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Application of Value-Based Benefit Design in Employer Settings

(16). Bluml BM, McKenney JM, Cziraky M, “Pharmaceutical Care Services and Results in Project ImPACT Hyperlipidemia,” Journal of the American Pharmacists Association. 2000;40:157-165. http://www.ncbi.nlm.nih.gov/pubmed/10730019.

• The authors, through this observational study, set out to demonstrate that pharmacists, working collaboratively with patients and physicians and having immediate access to objective point-of-care patient data, promote patient persistence and compliance with prescribed dyslipidemic therapy that enables patients to achieve their National Cholesterol Education Program (NCEP) goals. In a population of 397 patients over 24.6 months, observed rates for persistence and compliance with medication therapy were 93.6% and 90.1%, respectively, and 62.5% of patients reached and maintained their NCEP lipid goal at the end of the project. The authors conclude that working collaboratively with patients, health care providers, and pharmacists who have ready access to objective clinical data, and who have the necessary knowledge, skills, and resources, can provide an advanced level of care that results in successful disease management.
• Peer reviewed
• Keywords: Asheville Project; National Cholesterol Education Program; dyslipidemia; ambulatory care pharmacies; pharmacists

(17). Bunting BA, Cranor CW, “The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma,” Journal of the American Pharmacists Association. March 2006;46:133-47. http://www.ncbi.nlm.nih.gov/pubmed/16602223.

• The authors assessed clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program for 207 adult patients with asthma over 5 years. All objective and subjective measures of asthma control improved and were sustained for as long as five years. Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.
• Peer reviewed
• Keywords: Asheville Project; medication therapy management; disease manage­ment; asthma; health care costs; health out­comes; pharmacoeconomics.

(18). Bunting B, Smith B, Sutherland S, “The Asheville Project, Clinical and Economic Outcomes of a Community-Based Long-Term Medication Therapy Management Program for Hypertension and Dyslipidemia,” Journal of the American Pharmacists Association. 2008;48(1):23-31. http://www.ncbi.nlm.nih.gov/pubmed/18192127.

• The authors assessed the clinical and economic outcomes of a community-based, long-term medication therapy management (MTM) program for hypertension (HTN)/dys­lipidemia. The program was carried out in 12 community and hospital pharmacy clinics in Asheville, N.C., over a 6-year period from 2000 through 2005. Patients with HTN and/or dyslipidemia receiving education and long-term MTM services achieved significant clinical improvements that were sustained for as long as 6 years, a significant increase in the use of cardiovascular medications, and a decrease in cardiovascular events and related medical costs.
• Peer reviewed
• Keywords: Asheville Project, medication therapy management; disease manage­ment; hypertension; dyslipidemia; cardiovascular risk; health care costs; health out­comes; pharmacoeconomics.

(19). Chernew M, Juster IA, Shah M, Wegh A, Rosenberg S, Rosen AB, Sokol MC, Yu-Isenberg K, and Fendrick M. “Evidence That Value-Based Insurance Can Be Effective,” Health Affairs. February 2010;29(3):530-536. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2009.0119v1.

• As employers face constant pressure to control health care costs, value-based insurance design has received much attention as a cost-savings device. This paper examines one value-based insurance design program and found that the program led to reduced use of nondrug health care services, offsetting the costs associated with additional use of drugs encouraged by the program. The findings suggest that value-based insurance design programs do not increase total system-wide medical spending.
• Peer reviewed
• Keywords: disease management; medication adherence; diabetes

• This paper compares the effects of a large employer’s value-based insurance initiative that reduced copayments for five chronic medication classes as part of a disease management program with another employer who only used the disease management program. Adherence to medications in the value-based intervention increased for four of the five medication classes and nonadherence declined by 7-14 percent.
• Peer reviewed
• Keywords: large employer copayments; chronic conditions; cost sharing; financial effect; high-value services

(21). Chernew M, Rosen A, Fendrick MA, “Value-Based Insurance Design,” Health Affairs. January 30, 2007;26(2):w195-w203. http://content.healthaffairs.org/cgi/reprint/26/2/w195.

