Clinically Oriented Cost and Profit Design for Enhancing Well being Fairness: The Case of Weight problems Prevention and Remedy

Despite the significant success in reducing the number of uninsured Americans since the Affordable Care Act (ACA) was passed, more than one in five working-age adults is still considered “underinsured,” defined as having annual out-of-pocket expenses, excluding premiums, the 10th Percent of household income. Cost-sharing strategies that require consumers to pay more for all services, such as: B. High Deductible Health Insurance (HDHP), reduce the use of basic health care, especially by underserved populations. Clinically oriented payment and service concepts are therefore justified in order to promote access to necessary care for people at risk.

Value-based insurance design

Value-Based Insurance Design (V-BID) is a potential strategy for promoting equal access to essential services. In contrast to a “one-size-fits-all” cost-sharing approach (e.g. HDHP) which could reduce the use of quality services and potentially exacerbate health inequalities, V-BID sets consumer contribution to clinical benefit, not cost – of the service. For example, high-quality services, such as using statins to lower bad cholesterol, would incur little or no co-payment, while low-quality treatments with questionable benefits, such as prostate cancer screening for men over 70, would have a higher co-payment.

For more than 20 years, V-BID programs run by hundreds of private and public payers, including Medicare, have been shown to improve patient-centered outcomes and, in some cases, reduce healthcare spending. In particular, removing financial barriers has been shown to improve drug adherence, reduce health spending, and reduce health inequalities between minority groups, including African Americans and Hispanics. A recent review by one of us (Fendrick) and co-authors found that those who face the greatest financial hurdles for care appear to benefit most from the cost-sharing for preventive care services, as mandated by the ACA. Future policy efforts should combine V-BID strategies with targeted interventions with the provider in mind to optimize patient-centered outcomes and improve health equity.

Using V-BID to Improve Equity: Prevention and Treatment of Obesity

Obesity is a disease and also a primary risk factor for many common chronic conditions such as diabetes, cardiovascular disease, liver disease and COVID-19 related adverse events that disproportionately affect disadvantaged populations. Despite solid clinical and cost-effective evidence, obesity treatments – including intensive behavioral interventions, anti-obesity drugs (AOMs), and bariatric surgery – are significantly underutilized in legitimate individuals who might benefit from their use. The lack of adequate reimbursement by the doctor and insufficient insurance cover are among the main causes of suboptimal application.

Although a growing number of insurers, including Medicare, cover the diabetes prevention program, low reimbursement rates are likely to contribute to persistent undersupply. AOMs, including the recently approved drug semaglutide, which causes up to 17 percent weight loss, have the potential to transform the medical treatment of obesity; however, the coverage is very variable. Coupled with the high cost of AOMs (e.g., $ 1,300 per month for high-dose liraglutide and semaglutide with no insurance), the exclusion of all drugs used to treat obesity under Medicare Part D is a significant barrier to the expanded use of these drugs. Similarly, the use of bariatric surgery – one of the most effective treatments for obesity – has been much lower among ethnic and ethnic minorities, and the high intrinsic costs are recognized as one of the major obstacles. One of us (Kim), along with co-authors, conducted a model study that found that increased adoption of bariatric surgery could create significant clinical value for patients, payers and society, including greater benefits for minorities and the sick. Hence, reducing inequalities in the treatment of obesity requires higher reimbursement and expanded coverage for clinically indicated treatment options for patient subgroups for which the clinical benefit is well established.

The effectiveness of obesity treatments can be increased by ensuring that consumers have access to the resources to lose weight and maintain weight loss, including affordable, quality foods and safe spaces for physical activity. While nutritional support is typically not covered by health insurance, the Medicare Advantage V-BID model allows additional meal or other nutritional benefits for participants with select clinical or social circumstances. Private insurers should follow suit and offer these services to vulnerable populations with low co-payment or upfront co-payment status for those facing high co-payments.

Federal policy changes recently have given health plans more flexibility to provide more generous coverage for quality clinical services such as obesity prevention and treatment. A 2019 notice from the Internal Revenue Service (IRS) allows HDHPs to cover certain services used to treat chronic diseases before patients meet their deductibles. Then, on April 28, 2021, Senators John Thune (R-SD) and Tom Carper (D-DE) introduced the bipartisan, bicameral Chronic Disease Management Act of 2021 to build on the IRS criteria and HDHPs the Flexibility to give a wider range of chronic disease prevention services – such as The cost to the payer (or ultimately the policyholder) of providing subject to deductible coverage is minimal; an actuarial analysis of the insurance of more than 50 common drug classes estimated an increase in premiums of less than 2 percent. It is also important to recognize that treating obesity leads to the prevention or resolution of other costly chronic conditions such as diabetes, stroke, and coronary artery disease.

Pay yourself up: expand coverage by reducing low value services

In the past decade, policy makers have shifted their focus from volume-based care to value-based care. The ACA requires that private insurance plans provide no-cost insurance for patients rated “A” or “B” by the United States Preventive Services Task Force. Benefits that are rated “D” (no net benefits) can also be exempted from reimbursement (ACA Section 4105).

Nevertheless, payers and policy makers were reluctant because of the short-term budgetary implications (e.g. [now around 40 percent] potentially eligible for obesity treatments). One possible way to cover high-quality services more generously without increasing the premiums is to cover frequently overused, low-value services less generously, such as D deficiency. The savings made by reducing the use of these low value services could then help cover the additional expense of extending coverage to high quality services. As a rule, for the 2021 performance and payment parameters, the Ministry of Health and Social Affairs encouraged the use of V-BID, particularly to achieve greater use of high quality services and less use of inferior services when medically appropriate.

V-BID to improve equal opportunities in the health sector

It is well known that the causes of health disparities are linked to behavioral, economic, environmental and social factors. With such complex and multi-faceted problems, it is unlikely that a single approach can solve the prevailing health inequalities. However, concerted efforts through a range of evidence-based solutions can gradually improve health equity. Clinically oriented payment and benefit concepts are one approach to improve access to essential care for those at risk who are most likely to benefit from their use.

Authors Notes

David D. Kim, PhD, reported on a research grant from Arnold Ventures. Separate from this work, Dina H. Griauzde, MD, is an advisor to the National Kidney Foundation of Michigan. Caroline R. Richardson, MD reported on grants / contracts from NIH, CDC, BCBSMI, Apple, Dexcom, Twine Consulting and is the Editor-in-Chief of Annals of Family Medicine and JMIR-Diabetes. A. Mark Fendrick, MD reported consulting fees from AbbVie, Bayer, Centivo, Community Oncology Association, Covered California, Emblem Health, Exact Sciences, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, HealthCorum, Hygieia, MedZed , Merck, Mercer, Montana Health Cooperative, Pair Team, Phathom Pharmaceuticals, Risalto, Risk International, Semper Health, State of Minnesota, Department of Defense, Virginia Center for Health Innovation, Wellth, Wildflower Health, Yale-New Haven Health System, and Zansors ; Research support from AHRQ, Boehringer-Ingelheim, Gary and Mary West Health Policy Center, Arnold Ventures, National Pharmaceutical Council, PCORI, PhRMA, RWJ Foundation, Michigan State / CMS; and Associate Editor of the American Journal of Managed Care, member of MEDCAC and partner of V-BID Health, LLC.