Some VBID supporters worry that CMS limitations on the program, such as not allowing plans to cut Part D cost sharing, could mitigate any benefits from the pilot.


April 7—Health plans struggled to meet their enrollment goals at the start of Medicare’s first pilot to test value-based insurance design (VBID).

Insurers have yet to obtain any results from the seven-state pilot to test VBID approaches among the Medicare Advantage (MA) plan population, but they succeeded in launching products with about 100,000 enrollees nationwide on Jan. 1, according to Stephen Jenkins, the program’s lead for the Centers for Medicare & Medicaid Services (CMS).

Early enrollment struggles included those of Tufts Health Plan in Boston, which targeted 15,000 MA enrollees for its VBID pilot but was able to get only about 3,000, according to Jonathan Harding, MD, chief medical officer. Similarly, UPMC Health Plan was able to enroll only about 3,000 participants among 128,000 potentially eligible, said Helene Weinraub, vice president.

“It might have been good if we had a behavioral economist on our team because we were way off,” Harding said, referring to expectations that higher enrollments would be driven by the appeal of the VBID benefit package, which included reduced out-of-pocket costs.

The anticipated enrollment numbers were derived from the roughly 15,000 enrollees—among Tufts Health Plan’s 107,000 HMO members—who had the chronic health conditions targeted for management by the VBID pilot: diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of those conditions.

Among the reasons MA enrollees opted out of Tufts’ auto-enrollment effort for the pilot was that the program’s reduced copays would lower total out-of-pocket costs for beneficiaries and thus would make them ineligible for subsidized housing.

“We didn’t think about non-healthcare implications,” Harding said during the National Medicare Advantage Summit.

Different Designs

The VBID pilot gave plans some flexibility to tailor out-of-pocket costs and other components as part of their approaches.

“We wanted to assist the member in self-managing their condition to lead to better health, improve quality of life, and reduce medical costs,” Weinraub said. 

UPMC Health Plan’s VBID approach included education for enrollees about the effects of lifestyle choices, and efforts to steer them toward available resources from the health plan and in their community. Initial health surveys were followed by case management reviews, and then personalized quarterly healthcare activities were identified. The program incentivized participation in that process by offering $25 for the completion of each step—up to $150 annually.

The Tufts VBID program included mandatory enrollment in care management, elimination of copays for primary care physician (PCP) visits, and reduced copays for specialist visits.

“We still wanted to have a specialist/primary care differential because PCPs don’t want patients to have no disincentive to see the specialist instead of them,” Harding said.

Participating plans noted that CMS restrictions affected the components they could include. UPMC Health Plan’s initial VBID proposal would have reduced Part D costs, for instance, but CMS rejected that.

The resulting approach, which did not lower out-of-pocket costs for medications, drew criticism.

“As good of doctors as we might be, the way we keep people with heart failure out of the hospital is largely medication,” said Mark Fendrick, MD, policy director of the Center for Value-Based Insurance Design at the University of Michigan. Under the CMS-approved model, “You get to go to the doctor much more often and then complain to the doctor, the PA, or the NP that you can’t afford the meds.”

Fendrick noted that of patients with the types of chronic illnesses that are eligible for coverage in the VBID pilot, 75 percent take at least 10 drugs. Those patients could face large out-of-pocket costs even if most of their drugs are generic.

Other CMS rules that may the hamstring pilot, according to Fendrick, include bans on advertising to get more enrollments and on increased cost sharing for unneeded healthcare services.

Positive Signs

Among the positive early findings by insurers in the VBID pilot was an enthusiastic response from providers.

Harding said the Tufts plan reached out to providers and explained, “‘The reduced copay is going to come out of your fund; are you going to be willing to do that?’ Many providers said, ‘Yes, because we believe this could actually really help us in the long run.’” However, Tufts found that time limitations on designing and implementing the program meant that the plan had to reject physician ideas for improving the design.

“There’s a lot of enthusiasm actually from some of the providers who have been asking for flexibility,” Harding said. “All we can do is say, ‘We’re starting with this, we’ll see how it goes, and we may expand it as time goes on.’”

For instance, some providers suggested lowering the cost of inhalers for COPD patients to improve medication adherence and reduce emergency department use. But that would have required rewriting the plan’s physician contracts, among other complications.

“We couldn’t do what we wanted, so we did what we could,” Harding said.

The tight schedule for applying to and then implementing the pilot didn’t leave UPMC Health Plan enough time to integrate incentives for providers to alter their approaches, but the plan hopes to incorporate such measures in the remaining five years of the pilot, Weinraub said.

Anecdotal evidence has emerged that the VBID program has succeeded at enrolling in care management some beneficiaries who had rejected it previously.

Limitations

The challenges of implementing a VBID program included the large array of analytics required to identify which changes were needed to keep the program cost-neutral, Harding said. One of the surprising findings from his plan’s analyses was that many heart failure and COPD patients never visited their PCP; beneficiaries identified PCP copays as a financial barrier.

Also time consuming was the effort to obtain consent to participate from the 100 medical groups with which the Tufts plan contracts.

“The complexity of implementing this through claims systems, enrollment systems, and eligibility systems was just staggering,” Harding said.  

Harding warned that the VBID program will not work in a highly siloed organization—he described his as “modestly siloed”—because of the extent of “cross-functional work that has to happen.”

CMS plans to expand the pilot next year to three more states, and legislation was introduced this week to expand it to all 50 states.

Other federal VBID efforts include a larger initiative that is scheduled to launch in January 2018 within Tricare, the healthcare program for uniformed service members and their families.  


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, April 07, 2017