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Landscape Digest
A. Mark Fendrick, M.D.
Professor, Internal Medicine and Health Management and Policy
Co-Director, Center for Value-Based Insurance Design
University of Michigan
July 2009
Center for Value-Based Insurance Design
A. Mark Fendrick, M.D.
Professor, Internal Medicine and Health Management and Policy
Co-Director, Center for Value-Based Insurance Design
University of Michigan
Mari L. Edlin
Freelance Health Care Writer/Journalist
Sonoma, California
Acknowledgments: The authors would like to acknowledge Diana Enyedi, Andrea Hofelich, Sallie
Lyons, Gary Persinger, Sabrina Siddiqui, Jeffrey Warren, and Kimberly Westrich for their thoughtful
contributions to this report. The authors also thank Peter Sonnenreich for his expertise.
Funded and published by the National Pharmaceutical Council. Copyright 2009.
For copies of this report, please contact the National Pharmaceutical Council at 703-620-6390 or visit www.npcnow.org.
2 Bridging the Divide Between Quality Improvement and Cost Containment
3 The Role of Cost Sharing in Health Insurance
4 Value-Based Insurance Design: "Clinically Sensitive, Fiscally Responsible" Cost Sharing
6 Objectives of VBID
7 Approaches to VBID
8 Financial Impact of VBID
9 VBID Experience
10 Potential Barriers to VBID
12 VBID Case Studies
12 WellPoint, Inc.
13 Caterpillar, Inc.
14 Service Employees International Union Health Care Access Trust
15 Mid-America Coalition on Health Care
16 Health Alliance Medical Plans, Inc.
17 Hannaford Brothers Company
18 City of Springfield, Oregon
19 Midwest Business Group on Health
20 UnitedHealthcare
21 Evidence-Based VBID Program Evaluation
22 Measuring the Effects of VBID Programs
23 Models for Employers
24 Aligning Incentives: The Effect of VBID
25 Ways to Meet Cost Targets
26 Evaluating ROI
27 Establishing a Synergy with Ongoing Health Care Reform
30 VBID in a Transformed Health Care System
31 References
As private and public purchasers of health care struggle to constrain rising
costs, they must also strive to maximize the clinical benefit achieved for
the money spent. Although expenditures are the driving force behind health
care reform, concerns regarding access to medical services and quality of care
also share the limelight. Thus, the need for meaningful cost containment and
quality improvement has led to two prevailing trends in benefit design:
1) the use of financial incentives to alter behavior and to change
utilization, and
2) the implementation of wellness and disease management (DM)
initiatives to help individuals manage their health in an effort to avoid
future costly events.
In addition, provider-based interventions are disseminating widely, such as
Patient Centered Medical Homes (PCMH), Accountable Care Organizations
(ACO) and Pay-for-Performance (P4P) programs, which pay bonuses to
clinicians for adhering to evidence-based practices and attaining specific quality
It is a critical challenge to develop strategies that simultaneously address the
problem of spending growth and aim to improve population health. Value-
Based Insurance Design (VBID) incorporates complementary features to
produce effective and efficient care delivery, to ultimately maximize health
outcomes at any level of health care expenditure.
This report, "Value-Based Insurance Design Landscape Digest," defines the
VBID concept; outlines key objectives, design features and potential barriers to
implementation, and describes evaluation tools for measuring the outcomes
of VBID programs. In addition, the report provides examples of existing VBID
programs and reviews the clinical and economic implications of VBID.
Patient cost sharing is one of the fundamental mechanisms available to change
consumers' behavior and therefore will remain an important cost containment
tool. It is widely accepted that higher patient cost sharing reduces utilization of
health care services and consequently lowers health care spending, at least in
the short-term. Ideally, higher patient copayments would discourage only
the utilization of low-value care. However, for this important assumption
to be achieved, patients must be able to distinguish between high-value and
low-value interventions. When this ability to differentiate among services
does not occur, increased cost sharing has the potential to cause negative
clinical outcomes. A large and growing body of evidence demonstrates that
in response to increased cost sharing, patients decrease the use of both high-
value and low-value services.
The evidence linking modifications in patient cost sharing to changes in the
use of prescription drugs is relatively unambiguous, consistent from the time
of the Health Insurance Experiment undertaken in the 1970's.
increases in drug copayments and shifts to tiered formularies result in
decreased use of medications and lower treatment adherence. Consequently,
higher cost sharing for prescription drugs lowers pharmaceutical spending.
However, many observers have noted that reduced spending on prescription
drugs does not necessarily result in lower total spending on health care
because prescription drugs are only one of several important components of
health care expenditure. Medications keep patients healthy. Healthy patients
are less likely to use expensive non-drug services such as hospitalizations
and emergency rooms. Thus, the degree to which higher cost sharing for
prescription drugs affects overall health care spending crucially depends
on the magnitude of any cost-offsetting effects that result in other sectors
of health care. These offsets from increased use of non-drug services indicate
that aggregate decreases in total health care spending will be less than the
savings resulting from higher copayments in the pharmaceutical sector. In the
extreme case, the increases in costs arising from increases in non-drug services
may exceed the prescription drug savings achieved from lower utilization. The
result is an association of higher copayments for prescription drugs with higher
overall medical spending. A 2009 Canadian study reported that increases in
patient cost-sharing for drugs to treat asthma led to an overall increase in total
medical expenditures in that patient cohort.
A 2007 Journal of the American Medical Association study examining the
relationships among cost sharing, outcomes and utilization found that
increased cost sharing was associated with lower rates of drug treatment,
worse adherence among existing users and more frequent discontinuation
of therapy. Although increased cost sharing highly correlated with reductions
in pharmacy use, the study concluded that the long-term consequences of
benefit changes on health were still uncertain.
Therefore, while cost sharing is
likely to continue as a benefit design strategy, it is ill-advised in certain clinical
circumstances, and alternatives to high copayments should be considered.
VBID offers a potential incremental solution to a key problem in the health
care financing crisis – how to maximize health outcomes with available health
care dollars. Instead of simply asking patients to pay more for all of their care,
as is currently the case, a VBID plan adjusts out-of-pocket costs based on an
assessment of the clinical benefit value – not simply the cost – to a specific
patient population. Thus, the more clinically beneficial the service for the
patient, the lower that patient's cost-share would be. In a VBID program,
this "clinically sensitive" cost sharing is explicitly applied to mitigate the
adverse health consequences that result when high out-of-pocket expenditures
lower utilization of high-value clinical services. By aligning financial incentives,
this strategy encourages the use of high-value care while discouraging the use
of low-value or unproven services.
VBID is centered on the theory that reducing or removing financial barriers
to essential treatments and high performance providers will steer consumers
toward value-based health care and improved health status. While a variety
of stakeholders have defined VBID differently, there is consensus on the
core element of VBID: getting more health out of every health care dollar.
All parties also agree that benefit design changes must be accompanied by
education and strategies for consumer engagement in order to have maximum
VBID begins with its simplest definition: the lowering or elimination of
financial barriers to the purchase of "high-value" drugs or services in hope of
raising compliance and avoiding more expensive future medical costs, such as
hospitalization. As VBID becomes more widely adopted, the defining strategy
is expanding from the targeting of high-value drugs and services for copayment
reduction to the inclusion of an emphasis on the individual patient's condition
and its severity, and a focus on providers of care. Next generation offerings are
expected to incorporate aspects of wellness programs, disease management
and patient centered medical homes.
As defined by the University of Michigan's Center for Value-Based Insurance
Design, "value" is the amount of health gained per dollar spent on health care
services or health benefits.
Therefore, assessing the value of a treatment
or benefit package requires taking both cost and quality of services into
consideration simultaneously. "Value-based" does not necessarily equate
to less expensive. Contrary to popular opinion, less costly services may not
always generate sufficient health benefits to be considered of value.
Regardless of the definition, VBID encompasses several key principles:
• Value equals the clinical beneft achieved for the money spent.
• Health care services difer in the health benefts they produce.
• The value of health care services depends upon the individual who
receives them.
VBID packages adjust patients' out-of-pocket costs for health services based on
an assessment of the clinical benefit to the individual patient. Thus, the more
clinically beneficial a therapy is for a patient, the lower the patient's cost share.
The same concept applies to lower copayments for using quality providers.
VBID encourages demand for medically necessary utilization of evidence-based
medical services through appropriate cost sharing, and reduces barriers to
access for these services.
VBID challenges the postulation that increased cost sharing lowers costs by
noting that in many instances, reduced utilization – without consideration
of health effects – may not be a desirable goal. Reduced use of high-value
clinician visits, medications, diagnostic tests, and procedures for patients with
chronic disease can result in costly adverse events and, in some instances,
higher aggregate medical care costs.
olds should get
a colonoscopy
for free, but a
healthy 29-year
old who wants
a colonoscopy
should pay
100 percent of
the cost and be
fined $500 for
taking his or
her mother's
A. Mark Fendrick, M.D.,
Co-Director of the
Center for VBID
at the University
of Michigan
Cost savings should not be the exclusive goal applied to health care
reform efforts, which is not to say that VBID principles cannot facilitate
cost containment. Rather, VBID should be considered as a set of principles
that can help guide an inevitable increased reliance on cost containment
initiatives. Barriers for high-value services should remain low; but, on the
other hand, services of lesser or uncertain value may be subject to higher
cost sharing. VBID's objectives align with other strategies promoting cost
savings and higher quality care, such as pay-for-performance initiatives; high-
deductible consumer-directed health plans; and wellness, prevention and
disease management programs. Although it remains uncertain whether short-
term, direct medical cost savings result from a VBID program, studies have
linked lower copayments for drugs to higher compliance, which ultimately
has potential to yield long-term savings as a result of healthier members/
With multiple stakeholders involved in and affected by VBID programs, there is
no one VBID design. Each program must address the cultural context in which
it is implemented. Although all VBID programs should focus on value, the
definition of value is subjective.
