Value-Based Benefit Designs: Comparative Models Support Replication and Scalability

Nominee: Jack Mahoney, MD, MPH, Chief Medical Officer of Center for Health Value Innovation and the Florida Health Care Coalition, Strategic Consultant to Pitney Bowes.

Problem statement:  There are varied designs for VBBD.  The most focused is on the pharmacy benefit design, a critical component for chronic care management, complex case management, and high-risk/vulnerable population management.  But the real question is: "can we discern that copay reduction by itself can reduce total costs, or if condition management can reduce total costs or if the combination of the two is the most effective investment to manage risk and lower health cost trend."  If we can discern the best investment (either one or both investments) and replicate the health cost trend reduction, then we are showcasing the value of health investments and health innovation in the chronic care marketplace which would then provide impetus for CMS development in VBBD and for CER comparisons.

Target populations:  diabetes, asthma, and hypertension with co-morbid conditions as a corollary-continuum for care.

Objectives for project or solution:

1.  Create comparative analysis for existing evidence of the replicability and scalabilty of VBBD, particularly where Rx design is the primary treatment for the condition.

2.  Launch models that test the comparative analysis, measuring patient activation and competency for management.

3.  Create a matched cohort analysis that shows improvjement with one or both, interventions and if possible, compare to the earlier analysis.

Evaluation:

Dr. Mahoney and his team have taken the cumulative results from the Center's database, members of the Florida Health Care Coalition and other publications to showcase the extent of innovation in VBBD.

Some reduced total costs of Rx, some reduced total co-insurance tiers (thereby preserving generics-first as a construct where lowest cost affordability was an issue for the patient) and some reducing preferred brands/generics but not total class reduction.  These variances show variability in the extent of the innovatives possible, but allow the plan sponsor to create the Rx benefit that most aligns with the payer business strategy.

Conclusion:

Value-based benefit designs are replicable and scalable, delivering predictable results with and without mandatory condition management programs.