Congress may be divided over the fate of the Affordable Care Act (ACA), but there’s another healthcare idea with bipartisan support that might see more movement before the end of 2017: value-based insurance design (VBID).
The concept of VBID, which seeks to remove financial barriers to high-value care, has been around for some time, having been pioneered by A. Mark Frederick, MD, of the University of Michigan and its Center for Value-Based Insurance Design, and Michael E. Chernew, PhD, of Harvard Medical School, the co-editors-in-chief of The American Journal of Managed Care® (AJMC®).
VBID found its way into the ACA, which requires plans to cover preventive services that have at least a B rating by the US Preventive Services Task Force without cost sharing. VBID principles are reflected in initiatives of the Center for Medicare and Medicaid Innovation (CMMI).
But as Fendrick and other experts explained yesterday at the Fall 2017 Summit, “Engaging Consumers, Providers, and Payers for Future of Value-Based Insurance Design,” presented by the Smarter HealthCare Coalition in partnership with the University of Michigan V-BID Center, the increased popularity of high-deductible health plans (HDHPs) among employers demands a policy response, as consumers find themselves unable to afford necessary care because too few services and drugs meet the narrow definition of “preventive” under current Internal Revenue Service rules.
Whether it’s through action from Congress or administrative changes by Medicare or the Treasury Department, a second wave of change is needed to connect coverage to high-value care, promote care coordination, and pave the way for patients to afford high-tech medicine coming from advances like DNA sequencing. Without legislative and regulatory changes, Fendrick said, Americans face a future of “Star Wars science with Flintstones delivery.”
“I did not go to medical school to learn how to save people money,” Fendrick said, noting that nearly all the conversations about healthcare in Washington, DC, aren’t about making people well but about cutting costs. “We have to change the conversation from how much we spend to how well we spend.”
The Summit, held atop the Hart Senate Office Building overlooking the Capitol Dome, allowed attendees to hear directly from staff members and a member of Congress involved in crafting the language that could let VBID catch the year-end wave of activity in Congress. Even while the summit unfolded yesterday, the Congressional Budget Office released its score for the bipartisan Alexander-Murray legislation to stabilize the individual market, which contains language encouraging VBID activity in the states.
While VBID may not be making the headlines, there’s plenty happening, and more should be, according to Representative Earl Blumenauer, D-Oregon. No matter what a member of Congress thinks of Obamacare, he said, figuring out how to direct resources toward high-value care is a conversation worth having. “In fact, where you are on that continuum makes it more important to have this conversation."
Throughout the day, current and former Congressional staff said VBID was the one healthcare idea that appealed to both parties—Republicans liked the idea of rewarding solutions that work, and Democrats like the idea of ensuring that patients get care.
Partisan rancor over the ACA has been such that "We’ve lost sight that what we want to do is expand coverage and lower costs,” said Blumenauer. “Parts of this country deliver very high-quality care … VBID is one of the most powerful ways to reorient that discussion. It even makes sense to people in Congress.”
Chronic Care Management
Blumenauer has co-sponsored HR. 5652, the “Access to Better Care Act,” with Representative Diane Black, R-Tennessee, which would allow patients with chronic conditions covered by HDHPs paired with health savings accounts (HSAs) access to certain services and medications on a pre-deductible basis.
During a panel discussion, Danielle Janowiski, legislative assistant to Senator John Thune, R-South Dakota, and Nick Uehlecke, a staff member for the House Ways & Means Committee, discussed efforts to work with the administration that would allow broader interpretation of IRS “safe harbor” language, which right now does not allow coverage for any “existing illness, injury, or condition,” including medication, until the deductible is met for a HDHP-HSA plan. Changing this guidance to allow for chronic care management—for example, making sure people with diabetes got insulin—would net savings by preventing hospitalizations and worse outcomes.
Fendrick said this affects both patients and physicians as practices start taking on risk under the Medicare Access and CHIP Reauthorization Act. Is it fair to penalize physicians for patients’ outcomes if HDHPs make it difficult for patients to afford basic care?
Getting patients with diabetes to get eye exams is a basic measure, for example. But if the exams are not covered until the deductible is met, “you’re discouraging my patients from doing those exact things,” Fendrick said.
Outdated Laws and Care Coordination
Speakers said some laws designed for another era must be updated to reflect today’s thinking on care coordination and VBID. For example, Tim Gronniger, senior vice president of Development and Strategy at Caravan Health, a former CMS official, said that the attempt to allow practices to charge a $42 per-patient per-month chronic care management (CCM) fee has hit snags because the Physicians’ Fee Schedule does not allow practices to waive the copayment for Medicare beneficiaries. “There’s a strong case to be made that patients shouldn’t be charged for this,” he said.
Similarly, Gronniger said the Stark Law, passed in the late 1980s to prevent physicians from referring patients to medical practices in which they owned stake, can now make care coordination a challenge. The flexibility of CMMI and accountable care organizations (ACOs) only goes so far. “People are working on it,” he said.
But evidence continues to accumulate in favor of ACOs in Medicare. Mara McDermott, vice president of federal affairs for CAPG, formerly the California Association of Physician Groups, said the percentage of premium capitation model has worked best for her members. She cited a study that appeared recently in AJMC® involving physician-led Medicare Advantage ACOs in Oregon that showed a 6% improved mortality.
Empowering the Consumer
Ann Greiner, president and CEO of the Patient-Centered Primary Care Collaborative, said robust primary care is essential for VBID to be effective, for a host of reasons.
“We’re much more mindful of a more engaged patient,” and the look and function of a practice reflects that—or should. Consumers’ expectations should go well beyond a strong physician-patient relationship.
Primary care, she said, “is the general contractor” that manages all the relationships with specialists and, at times, non-medical providers. There’s more awareness than ever of social determinants of health, of food insecurity, of behavioral health needs. Trust is essential. “If they are steering you to less expensive options, you need to trust they have your best interests at heart,” Greiner said.
And yet, she said, too few resources are put in primary care for what we expect from this level. Clinicians must be rewarded for delivering evidence-based medicine, for incorporating patient input, and for valuing shared decision-making.
She noted the brand-new findings from Choosing Wisely, which call for putting more focus on patients in the next wave of eliminating low-value care. “We want to make sure that not only costs are being looked at, but that quality is evidence-based.”