That being said, VBID programs strive to meet the following objectives:
• Obtain the greatest positive health impact from medical expenditures.
• Create an opportunity to restructure health benefts and to change the
focus of the health care debate away from cost alone, to the clinical
value of health services.
• Minimize the lack of adherence to evidence-based services that may
result from setting across-the-board cost sharing levels.
There are four basic approaches to VBID:
1. Design by service. Waive or reduce copayments or coinsurance for
select drugs or services, such as statins or cholesterol tests, no matter
which patients are utilizing them. This is the strategy employed by
Pitney Bowes, which in 2002 reduced the copayments for drugs that
treat asthma, diabetes and hypertension.
Marriott International, Inc.,
adopted a similar approach for drug classes used to treat diabetes,
asthma and heart disease.
2. Design by condition. Waive or reduce copayments or coinsurance
for medications or services, based on the specific clinical conditions
with which patients have been diagnosed. This approach is illustrated
by the University of Michigan Focus on Diabetes Program, which
lowered copayments for selected evidence-based medications and
services for all employees with diabetes.
3. Design by condition severity. Waive or reduce copayments
or coinsurance for high-risk members who would be eligible for
engagement in a disease management program.
4. Design by disease management participation. An extension
of the third design approach, this VBID solution provides reduced
or waived copayments or coinsurance to high-risk members who
actively participate in a disease management program. The City of
Asheville Project highlighted this approach through offering free
medications and testing equipment only for diabetics who attended
educational seminars. Wisconsin-based QuadMed, a subsidiary of
QuadGraphics, sponsors eight worksite clinics and three pharmacies
that play an integral role in its value-based insurance design.
Employees who utilize an onsite clinic have a lower copayment than
that for alternative care sites. Moreover, if they choose a preferred
PPO network, employees pay a lower coinsurance rate for an
office visit than for non-preferred network physicians. In addition,
employees earn financial incentives if healthy behaviors are achieved,
such as exercising three times a week or reaching certain clinical
benchmarks, like improvement in diabetes management measured
by reductions in HbA1c levels.
design is a
viable and
that – when
integrated with
other employee
initiatives such
as focused
and wellness
programs – can
better support
and influence
the interactions
between patients
and providers and
enable positive
patient behaviors
while improving
Jennifer Boehm,
Hewitt Associates
The financial impact of VBID programs on health care spending depends on
the level and precision of clinical targeting and the extent of the changes in
copayments. Since many clinical services provide higher value for a select
subset of patients, the better the system is at identifying those patients,
the greater the likelihood of achieving a high financial return. More careful
targeting of interventions results in lower program costs, because fewer
individuals are eligible for copayment reductions.
Offsetting the added costs of collecting lower copayments and the related
increased use of high-value services are the savings incurred by reductions
in future adverse events, which are avoided by achievement of better clinical
outcomes. For example, the increased direct costs of lower patient cost sharing
for asthma control medications would be at least partially offset by savings
resulting from fewer emergency room visits for acute asthma.
The net financial benefit of the VBID program improves if:
• the underlying risk of an adverse outcome is high;
• the cost of that adverse outcome is high;
• consumers are responsive to lower copayments; and,
• the service is efective at preventing the adverse outcome.
Additional return on investment accrues if the non-medical benefits of
improved health are considered, such as reduced disability and absenteeism,
and enhanced productivity.
A recent Medical Care editorial reviewed the literature on the financial impact
of changes in patient copayments, and found that cost offsets do occur,
particularly among those with chronic diseases. Several studies evaluated
how decreases in prescription drug spending that resulted from higher
patient copayments led to increases in utilization of non-drug services such as
hospitalizations, emergency room visits, etc. Offsets tended to be higher in the
more targeted populations with chronic medical diagnoses.
return on
accrues if the
benefits of
health are
such as
disability and
and enhanced
Several private and public sector employers, health plans, and pharmacy
benefit managers have implemented VBID programs providing incentives to
increase the use of high-value services. Notable early adopters include the
City of Asheville, North Carolina; Pitney Bowes; Marriott International, Inc.; the
State of Maine and the University of Michigan. In most cases, VBID programs
simply lowered copayments on classes of medications identified as high value,
typically those used for managing diabetes or heart disease, as in Approach
1, above. In other cases, such as the Asheville Project, the Focus on Diabetes
program at the University of Michigan, and the UnitedHealthcare Diabetes
Health Plan, the VBID program targets patients with a particular clinical
From the experience of these early programs and efforts that followed, it is
clear that to be successful, VBID programs need to adhere to the "clinically
sensitive" principle, recognizing that the value of various services differs and
the value of any specific intervention likely varies among patients. Allocation
of resources is more efficient when the amount of patient cost sharing is
based on the value of the specific health care service to a targeted patient
group. The archaic "one-size-fits-all" approach, in which employers focus
exclusively on reducing costs by increasing copayments across the board,
fails to acknowledge the unique differences in clinical value among medical
interventions and among patients.
Although there is growing interest from employer groups and health plans in
VBID programs, their uptake is gradual, indicating that there are some barriers
to implementation. Recognition of these possible obstacles is part of the
solution to overcoming them.
Potential for short-term increase in utilization and cost. Lowering
costs for targeted drugs will increase short-term pharmacy spending
and utilization. Yet, the expectation is that better adherence will result
in better health and fewer adverse complications in chronic conditions.
There is a concern, however, that when copayments are reduced and
costs rise, clinical status may not improve for enough of the targeted
population to offset the costs associated with increased use of benefits.
Need for sophisticated data systems to identify high-value services,
specific patient groups using them, and compliance. Broader data
are the key to understanding opportunities and integrating VBID
into existing and emerging health information systems and disease
management programs.
Negative reactions from plan members whose copayments are
higher than those of other members for the same medical service
or drug. VBID programs that target specific diagnoses or high-risk
patients may encounter this problem, but clear communication of VBID
objectives can engender a positive response from employees.
Privacy issues. The transfer of data and communications efforts
must comply with the Health Insurance Portability and Accountability
Act (HIPAA), the same compliance issue that arises with disease
management programs.
Quantifying clinical and economic return on investment (ROI).
Although there is an ongoing debate about whether VBID strategies
produce a short-term positive ROI, expanded use of VBID and improved
adherence to beneficial therapy hold the prospect of improved health
outcomes, lower costs, and healthier, more productive employees.
Measuring outcomes. There are few studies on the impact of
decreased copayments on utilization of and adherence to clinically
sensitive health care services. It is critical, however, to measure
outcomes, specifically increased utilization and adherence, with the
appropriate clinical outcome metrics associated with targeted therapy.
Unintended incentives. If copayments are lowered for all products
to treat the conditions targeted by the VBID program, use of some
products for other conditions that would otherwise provide high value
for the health care plan may, in effect, be discouraged.
Adverse selection. VBID may attract a disproportionate number of
patients with chronic conditions by specifically targeting those patients
or the services they use. Adverse selection will be less of an issue when
the health plan population is relatively stable.
Difficulty in accurately determining the value of services. Measuring
value requires using a blend of clinical judgment, health economics,
and actuarial techniques. Setting copayments appropriately takes robust
actuarial analysis. VBID programs become easier to create as we learn
more about high-value services through comparative effectiveness
Potential for fraud. VBID programs may have difficulty in differentiating
between patients who qualify for lower copayments and those who do
not, encouraging some providers and patients to misreport information
in order to qualify for the reduced copayment. Information that
identifies and classifies patients could prevent this type of fraud.
As VBID matures, a variety of organizations – business coalitions, health
insurers, employers, managed care organizations, and labor unions – have
created programs that reflect the ideals of value-based design: clinically
sensitive to the variation in benefits both across medical services and among
patients, and yielding the most value out of each health care dollar spent.
Some of the case studies presented here describe programs that are in their
development stages; other examples have a longer track record.
WellPoint, Inc.
BUSINESS DESCRIPTION: Headquartered in Indianapolis, Indiana, WellPoint is a health
benefits company serving the needs of approximately 35 million medical members
INITIATION OF VBID PROGRAM/STRATEGY: Late 2002.
PROGRAM OBJECTIVE: To determine the effect toward improving member health care of
increased member education and waived or reduced copayments for drugs used to treat
chronic disease states.