• This paper makes the case for value-based insurance design and outlines current initiatives in the private sector as well as barriers to further adoption.
• Peer reviewed
• Keywords: barriers; financial effects; disease management; pay-for-performance

(22). Choudry NK, Fischer MA, Avorn J, Schneeweiss S, Solomon D, Berman C, Jan S, Liu J, Lii J, Brookhart MA, Mahoney JJ and Shrank WH, “At Pitney Bowes, Value-Based Insurance Design Cut Copayments and Increased Drug Adherence,” Health Affairs. November 2010;29(11):1995-2001. http://content.healthaffairs.org/content/29/11/1995.abstract?sid=142ee191-5681-4bd1-a856-fd6a22049b54.

• The authors of this study evaluate the Pitney Bowes VBID program to provide empirical evidence in support of VBID strategies. Pitney Bowes eliminated copayments for statins and reduced them for blood clot inhibitors, and immediately saw a 2.8 percent increase in adherence to statins relative to the controls. For clopidogrel, the blood clot inihibitor, the VBID impact was associated with an immediate stabilizing of the adherence rate and a four- percentage-point difference between intervention and control subjects a year later. The authors conclude that this study provides empirical basis for the use of this approach to improve the quality of health care.
• Peer reviewed
• Keywords: Pitney Bowes; statins; value-based insurance design cost sharing; FREE; Free Rx Event and Economic Evaluation trial

(23). Choudry NK, Rosenthal MB, Milstein A, “Assessing the Evidence For Value-Based Insurance Design” Health Affairs. November 2010;29(11):1988-1994.  http://content.healthaffairs.org/content/29/11/1988.abstract?sid=142ee191-5681-4bd1-a856-fd6a22049b54.

• High copayments for medical services can cause patients to underuse essential therapies. Value-based health insurance design attempts to address this problem by explicitly linking cost sharing and value. Results from the Mercer National Survey of Employer-Sponsored Health Plans demonstrates that value-based insurance design use is increasing and that 81 percent of large employers plan to offer it in the near future. The authors argue that despite the growing interest in VBID, few studies have adequately evaluated its ability to improve quality and reduce health spending. Maximizing the benefits of value-based insurance design will require mechanisms to target appropriate copayment reductions, offset short-run cost outlays and expand its use to other health services.
• Peer reviewed
• Keywords: Value-based insurance design; Mercer; cost sharing; Pitney Bowes; The Asheville Project

(24). Cranor CW, Bunting BA, Christensen DB, “The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program,” Journal of the American Pharmacists Association. 2003:43:173-84. http://healthmaprx.com/yahoo_site_admin/assets/docs/Cranor31.90105431.pdf.

• The authors assessed the persistence of outcomes for up to 5 years following the initiation of community-based pharmaceutical care services (PCS) for patients with diabetes. Patients with diabetes who received ongoing PCS maintained improvement in A1c over time, and employers experienced a decline in mean total direct medical costs.
• Peer reviewed
• Keywords: Asheville Project; pharmaceutical care; diabetes; quality of life; health care costs; health outcomes

(25). Fera T, Bluml B, Ellis WM, “Diabetes Ten City Challenge: Final Economic and Clinical Results,” Journal of the American Pharmacists Association. May/June 2009;46(3):e52-e60. http://www.diabetestencitychallenge.com/pdf/dtccfinalreport.pdf.

• This study investigates the economic and clinical outcomes for the Diabetes Ten City Challenge (DTCC), a multi-site community pharmacy health management program for patients with diabetes. With favorable results in reducing costs and improving clinical measurements, the authors conclude that DTCC successfully implemented an employer-funded, collaborative health management program using community-based pharmacist coaching, evidenced-based diabetes care guidelines, and self-management strategies.
• Peer-reviewed
• Keywords: Diabetes Ten City Challenge; Patient Self-Management Program; pharmaceutical care; diabetes; disease management; chronic disease; quality of life; health outcomes; health benefits; collaborative practice; Asheville Project; HealthMapRx

(26). Garrett DG, Bluml MB, “Patient Self-Management Program for Diabetes: First-Year Clinical, Humanistic, and Economic Outcomes,” Journal of the American Pharmacists Association. 2005;45:130-137. http://www.diabetestencitychallenge.com/pdf/psmp.pdf.

