Explore the vast range of titles available.

We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy. All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline. 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (−57%) and patient satisfaction. No savings were realized because the cost reduction threshold (−9%) was not met during PP1 (+1.7%) or PP2 (−0.4%). Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs. •Assessed the medical value of a Shared Savings Program for pediatric appendicitis.•Quality targets included time to surgery, length of stay, readmission, and patient satisfaction.•Two quality targets were met during the study period, readmission and satisfaction.•However, no savings were realized because the cost threshold was not met.•Payer-provider partnerships can be a platform for testing value-based reimbursement.

Abstract Inflammatory bowel disease (IBD) is a chronic inflammatory disease associated with significant resource utilization and health care burden. It is emerging as a global disease affecting an increasing proportion of the population. Along with evolving epidemiological trends, the paradigm of managing IBD has also changed. With a burgeoning repertoire of therapeutic options, improved use of health informatics, and emphasis on health care value, the treatment paradigm for IBD has experienced seismic shifts. In this review, we focused on value-based health care (VBHC)-a health care model that emphasizes monitoring outcomes to emphasize patient-centered, cost-effective IBD patient care. Several quality initiatives have been developed worldwide, and successful models of care were created for proper implementation of these initiatives. Although there are significant challenges to scale these models to a national level, it is still possible to successfully implement VBHC models within health systems to improve the quality of care provided to patients with IBD.

Value-based health insurance designs (VBIDs) are one approach to increase adherence to highly effective medications and simultaneously contain rising health care costs. The objective of this systematic review was to identify VBID effects on adherence and incentive designs within these programs that were associated with higher effects. Eight economic and medical databases were searched for literature. Random effects meta-analyses and mixed effects meta-regressions were used to synthesize VBID effects on adherence. Thirteen references with evaluation studies, including 12 patient populations with 79 outcomes, were used for primary meta-analyses. For qualitative review and sensitivity analyses, up to 19 references including 20 populations with 119 outcomes were used. Evidence of synthesized effects was good, because references with high risk of bias were excluded. VBIDs significantly increased adherence in all indication areas. Highest effects were found in medications indicated in heart diseases (4.05%-points, p < 0.0001). Each additional year increased effects by 0.15%-points (p < 0.01). VBIDs with education were more effective than without education, but the difference was not significant. Effects of VBIDs with full coverage were more than twice as high as effects of VBID without that option (4.52 vs 1.81%-points, p < 0.05). These findings were robust in most sensitivity analyses. It is concluded that VBID implementation should be encouraged, especially for patients with heart diseases, and that full coverage was associated with higher effects. This review may provide insight for policy-makers into how to make VBIDs more effective.

Value-based insurance design (VBID) is a strategy that reduces cost sharing for high-value services and increases consumers' out-of-pocket spending for low-value care. VBID has increasingly been implemented by private and public payers and has inspired demonstration programs in Medicare Advantage and TRICARE. Given the recent publication of several studies, we performed an updated systematic review that evaluated the effects of reducing consumer cost sharing on medication adherence and other relevant outcomes. Searches were conducted in key online databases, and the screening of citations yielded twenty-one unique studies, of which eight had not been included in previous reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, we found moderate-quality evidence showing improvement (range: 0.1-14.3 percent) in medication adherence with VBID. This increase in adherence was associated with no effect on total health care spending, which suggests that the incremental drug spending was offset by decreases in spending for other health care services.

I've been meeting with physicians nationwide about their planned, ongoing and potential transitions from fee-for-service to value-based reimbursement. It's certainly a work in progress.I've been meeting with physicians nationwide about their planned, ongoing and potential transitions from fee-for-service to value-based reimbursement. It's certainly a work in progress.

Value-based insurance design (VBID) plans selectively lower cost sharing to increase medication adherence. Existing plans have been structured in a variety of ways, and these variations could influence the effectiveness of VBID plans. We evaluated seventy-six plans introduced by a large pharmacy benefit manager during 2007-10. We found that after we adjusted for the other features and baseline trends, VBID plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The effects were as large as 4-5 percentage points. These findings can provide guidance for the structure of future VBID plans. [PUBLICATION ABSTRACT]