VBID PROGRAM COMPONENTS: WellPoint developed four similar pilot programs testing the
benefits of a VBID model: the State of Maine, with 40,000 employees, targeting diabetes;
a large retailer, with 24,000 employees, addressing diabetes and transplant medications; a
large laboratory company, with 25,000 employees, targeting diabetes; and a midwestern
city, with 5,000 employees, targeting diabetes and hypertension. WellPoint waived or
reduced copayments for all four pilots. In the case of the retailer, WellPoint waived the
copayment for transplant drugs for the first year, with a 10 percent coinsurance during
subsequent years. The rationale, says Brian Sweet, WellPoint's chief pharmacy officer,
is based on the expense and quality-of-care consequences of organ rejection without
appropriate medications.
In addition, for 2009, WellPoint is offering four value-based benefit designs that correspond
to the four basic VBID models: 1) design by service, 2) design by condition, 3) design by
condition severity, and 4) design by disease management participation. Four groups have
adopted model #1, and one group is using model #4, with other clients exploring various
models expected to be available in 2010.
PROGRAM RESULTS: Preliminary results for the City of Maine pilot, the Telephonic Diabetes
Education and Support program, show an improvement in medication possession rate
(MPR), jumping from 77 percent to 86 percent after the program. In addition, compared
to a randomly matched control group, members who participate in this program have an
adjusted average cost of $1,300 less over 12 months of follow-up, according to HealthCore,
WellPoint's outcomes research subsidiary.
Caterpillar, Inc.
BUSINESS DESCRIPTION: Based in Peoria, Illinois, Caterpillar is a Fortune 50 company
specializing in forestry, construction and mining equipment, and energy solutions, with
80,000 employees and 120,000 covered lives.
INITIATION OF VBID PROGRAM/STRATEGY: January, 2005.
PROGRAM OBJECTIVE: To develop a risk management strategy to identify those at highest
risk for coronary, diabetes or stroke events. These conditions were not only contributing to
claims costs, but also to disability and unscheduled absences. Direct health care costs had
increased 20 percent over four years.
PROGRAM COMPONENTS: According to Michael Taylor, M.D., medical director for health
promotion at Caterpillar, the program, although not yet entirely founded on value,
• One hundred percent coverage for well-women and well-baby care; zero
copayments for drugs for diabetes and its associated co-morbidities, and free
colorectal screenings for those at high-risk for colon cancer.
• Tracking of both fnancial and clinical outcomes over time.
• Health Risk Assessment (HRA), which earns employees, spouses and retirees under
65 a $900 reduction on their yearly insurance premium. Disease management
programs to reflect HRA information.
• Risk stratifcation by cardio-metabolic indicators for diabetes, such as blood
pressure, lipids, triglycerides and fasting glucose, in order to target members most
at-risk for an adverse event.
• A Healthy Lifestyle index to encourage employees to make behavioral changes.
• Onsite nurse coaches who schedule one-on-one meetings with program
participants, offer classes, and coordinate awareness and screening campaigns.
PROGRAM RESULTS: Caterpillar's diabetes program has rendered positive results:
• Fifty percent of enrollees experience HbA1c reduction, from 8.7 to 7.2, on average,
over the course of a year;
• Ninety-six percent of enrollees measure their HbA1c levels.
• Seventy-two percent meet activity recommendations promoted by the Surgeon
"We want
to make our
members as
healthy as
We don't provide
insurance to
make money but
rather to get the
most value for
each health care
dollar spent."
Dania Palanker, Deputy
Administrator, SEIU
Health Care Access Trust
Service Employees International Union (SEIU)
Health Care Access Trust
BUSINESS DESCRIPTION: Headquartered in Washington, D.C., the two million-member
union represents workers in three sectors: health care, including hospitals, nursing homes,
and home care; property services, including building cleaning and security; and public
INITIATION OF VBID PROGRAM/STRATEGY: Spring, 2009.
• Expand frst-dollar coverage for building cleaning and security personnel.
• Provide insurance for all union members.
• Improve quality of health care.
• Help members better manage health.
PROGRAM COMPONENTS: SEIU introduced a pilot program in Minneapolis, Minnesota,
and Milwaukee, Wisconsin, addressing janitorial and security employees. The program
established a zero copayment tier for drugs for asthma, hypertension and diabetes, based
on information gleaned from health risk assessments. In addition, if employees participated
in a disease management program, they were reimbursed for their doctor visit copayment
or received a free debit card to cover copayments. Those without a chronic disease but who
participated in telephonic coaching for weight loss or smoking cessation received the same
debit card or reimbursement benefits. The benefits will be expanded to other conditions.
PROGRAM RESULTS: Although results for the program are not yet available, Dania Palanker,
deputy administrator of the SEIU Health Care Access Trust, expects the program to be cost-
neutral, while improving the health of members.
"The program
is not just a
drug design,
but we are
putting our
arms around
the total health
care spend and
Bill Bruning, President and
Mid-America Coalition on Health Care (MACHC)
BUSINESS DESCRIPTION: MACHC is an employer-driven, non-profit collaboration of
stakeholders in the bi-state Kansas City region, including 465,000 covered lives.
INITIATION OF VBID PROGRAM/STRATEGY: November, 2008.
PROGRAM OBJECTIVES: Use value-based design principles to develop data-driven tools and
resources to:
• Help employers improve the health of employees and their families.
• Promote employee wellness.
• Manage longer-term health care costs.
PROGRAM COMPONENTS: Called the Kansas City Collaborative (KC2), this two year
collaborative, employer-based national pilot program is not simply an insurance program,
but also one that encompasses health and wellness. "KC2 aims to educate employers
on the value of aligning incentives for desired health behaviors and removing health
care barriers for their employees. It also seeks to build data-driven resources and tools to
demonstrate how Value Based Benefits concepts can be implemented across a broad range
of workforces and corporate cultures to improve employee health and manage health care
costs. Key learnings from Kansas City employers will be shared so that Value Based Benefits
concepts can be replicated by other employers across the country." The National Business
Coalition on Health (NBCH) will disseminate the strategies; Pfizer Inc. is providing technical
and financial assistance.
Prior to launch, KC2 offered a series of educational sessions to support employers in
implementing value-based benefit initiatives, which will be introduced during the second
year of the project. The collaboration also is developing an Employer Guide, which will track
informational content gathered during the project and highlight the experience of coalition
members in applying the value-based strategies to their organizations.
PROGRAM RESULTS: Results are not yet available.
Health Alliance Medical Plans, Inc. (HAMP)
BUSINESS DESCRIPTION: Health Alliance Medical Plans, based in Urbana, Illinois, is a
provider-sponsored health insurer providing health care coverage to more than 310,000
members in Illinois and Iowa.
INITIATION OF VBID PROGRAM/STRATEGY: October, 2008.
• Increase medication compliance.
• Reduce cost barriers to accessing drugs.
• Achieve better health outcomes.
• Manage disease states more efectively.
• Reduce medical costs for asthma and diabetes.
PROGRAM COMPONENTS: Available to 86,000 fully insured members and dependents,
the HAMP program has developed a fourth copayment tier called the Value Based Benefit
tier, which addresses members with diabetes, hypertension and asthma. The new benefit
makes specific drugs related to the three conditions available for a 10 percent copayment
(10 percent of the retail cost), a copayment less than HAMP's second tier $22 copayment.
All statins are available for $10 or less. Health Alliance expects to expand the program to
include drugs for multiple sclerosis, rheumatoid arthritis and other rare diseases, using
incentives based on compliance, both to encourage compliance and to reward it. It also
moved lower value drugs to higher tiers and chose not to cover over-the-counter non-
sedating antihistamines, the latter decision saving $2 million.
PROGRAM RESULTS: A pilot group demonstrated increased compliance due to the new
fourth tier; better blood sugar control; a move from rescue to control drugs for asthma;
and fewer heart attacks, strokes, and kidney failures. Although utilization and monthly
prescription drug costs increased for diabetes and asthma, medication adherence
(medication possession rates) for diabetics and asthmatics increased 10.6 percent and
32.7 percent, respectively. Christina Barrington, HAMP's director of pharmacy, anticipates
that the program will generate long-term medical savings.
"For every
medical dollar
saved, we could
save two to
three dollars
in absenteeism
Peter Hayes, Director of
Associate Health and Wellness,
Hannaford Brothers Company
Hannaford Brothers Company
BUSINESS DESCRIPTION: Founded in 1883 and based in Maine, Hannaford Brothers
Company operates 167 supermarkets in the northeastern United States, employing more
than 27,000 associates. Hannaford is a part of the Brussels-based Delhaize Group, a global
food retailer with $27.8 billion in annual sales.
INITIATION OF VBID PROGRAM/STRATEGY: January, 2004, for the VBID program addressing
incentives for selecting top-quality providers; January, 2008, for the non-invasive surgery
• Improve quality of care for employees.
• Provide safer care by promoting the use of minimally invasive surgery.
• Deliver care more efciently.
• Reward employees for using higher performing providers.
PROGRAM COMPONENTS: Hannaford has promoted richer benefits for individuals using
top-tier providers; reduced copayments for certain disease states; offered healthy behavior
credits; maintained real-time data on biometric outcomes for patients and providers and
offered incentives for using certain providers for minimally invasive procedures. Hannaford
has pushed for changes in surgical standard practice in Maine hospitals toward less-invasive
techniques. Because minimally invasive surgery for hysterectomies, appendectomies and
gastric bypass can shorten the length of hospital stay, reduce complications and speed up
return to work, Hannaford wanted to make these procedures more available to its workers.
