 and 2009 (preintervention) and 2011 through 2014 (postintervention). The VBID group included enrollees insured by an Anthem-affiliated health plan from an employer that removed cost sharing; they were compared with other Anthem members whose cost sharing was not waived.

The VBID group had a relative reduction in total spent per member per month of $12 compared with the group that retained cost sharing. The authors, who are employees of Anthem or a subsidiary, HealthCore, hypothesized that the removal of cost sharing for primary care may have led to faster and optimal treatment of urgent or chronic conditions, keeping patients healthy and out of the ED.

“When primary care doctors see patients who are in earlier stages of disease, such as those who are prehypertensive and prediabetic, they can make an impact on disease progression through nutrition and exercise counseling,” said study coauthor Manish Oza, MD, Anthem regional vice president and practicing ED doctor. “If patients’ co-pay or high-deductible plan is a barrier to paying for that primary care visit and they wait until their symptoms worsen and go to the ED, it’s much more difficult to contain a condition or disease that is further along. We believe this is why the study saw reduced ED visits for those with waived co-pays.”

In an accompanying editorial, Betsy Q. Cliff, MS, and A. Mark Fendrick, MD, write that increased consumer cost sharing has become a widely used tool by both commercial and public payers to reduce healthcare spending. However, they note that encouraging access to primary care by removing financial impediments will increase use of high-value care, but it can also unintentionally increase utilization of low-value care. They call for a more targeted VBID design that acts like a “screen door” by selectively promoting high-value care while discouraging low-value services. “As healthcare costs continue to rise, the need for targeted payment policies and benefit designs that concurrently encourage high-value services and discourage waste is greater than ever,” said Fendrick, who is co-editor-in-chief of AJMC®.

For the full study, click here.

For the full editorial, click here.

About The American Journal of Managed Care®

The American Journal of Managed Care® (AJMC®) is a peer-reviewed, Medline-indexed journal that keeps readers on the forefront of health policy by publishing research relevant to industry decision makers as they work to promote the efficient delivery of high-quality care. AJMC.com is the essential website for managed care professionals, distributing industry updates daily to leading stakeholders. Other titles in the AJMC® family include The American Journal of Accountable Care® and two evidence-based series, Evidence-Based Oncology and Evidence-Based Diabetes Management. These comprehensive offerings bring together stakeholder views from payers, providers, policymakers and other industry leaders in managed care. To order reprints of articles appearing in AJMC® publications, please contact Gil Hernandez at 609-716-7777, ext. 139.

AJMC® Media Contacts

Alexandra Ventura, 609-716-7777, ext. 121


John Patricolo, 609-325-4630, ext. 133


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