From the Editor-In-Chief Health AffairsVol. 29, No. 11: Designing Insurance To Improve Value In Health Care Enhancing Care’s Value While Cutting CostsSusan DentzerPUBLISHED:November 2010Free Accesshttps://doi.org/10.1377/hlthaff.2010.0977AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InReddit ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPharmaceuticalsComparative effectivenessValueHealth insurance benefit designQuality of careSafety net hospitals By now it should be clear to most Health Affairs readers that no magic bullets exist for improving health, for making health care more cost-effective, or for producing care of higher quality. But there is a lot of scattered buckshot that, if not magic, at least holds the potential to move us toward these various goals. We continue our investigation of those possibilities this month with a cluster of papers on value-based insurance design, made possible through the generous support of the California HealthCare Foundation. This approach is payer jargon for a simple concept: Incentives matter. And if insurance coverage is an obvious set of incentives for both provider and patient, you might as well structure those incentives to advance key objectives.For example, if you are an insurer and you want chronically ill people to take their medicine so their conditions stay under control, don’t erect roadblocks in the form of high drug copays. If you want patients to get health care that is effective rather than of dubious value, don’t pay equal amounts toward coverage of both types of care, but skew coverage so patients are encouraged to pick the more effective type.Modest EvidenceThe articles in this issue advance the evidence that these approaches work, at least modestly. Niteesh Choudhry and colleagues report that at Pitney Bowes, one of the first self-insured companies to try the approach, eliminating copayments for cholesterol-lowering statin drugs and reducing them for blood clot inhibitors boosted the likelihood that patients would stay on their medication. Although positive, the results weren’t dramatic: Adherence to statin use increased 2.8 percent, for example. But this scattered buckshot no doubt means that some group of Pitney Bowes employees will be less likely to have heart attacks, for which the company would pay much of the bill.Based on this sort of evidence, other authors believe the potential of value-based insurance design hasn’t yet been fully exploited. James Robinson suggests that the approach should be “extended to expensive services and to those for which the evidence is limited or controversial”—including costly specialty drugs, implantable medical devices, certain advanced imaging, and major surgical procedures.Mark Fendrick and coauthors point out challenges. The 1990s backlash to managed care illustrated the difficulties of not covering care for which evidence exists. Those who stand to profit from that care will exert political pressure to get it covered, and feed on patients’ and providers’ hopes that it will work.That’s all the more reason to make greater investments in distinguishing “low-value” from higher-value health care, such as through comparative effectiveness research—the subject of last month’s issue. This month we feature several more key entries on that topic.Among them is a call from Robert Giffin and Janet Woodcock for a major effort to enlist community-based clinicians and their patients to participate in comparative effectiveness research trials. Otherwise, they say, there simply won’t be enough capacity to carry out the research. Douglas Peddicord and colleagues attempt to forge a balance between protecting the privacy of certain health information—for example, how a given patient fared on a particular drug—and still channeling that information into the hands of those who can examine and synthesize it for the purposes of comparative effectiveness research.Implementation UpdateMeanwhile, on the health reform implementation front, Lester Feder’s Entry Point spotlights the new Innovation Center at the Centers for Medicare and Medicaid Services. Acting director Richard Gilfillan was an architect of innovations at Geisinger Health System and seems perfectly suited to his new role. But as Geisinger’s CEO, Glenn Steele, and others describe in a commentary, successful innovation requires repeated iterations of the cycle popularized by quality guru Walter Shewhart: Plan, Do, Study, Act. It remains to be seen how well forthcoming regulations governing innovations such as accountable care organizations will foster rapid-cycle experimentation.Shewhart, the grandfather of Total Quality Management, was W. Edwards Deming’s teacher, and their spirits may be roaming the halls at Denver Health. In Report From the Field, Harris Meyer recounts how this safety-net provider has embraced “Lean” techniques to strip $54 million in costs out of the system. The story provides reassurance that innovations in health care can still come from applying principles that date back eighty years or more. And if a safety-net provider can do it, what excuse is there for others not to follow? Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 November 2010 Information Project HOPE—The People-to-People Health Foundation, Inc. PDF download