Hannaford worked with Eastern Maine Healthcare Systems on the project. Surgeons at
the system's 337-bed Eastern Maine Medical Center in Bangor now use minimally invasive
surgery as the default for hysterectomies and a number of other procedures.
PROGRAM RESULTS: According Peter Hayes, Hannaford's director of associate health and
wellness, Hannaford has realized improvements in diabetes biometrics and decreased
the risk of heart attacks, and has saved both employees and the company money through
incentives for choosing top-tier providers.
City of Springfield, Oregon
BUSINESS DESCRIPTION: Springfield is a municipality with 241 employees, excluding fire
and police, and 1,140 covered lives with a fully insured benefit plan.
INITIATION OF VBID PROGRAM/STRATEGY: December, 2005.
• Promote a value-based beneft design similar to the successful one embraced by the
City of Asheville.
• Produce evidence that the model, which waives copayments and provides
pharmacist counseling for diabetics, could positively affect business.
PROGRAM COMPONENTS: Based on the Asheville model, the city conducted a study called
EMPOWER for patients with both type 1 and type 2 diabetes. Patients were enrolled from
December, 2005, through February, 2006. Copayments and coinsurance were waived for
drugs and physician office visits related to diabetes control, and the intervention group also
received referrals to a participating pharmacist for individualized consultation. The program
focused on improvement in HbA1c and cholesterol levels, medication adherence, and sick
PROGRAM RESULTS: Upon entry into the program, the mean HbA1c levels were
7.25 percent and 7.32 percent for those in the control and intervention groups, respectively.
After the waived copayment for both groups and additional counseling for the intervention
patients, HbA1c levels decreased 30 percent and 50 percent for control and intervention
groups, respectively.
The study also looked at the percentage of patients at an HbA1c target level of less than or
equal to 7 percent, as recommended by the American Diabetes Association. Data showed
that in the control group the percentage that achieved the target level decreased from
50 percent to 48 percent before and after the program, but for the intervention patients the
percentage rose from 46 percent to 63 percent.
Mean serum cholesterol dropped by 8.7 mg/dL for the control group and 13.5 mg/dL
for the intervention group, while LDL decreased by 1.6 mg/dL and 5.8 mg/dL for the
two groups, respectively. On the other hand, HDL decreased in both groups. Sick leave
decreased dramatically for those in the intervention group, from 83.7 hours to 68.4 hours,
but rose for the control group, from 87.7 hours to 90.4 hours. Although the average cost
per intervention patient was $950, compared to $500 per patient in the control group,
intervention patients showed better glycemic control and took fewer days off work.
Ardis Belknap, human resources manager for the City of Springfield, Oregon, is optimistic
that the program may translate into improved health for those with diabetes – not
immediately, but in the future – and remove barriers to access to care. She says that the
value-based design has been adopted by other employers and organizations and is slated
to include more diseases, such as depression. Because of the success of the program, the
benefit became a regular offering available to all covered lives with diabetes in early 2008.
Midwest Business Group on Health (MBGH)
BUSINESS DESCRIPTION: Based in Chicago, the Midwest Business Group on Health is a
not-for-profit coalition of 90-plus private and public employers that promotes collaboration
to improve the cost and quality of health care.
INITIATION OF VBID PROGRAM/STRATEGY: Summer, 2007.
• Adopt a VBID program.
• Improve diabetes chronic disease management.
• Balance quality and costs.
• Demonstrate clinical improvements in employees with diabetes.
PROGRAM COMPONENTS: MBGH's VBID program, "Taking Control of Your Health," is part
of the Diabetes Ten City Challenge in which employers provide employees, dependents
and retirees who have diabetes with a voluntary health benefit, waive the copayments for
diabetes medications and supplies, and help people manage their diabetes with the help
of a specially-trained pharmacist "coach." "Taking Control of Your Health" is a multi-year
effort to address diabetes and other conditions that represent a significant health issue
in the seven-county Chicago metropolitan area and in North Carolina. About 200 people
are participating in the program, representing employees from Hospira, Inc., the Jewish
Federation of Metropolitan Chicago, and Pactiv Corporation. Jessica Westhoff, director of
projects and communications at MBGH, says the consultations with pharmacists have been
a positive addition to the waived copayments. MBGH is actively recruiting other employers
to participate.
PROGRAM RESULTS: Although statistics on adherence to medications and costs associated
with the program are not yet available, MBGH does indicate positive process measures after
a year in the program: on average, patients' HbA1c levels dropped from 7.1 percent to
6.9 percent; systolic and diastolic blood pressure decreased from 129 and 78 to 125 and
76, respectively; LDL cholesterol fell from 92 to 87; and body mass index (BMI) fell from
32.3 to 31.
BUSINESS DESCRIPTION: UnitedHealthcare, part of the UnitedHealthcare Group, provides
benefit plans and service solutions on a dedicated basis to large, multi-site employers, and
coordinates network-based health care benefits and services on behalf of small to mid-sized
employers, as well as individuals and families. UnitedHealthcare offers a full spectrum of
consumer-oriented health benefit plans and services to 26 million covered lives.
INITIATION OF VBID PROGRAM/STRATEGY: January, 2009.
• Help diabetics and pre-diabetics manage their conditions more efectively.
• Control employers' escalating costs in insuring this diabetes population.
• Delay the progression of the disease in people with diabetes.
PROGRAM COMPONENTS: The Diabetes Health Plan, a first-of-its-kind program, rewards
diabetics and pre-diabetics who routinely follow medically proven steps to help manage
their condition, including regular blood sugar checks, routine exams, preventive screenings
and wellness coaching. The benefit incentives include some diabetes-related supplies
and prescription drugs at no charge (insulin, oral anti-glycemics, anti-depressants,
statins, angiotensin receptor blockers and ACE inhibitors), lower copayments for related
doctor visits, and a voluntary screening model to help members determine if they have
undiagnosed diabetes or suffer from pre-diabetes conditions. Participants also have access
to online monitoring and education tools at no cost, and they must comply with diabetes
and preventive care evidence-based guidelines to remain in the plan.
PROGRAM RESULTS: UnitedHealthcare anticipates that the Diabetes Health Plan will result
in a savings of $500 a year per member. According to UnitedHealthcare data, treating pre-
diabetic patients costs $5,000, while the average annual cost of diagnosed diabetics with
complications, such as heart disease or kidney failure, can be as high as $30,000.
"The Diabetes
Health Plan
to empower
diabetics and pre-
diabetics to take
charge of their
health and well-
being, helping
them delay or
prevent the onset
of dangerous
later in life, which
in turn should
help employers
lower the cost of
providing health
Sam Ho, M.D.,
Vice President and
Chief Medical Officer,
As employers seek to become more prudent purchasers of health care, they
need value-based measurement tools to help assess the benefits of their
expenditures. Avalere Health and its research partners – the Center for Value-
Based Insurance Design, the National Business Coalition on Health and Pfizer
Inc. – concluded in an analysis published in November, 2007, that employers
lacked reliable ways to evaluate the value of the pharmacy benefits they
purchase. Of the more than 175 existing pharmacy benefit-related measures
identified in the analysis, only 4 percent focused on value. The researchers'
white paper, "Assessing Value in Pharmacy Benefits/Do Employers Have the
Right Tools?" studied the landscape of measures used to evaluate the U.S.
health care system. The paper classified the measures according to whether
they assess cost, quality or value, the latter defined as taking into account both
cost and quality.
In light of the current lack of value measures, the report
recommends five areas for employers to consider:
• Acknowledge the tension between cost constraint and quality
improvement by encouraging the development of measures of value.
• Acknowledge that health care services difer in the value they
provide; thus, treat high-value services differently.
• Attain information on value across the health care system by
investing in information technology and linking all claims data.
• Acknowledge that patients respond to both fnancial and non-fnancial
incentives when it comes to medication adherence.
• Understand the value of benefts ofered in terms of the entire health
care spectrum.
An essential yet underestimated component of the VBID agenda is the
requirement for rigorous evaluations of both the clinical and economic aspects
of these innovative programs. An ideal evaluation should:
• Measure patient-reported clinical outcomes in addition to process
measures that predict high-quality care.
• Use appropriate control groups. Controls make it possible to
determine the extent to which observed clinical and economic
changes are the result of the VBID design.
• Incorporate long-term follow-up to more efectively reveal the clinical
gains of high-value services.
• Measure the non-medical benefts of health improvement, such as
effects on productivity and disability.
The reported clinical and economic effects of VBID programs – from studies
with marked variation in scientific rigor and often published in non-peer
reviewed sources – shed some preliminary light on the impact of different cost
sharing arrangements on health outcomes and utilization of services. These
studies, for the most part, use a "pre-post" research design without a control
group, are of short duration, and focus on process measures. One study, the
"Impact of Decreasing Copayments on Medication Adherence Within a Disease
Management Environment," did use an appropriate control group to assess
the effects of reducing copayments for five chronic medication classes in
the context of a disease management program.
This study found increased
adherence in four of the five classes and a decrease in non-adherence by
7 percent to 14 percent. It also concluded that the full financial and clinical
consequences were difficult to assess because health gains and financial
offsets associated with better adherence may accrue over time.
