What roles can comparative effectiveness research (CER) and value-based benefit Design (VBBD) play in designing and providing cost-effective, competitive health care benefits for employees?

During 2009, the BHCG sponsored or co-sponsored two seminars with nationally known speakers to address the integrally related topics of CER and VBBD. Here are the highlights of those presentations and the implications of these topics for employers.

What is comparative effectiveness research (CER)?
As defined by the Institute of Medicine, “CER is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels.”

Why are CER and other comparative analyses important?
In the realm of health care, historically, consumers and payers have been too passive in their approach to the use of comparisons. Presently drugs and devices are approved if they are considered safe and are better than a placebo. The approval process is not set up to compare the effectiveness of drugs, protocols or treatments. As consumers, we need the ability to accurately compare:

• Treatment A to no treatment (a placebo)
• Treatment A to Treatment B
• Physician A/Hospital A to Physician B/Hospital B
• Health Policy A to Health Policy B

Who is doing CER? How is it funded?
The recently enacted stimulus package provides a substantial $1.1 billion in funding split among the Agency for Healthcare Research and Quality (AHRQ), the Department of Health and Human Services (HHS) and the National Institutes of Health (NIH). The purpose of this funding is “to conduct or support research to evaluate and compare clinical outcomes, effectiveness, risk and benefits of two or more medical treatments and services that address a particular medical condition.” Further, the emphasis will be on clinical outcome-based research and analysis (as opposed to research driven by cost analysis and cost containment).

What is value-based benefit design (VBBD)?
The National Business Coalition on Health (NBCH) defines value-based benefit design as, “the use of incentives, through the design of employee benefits, to encourage consumers to choose healthy behaviors, to seek high value health services, and to select high performance plans and providers.”

What are the key principles of value-based design (VBBD)?

• Medical services differ in the clinical benefit provided.
• A value-based benefit package should be “clinically sensitive.” The more clinically beneficial the therapy for the patient, the lower that patient's cost share should be.  Higher cost sharing should apply to interventions with little or no proven benefit.
• Couple efforts to change consumer behavior with changes to provider reimbursement (i. e., the more clinically beneficial the therapy, the higher the clinician’s payment).
• Patient accountability is an important component.

Three examples of VBBD in action:

• Basing drug copays on their value to the patient not on their price. Most prescription drug plans set copays for generic drugs the lowest, copays for preferred brands higher and copays for non-preferred brands the highest with little thought to the value these drugs provide to the patient.
• Spending more money on health screenings and wellness to maximize health. Substantial underutilization of high value health care services persists. Adults in the United States only receive approximately one-half of recommended care. Instead of encouraging the utilization of valued health services, we have placed impediments to their utilization including denial of services, prior authorization protocols and increasing copays, all of which create barriers to receiving necessary care.
• Encourage the use of high performance providers for complex procedures. Research has clearly shown that providers with the best outcomes are those that perform the highest volume of a particular procedure, especially complex procedures. Identify Centers of Excellence for transplant services and pay a higher level of benefits for their use and/or not pay for the utilization of other providers for these procedures.

To view the complete executive summaries on these topics, click here CER (PDF) or here VBBD (PDF)

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