An Evaluation of a Value-Based Health Plan Design at Group Health
David Grossman, MD, MPH
Group Health Research Institute
Seattle, Washington
Disclosures and FundingPI is employee and shareholder, Group Health Permanente medical group
Funding from AHRQ (R01 HS018913-01) and Group Health Cooperative
Improving Value of US Healthcare ExpendituresIncreased 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
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
Value-based Cost-SharingFirst 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
Science of Value-Based DesignLarge body of evidence on impact of increased cost-shares• Tends to be focused on discrete services
Much smaller literature on impact of reducing cost sharesEven smaller literature on impact of cost-sharing on health outcomes and productivityTiny literature using control group with multiple outcomes
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
Group Health’s Total Health Plan for EmployeesEmployer 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
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.
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
Total Health Design OverviewValue-based copayments
Preventive services (already 1st dollar): no changeChronic 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, ANDAchievement of point thresholdPoints aimed at both healthy and chronically ill staff
Visit Cost-SharingWaiver 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
Pharmacy Co-paymentsCopayments reduced to zero for:• generic, mail dispensed meds for same diseases plus
depression
Copayment reduced for brand name drugs for same diseases
DevicesWavier of cost-sharing for:• Home BP monitors
• Diabetic glucose monitors
• Spaces for inhaled asthma meds
Obesity Management Programs50% discount for enrollment100% coverage (50% rebate) for diabetics that lose five percent of body weight
Cost-Shares IncreasedOutpatient surgeryHigh cost imaging procedures• CT, MRI, PET
Total Health Website
Total Health Evaluation DesignStudy Design• Quasi-experimental 2 group before/after design
• Repeated measures
• Control group: Kaiser Permanente Colorado employees
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 SurveyE.g. smoking, activity
• Employee satisfaction Survey
• Costs and service utilization Claims data
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
Administrative DataHealth utilization/cost/quality• Group Health Research Institute data warehouse
Claims
Pharmacy
EMR data
Employee characteristics• Human Resources administrative data
Data CollectionSample 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
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%
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
Progress to DateBaseline 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
Challenges and StrengthsPrivacy issues/concerns• Employer is also provider of care
• Key engagement of organized labor units
Validity of self-reported dataStudy design and potential for confounding• Use of highly similar control group external to Group Health
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
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