"In developing
a value-
based design,
you have to
consider the
impact of
not just the
design's effect
on pharmacy or
medical costs.
The impact of
lost time from
is significantly
larger than
time lost from
and must be
Thomas Parry, PhD,
President, Integrated
Benefits Institute
San Francisco-based Integrated Benefits Institute (IBI) offers a variety of
tools to help employers benchmark their benefits programs and assess the
health and productivity of their workforces. IBI President Thomas Parry, PhD,
is concerned about conditions that may not incur high medical costs but do
have a huge impact on productivity, such as depression, which is a large driver
of presenteeism (working at impaired levels). IBI's models can measure a
medical condition's contribution to lost productivity and identify interventions
to increase productivity. Parry supports the use of valid employee self-reported
data, such as health risk assessments, as a means of uncovering medical
conditions that affect productivity. With this information in hand, he believes
that employers can align benefits with employee needs.
Based on data from 10 corporations, a 2009 study reported in the Journal of
Occupational and Environmental Medicine indicates that health-related lost
productivity costs are 2 to 3 times greater than measures of direct spending
alone. Researchers found that, when full costs are measured rather than
medical costs alone, health conditions such as depression, obesity, arthritis,
and other musculoskeletal problems have a stronger influence on driving up
health care costs. To fully gauge health-related productivity costs, researchers
measured direct medical and pharmaceutical spending along with calculations
of the monetary value of lost productivity when employees were absent or
working at impaired levels known as "presenteeism." The study notes that
employers have not historically assessed costs in this way, preferring instead a
"siloed" approach that seeks to manage single health-cost categories, such as
medical visits or pharmaceuticals, through benefit-package design.
Additionally, Hewitt Associates has developed a real-time Value-Based Design
Model that analyzes the effect of reducing employee cost sharing for specific
health care services and increasing employee cost sharing for others. The
consulting group is helping companies develop evidence-based VBID programs
that reduce or remove financial barriers for health care services proven to be
effective for treating certain conditions, while potentially increasing cost sharing
for services that have proven to be less effective. The model's objective is to
create value-based designs that enable employers to minimize costs while
ensuring that their employees receive the highest quality health care. Hewitt
creates ROI scenarios for employers based on specific diseases, employee
participation in disease management programs, and focus on target audiences.
Prime Therapeutics, a pharmacy benefits manager owned by 10 Blue Cross and
Blue Shield plans, and subsidiaries and affiliates of those plans, has developed
its Efficiency Program. The program stratifies members by risk for a future
adverse medical event, provides a metric to understand how well pharmacy
dollars are being spent, and allows for the implementation of targeted clinical
programs and benefit designs based on member needs. The program focuses
on therapeutic categories in which there are proven health outcomes, using
predictive modeling and medical claims data to identify the high-risk members,
and pharmacy claims data to determine who is adherent to their medications.
An efficiency report documents utilization and spending; an efficiency ratio
displays how effective an employer is in spending pharmacy dollars. Prime
Therapeutics designs value-based benefits and clinical intervention programs
aligned with certain conditions. They include exemption from step therapy
and prior authorization for high-risk members, a lower cost share for drugs
and services for those at high-risk, and inclusion of disease management and
compliance programs.
Aetna is in the midst of a multi-year prospective study that is looking at a group
of heart attack patients who have no copayments for their cardiac drugs versus
a control group that has a normal copayment for the drugs. The objective is to
measure the effect of the copayment on compliance and on the incidence of
second heart attacks.
If an immediate monetary return on investment (ROI) on direct medical
expenditures is a major objective of a value-based insurance design, then
the program sponsors may be disappointed. The VBID proposition implies
that all benefits that come from improvement in health are to be considered,
encompassing benefits beyond those in expenditure on health care. Value
implies cost effectiveness, not cost savings, although VBID offers a set of
principles that can help guide the inevitable increased reliance on demand-
side containment initiatives. The goal of the health care system is to improve
health, not save money.
In the long run, VBID will guarantee more health per dollar spent by increasing
the use of highly valued services and decreasing use of those of lesser value.
The economic impact of a VBID program, however, largely depends on the
details of each program. The likelihood of lowering medical expenditures
is directly related to the decreased use of medical interventions that do not
produce value.
The goal of
the health
care system
is to improve
health, not
save money.
Assuming that high-value and low-value services can be adequately
distinguished, it is possible to achieve any cost target by financing the costs
of lower copayments for high-value services through higher copayments for
those services of lesser value. Distributing costs over a wide list of services
helps minimize the copayment increase for any one service. However, because
health and financial outcomes are dependent not only on benefit structure, but
also on such elements as care management initiatives, pricing, and provider
reimbursement and incentives, it is difficult to determine ROI exclusively as a
result of VBID.
VBID will not necessarily save money by reducing the use of expensive
services; however, there is a possibility that it could succeed if services are
well targeted to those patients at high risk for expensive adverse outcomes.
Employers with more targeted programs incur lower costs because only a
limited number of services are eligible for lower copayments. Most of the
financial and clinical gains are still realized because patients who benefit most
from the services pay the lower copayment.
One concern is whether or not health status from extra health services will
improve enough in the targeted population to offset the costs associated with
lower copayments and more use. Measuring adherence to therapy and clinical
outcomes against baseline measures for the therapy would help quantify and
qualify ROI. Other savings may be accrued through improved productivity and
lower disability resulting from increased utilization of highly valued services.
The following financial scenarios are likely to occur, depending on the goals
of the VBID program and the willingness to raise copayments on low-value
• Targeted copayment reductions only. Result: higher value for each
market basket of services because of incentives to use services that
produce high levels of health benefit. Uncertain effect on total health
care cost trend.
• Targeted copayment reductions and targeted copayment increases to
offset short-term costs of increased utilization of high-value services
(actuarial equivalence). Result: higher value for each market basket of
services because of incentives to use services that produce high levels
of health benefit. Equal or lower costs, depending on the extent of
savings arising from offsets from improved health and lower utilization
of low-value services because of higher copayments.
The Pacific Business Group on Health, a San Francisco-based
employer coalition, and the California HealthCare Foundation engaged
PricewaterhouseCoopers (PwC) to assess the state of research evidence
regarding quality-based benefit design, which they define as, "a process of
designing a health plan that explicitly takes into account the effect that a
design element will have on the delivery of health care and health outcomes
of covered individuals." PwC reviewed about 100 articles published since
the year 2000, both from health services research (HSR), or academic, peer-
reviewed literature, and from applied health benefits research (AHBR), or what
is called "gray literature." In general, PwC concluded that the HSR literature
yielded few studies that were specific to benefit design tactics, while the AHBR
literature lacked sufficient disclosure for employers to judge the quality and
strength of the evidence.
The study focused on six elements of quality-based tactics/benefit design
strategies that seek to increase the net value of health care spending: 1) health
plan options, eligibility and premium contributions; 2) provider selection and
differentiation of provider performance; 3) inpatient/outpatient benefit design;
4) pharmacy benefit design; 5) health promotion/risk reduction and chronic
care management; and 6) provision of price and quality information to health
care consumers. In general, the study found that for four of the six tactics –
excluding pharmacy benefit design and health promotion programs – there
was only partial evidence that they improved the quality of care and limited
or reduced costs. The study also found that there was little good evidence
in the reviewed literature indicating a positive ROI, a factor that is one of
the challenges facing employers who are determining whether they should
implement value-based insurance designs.
Other findings include:
• Employees' share of premium costs is still the most important factor
in their choice of a health plan.
• Consumers are generally willing to accept less choice of providers if
their share of costs is lower, which can lead to short-term savings. In
turn, employers are less interested in offering benefits plans that have
high-quality providers but cost more.
• Case studies suggest that high-deductible plans can lead to lower
claims in the short term, over a two- or three-year period.
• Some evidence indicates that greater cost sharing reduces spending,
but none demonstrates maintenance of, or improvement in, quality of
• Health promotion programs can improve workers' health and
productivity, but only over many years.
• Evidence that consumers' use of health care information has an
impact on their health or their health care purchasing decisions is
It may be safe to say that, although there is no conclusive evidence as to ROI
accrued through VBID programs, a plan design that aligns incentives to
encourage use of high-value services and discourage use of services of
marginal value will improve the effectiveness and efficiency of utilization
of health care resources.
Balancing cost growth and quality gaps in health care is no easy task, but there
are several tools being tried to address quality improvement while containing
costs on regional and national levels. Frequently mentioned reform platforms
include: health information technology (HIT), consumer-directed health plans
(CDHPs), pay-for-performance (P4P), comparative effectiveness research
(CER), and patient centered medical homes (PCMH).
Providing Information Through Technology. Ultimately, sophisticated
information systems will tie together electronic medical records, clinical
information (e.g., comparative effectiveness research, evidence-based
guidelines, etc.), and financial data to create "personalized benefits" that
encourage value and discourage waste. An IT infrastructure is not yet
established that will allow consumers better access to unbiased information
on quality and cost of care, a situation that causes unwanted clinical effects
that are directly related to misaligned financial incentives. Access to more
information in and of itself doesn't produce value, but combining an HIT
infrastructure with VBID principles should facilitate attainment of this goal.