Context: High-value oncology requires physicians to monitor and coordinate all aspects of care, educate and engage their patients, and adopt cost-effective drug treatments. However, oncology practices in the United States traditionally have been reimbursed based on the number of office visits performed and through cost-plus margins from prescription of expensive drugs. Public and private payers now are experimenting with methods of payment that include monthly care management fees, annual bonuses, and incentives for conservative choice among alternative drug regimens. Methods: This paper uses case study methods to examine oncology payment initiatives at Medicare, Anthem, Aetna, and UnitedHealthcare, the nation's largest public and private health insurance plans. Findings: The 4 insurers supplement traditional fee-for-service payment with payment methods designed to promote coordination of care and conservative use of health care resources. Medicare, Aetna, and UnitedHealthcare reward oncology practices that reduce per-patient spending, targeting unnecessary patient visits to emergency departments and hospitals. Anthem offers monthly payments to practices that adhere to lower-cost drug treatment pathways; Aetna increases the percentage markup on low-cost generic chemotherapies but not on high-cost biologics; and UnitedHealthcare removes the linkage between physician payment and spending on office-infused drugs. As a condition for receiving the new payments, each of the initiatives requires participating practices to report and, in some cases, improve performance on quality metrics. None of the initiatives bundles payment for oncology drugs together with payment for other oncology services, out of concern for shifting financial risk onto physicians and creating access barriers for patients. Conclusions: The emerging \"value-based\" methods of oncology payment supplement fee-for-service and cost-based reimbursements with per-month and per-episode payments, but none of the payers bundle spending on cancer drugs with payments for other services. Payers recognize that bundled payment could create access barriers for patients and undermine innovation in effective but expensive new pharmaceuticals.

To examine whether the growth of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) and Medicare Advantage (MA) penetration was associated with changes in health care use among commercially insured populations. Observational study using claims data. Using Health Care Cost Institute claims data (2015-2019), we conducted a repeated cross-sectional study of 13,041,197 enrollees aged 55 to 64 years in 50 states and the District of Columbia in employer-sponsored insurance plans of 4 national payers. Linear models estimated relationships between enrollees' health care use and county-level MSSP ACO and MA penetration, controlling for enrollee and market characteristics and county and year fixed effects. Outcomes of interest were enrollees' probability of receiving preventive care services (influenza immunization, breast cancer screening, colorectal cancer screening), having any outpatient emergency department visits, and having any inpatient hospitalization in a year. A majority of counties (72.1%) experienced increases in penetration of MSSP ACOs and MA from 2015 to 2019. Median (IQR) MSSP ACO penetration increased from 5.9% (1.6%-16.9%) to 18.9% (9.3%-31.5%), and median (IQR) MA penetration increased from 19.5% (11.2%-29.3%) to 26.8% (15.9%-36.6%). MSSP ACO and MA penetration was not substantively associated with changes in commercial enrollees' use of preventive care, emergency department, and hospital services. The expansion of MSSP ACOs and MA was not associated with substantive changes in health care use among commercial enrollees. The lack of spillovers from Medicare to commercial enrollees may stem from misaligned incentives from different payers, indicating the potential importance of multipayer alignment in ongoing payment reforms.

To quantify the magnitude of an ISPOR novel value element, insurance value, as applied to new treatments for a rare, severe disease with pediatric onset: Duchenne muscular dystrophy (DMD). Prospective survey of individuals planning to have children in the future. A survey was administered to US adults (aged ≥ 21 years) planning to have a child in the future to elicit willingness to pay (WTP) for insurance coverage for a new hypothetical DMD treatment that improved mortality and morbidity relative to the current standard of care. To identify an indifference point between status quo insurance and insurance with additional cost that would cover the treatment if respondents had a child with DMD, a multiple random staircase design was used. Insurance value-the value individuals receive from a reduction in future health risks-was calculated as the difference between respondent's WTP and what a risk-neutral individual would pay. The risk-neutral value was the product of the (1) probability of having a child with DMD (decision weighted), (2) quality-adjusted life-years (QALYs) gained from the new treatment, and (3) WTP per QALY. Among 207 respondents, 80.2% (n = 166) were aged 25 to 44 years, and 59.9% (n = 124) were women. WTP for insurance coverage of the hypothetical treatment was $973 annually, whereas the decision-weighted risk-neutral value was $452 per year. Thus, insurance value constituted 53.5% ($520) of value for new DMD treatments. Individuals planning to have children in the future are willing to pay more for insurance coverage of novel DMD treatments than is assumed under risk-neutral, QALY-based frameworks.

In 2011 Connecticut implemented the Health Enhancement Program for state employees. This voluntary program followed the principles of value-based insurance design (VBID) by lowering patient costs for certain high-value primary and chronic disease preventive services, coupled with requirements that enrollees receive these services. Nonparticipants in the program, including those removed for noncompliance with its requirements, were assessed a premium surcharge. The program was intended to curb cost growth and improve health through adherence to evidence-based preventive care. To evaluate its efficacy in doing so, we compared changes in service use and spending after implementation of the program to trends among employees of six other states. Compared to employees of other states, Connecticut employees were similar in age and sex but had a slightly higher percentage of enrollees with chronic conditions and substantially higher spending at baseline. During the program's first two years, the use of targeted services and adherence to medications for chronic conditions increased, while emergency department use decreased, relative to the situation in the comparison states. The program's impact on costs was inconclusive and requires a longer follow-up period. This novel combination of VBID principles and participation requirements may be a tool that can help plan sponsors increase the use of evidence-based preventive services.