246455 Creating a value-based insurance benefit package to promote effective use of evidence-based health care services

Monday, October 31, 2011: 9:06 AM

Cat Livingston, MD, MPH , Department of Family Medicine, Department of Public Health and Preventive Medicine, Oregon Health & Sciences University, Portland, OR
Darren Coffman , Director, Health Services Commission, Oregon Health Authority, Salem, OR
Somnath Saha, MD, MPH , Portland VA Medical Center, P3MED, Portland, OR
Ariel Smits, MD, MPH , Health Services Commission, Oregon Health Authority, Salem, OR
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.

Learning Areas:
Chronic disease management and prevention
Clinical medicine applied in public health
Provision of health care to the public
Public health administration or related administration
Public health or related public policy

Learning Objectives:
1. Identify evidence-based health care services that are low cost, improve health outcomes, and prevent disease 2. Discuss strategies to encourage health-promoting and disease-preventing behaviors through health insurance benefit package design

Keywords: Health Care Reform, Evidence Based Practice

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I serve as the Clinical Services Consultant within Oregon's Health Authority and have been significantly involved in developing the list of Value-Based Services and performing the evidence reviews. I am a physician dual-boarded in Family Medicine and General Preventive Medicine.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.