Such health information technology, which the Obama administration and
the U.S. Congress have deemed crucial to an economic recovery, is clearly
consistent with the objectives of VBID and other health care reform initiatives.
In a 2007 Health Affairs article, Troyen Brennan, M.D., executive vice president
and chief medical officer of CVS Caremark, and Lonny Reisman, M.D., chief
medical officer of Aetna, wrote that information technology should be "fused"
into benefit design and used to identify by reported claims which patients
have suffered a medical event or what medications patients are taking. Then it
would be possible to change the benefits to reflect individual needs.
VBID/CDHPs: Complementing Each Other. Consumer-directed health plans
and VBID complement each other by aligning clinical and financial incentives
to encourage the use of high-value services and discourage services of lesser
value. Similar to VBID programs, some CDHPs offer no deductible, first-
dollar coverage for certain medications, preventive care, and services that are
critical for chronic disease patients. Both models promote greater consumer
responsibility and use evidence-based information to induce consumers to
be more cost-conscious and purchase clinically appropriate, high-value care.
The next generation of consumer-driven care will require more attention
to value-based insurance design so as to ensure that patients have access
to appropriate and high-quality care. This can be accomplished so long as
insurers carefully integrate financial incentives into benefit design, build advice
about evidence-based medicine into their plans and thoroughly use the
increased facility of information technology in their efforts.
Physician Payment Reform. One primary principle behind P4P and PCMH is
to reward providers for achieving quality measures, increase preventive care,
and decrease overuse of services, all based on evidence-based medicine.
For the health care system to become efficient, it must achieve an alignment
of incentives, both non-financial and financial, for all stakeholders. Patients
should have minimal or no barriers to accessing those services for which
providers receive incentives; if they do, this constitutes a direct conflict with the
fundamental tenets of these initiatives.
Patient centered medical homes, an idea which has been in formation for
several decades, also shares many of the same features as VBID: evidence-
based support for clinical decisions, information systems, provider incentives
and quality improvement along with cost effectiveness. The medical home
concept endorses the delivery of primary care that is accessible, continuous,
comprehensive, family-centered, coordinated, compassionate and culturally
effective. It emphasizes collaboration between patients and personal
physicians. Several organizations have put forth basic principles for medical
homes that focus on practice redesign that is delivered in response to
patients' needs and preferences; adoption of health information technology to
facilitate evidence-based integrated care; structuring of payment to align with
measurable improvement in care; and accountability.
Comparative Effectiveness Research. Comparative effectiveness research
assesses how various procedures or interventions compare with each other for a
given medical condition for a specific group of patients, and thus contributes to
maximizing the value realized from those procedures or interventions. In 2007,
the Institute of Medicine published "Learning What Works Best: The Nation's Need
for Evidence on Comparative Effectiveness in Health Care." The report states:
"Within the overall umbrella of clinical effectiveness research, the most
practical need is for studies of comparative effectiveness, the comparison
of one diagnostic or treatment option to one or more others. In this
respect, CER involves the direct generation of clinical information on the
relative merits or outcomes of one intervention in comparison to one or
more others."
Without a strong investment in CER, patients and providers are more likely to
face unintended "across-the-board" restrictions on the provision of valuable
care. Although some have argued that CER should include cost-effectiveness
analysis, recent legislative efforts to expand the national capacity for CER have
focused on outcomes and effectiveness, and not cost.
VBID's synergism with key reform initiatives – health information technology,
CDHPs, P4P, comparative effectiveness and medical homes – is indicative of
the new role that value is playing in the utilization and purchase of health
care. It also is indicative of a trend toward integrated health care, away from
the siloed perspective of traditional health care and an emphasis on individual
consumers and their responsibility for their own well being.
the overall
of clinical
research, the
most practical
need is for
studies of
the comparison
of one
or treatment
option to one or
more others."
Learning What Works Best:
The Nation's Need for
Evidence on Comparative
Effectiveness in Health Care,
Institute of Medicine, 2007
Payers desiring to optimize health gains per dollar spent should adopt a
"clinically sensitive" design that removes barriers and provides incentives to
encourage desired behaviors. VBID programs become easier to create as
more is learned about high-value services through comparative effectiveness
research, and easier to implement with the wider dissemination of health
information technology.
While barriers to VBID implementation certainly exist, such as concern
over beneficiary reaction to the program and implementation costs, private
purchasers are increasingly adopting VBID programs as they acknowledge
that efforts to control health spending through patient cost sharing should
not produce preventable reductions in quality of care. This realization also
has spread to the Medicare program; legislation entitled, "Seniors' Medication
Copayment Reduction Act of 2009," was introduced in Congress (S.1040) to
require Medicare to test the impact of reduced cost sharing for medications
used to treat 15 common clinical conditions in the Medicare population.
Moreover, the June, 2009, MedPAC Commissioners Report acknowledges VBID
as an important part of a more efficient Medicare system.
Experience in the field indicates that VBID programs are feasible, acceptable
by all vested stakeholders, and have been very well received by beneficiaries.
VBID can address several important inconsistencies in the current system and
work synergistically with other initiatives such as HDHP, DM, PCMH, and P4P
programs. By allowing different cost sharing provisions for different services,
value can be enhanced without removing the role of cost sharing in the system
overall. Targeted efforts to reduce utilization of low-value services are more
likely to contain cost growth while maintaining quality of care.
We do not expect VBID to solve our health care crisis. Technological advances
will continue to generate upward pressure on costs, and the ability of
individuals and their employers to afford such coverage will be increasingly
strained. However, the inability to construct the perfect benefit design should
not lead to abandonment of key VBID principles that explicitly aim for more
efficient allocation of health care resources. The alignment of financial
incentives – for patients and providers – would encourage the use of
high-value care, while discouraging the use of low-value or unproven
services, and ultimately produce more health at any level of health care
expenditure. The cost of maintaining the status quo, in terms of higher
spending and worse health outcomes, is undesirable.
The alignment
of financial
incentives –
for patients
and providers
– would
the use of
care, while
the use of
or unproven
services, and
produce more
health at
any level of
health care
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text: The human nose can sense 10 basic smellsGeorge Dvorsky9/20/13 11:10amFiled to: Biologyolfactionsmellsensestasteperceptionsensory perceptionscienceodors592EditPromoteShare to KinjaToggle Conversation toolsGo to permalink We've got categories to describe our perceptions of taste, colors, and sounds. But things aren't as clear-cut when it comes to our sense of smell. Looking to overcome this surprising limitation, a team of researchers have proposed a list of 10 basic smells. Indeed, we're all set when it comes to describing the way our other senses work. Our 100,000 taste buds elicit five different sensations, namely sweet, bitter, sour, salty, and umami (a Japanese word for a pleasant savory taste, but distinct from pure saltiness). When talking about vision, we're able distinguish between wavelengths by referring to them by color, like red, green, and yellow. And when it comes to sound, we can speak of timbre, dynamic range, and frequency response. The Perception of SmellBut until this new investigation, scientists were unable to explain the characteristic perceptual qualities of olfaction — our sense of smell. The sense of smell comes about through the stimulation of specialized cells in our nasal cavities — cells that are similar to the sensory cells of the antennae of invertebrates. The human olfactory system works when odorant molecules bind to specific sites on the olfactory receptors, which are used to detect the presence of smell. Advertisement Advertisement And it all comes together at the glomerulus, a structure which transmits signals to the olfactory bulb — a part of the brain directly above the nasal cavity and below the frontal lobe. The end result is the subjective experience we call smell.As we all know, odors can be rich and complex. And we have many ways of describing smells (e.g., smoky, sweet, pungent, etc.). But what we haven't done is create a definitive list that organizes odors into their basic, or essential, categories.Odor ProfilingTo overcome this limitation, a research team consisting of Jason Castro, Arvind Ramanathan, and Chakra Chennubhotla analyzed 144 different odors to see if they could identify consistent odor profiles. These 144 odors were derived from an olfactory "atlas" created in 1985 at the Institute of Olfactory Sciences in Park Forest, Illinois. Sponsored To assist them with their task, the researchers used advanced statistical techniques (a mathematical technique called non-negative matrix factorization [NMF]) to develop an approach for the systematic description of smells. The researchers likened the process to digital data compression when a digital audio or image file is reduced in size; the basic elements are retained at minimal expense to quality or essence. Their analysis showed that olfactory space is highly dimensional — 10 dimensions to be exact. Advertisement They are as follows:Fragrant (e.g. florals and perfumes)Fruity (all non-citrus fruits)Citrus (e.g. lemon, lime, orange)Woody and resinous (e.g. pine or fresh cut grass)Chemical (e.g. ammonia, bleach)Sweet (e.g. chocolate, vanilla, caramel)Minty and peppermint (e.g. eucalyptus and camphor)Toasted and nutty (e.g popcorn, peanut butter, almonds)Pungent (e.g. blue cheese, cigar smoke)Decayed (e.g. rotting meat, sour milk)The last two items, pungent and decayed, get a kind of meta-category of their own, one the researchers describe as "sickening." Advertisement Other aromas, like baked bread or fresh-brewed coffee, are amalgams of two or more of these 10 elements.Smells Fishy?This study is certainly interesting and helpful, but it's lacking in several areas. Advertisement First, we're talking about something that's very subjective. Take pungent, for example, an odor the scientists placed into the "sickening" category. While strong and sharp, it's not necessarily an unpleasant odor. What's more, our appreciation and comprehension of smells are both culturally instilled and the result of such processes as developing an "acquired taste" for something. Also, the 144 odors considered by the scientists comes from a very small sample pool. And indeed, the scientists acknowledge this in their paper, suggesting that future studies should broaden the scope of data.Lastly, the study didn't distinguish between perceptual and cognitive influences on the organization of human odor space. This would help alleviate some of the subjectivity problems inherent in the study by showing the various autonomous responses involved in olfaction. Advertisement Read the entire study at PLoS One: "Categorical Dimensions of Human Odor Descriptor Space Revealed by Non-Negative Matrix Factorization." Images: nrt/ Shutterstock, Sunny Forest/Shutterstock.Reply59 repliesLeave a reply

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The Penn Kingsmen football team won Friday's home conference game against South Bend Riley by a score of 21-11.
