Early Adopters of VBID Sought to Remove Barriers to High-Value Care

A desire to remove barriers to high-value care and provide services that would improve health and quality of life drove early adopters of value-based insurance design (VBID), according to the panelists during the second session of the V-BID Summit 2021, hosted by the Center for Value-Based Insurance Design at the University of Michigan.

Mike Critelli, currently president and CEO of MoveFlux Corporation, was at Pitney Bowes when it began to implement VBID policies. In the 1990s, Critelli learned about a category in health care called preference-sensitive care, which had a 5 to 1 spread in costs, but essentially no difference in outcomes.

“And I came to realize that if we looked at what the low-cost spend areas with higher performance were doing, as a self-insured employer we could drive much better health and health care at a much lower cost than we were getting outcomes for at Pitney Bowes,” he said.

The company began emphasizing prevention, designing navigators for mental health and substance abuse, providing more conservative care for conditions like obesity, and giving away branded chronic disease medications. “We started to get positive impacts from those kinds of tools, and that just created a great forward momentum,” he said.

As the administrator for the Oregon Public Employees’ and Oregon Educators Benefit Boards from 2007 to 2014, Joan Kapowich, RN, now an independent consultant, got involved in VBID because the benefit boards were very dedicated to preventive care and provided generous benefits that they wanted their workers to use. “So, making no barrier to those services was a no brainer,” she said.

Then, they added things like free weight management, free tobacco cessation, mood assistance therapy, and team-based, evidence-based services “to encompass the whole picture of health.” For Kapowich, the appeal of VBID is that the design enabled a health benefit that provided people the ability to gain skills to manage their health and improve their quality of life.

According to Lonny Reisman, MD, founder and CEO of HealthReveal, he might not have had a career without VBID. Prior to founding HealthReveal, Reisman was at Aetna, and before that at ActiveHealth Management, which worked with self-funded employers to get patients access to therapies.

“And it occurred to me then, and it's been painfully apparent to me throughout my career, that to the extent that we can overcome clinical inertia and get doctors to write for high-value services, if the patient can’t afford them, then it's all moot,” Reisman said.

At the time, that was the challenge they kept running into: they would make suggestions about treatments, but patients were saying they couldn’t afford it. Then, Reisman read an article by A. Mark Fendrick, MD, and Michael E. Chernew, PhD, about benefit-based co-pays, which were later renamed VBID. “I said, ‘Gee, these guys sound a little bit like what I’m trying to overcome,’” he recounted.

When Katy Spangler was working as the deputy health policy director of the Committee on Health, Education, Labor, and Pensions for a senator from Wyoming, she was taken by the idea of VBID and the policy proposal that would “make it easier to get more health out of every health care dollar being spent.”

Spangler, now principal of the consulting firm Spangler Strategies, noted that when there were bipartisan discussions happening about the Affordable Care Act, one thing she remembered was that there was agreement among the staffers around the idea of making it easy for patients to access preventive care.

The panelists were all given the opportunity to look back and identify the challenges they overcame, lessons learned, what would they have done differently, and what they were able to bring forward to continue building on VBID today. Critelli started by noting immediate rewards to people are more important than quantitative rewards, and that the diversity of the population needs to be recognized.

For Kapowich, the biggest challenge was that as a leader, no one else was doing what they were planning to do, which meant they had no one else to talk to. As a result, communicating the plan was a challenge. What they ended up doing was putting additional costs for people to use certain services. For instance, hip and knee replacement cost more, but a weight management program and other health promotion services were offered for free.

Reisman highlighted that clinical inertia is a real barrier and that there is a need to engage, educate, and incentivize physicians so they are better adherent to clinical guidelines. In addition, he said there has to be better alignment between high-value services and clinical measures.

“So, I think that we’ve got to broaden our measurement set as we think about incentives for doctors, and even patients, in order to support what we all agree is important, which is, you know, broader adherence to clinical standards that have been promulgated by specialty societies,” he said.

Spangler discussed the work she is doing with the Smarter Healthcare Coalition, which has a broad membership and has been trying to remove barriers to VBID. One aspect has been to get certain chronic condition medications and services to be offered for free in high-deductible health plans with health savings accounts. She viewed that success as the first step, which should continue with getting the guidance expanded.

“It's small steps, and it takes a while, but I do [believe in] taking smaller steps and really getting your ducks in a row as far as having the data,” she said. “You know, we had great data just showing how important it was to remove barriers to high-value chronic disease prevention within these highly regulated plans. And so that work continues.”