As value-based reimbursement forces healthcare providers to revamp their practices, a new Medicare Advantage pilot program is leading insurers to make their own quality adjustments as well.
In many ways, value-based insurance design is revolutionary, as it gives participating Medicare Advantage payers the flexibility to design benefits for smaller subsets of their enrollees. Historically, the Centers for Medicare and Medicaid Services has mandated universal benefit requirements in its programs.
Under value-based insurance design, for example, an insurer can waive the $20 copay for a diabetic patient to get an eye exam. Eyes can become damaged by diabetes, and getting care early for a condition revealed by an eye exam could prevent further complications and save money.
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Before, CMS would have said, "'You can't do this special thing for this diabetic because everybody has to have this opportunity,'" said Judith Nelson, director of Medicare Advantage Strategy, for healthcare consultant DST Health Solutions.
While it doesn't seem that $20 would prevent anyone from seeing their doctor, senior citizens living on a fixed income are frugal, Nelson said.
"If they don't feel the need to go to an eye doctor, they won't go," she said.
The real beauty of benefit design is that health plans can create plan benefits for a combination of conditions, Nelson said. A plan could be geared for diabetics who also suffer from hypertension or mood disorders.
There are nine participating organizations in the new model, including Blue Cross Blue Shield, Fallon Community Health Plan, Tufts Associated Health Plan, Geisinger Health Plan, Aetna, Independence Blue Cross, Highmark, UPMC Health Plan and the Indiana University Health Plan.
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These plans have already received approval from CMS to offer varied benefits for enrollees who have certain clinical conditions including diabetes, chronic obstructive pulmonary disease, congestive heart failure, past stroke, hypertension, coronary artery disease or mood disorders.
The participating insurers contacted said they couldn't yet give details of their plans.
CMS is not allowing plans to market their new benefits and promote details of their plans during Medicare open enrollment, which starts Oct. 15, according to Nelson.
Members who are eligible for the new model will be notified in the new year, said one insurer.
Whether Medicare Advantage value-based insurance design works to bring down costs and improve care won't definitively be known for five years, at the end of the pilot period which starts on Jan. 1, 2017.
What is known is that Medicare Advantage is growing in popularity for seniors, and that senior citizens are a growing population.
Nelson believes CMS is using the pilot program to identify which plans make sense by improving quality and saving money, and then standardizing those plans in some way.
"For me, that is really setting the model and structure in place to be the health plan of the future," Nelson said. "I think a lot of plans are watching. I think it's a good program. It will be interesting to see how it plays out."
Twitter: @SusanJMorse