Implementing value-based insurance design (VBID) programs under a new five-year test with CMS may be more difficult than some Medicare Advantage plans had expected. Sharing new details of their VBID tests during an April 6 session of the National Medicare Advantage Summit held in Arlington, Va., executives from Tufts Health Plan and UPMC Health Plans, Inc. discussed the incredible amount of pre-planning and interdepartmental work that went into implementing the initiatives. Despite this and, in the case of Tufts, lower than-anticipated enrollment, the plans remain hopeful that their newfound flexibility in benefit design will have its intended effect on members with the targeted conditions.

CMS in September 2015 unveiled the VBID model, which for the first time allows plans to offer VBID to MA members through a limited waiver to federal uniformity benefit-design requirements (MAN 9/17/15, p. 1). MA plans can offer targeted extra benefits or reduced cost-sharing to enrollees with at least one of seven specific chronic conditions, which will be expanded to nine conditions for the second year of the five-year test. The agency in October 2016 selected nine MA organizations operating 11 plans for the first year, which kicked off on Jan. 1, 2017. CMS has said the purpose of the model is to test the theory that by enabling MA plans to offer supplemental benefits or reduced cost sharing to targeted enrollees, it will promote the use of “high-value” services and providers and thus lead to higher-quality, more cost-efficient care. According to initial enrollment projections provided by a CMS official who co-presented with Tufts and UPMC on the panel, an estimated 100,000 MA beneficiaries overall are participating in the voluntary programs.

Knowing the significant “lift” it would take to coordinate such an initiative, Jonathan Harding, M.D., Tufts’ chief medical officer, senior products, said one of the health plan’s goals in designing the new benefit was to “keep it simple.” The insurer also had to work closely with its very engaged network of providers — many of whom share risk with the plan — to make sure the program would align with other initiatives such as star quality ratings and risk adjustment, and had a multidisciplinary team analyze 14 hypothetical benefit design concepts for their impact on administrative costs, key departments’ other projects, medical costs, providers and members.

After considering various use cases, including one that would have reduced physical therapy copayments to promote reconditioning and the prevention of falls in members with certain conditions, Tufts ultimately designed a program around congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), which are major cost drivers and have the highest rates of avoidable admissions, said Harding. Dubbed “Custom Care,” the program offers reduced copays for PCP visits and specialist copays at the PCP level for visits with cardiologists and pulmonologists. Members with CHF or COPD who are currently in care management were automatically enrolled in the voluntary program and given the option to disenroll. Harding noted that about half of the eligible patients had been identified for care management but had declined, so Tufts wanted to offer them an inducement to get into that program as well.

“Our theory was that improved access to PCPs and specialists should reduce [emergency room], inpatient and [skilled nursing facility] utilizations, and when we did some analysis we found a lot of patients with those conditions didn’t see their PCPs during the year and that the primary care copay was a barrier,” Harding told attendees. The insurer hoped that a reduced copay for physician visits would be an incentive for those resistant patients, he added.

Tufts Enrolled Fewer People Than Expected

But with about 15,000 members estimated to be eligible for Custom Care, only about 20% — or roughly 3,000 individuals — enrolled in the program, revealed Harding. And Tufts observed that people chose not to participate for numerous unanticipated reasons, such as members’ concern over losing their subsidized housing due to a reduction in their out-of-pocket costs.

Meanwhile, the complexity of implementing the new initiative through claims systems, enrollment systems, eligibility systems, etc. was “just staggering” and involved a lot of “cross-functional work,” remarked Harding. There were nine different workflows involving seven departments, working on everything from training customer service on the new benefit and creating a separate care management enrollment track to drafting member materials for CMS approval and designing new Custom Care ID cards. There were also numerous post-implementation issues, such as specialists complaining about lost copays. And while it’s too early to provide any outcomes data, Harding added that “anecdotally some people are getting into care management that hadn’t [when] we tried to get them in, and we’re hoping coming down the road are the positive outcomes that should come from this.”

In launching the “Spark Your Health” VBID program in Western Pennsylvania, UPMC Health Plans faced its share of implementation challenges, said Vice President for Medicare Helene Weinraub. “But I think we’re on the right track,” she told panel attendees. Aimed at promoting self-management in members with CHF and diabetes, CHF and COPD or all three conditions, the UPMC initiative features a health assessment survey, personalized quarterly activities and a direct reimbursement for Part C cost sharing (MAN 11/17/16, p. 3). Members can earn $25 for each activity they complete and up to $150 per year in the form of a check at the end of the quarter to cover copayments and coinsurance for medical services utilized during the period.

Weinraub said the insurer wanted its MA VBID program to align with incentive programs in its other lines of business, that “ease of implementation” was a key factor in designing the program, and that UPMC was very focused on member touchpoints during implementation. “We really wanted to make sure the member didn’t feel lost…that the marketing materials focused on the benefits to the member,” and that all follow-up communications had a “positive feel” to reinforce their behaviors, she said. A member service concierge plays an important role in helping members determine how much they’re earning; members can also use a web portal to track their earnings, the status of their check, etc.

And while it’s too early to have any earnings progress or outcomes to share, Weinraub said the insurer is tracking several “process measures” such as enrollment, participation and reason(s) for disengagement to assess the program’s success. UPMC will eventually be looking at “outcome measures” that it hopes will demonstrate, among other things, reductions in unplanned care, readmissions, emergency department utilization, per-member per-month medical costs and increased member satisfaction.

Weinraub added that the program has enrolled about 3,000 members.

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