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). 

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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.

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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Devices

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

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Obesity Management Programs

• 50% discount for enrollment
• 100% coverage (50% rebate) for diabetics that lose five percent of body weight

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Cost-Shares Increased

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

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Total Health Website

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

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Total Health Evaluation Design

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

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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

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Survey Tool

Survey invitation to employees.

• Web survey tool
  Paper survey on request

Domains	Instrument
Functional Status:	(SF-12)
Workplace productivity:	Work Health Interview
Health Risk Behaviors Tobacco Alcohol BMI Physical Activity Satisfaction w/ plan	BRFSS, other

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Administrative Data

• Health utilization/cost/quality:
  • Group Health Research Institute data warehouse
    • Claims
    • Pharmacy
    • EMR data
• Employee characteristics:
  • Human Resources administrative data

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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

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Statistical Power

	Mean/ Percent	SD	Mean detectable difference
Presenteeism (hours)	5.2	7.5	0.57
Absenteeism (hours)	11.0	14.0	1.06
Lost productive time (hours)	15.3	14.4	1.09
Self-rated health (excellent/very good)	57%	--	3.8%

 

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Demographic Characteristics
Group Health and KPCO

Demographic Characteristics	Group Health N=8,018	KP Colorado N=5,104
Mean age (year)	45 years	45.3 years
% White	80%	86%
% Hispanic	3%	13
% Female	80%	83%
% Part-time	29%	14%
Mean time with employers (years)	10 years	8.9 years
Mean salary	$58,385	$59,421

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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.

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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

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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

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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