In January 2017, the Centers for Medicare & Medicaid Services (CMS) began experimenting with a value-based insurance design (VBID) model for enrollees with certain chronic diseases.
We at Highmark Inc., the nation’s fourth-largest Blue Cross and Blue Shield-affiliated organization, are thrilled to be participating in this innovative program. Our company and its affiliates operate health plans in Pennsylvania, Delaware, and West Virginia that serve 5 million members along with hundreds of thousands of additional members through the BlueCard® program.
We recognize that VBID is a promising trend in health insurance, allowing payers to structure benefits and cost sharing to encourage enrollees to use high-value clinical services (defined as those with the greatest potential, relative to cost, to positively affect enrollee health).
About the Pilot
As health plans achieve success with VBID models in their commercial memberships, CMS is testing whether this model can improve outcomes and reduce expenditures for Medicare Advantage (MA) enrollees. Addressing chronic conditions is critical because today’s healthcare costs are driven more by chronic disease than by acute illness.
For the next five years, CMS will issue a limited waiver from federal uniform-benefit design requirements to health plans in seven states, allowing the plans to offer clinically nuanced benefit packages with extra benefits and/or reduced cost sharing.
Plans can choose from among the following options:
- Reduced cost sharing for high-value services
- Reduced cost sharing for high-value providers
- Reduced cost sharing for enrollees participating in disease management programs
- Supplemental benefits, such as tobacco cessation assistance for enrollees with chronic obstructive pulmonary disease (COPD)
Plans can use more than one VBID approach, choose combinations of comorbidities, or create different combinations of benefits and cost-sharing strategies. The goal is to see which approaches prove most successful.
Highmark’s Approach
We chose to target diabetes and COPD. Our approach layers disease management participation and financial incentives for choosing high-value primary care physicians and specialists. In addition, we include other benefits that encourage members to engage with their health, such as lower coinsurance on diabetes-testing supplies.
Highmark’s risk-adjusted data indicate that some physicians and practices are more effective than others at managing chronic disease. We identified these providers and offered reduced cost sharing to enrollees who seek care from these providers. We structured the copay differential to be significant enough that members would easily appreciate the value to them.
(However, members remain free to select any physician within the network associated with the MA plan that they purchased. One of CMS’s requirements is that enrollees in the VBID model plans must never receive fewer benefits or be charged higher cost sharing than other MA enrollees in their plan.)
We place great emphasis on providing access to personal health coaches who can offer individualized attention to our members, filling gaps between doctor’s appointments with education and motivation. They encourage compliance with the prescribed treatment plan and use motivational interviewing to help members set goals and then take action steps to achieve them.
Yet, in the end, each member is unique. Our program, therefore, ultimately focuses on meeting members where they are in their health journey and providing that bit of extra support and encouragement to help them move in a healthier direction.
Ellen Galardy is vice president, Senior Markets, Highmark Inc., Pittsburgh.
Note: The statements contained in this article are solely those of the author and do not necessarily reflect the views or policies of CMS. The author assumes responsibility for the accuracy and completeness of the information contained in this article