Game Details: Penn, Football Varsity
The crowd at Friday's league contest between the Penn Kingsmen (Mishawaka, IN) and the visiting South Bend Riley Wildcats (South Bend, IN), observed Penn's football squad defeat South Bend Riley by a count of 21-11.
The Kingsmen now own a 8-0 record. They play next when they travel to Mishawaka for a Northern Indiana contest on Friday, October 18. Penn will play a Cavemen squad coming off a 28-14 league win over Mishawaka Marian (Mishawaka, IN). The Cavemen record now stands at 6-2.
Coming up next, the Wildcats play the South Bend Clay Colonials (South Bend, IN) in a Northern Indiana outing, on Friday, October 18. South Bend Riley will attempt to upgrade on its 4-4 season record. The Colonials go into the outing with a 1-7 record after their 42-14 league loss to South Bend St. Joseph (South Bend, IN).


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4 Tools You Need For Your Sheet Metal Fabrication DIY's
So you want to get into sheet metal fabrication? The workshop that you dedicate to your fabrication hobby will no doubt house your basic tools like screwdrivers, wrenches, ratchets, and the like, but there are a few gadgets that you will definitely want to include in your tool kit for do-it-yourself metal fabrication. Sheet metal fabrication is precise work, with precise cuts, casts, and welds, and if you don't have the proper tool for a specific purpose or technique, the metal you're working with won't have that clean precision. But in cases of botched work, thank heaven for custom sheet metal fabricators! Angle Grinder When setting up your fabrication shop you will need to have at least one angle grinder. Much as their name implies, these grinders smooth the rough edges of any angles on the sheet metal that were previously cut. Your best bet would be to store two angle grinders, one smaller than the other, for different angle measurements. Small Drill Press A drill press, even a smaller model, can benefit the fabrication process in more ways than one. A small drill press can help you easily get the job done without the small margin of error of that can come with hand drilling. A drill press will also ensure more precision for thinner and smaller pieces of material than a hand held drill. Stick Welder If you're going to work with metal, you're going to have to weld the metal at some point. Every professional fabrication shop has a variety of welders, but to start, a stick welder will do nicely. A stick welder uses a 'stick' made of a flux covered electrode material that lays the bead, or weld, down onto the metal. A small arc of electricity travels from the stick to the metal, heating it and bonding it. So if you plan on sticking two pieces of metal together, you need a welder. Chop Saw A good chop saw can cut through most sheet metals, and is a necessary component of any metal workshop. Most chop saws for home use come in a fourteen-inch measurement, and you can easily find replacement blades. Remember that your new metal workshop will take some time and planning to build, and if you need custom sheet metal fabrication before your workshop is complete, look for a professional in your area. They might even have some tools for...read more
Should You Repair Or Replace Your Business's Malfunctioning Can Seamer?
If you run a manufacturing facility that depends on the services of a trusty can seamer to package your products, you may find that production comes to a screeching halt upon the first sign of trouble with your seamer. When dealing with these types of hiccups, you may be tempted to simply purchase a new seamer rather than try to identify the problem with your current one and determine the cost of repairs and the length of time your machine will be out of commission. However, there are several issues you should be able to easily troubleshoot yourself, saving a substantial amount of money. Read on to learn more about some quick repairs you can make to your can seamer, as well as some situations in which replacement may be the better option. Which can seamer repairs can you perform yourself? Because the success of a can seamer's seal depends entirely on the calibration of the small parts used to hammer out and pin shut the two adjacent pieces of tin, even minor damage to the seamer chuck or rolls can lead to bubbling or misshapen seams that aren't effective at sealing the can's contents from outside air. If the defects you notice seem fairly minor and appear to be due to a shift in the positioning of the seamer chuck or the rolls used to create the seal, you may be able to carefully direct these parts to their proper locations, testing on can lids as you go to ensure you don't move these parts too far from the target. In other cases, the surface of the rolls used to shape the metal may become chipped, cracked, or damaged, making the roll less effective at creating a perfect seal. You should be able to replace a defective roll yourself with just a screwdriver and a few other small tools. When should you replace a can seamer instead of attempting repair? When your seamer problems appear to be mechanical in nature — for example, if your seamer is losing power at crucial moments or making odd noises that could indicate a problem with the small engine used to turn the seamer chuck — you may want to investigate the cost of replacement. Many new can seamers come with an extended warranty that can help financially insulate your business from these types of problems for years, and the cost of repairing or replacing this small engine may rival the cost of a new (or gently used) can...read more
Secure Your Property with Knowledge and Confidence—Advantages of Installing a Metal Roof
If you've spent time dealing with repeated leaks from your roof, or shingles which have been thrown around your yard by storm systems, you need to explore your options for strengthening your protection. Many people commit to wooden or stone shingles without even considering alternate options, and in doing so, they don't realize the benefits that metal roofing may have to offer. Below, you'll find a guide to some of the advantages of installing a metal roof on your home. Hopefully, these positives open your eyes to the possibilities which come with alternate roofing materials and provide you with the confidence to explore new options that will secure your home for many years to come. Energy Efficiency In warm climates, the battle to keep your home comfortable while keeping your electricity costs low is an ongoing struggle. Many people neglect to consider the way their roof affects this struggle, as some roofing materials actually imbibe additional heat and raise your home's temperature regardless of your air conditioner's efficiency. Metal roofs, however, often deflect sunlight rather than imbibe it, guaranteeing that the temperature in your home's upper levels can be kept cooler. You can also treat your metal roof with whatever paint or finish you desire, allowing you the ability to add a layer of ultraviolet protection, which can help you achieve your temperature goals. Durability As mentioned above, slow leaks and loose shingles can be sources of immense frustration that drive a home owner to look for alternative solutions. However, even the strongest and most well maintained asphalt roof has a definite limitation on its life span, and you may find yourself investing in a replacement roof far more often than you'd like. Metal roofing often has a lifespan that far exceeds asphalt, allowing it to remain strong and stable, likely throughout the duration of your home ownership. Your investment in your metal roof is a one-time expense that will stop you from continuing to throw good money after bad for years to come. Customization Other roofing types are restricted in cut and color by the naturally occurring patterns in stone. This may make certain roofs unavailable in your area, or may stick you with a material that isn't ideal for your particular climate. A metal roof, however, is extremely customizable. You can select the finish, the color, and the shape of your roof, guaranteeing that you'll be able to find the most efficient and fashionable solution for your needs. Contact a roofing company like JD Metals if you have further questions or if you would like to set up an appointment to install your metal...read more
3 Reasons To Buy A Stretch Wrapper For Your Warehouse
When you start mulling over the equipment options for your back room, you might be tempted to side with a cardboard compactor or a brand new forklift over a stretch wrapper. However, stretch wrappers, which are automated devices that completely encapsulate pallets of product with a few layers of plastic wrap, can help you in more ways than you might think. Here are three reasons to buy a stretch wrapper for your warehouse, and why you might never go back to your old way of doing things: 1: Protect Your Merchandise When you ship products out of your warehouse, you never know what kind of journey they stand to endure. In addition to dealing with a bumpy ride and a forceful crew, your products might also have to withstand dust and grime accumulation. Unfortunately, if they arrive at your retail stores in less-than-perfect condition, they might not be suited for the sales floor. Fortunately, stretch wrapping your pallets can help to protect your products. After pallets are wrapped, the covering acts as a barrier against dirt, moisture, and even pests. You won't have to worry about your delicate paper packaging being warped by a little rainstorm during the unloading process or having a customer surprised by a spider that made its way into a box. 2: Keep Pallets Safe If you have ever volunteered in your own back room, then you understand how heavy and unstable a pallet can be. Unfortunately, when high, unstable stacks of goods have to be moved across the room or into the back of a truck, boxes can fall off of the sides, strike your employees, and cause legal trouble. Fortunately, in addition to protecting your goods, pallet wrapping can also keep those pallets safe for employees to handle. Stretch wrapping material is typically composed of linear low-density polyethylene, which is a strong, clear type of plastic. Believe it or not, some types of this plastic wrap are capable of stretching 500% at their break point, so that you can wrap pallets tightly without worrying about stretch wrap failure. When pallets are wrapped with several layers of stretch wrap, products will stay in place, and your employees don't have to worry. 3: Label Shipments Easily Another great benefit of stretch wrapping is that it allows you to label pallets easily without extra equipment. Because most stretch wrappers apply multiple layers of plastic, you can simply tuck your shipping label or invoice between a few of the exterior layers. Not only does this eliminate the need for extra tape and envelopes, but it also might make it easier for your stores to spot important documents. For more information about stretch wrappers, contact SIAT S.p.A. or a similar...read more
