Expensive and steadily rising health care costs without a concomitant increase in quality have generated a search for solutions to fund health care in the United States. Recent health care reforms and proposals on the agenda have spurred debate about alternative payment plans for health care. Much of the talk centers on imaging, which is a fast-growing and expensive component of health care. Value-based insurance design (VBID), a “clinically sensitive” means of sharing the cost of health care, has been proposed as a means to control the runaway costs of health care management including diagnostic testing. A corollary of pay-for-performance initiatives in which physician incentives are aligned with evidence-based medical practices, VBID seeks to increase patient incentives to comply with evidence-based health care consumption. We previously reviewed the principles of VBID and provided examples of VBID in practice using diabetes management as a model, as well as suggested some areas in diagnostic testing that lend themselves to VBID benefit design. In this article, we summarize the barriers to implementation and outline potential solutions, with particular regard to radiology.
Economic theory holds the rationale that the value of insurance arises because it allows people to alleviate the financial burden associated with the risk of illness and because it allows those who become ill to afford care that they would otherwise not be able to purchase . In the current system, cost-sharing amounts are constant for a particular service, although the clinical value of the service will vary depending on who receives it. Ideally, uniform copayments would discourage the use of low-value health care but this assumes that patients can distinguish between high- and low-yield therapies. Evidence shows that higher copayments reduce the use of all services, including highly valuable health care services, which could thus result in worse health outcomes . The concern is also that cost-sharing most adversely affects consumption in low income seniors, who need the health care the most . Uniform coinsurance and reference pricing are inherently cost-based rather than value-based incentive mechanisms. Patients pay more for services that cost more, regardless of whether those diagnostic tests or therapies will have a major or minor impact on their health. Patients are not given information to help distinguish between very effective, partially effective, and totally ineffective tests and treatments.
With respect to imaging, Bluestein et al demonstrated that mammography uptake rates were decreased in Medicare patients without supplemental insurance (14.4%), compared to patients with Medicaid supplemental insurance (23.9%), patients with the Medicare screening benefit (36.9%), employer-sponsored supplemental insurance (44.7%), and those with self-purchased supplemental insurance (40.1%) . Solanki and colleagues demonstrated negative direct (and to a lesser degree, indirect) effects of cost sharing (copayments, co-insurance, and deductibles) on the number of mammograms in patients belonging to both health maintenance organizations and preferred provider organizations/indemnity plans . The converse is also true; decreasing copayments was shown by Chernew and colleagues to increase medication adherence within a disease management program in a large employer-based health system .
In response to these adverse effects of the current copay system, a benefit-based copay system was advocated by Fendrick and colleagues, in which copayment rates are set based on the value of clinical services, rather than costs . The amount of patient cost sharing would be based inversely on expected clinical benefits. This concept was expanded outside prescription drugs to health insurance in general, and the term value-based insurance design or VBID emerged . This VBID system is based on the “medical appropriateness” of the imaging test and is different from a cost-effectiveness exercise.
Barriers to implementation of VBID in radiology
Challenges arising in VBID programs include the collaborative relationship between payers and providers necessary for short- and long-term program success. The structure of a VBID initiative must be designed to overcome provider resistance, skepticism, and legal challenges. The development and implementation of an effective VBID program and chance of success could be improved with collaboration of payers and providers in the VBID development stages allowing for multidimensional performance initiatives with long-term benefits for each party. These collaborations could foster a sound organizational infrastructure, cooperative culture, and enhanced professional resources vital to the long-term success of VBID programs. Clinicians and radiologists should be involved in program design and implementation, and the use of evidence-based guidelines is imperative. Finally, rigorous follow-up processes should be established with a substantial commitment to information technology support for monitoring and maintaining the program’s success.
Despite the advantages of VBID, uptake has not been rapid, which reflects many barriers. With respect to imaging services, there are also some specific barriers.
Economic barriers
Increased Costs and Inappropriate Utilization
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Medicare Reimbursements of Inpatient Services
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Self-Referral and Auto-Referral
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Unintended Incentives
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Practice barriers
Care and Complexity of Implementation
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Lack of Evidence Supporting Value-based Provision of Imaging Services
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Health Information Technology, Data Transfer, and Storage Issues
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The Responsibility Needed to Make Decisions about Appropriate or High-yield Imaging
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Adverse Selection
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Other barriers
Ethical Concerns
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Privacy Concerns
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Encouragement of Fraud
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Legal Barriers
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Why we need VBID in radiology
Need to Improve the Quality of Health Care
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Need to Curb Health Care Expenses
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Financial implications of VBID
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Increased Direct Costs Now and Added Value Later
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Savings from Improved Health
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The Targeting Factor
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Potential implementation of VBID in radiology
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Conclusion
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