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

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

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

Slide 2

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

• 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

• 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

• 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

• 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

• 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

• 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

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

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

• 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

• 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

• 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

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

Slide 15

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

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

Slide 17

Total Health Website

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

Slide 18

Total Health Evaluation Design

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

Slide 19

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 invitation to employees.

• Web survey tool
  Paper survey on request

Slide 21

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

• 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

Slide 24

Demographic Characteristics
Group Health and KPCO

Slide 25

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

• 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

• 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

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