Creating a value-based insurance benefit package to promote effective use of evidence-based health care services

With the current federal mandate to develop statewide insurance exchanges, there is an opportunity to design health insurance packages that optimize utilization of effective health care services. The State Of Oregon set forth to identify a set of high-value health care services that have a low cost relative to their effectiveness at improving disease outcomes or promoting health. Through insurance redesign, a series of health care services were identified that are encouraged to be offered outside of any deductible and with little or no co-pays or co-insurance to all Oregonians. Criteria were developed to define “value-based services” that include outpatient services with low up-front cost, whose utilization is encouraged in order to: avoid hospitalizations and/or emergency department visits, reduce future exacerbations or illness progression, or improve quality of life. These are chronic illness management, preventive care, and/or maternity care services that are of clear benefit, strongly supported by evidence, and have a low risk of inappropriate utilization. They are ideally offered in a medical home setting. High quality systematic reviews and evidence-based guidelines were used to determine treatment efficacy and potential cost impacts. A list of value-based services based on these criteria was developed, and then refined through a series of public meetings and stakeholder input. Twenty sets of value-based services were approved, comprised of specific medications, diagnostic tests, screening tests, and other outpatient services. They include the evidence-based treatment for chronic diseases such as congestive heart failure and diabetes, as well as preventive services such as tobacco cessation and immunizations. All of these services would be offered with little or no cost-sharing, with the goal of reducing barriers to utilization of these services. Developing ways to improve health outcomes while containing costs is a pivotal topic at state and federal levels. The public process used to identify value-based services in Oregon resulted in the identification of a series of health care services that, based on high-quality evidence, are effective, low cost, and will improve health outcomes. These sets of services are a key component of a value-based benefits package projected to offer modest reductions in health care costs. Such a benefits design is being considered for introduction into Oregon's commercial insurance market and could be a model for other states to adopt for use both inside or outside a health insurance exchange.