Manufacturing Production Software Made To Your Specifications
Manufacturing processes are often made to attack a specific challenge. You may have some general use equipment, but if you're producing a truly useful and groundbreaking process, you likely have some customized technology and policies in place. Since your software is often part of the production process, make sure that you voice your opinion and make requests for features that can change the way your software works for you. A few examples can help you get into the mindset of how to ask for changes to your software. Your imagination and the programming team's abilities are the only limits. What Can Production Software Do? For manufacturing industries, automation and monitoring are key. In order to get the most out of your process, you need to get as much information as possible. For example, consider the chemical processes in a food product manufacturer's line. Some ingredients need to be at a specific temperature. They also need to be moved to other parts of the process at a specific time, produced and packaged at a specific volume. Production software can be used to monitor the information if you have the specific instruments to measure available. For temperatures, digital thermometers exist that can be connected to a computer. When the information is recorded by the digital thermometer, the software programmer can write code that brings the temperature information into your software. To measure the time it takes for product to move from one place to the other, a number of measurements can be made. You could start a timer when worker sends ingredients down a line to the time that the next worker receives the ingredients. For automated processes, you could install lids on hinges, pressure gauges or anything that notifies the passage of product. The start and stop times can be recorded and sent to the software. Basically, any information that is based on time or can be measured can be put into software. The difficulty comes from refining the measurement to the smallest unit as possible. Going into milliseconds or micrograms, for example, may be very difficult to design into the physical equipment. Once that measurement is possible, recording it in software is the easy part. Why Would Programmers Make Such Changes? In a world of software that is bought from the shelf or an online store, many people are satisfied to just buy what's available. What you need to realize is that much of the software available came from demand. You may not be able to bend the ear of the biggest software companies in the world without a sizable bank account to make a product just for you, but programmers are looking for your work. Individual teams in large software engineering firms and smaller firms alike are ready to take your project and make something work. It could be an entirely new project or a plugin for their existing product. It all depends on the level of customization you're willing to request. Contact a manufacturing production software professional to begin planning your changes. Talk to experts like JobPack for more...read more
Get The Lowest Price Possible For Oil And Fuel When Buying Wholesale
Even though oil prices have been falling in recent months, oil can still be an expensive part of a freight company's business expenses. Purchasing oil in bulk at the lowest price possible is the best way to slash business operating costs. Watch Market Movements If you want to purchase oil at the lowest price possible, you will need to purchase oil in bulk while watching market movements. The value of oil fluctuates, so you will need to be able to predict when the oil prices have reached the bottom. Work with wholesalers to purchase as much oil as possible before the demand increases. Do not wait until your tanks are almost empty before having the tank refilled. Determine How Much Oil to Store By purchasing oil in bulk, you will need to have an effective way of storing it. You will need to determine how much oil you will store so you can purchase a suitably-sized tank. Fortunately, you usually do not have to receive all of the oil all at once, but you can instead have it delivered after paying a fixed price. To avoid running out of fuel early, you will need to track how much fuel you typically use per month. That way, you can have the right amount of fuel delivered to you at the right moment and minimize the amount of fuel you lose through evaporation. Get a 12 Month Fixed Price Tariff To ensure that you get a specific price, consider getting a 12-month fixed price tariff. Even though the price of the tariff is usually higher, you are protected from a sudden spike in oil prices for 12 months. Know the Oil Prices Beforehand Before purchasing the oil, make sure you research the current oil prices. The wholesale supplier will probably charge more than the value of the oil to earn a profit, but the price should be close to the current oil price. Purchase Near the End of the Season While it can vary, the best time to purchase fuel is usually at the season's end. This is when wholesale fuel companies need to empty their tanks, especially companies that purchased too much for the particular season. Don't Be Afraid to Negotiate Oil companies are haggling businesses, so you can usually negotiate down the price of your order. One approach is to find another company that has a lower price and ask the current company you're negotiating with of whether they can beat that price. Most companies have some room to come down in order to make a sale. Talk to a company like Small & Sons Oil Dist...read more


text: Meet John Chang, the real-world equivalent of Raiden from Mortal KombatCyriaque Lamar9/19/11 6:50pm66EditPromoteGo to permalinkIn this clip from the documentary series Ring of Fire: An Indonesian Odyssey, the filmmakers visit qi master John Chang a.k.a. the "Magus of Java" a.k.a. the man whose nickname I want on my business cards.


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Makes 8 enfrijoladas
Here is an inspired contemporary version of that famous Tex-Mex combination of beans and cheese. If you thought you liked refried beans and cheddar, wait until you taste these tortillas stuffed with goat cheese topped with Black Bean Sauce.
12 ounces fresh goat cheese at room temperature
1 tablespoon chopped fresh epazote or cilantro
2 teaspoons dried epazote
4 scallions chopped
1/4 cup vegetable oil
8 corn tortillas
Black Bean Sauce, heated
1 cup Pineapple Pico
4 fresh cilantro sprigs
Preheat an oven to 325 degrees F. In a small bowl, combine the goat cheese, epazote or cilantro, and scallions. Stir well, season with salt, and set aside.
In a medium-sized skillet, heat the vegetable oil over medium heat. When the oil is hot, dip a tortilla into the hot oil and cook for 10 to 15 seconds on each side, or until soft. Drain on paper towels. Repeat with the remaining tortillas.
Divide the goat cheese mixture evenly among the tortillas, roll them up, and place seam-side down in a greased baking pan. Place in the oven and bake for 5 minutes, or until the cheese melts.
Remove from the oven and transfer to plates. Cover with the bean sauce. Garnish with the Pineapple Pico and cilantro sprigs.
Nuevo Tex-Mex
By David Garrido and Robb Walsh
Chronicle Books
Full-color photographs and illustrations throughout
Paperback, $19.95
Recipe Reprinted by permission.
This page created 1998 and modified September 2007
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Nylon American Flag (Without Fringe) - 36" x 62"$34.99Colorfast with canvas headers, brass grommets, and stars/stripes on both sides. 36 inch X 62 inch. Made in the USA. Learn More
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text:
Thanks Jim - will copy mother on this so she can share it w/ her friend
Marge. I speculated that the plant might need to get a little older to
bloom (like my viburnums). Appreciate the info!
Pam Evans
Kemp, TX
zone 8A
----- Original Message -----
From: james singer
Sent: 5/29/2004 5:24:10 AM
To: email@example.com
Subject: Re: [CHAT] Pam--Maxicrop
> The orange-flowered bird [Strelitzia reginae, named for Queen Victoria]
> seems to bloom best in the "cool" season, when well fed, and when
> crowded. It does not bloom easily when small or young. But I think
> crowding is the key. Even when planted out, a big clump blooms from the
> center, not from the periphery. I do not have one of these myself, but
> we use a lot of them in landscapes--but never in sizes smaller than 7
> gallon [about the size of your mother's friend's plant]. Occasionally a
> 7-gallon plant will bloom, but it's not a given.
> The white-flowered bird [S. nicolai, named for Tsar Nicholas] seems to
> need to reach a certain age to bloom. I do have two of these, only one
> of which blooms. It blooms all year, and at the moment has about 10
> flowers, all above the roof line of the house.
> On Friday, May 28, 2004, at 10:36 PM, ""
> <email@example.com> wrote:
> > Mother's friend Marge (not our Marge) has a 3 foot bird-of-paradise
> > plant in a pot in her sunroom. It does get to go outside when it's
> > really warm (July & August up there) then back to the sunroom. It gets
> > lots of light according to mother but it has never bloomed. Can you
> > think of anything special she needs to do to it to get it to bloom?
> >
> >
> > Pam Evans
> > Kemp, TX
> > zone 8A
> >
> Island Jim
> Southwest Florida
> Zone 10
> ---------------------------------------------------------------------
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Together: Respect, Safety and Dignity for All. A UN System-wide initiative led by the Secretary-General.
UN Summit for Refugees and Migrants is an historic opportunity for the world to agree on a better response to large movements of refugees and migrants.
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Which countries host the most refugees? How many migrants lose their lives on route? Explore our infographics based on official data sources.
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tim tebow
A detailed history of the bond between hip-hop and 63-year-old Skip Bayless
'I have created wars on Twitter, because for me and my taste, you're better than Jay Z.'
That awkward moment a former colleague calls Tim Tebow the worst QB he's ever seen
But hey, we had some good times Tebowing.
The reason soccer seems huge in America is the reason why It's not
On Twitter, things might appear larger than they are.
The future of the NFL, according to @PFTCommenter
The future of the NFL, according to @PFTCommenter.
Former NFL star counters every argument against gay players
"If any NFL team can't 'handle the media coverage' of drafting Sam, then your team is already a loser on the field."