CMS’s plans for easing participation by insurers include an easier application process and allowing for marketing to potential enrollees.


May 18—Medicare Advantage (MA) plans are evolving their approaches in the expanding Medicare pilot for value-based insurance design (VBID).

The lessons learned by nine early participants in the VBID pilot could prove critical for other MA insurers, as the model is scheduled to expand from 10 states to 25 states in 2019.

The five-year pilot, now in its second year, aims to test the effect of offering targeted extra benefits or reduced cost-sharing to enrollees who have certain conditions.

UPMC Health Plan

UPMC Health Plan’s VBID approach has aimed to use “sustained management and engagement” to get enrollees involved in their care, said Helene Weinraub, MPH, vice president for the insurer. The approach includes dedicated member service phone lines that enrollees can call to get information about their care.

“We really wanted the member to become involved in taking care of themselves,” she said during a presentation at the Second National Medicare Advantage Summit.

Among lessons learned was that the insurer needed a “toned down” behavioral economics approach.

“So basically, when a member does something we try within a very short time frame to give them a reward and remind them why they have gotten that reward, and then continue throughout the year,” Weinraub said. 

In 2018, UPMC Health Plan ramped up its data collection and analysis to inform creation of 2019 plan designs and flexible benefits, Weinraub said. The goals are to examine the ability to reduce costs through interventions and to find better ways to balance risk and reward.

“We wanted the target population to be large enough to be relevant yet small enough to manage and minimize potential loss just in case things didn’t work out like we thought,” Weinraub said.

Reassessments for 2019 include whether the insurer picked the right patient populations—various combinations of patients with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes—and whether patients should lead the response to their disease or if the effort should be provider network-driven.

The plan has moved from an opt-in approach to a “modification opt-in,” where care managers provide more screening to determine the program’s appropriateness for enrollees, she said.

Positive results so far include good data flow and collaboration. Most surveyed enrollees said the program helped them take control of their health.

Challenges have included enrolling patients with the specific disease mix that UPMC Health Plan targeted in the pilot and effectively engaging enrollees. The insurer saw initial engagement of the 18,000 potentially eligible members fall below a rate of 20 percent after the first year, which it blamed on the need to annually renew enrollment in the program and challenges with making initial member connections.

 The average enrollee age in the pilot, 76, was several years older than that of the insurer’s average MA plan enrollee.

Aetna’s Experience

Aetna also is in its second year in the VBID pilot, with participating plans in Pennsylvania and the intent to expand next year into West Virginia.

The CHF-focused plans also require members to opt in and to “actively participate in the care management program in order to receive the cost-sharing reductions,” said Greg A. Jones, government affairs and public policy adviser for Aetna.

 “The reason why we designed it like that is because we think that active member engagement is really crucial; waiving the cost-share of the copayment is simply not enough” to trigger enrollee action, he said. “Our participation rate is lower because of this process, so as we look to expand these kinds of models more broadly outside of the demonstration, that’s something that we’re going to have to look at.”

Cost sharing is waived in Aetna’s VBID plan for all primary care and cardiologist visits, as well as for certain generic CHF drugs.

The plan also disenrolls beneficiaries if they don’t meet participation requirements, such as quarterly visits to a primary care provider.

Lessons learned include the need to establish processes for case managers to identify the eligible population, based on ability to participate. That required enhancing the plan’s care management system and building an opt-in process. Aetna also shared internally the approaches of the nurse case managers who were more effective in recruiting enrollees.

One change Aetna is looking to implement in the third VBID year is to integrate transportation benefits—funding 24 trips per enrollee to plan-approved locations.

“If the member needs to get to their doctor’s office, a lab, a hospital, or a radiology appointment we help provide that transportation at no cost to them, so long as it’s to visit one of the providers that are already in our network,” Jones said.

Another addition will be limited meal deliveries—14 “heart-healthy” meals three times a year, such as after a surgery. Qualifying patients include those with little home support or who face financial distress.   

Looking Ahead

Longtime VBID advocate A. Mark Fendrick, MD, professor in the Department of Internal Medicine and the Department of Health Management and Policy at the University of Michigan, said the limited initial interest in the VBID pilot by MA insurers likely stemmed from other high-profile priorities and from Centers for Medicare & Medicaid Services (CMS) restrictions on advertising. Another challenge was the requirement by CMS to produce cost savings, even though previous research has shown that VBID programs actually increase spending outside CHF, COPD, and diabetes.

Fendrick noted that the pilot’s cost-neutral requirements have led plans to focus on CHF instead of options like rheumatoid arthritis, where “the numbers don’t work out actuarially as well.”

“For me, the opportunities for improving health are actually greater in the conditions that may not in the first five years meet the cost-neutrality requirement,” Fendrick said.

Stephen Jenkins, lead in the VBID office at CMS, said the early experiences of insurers that figure out how to succeed under VBID will likely draw more to participate. He also noted CMS has recently allowed greater flexibility in marketing for both VBID plans and other MA plans.

Coinciding with the early years of the VBID pilot, Medicare recently gave MA plans the option to offer a new range of “flexible benefits,” which mirror some VBID offerings. That will challenge plans to pick between the somewhat similar options of participating or not participating in VBID, said Jane Galvin, managing director of regulatory affairs for the Blue Cross Blue Shield Association.

Jenkins said CMS is trying to ease the application process to help the pilot bring in more MA plans.

Aetna plans to stay in VBID, but UPMC Health Plan is still considering whether to remain or move its MA plans toward the flexible-benefits approach.

Remaining questions that insurers are waiting to see answered include whether CMS will use its “plan finder” website to explain the flexible benefits that plans have started to offer—or allow other ways to explain them, Galvin said.


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

Publication Date: Monday, May 21, 2018