• The authors assessed the outcomes for the first year following the initiation of a multi-site community pharmacy care services (PCS) program for patients with diabetes. They found that patients who participated in the program had significant improvement in clinical indicators of diabetes management, higher rates of self-management goal setting and achievement, and increased satisfaction with diabetes care, and employers experienced a decline in mean projected total direct medical costs.
• Peer reviewed
• Keywords: Patient Self-Management Program; pharmaceutical care; diabetes; disease management; chronic care; quality of life; health care costs; health outcomes

• This pharmacist intervention model was developed and implemented by Polk County, Florida, to engage patients with diabetes in managing their health based on the Asheville Project’s framework. The program was implemented in February 2005 with an onsite clinical pharmacist to counsel participants with diabetes. Measured outcomes included changes in HbA1c, blood glucose, and blood pressure values as well as utilization metrics, such as hospitalization and emergency room visit rates, from baseline to one year after pharmacist intervention. Results showed that an employer-based pharmacist intervention model for patients with diabetes improved HbA1c levels, reduced systolic and diastolic blood pressure values, and decreased hospitalizations and emergency room visits after one year.
• Peer reviewed
• Keywords: diabetes; Polk County Florida; pharmacist

(28). Kapowich JM, “Oregon’s Test of Value-Based Insurance Design in Coverage For State Workers,” Health Affairs.November 2010;29(11):2028- 2032.  http://content.healthaffairs.org/content/29/11/2028.abstract.

• The author of this paper is the administrator of the Public Employees’ Benefit Board and Oregon Educators Benefit Board in Salem, Oregon. This paper details the process by which the two entities/benefit boards implemented value-based insurance design for state workers in 2010. The paper illustrates the need to balanced optimal policies on coverage and payments with what is politically acceptable to those covered, not only in the state but also nationwide.
• Peer reviewed
• Keywords: Oregon; Oregon Public Employees’ Benefit Board; Oregon Educators Benefit Board; Oregon Health Leadership Council; state employees; communication

(29). Maciejewski ML, Farley JF, Parker J, Wansink D, “Copayment Reductions Generate Greater Medication Adherence In Targeted Patients,” Health Affairs, November 2010;29(11):2002-2008.  http://content.healthaffairs.org/content/29/11/2002.abstract?sid=e8f7774f-0c8c-4c23-be34-9815c2aeaf76.

• Blue Cross Blue Shield of North Carolina eliminated generic medication copayments and reduced copayments for brand-name medications. This study showed that the program improved adherence to mediations for diabetes, hypertension, hyperlipidemia and congestive heart failure. Adherence rates improved –increasing 3.8 percent for diabetic patients to 1.5 percent for those taking calcium-channel blockers—when compared to others whose employers did not offer a similar program. The authors conclude that despite these promising signs of VBID impact, longer-term adherence and trends in health care spending is still needed.
• Peer reviewed
• Keywords: copayment; Blue Cross Blue Shield of North Carolina; value-based insurance design

(30). Mahoney J and Hom D, Total Value and Total Return: Seven Rules for Optimizing Employee Health Benefits for a Healthier and More Productive Workforce, 2006, Philadelphia: The GlaxoSmithKline Group of Companies.

• A chronological account of implementing value-based approaches at Pitney Bowes.
• Grey literature
• Keywords: Pitney Bowes; Jack Mahoney; David Hom; value-based strategies; diabetes; depression; asthma

(31). National Business Coalition on Health, “Aligning Incentives and Systems: Promoting Synergy Between Value-Based Insurance Design and Patient Centered Medical Home,“ 2010.  http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000884/VBID-H2R-PCPCC%20v4-1101NBCH%20cover.pdf.

• This report examines the partnership of value-based insurance design and patient-centered medical home and how these two strategies impact quality of care and health care costs.
• Grey literature
• Keywords: patient-centered medical home; PCMH; value-based insurance design; Battle Creek, Michigan; IBM, Geisinger Health Plan; Roy O. Martin; Whirlpool Corporation

(32). National Business Coalition on Health, “Engaging the C-Suite: Can We Do It?” June 2008.  http://nbch.kma.net/NBCH/files/ccLibraryFiles/Filename/000000000250/NHLC%20White%20Paper%20July%202008.pdf.

