An Evaluation of a Value-Based Health Plan Design at Group Health (Text Version)

Slide presentation from the AHRQ 2010 conference.

On September 28, 2010, David Grossman made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (280 KB). Free PowerPoint® Viewer (Plugin Software Help).


Slide 1

 An Evaluation of a Value-Based Health Plan Design at Group Health

An Evaluation of a Value-Based Health Plan Design at Group Health

David Grossman, MD, MPH
Group Health Research Institute
Seattle, Washington

Slide 2

 Disclosures and Funding

Disclosures and Funding

  • PI is employee and shareholder, Group Health Permanente medical group.
  • Funding from AHRQ (R01 HS018913-01) and Group Health Cooperative.

Slide 3

 Improving Value of U.S. Healthcare Expenditures

Improving Value of U.S. 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

Slide 4

 Cost-Sharing and Health

Cost-Sharing and Health

  • Impact 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

Slide 5

Value-based Cost-Sharing  

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

Slide 6

 Science of Value-Based Design

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

Slide 7

Worksite Wellness  

Worksite Wellness

  • Another 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

Slide 8

 Group Health's Total Health Plan for Employees

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

Slide 9

 Specific Aims

Specific Aims

To 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
    • Employer-paid health costs for the employee population

Slide 10

 Figure 1. Conceptual Framework

Figure 1. Conceptual Framework

Image: A conceptual framework is shown. The framework begins with "Invitation of complete HRA"; one can opt out, or choose "Feedback report with health risks identified." If Feedback is chosen, one then chooses a series of further options to manage illness or address lifestyle and behavioral risk factors.

Slide 11

 Total Health Design Overview

Total Health Design Overview

  • Value-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
      • Achievement of point threshold
      • Points aimed at both healthy and chronically ill staff

Slide 12

 Visit Cost-Sharing

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

Slide 13

Pharmacy Co-payments  

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

Slide 14

 Devices

Devices

  • Wavier of cost-sharing for:
    • Home BP monitors
    • Diabetic glucose monitors
    • Spaces for inhaled asthma meds

Slide 15

Obesity Management Programs

Obesity Management Programs

  • 50% discount for enrollment
  • 100% coverage (50% rebate) for diabetics that lose five percent of body weight

Slide 16

Cost-Shares Increased  

Cost-Shares Increased

  • Outpatient surgery
  • High cost imaging procedures:
    • CT, MRI, PET

Slide 17

 Total Health Website

Total Health Website

Image: A screen shot of the Total Health Web site is shown.

Slide 18

 Total Health Evaluation Design

Total Health Evaluation Design

  • Study Design:
    • Quasi-experimental 2 group before/after design
    • Repeated measures
    • Control group: Kaiser Permanente Colorado employees

Slide 19

 Outcomes

Outcomes

  • Primary:
    • 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

Slide 20

 Survey Tool

Survey Tool

Survey invitation to employees.

  • Web survey tool
    Paper survey on request
DomainsInstrument
Functional Status:(SF-12)
Workplace productivity:Work Health Interview
Health Risk Behaviors
  • Tobacco
  • Alcohol
  • BMI
  • Physical Activity
  • Satisfaction w/ plan
BRFSS, other

Slide 21

Administrative Data  

Administrative Data

  • Health utilization/cost/quality:
    • Group Health Research Institute data warehouse
      • Claims
      • Pharmacy
      • EMR data
  • Employee characteristics:
    • Human Resources administrative data

Slide 22

 Data Collection

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 E-mails
    • No telephone follow-up

Slide 23

 Statistical Power

Statistical Power

 Mean/ PercentSDMean detectable difference
Presenteeism (hours)5.27.50.57
Absenteeism (hours)11.014.01.06
Lost productive time (hours)15.314.41.09
Self-rated health (excellent/very good)57%--3.8%

 

Slide 24

 Demographic Characteristics

Demographic Characteristics
Group Health and KPCO

Demographic CharacteristicsGroup Health
N=8,018
KP Colorado
N=5,104
Mean age (year)45 years45.3 years
% White80%86%
% Hispanic3%13
% Female80%83%
% Part-time29%14%
Mean time with employers (years)10 years8.9 years
Mean salary$58,385$59,421

Slide 25

 Total Health-participation

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 Web site.

Slide 26

 Progress to Date

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

Slide 27

Challenges and Strengths  

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

Slide 28

 Research Team

Research Team

GHRI/UW:

  • Paul Fishman
  • Nora Henrikson
  • Rebecca Hubbard
  • Diane Martin
  • Rob Reid
  • Ellen Schartz
  • Aaron Scrol
  • Kay Theis

KPCO:

  • Arne Beck
  • Debra Ritzwoller
  • Nancy Brace
Current as of December 2010
Internet Citation: An Evaluation of a Value-Based Health Plan Design at Group Health (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/grossman2/index.html