An Evaluation of a Value-Based Health Plan Design at Group Health
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An Evaluation of a Value-Based Health Plan Design at Group Health
David Grossman, MD, MPH
Group Health Research Institute
Seattle, Washington
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Disclosures and Funding
PI is employee and shareholder, Group Health Permanente medical group
Funding from AHRQ (R01 HS018913-01) and Group Health Cooperative
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Improving Value of US Healthcare Expenditures
Increased purchaser focus on:
• Improving value of expenditures
• Reducing waste
• Improving health outcomes for beneficiaries
• Preventing chronic illness and complications
Two main levers
• Health plan design
• Delivery system design
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Cost-Sharing and HealthImpact of larger cost-shares on chronic disease self-management
Chronic disease the major driver in health care costs
Re-consideration of indiscriminate cost-sharing
• Consumer holds the early short term risk
• Purchaser/health plan holds the longer term risk
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Value-based Cost-Sharing
First iterations:
• Preventive service coverage
• Tiered pharmacy benefits
Generics
Brand-name
Non-preferred and non-formulary
Most recent efforts focused on pharmacy cost-sharing: reducing cost-shares
• Pitney Bowes
• University of Michigan employees
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Science of Value-Based Design
Large body of evidence on impact of increased cost-shares
• Tends to be focused on discrete services
Much smaller literature on impact of reducing cost shares
Even smaller literature on impact of cost-sharing on health outcomes and productivity
Tiny literature using control group with multiple outcomes
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Worksite WellnessAnother approach to reducing costs and improving health
• Focus on lifestyle change
Incenting health behavior
Healthy work environments
Change of work culture
• Outcomes of interest
Health status and utilization
Absenteeism and presenteeism
Productivity
• 77% of large employers offer these services
• Health risk assessments are entry portal for engagement
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Group Health’s Total Health Plan for Employees
Employer Aims
• Improve productivity through
Better health of staff
Decreased absences
Improved on-the-job productivity
• Decrease health expenditure trend rate
Mechanism
• Incent healthy behaviors and improved chronic disease control through monetary incentives and value-based health benefit pricing
• Reinforce culture of self-awareness, accountability and reporting of health and health behaviors through monetary incentives and culture change
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Specific AimsTo assess the impact of the new value-based insurance design on:
PRIMARY: changes over time in employee self-reported:
• health status
• absenteeism due to illness and disability
• presenteeism (i.e. lost productivity time at the workplace)
SECONDARY:
• clinical quality scores for chronic illness care and preventive screenings,
• lifestyle behavioral risk factors,
• employee satisfaction with health benefits,
• health services utilization by employees, and
• employer-paid health costs for the employee population.
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Invitation to complete HRA
Feedback report with health risksIdentified
· Improved health status· Decreased absenteeism· Improved workplace productivity
Lifestyle & behavioral risk factors
Improved management of chronic illnessChronic
Illness self-management
needs
TotalHealth Program
Design and Incentives
Reduction in lifestyle and
behavioral risk factors
Figure 1: Conceptual Framework
Opt-out*
· Reduced unexpected healthcare utilization
· Decreased employer health costs
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Total Health Design OverviewValue-based copayments
Preventive services (already 1st dollar): no change
Chronic disease cost-sharing decreased for
Selected Visits
Pharmacy
Worksite wellness and health promotion activities
• Engagement tied to premium stabilization for 3 years
Health risk assessment annually, AND
Achievement of point threshold
Points aimed at both healthy and chronically ill staff
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Visit Cost-Sharing
Waiver of co-pay for 2 visits/year for chronic care
• Coronary Artery Disease
• Diabetes
• Hypertension
• Congestive Heart Failure
• Asthma
• Mental Health (first ten visits)
Waiver of copay for chemical dependency visits and lactation service visits
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Pharmacy Co-payments
Copayments reduced to zero for:
• generic, mail dispensed meds for same diseases plus depression
Copayment reduced for brand name drugs for same diseases
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Devices
Wavier of cost-sharing for:
• Home BP monitors
• Diabetic glucose monitors
• Spaces for inhaled asthma meds
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Obesity Management Programs
50% discount for enrollment
100% coverage (50% rebate) for diabetics that lose five percent of body weight
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Cost-Shares Increased
Outpatient surgery
High cost imaging procedures
• CT, MRI, PET
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Total Health Website
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Total Health Evaluation Design
Study Design
• Quasi-experimental 2 group before/after design
• Repeated measures
• Control group: Kaiser Permanente Colorado employees
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OutcomesPrimary
• Health status change: Survey
• Absenteeism due to illness: Survey +HR data
• Productivity at work: Survey
Secondary
• Care Quality scores
Chronic illness: HEDIS scores
Preventive services HEDIS scores
• Lifestyle behavioral risk factors Survey
E.g. smoking, activity
• Employee satisfaction Survey
• Costs and service utilization Claims data
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Survey ToolSurvey invitation to employees
• Web survey tool
Paper survey on request
Domains: Instrument
Functional Status: (SF-12)
Workplace productivity: Work Health Interview
Health Risk Behaviors BRFSS, other
» Tobacco
» Alcohol
» BMI
» Physical Activity
» Satisfaction w/ plan
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Administrative Data
Health utilization/cost/quality
• Group Health Research Institute data warehouse
Claims
Pharmacy
EMR data
Employee characteristics
• Human Resources administrative data
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Data Collection
Sample of 5000 employees invited to take e-survey tool
• Active opt-out
• Implied consent with survey completion
• Separate permissions to link claims and HR data
• 3 follow-up emails
• No telephone follow-up
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Statistical Power
Mean/
Percent SD
Minimum detectable difference
Presenteeism (hours) 5.2 7.5 0.57 Absenteeism (hours) 11.0 14.0 1.06 Lost productive time (hours) 15.3 14.4 1.09 Self-rated health (excellent/very good) 57% -- 3.8%
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Total Health – participation• >80% of all staff and spouses/domestic partners on the TH medical plan have taken the HRA
•73% are earning points on the wellness website
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Progress to Date
Baseline survey completed early 2010
• Group Health: 70% response rate
• KPCO: 60% response rate
Permissions to link survey data
• Approximately 60-64% agree to linkage with HR and/or medical data
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Challenges and Strengths
Privacy issues/concerns
• Employer is also provider of care
• Key engagement of organized labor units
Validity of self-reported data
Study design and potential for confounding
• Use of highly similar control group external to Group Health
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GHRI/UW KPCO
Paul Fishman Arne Beck
Nora Henrikson Debra Ritzwoller
Rebecca Hubbard Nancy Brace
Diane Martin
Rob Reid
Ellen Schartz
Aaron Scrol
Kay Theis
Research Team