Wednesday, March 31, 2010

Value Based Insurance Design and the Synergies with the Medical Home, P4P, HIT and Disease Management. We've Only Just Begun

More than a year ago, the Disease Management Care Blog posted a prediction. It said that the key to achieving improved population-based outcomes at lower cost will lie in the combined five-fold synergies of: 1) Ver 2.0 care/disease management, 2) the patient centered medical home (PCMH), 3) provider pay-for-performance (P4P), 4) the electronic medical record (EMR) and 5) consumer directed health plans. It turns out that the DMCB was slightly wrong in several domains. It's not necessarily just 'pay for performance' but flexible provider compensation that includes enhanced fee-for-service, risk-adjusted capitation, P4P and gain sharing. It's not just the EMR, but EHRs plus decision support and registries. And it's not consumer directed health plans but value based insurance designs (VBID).

What is VBID? It's any commercial insurance product that includes adjustments of patients' out-of-pocket costs and provider reimbursement for specific services based on their clinical benefit. The greater the benefit to the patient, the lower that patient's cost share and the higher the provider payment. It can be tailored to certain services (for example, lipid testing) and/or for certain conditions (diabetes mellitus) and/or condition severity (enrollees with recurrent hospitalizations) and/or level of participation (in care management). It's not necessarily easy to implement, since there are Federal and State regulations to consider, the possibility of employee push-back over perceptions of unfairness, a still evolving business model and questionable scalability across a network.

You can read more about it here and view this helpful YouTube video here.

VBID was an important topic that was discussed by Mark Fendrick at the Patient Centered Primary Care Collaborative Stakeholder's meeting that was held in Washington DC on March 30. His presentation (the PowerPoint is not yet available on line) was timed to match the release of this PCPCC white paper. It's worth downloading and reading. It describes in some detail how the PCMH and VBID can be integrated through reduced patient out-of-pocket expenses for medical home-based visits as well as for referrals coordinated by the medical home, increased health reimbursement/savings accounts to pay for medical home services and co-pay tiering that favors testing and medications ordered by medical home team members.

The March 30 meeting also featured Dr. Blumenthal of ONC, who spoke rather extensively about the synergies of health information technology (HIT) and the medical home. Unlike discussion of VBID, however, there was little else that was particularly new in this discussion, including the assertion that this time, and we really REALLY mean it this time, that "meaningful use" combined with luster of federal funding will cause all those hold-out physicians relent and spend tens of thousands on an outpatient EHR.

What was missing from both Dr. Fendrick's and Blumenthal's presentations, however, was how HIT, VBID and the medical home are probably more than the sum of any of its parts. For example, HIT-based decision support tapping into registries can help prompt value-based interventions coordinated by PCMH team members even if the patient is not physically present.

The DMCB says toss in the right kind of provider reimbursements and the option of distance telephonic support to help coach the patient using principles of shared decision making and....

Well, the DMCB thinks anyone can see the potential here.

Years ago, the DMCB also submitted a paper to Health Affairs on the topic of an overlapping and mutually supportive five-way approach to population-based care. After some tantalizing positive reviewer feedback and requests for revisions, it was ultimately rejected. The thinks it was ahead of its time. The manuscript is in some folder in the DMCB World Headquarters somewhere. Maybe it's getting time to dust it off.

And maybe at a next PCPCC confab, it'll be realized that PCMH-VBID or PCMH-HIT dyads are only the beginning.

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