In a value-based health plan, the idea is to reward employees for seeking specific treatments that promote wellness.

The more clinically important the treatment relative to the employee’s health risks, the less an employee pays out of pocket for it. 

Example: Women over 40 and younger employees with a family history of breast cancer pay less for a yearly mammogram than employees for whom the test isn’t as necessary.

Supporters of value-based plans say the plan design can work better than high-deductible plans when used in combination with standard wellness program features such as health risk assessments.

Four criteria for measuring quality

According to Simply Well, there are four criteria that have emerged as key benchmarks of measuring the effectiveness of a value-based plan:

1. health care management guidelines
2. preventive screenings and treatments
3. quality of member service, and
4. easy access to care.

Clinical areas of particular concern in many value-based plan designs:

• Employees’ dependents receiving appropriate and timely childhood and adolescent immunizations
• Breast cancer screenings for female health plan enrollees, ages 52 to 64
• Diabetic employees receiving hemoglobin A1C and LDL-C testing
• Members receiving proper referrals and treatment for mental health issues (e.g., primary care physician refers a patient to a specialist to ensure proper prescription and management of an anti-depressant medication), and
• Pregnant employees receivig time and appropriate prenatal and postpartum care, and avoidance of antibiotic treatment in adults with acute bronchitis.

The quality and continuity of care for the aforementioned issues can suffer when employees foot too much of the bill out of their own pockets.

Proponents of  value-based plans say the plans are a way to provide cost relief to employees in need while increasing the chance they’ll seek out treatments that will reduce plan sponsor costs in the long run.

Tags: value-based healthcare, wellness