What do we really know about VBID? Quality of the evidence and ethical considerations for health plan sponsors.

Abstract

Advocates of value-based insurance design (VBID) have argued based on break-even economic modeling that VBID can be effective but acknowledge that direct medical savings from increased use of services with strong evidence of clinical benefit are unlikely to finance the entire [VBID] investment in the short term. Thus, these VBID proponents support investments in processes to define low-value care and a benefit design that couples cost-sharing reductions for high-value services with cost-sharing increases for services not identified as high value. This suggestion has led to an important emerging issue for employers considering VBID adoption, provider and patient acceptance of higher levels of cost-sharing for services deemed low-value. Since publication of our earlier observations about deficiencies in research on VBID, new copayment reduction studies using nonrandomized comparison groups have been published, and an additional study measured the association between medication adherence and all-cause health care costs. Although all the VBID studies provided evidence that implementation of VBID might have a small favorable effect on medication adherence, none provided the information that payers need to make an informed decision about VBID because of serious problems in reporting, program design, and effect calculation. None of the new VBID studies reported its effect on generic drug utilization, and none reported the cost of the intervention to the payer. There are still no randomized controlled trials of VBID. Thus, nearly a decade after pharmacy benefit copayment reduction was initially proposed as a means to improve the outcomes of patients with chronic health conditions, health plan sponsors have little of the information that they need to assess the costs and benefits of VBID.A follow-up article on the subject of this editorial is available here: VBID, the PPACA, and FREEE Medications: Did Politics Trump the Evidence About Cost Sharing?