Why Payers Should Reduce Cost Sharing for High-Value Care

January 17, 2017 - Today, more healthcare payers are positioning greater cost-sharing onto the consumers to keep from raising premium rates, according to commentary published in JAMA Internal Medicine. The 2016 National Health Insurance Survey discovered that 40 percent of consumers with commercial health plans under the age of 65 are enrolled in a high-deductible health plan, which is about a 15 percent increase from 2010 results.

The Kaiser Family Foundation conducted a poll last year that found the average deductible among health plans rose from $818 in 2006 to $2,069 in 2015. While payers implement high-deductible health plans among their members, consumers will likely need to be educated in reducing their use of low-value care. However, members will need to continue utilizing high-value care even with a high-deductible health plan, the report states.

Research shows that high-deductible health plans tend to lead low-income and sick patient populations such as diabetes patients to forego some medical interventions. Since healthcare spending has been rising in recent years and payers have positioned their members with larger cost sharing through high-deductible health plans, consumer engagement in clinical decision-making will need to be implemented.

Ensuring affordability along with better health outcomes remains key, the JAMA Internal Medicine report states. In order to keep patients healthy and pursuing high-value care, healthcare payers may need to begin innovating their cost-sharing approaches and designing new systems. In particular, payers may need to reduce cost sharing associated with high-value care.

“Clinically-nuanced - or smarter - deductibles might be a natural evolution of health plans, in that consumer cost-sharing would be reduced for the clinical services that are encouraged under many alternative payment models,” the report authors wrote. “As value-based reimbursement promotes the delivery of evidence-based, high-quality care, consumer-facing initiatives must encourage - not create barriers - to these high-value services.”

A high-deductible health plan will need to bring more focus on incentivizing the use of high-value care and reducing wasteful spending. Value-based insurance design is an innovative approach to bringing reduced cost-sharing for high-value care and increased cost-sharing for low-value services.

Evidence-based clinical guidance should be used when implementing value-based insurance design such as ensuring patients with diabetes mellitus receive regular eye examinations.

While commercial payers have conducted the majority of value-based insurance design in cost-sharing applications, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Advantage Value-Based Insurance Design Model in January 2017. The program will allow payers in certain states to provide new benefit designs for beneficiaries who were diagnosed with specific chronic medical conditions.

“Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure enrollee cost sharing and other health plan design elements to encourage enrollees to use high-value clinical services – those that have the greatest potential to positively impact enrollee health,” according to a press release from CMS.

“VBID approaches are increasingly used in the commercial market, and evidence suggests that the inclusion of clinically-nuanced VBID elements in health insurance benefit design may be an effective tool to improve the quality of care while reducing its cost for Medicare Advantage enrollees with chronic diseases.  As part of the ‘better care, smarter spending, healthier people’ approach to improving health care delivery, CMS will test VBID in Medicare Advantage and measure whether structuring patient cost sharing and other health plan design elements encourages enrollees to use health care services in a way that improved their health and reduces costs.”

The Patient Protection and Affordable Care Act has also emphasized the need for value-based insurance design. For instance, the legislation requires all health plans to include specific preventive services without a copayment such as cancer and blood pressure screening, according to the National Conference of State Legislatures.  

Along with public and private payers, employers have also taken part in implementing value-based insurance design. As of September 2015, 33 percent of large companies have incorporated wellness programs and financial incentives to participants. Additionally, 50 percent of polled, large employers are offering health risk assessments and biometric screenings, which are completed by medical professionals.

Private payers can work with larger employer networks to create wellness programs that include a general focus on value-based insurance design. Payers could benefit their member populations by innovating new high-deductible health plan options and cost-sharing strategies. By bringing more cost-sharing onto low-value services and reducing the out-of-pocket costs of high-value treatment, payers will be able to improve patient health outcomes and ensure coverage remains affordable for their members.