• The NBCH’s National Health Leadership convened in June 2008 to discuss ways to engage corporate executives and boards of directors in promoting employee health and productivity through value-based approaches. The Council agreed that it was not enough to engage executives in the moral rationale, but rather to convince them that doing so is a business imperative. The report provides four key dimensions for engaging the C-suite.
• Grey literature
• Keywords: C-suite; corporate executives; return-on-investment; communication; culture of health

(33). National Business Coalition on Health, “Tailoring Health Care Benefits to Your Employees,” 2010. http://www.nbch.org/nbch/files/ccLibraryFiles/Filename/000000000964/NBCH%20Tailoring%20Health%20
Care%20Benefits%20to%20Employees%20White%20Paper.pdf.

• A report by NBCH which provides an overview of employer strategies to combat rising health care costs and improve employee health.
• Grey literature
• Keywords: productivity; Integrated Benefits Institute; out-of-pocket costs; employee health programs; value-based benefit design; data

(34). Nayer C, Mahoney J, and Berger J, Leveraging Health, Center for Health Value Innovation, 2009. http://www.booksurge.com.

• An inventory of all of the levers purchasers have at their disposal to bring about improvements in their health and financial outcomes.
• Grey literature
• Keywords: Center for Health Value Innovation; Pitney Bowes; Health Intelligence Partners; health management; RAND; Asheville; North Carolina; QuadMed; Gulfstream; Quest Diagnostics; Partners in Care

(35). Nayer C, Berger J, Mahoney J, “Wellness. Hard to Define, Reduces Trend Up to 4 Percent,” Population Health. April 2010;13(2):83-89. http://www.liebertonline.com/doi/abs/10.1089/pop.2009.0014.

• The purpose of this qualitative study was to identify a common language for “wellness” and a correlating health cost trend reduction through incentive-driven prevention and wellness. Mapping the results of the survey with the trend lines reported by innovative employers could uncover increased financial value in health investments. A 10-question survey was designed for telephone interviews with 26 businesses (Innovators) from the Board of the Center for Health Value Innovation; a paper-based survey with the same questions was completed by attendees at a seminar. Then, an online trend survey was conducted with members of the Board (Innovators) to track the total health cost trends in their companies over the past 3–4 years. Responses were compared and analysis of alignment and differences were recorded by graphing. The trend survey results were mapped and tracked with weighted averages. Innovators' responses to the phone survey showed broader definitions of “wellness” than other companies, with little difference in the Innovators' responses when subdivided by size of company. The online trend survey showed that companies that provided incentives for wellness averaged a trend of 4% over the past 3–4 years—approximately 50% of the national trends of 8%–10% over the same time frame. Innovators have defined wellness in ways that would accelerate adoption in the broader business community and drive implementation of wellness programs. The bigger win could be the community-level shift to a culture of health as employees carry these health competencies to the next business in the community.
• Peer reviewed
• Keywords: Center for Health Value Innovation; wellness; incentives; health cost trends

(36). Spaulding, A. et al. “A Controlled Trial of Value-Based Insurance Design—The MHealthy: Focus on Diabetes (FOD) Trial,” Implementation Science. Published on-line April 7, 2009;4(19). http://www.implementationscience.com/content/4/1/19.

• This article describes the design and implementation of MHealthy: Focus on Diabetes (FOD), a prospective, controlled trial of targeted co-payment reductions for high value, underutilized therapies for individuals with diabetes.
• Peer reviewed
• Keywords for Web-Based Search: diabetes; out-of-pocket costs; prevention therapies; University of Michigan; co-payments

• Biennial rates of screening mammography were significantly lower among enrollees in health plans requiring cost sharing than among those plans with full coverage. This effect of cost sharing was magnified among women residing in areas of lower income or educational levels.
• Peer reviewed
• Keywords: Medicare, mammography; cost sharing; cancer prevention

• The effects of implementing a value-based insurance design program were evaluated for diabetic patients within a single company: one group participated in a disease management program, while the other did not.
• Participation in both value-based insurance design as well as disease management programs resulted in sustained improvement over time with diabetes medication use up 6.5 percent over three years, including an increase in the adherence to diabetes medical guidelines, resulting in a return on investment of $1.33 saved for every dollar spent during a three-year follow-up period.
• Peer reviewed
• Keywords: diabetes; value-based insurance design; disease management