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Benefit Designs Should Include "Clinical Nuances" to Reduce Costs

From the National Business Coalition on Health: Drs. Mark Fendrick and John Ayanian argue that in order to shift health care spending from volume-based to value-based, payment models must consider certain “clinical nuances.” The authors conclude that "By basing consumer cost sharing on the clinical value – not the price – of services, payers can actively engage consumers in seeking high-value care and foster more regular conversations with providers regarding low-value services." 

Examples of "clinical nuance" include:

"An example of using clinical nuance to make health plans more efficient is the evidence-based recommendation that individuals with diabetes undergo routine eye examinations.  While it is not clinically appropriate for everyone to receive such exams, the delivery of this evidence-based service to patients with diabetes is a frequently employed quality metric.  In a nuanced design, cost sharing for eye exams would be substantially lower for those with diabetes than for those without."

"More recently, V-BID (value-based benefit designs) programs have incorporated nuanced disincentives to discourage the use of low-value care.  Key stakeholders, such as the medical professional societies participating in the Choosing Wisely initiative, agree that discouraging the misuse or overuse of identified low-value services must be part of the strategy. These “stick” programs, while more difficult to implement, are substantially more likely to achieve short-term cost savings."

Read more about why to introduce clinical nuances into your benefit design.

MBGH members can get a copy of our Choosing Wisely Employer Toolkit with ready-to-use resources to help you promote wise health care choices by your employees by contacting thill@memphisbusinessgroup.org.

Posted by Cristie Travis at 10:08 AM

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