Promoting Value Through Health Insurance Design: Empirical and Normative Assessments

Abstract

Chapter 1. The Effect of a Large Regional Health Plan’s Value-Based Insurance Design Program on Statin Use. My first chapter examines a value-based insurance design (VBID) program for statins implemented by a large regional health plan. Copayments on VBID brand statins were reduced by 42.9% for the treatment group and increased by 16.7% for the comparison group between the pre- and post-intervention periods. Using a difference-in-differences analysis, I found a 2.7 percentage point increase in medication adherence among VBID brand statin users in the treatment group relative to the comparison group (p=0.033). With a baseline adherence rate of 77.6%, nonadherence was reduced by 11.9%. Chapter 2. The Impact of a Tiered Network on Hospital Choice. This chapter evaluates the effect of a tiered network (TN) on hospital choice for scheduled admissions using 2009-2012 patient-level claims data from Blue Cross Blue Shield of Massachusetts (BCBSMA). BCBSMA’s three-tiered hospital network employs large differential cost sharing to encourage patients to seek care at hospitals on the “preferred” tier. During the study period, 44% of hospitals were moved to a different tier based on changes in cost or quality performance. I relied on this longitudinal variation for identification and specified conditional logit models to estimate the effect of the TN on patients’ hospital choices relative to a non-TN comparison group. The TN was associated with increased use of hospitals on the preferred and middle tiers relative to the nonpreferred tier for planned admissions. The results suggest that if all members were in a TN plan, relative to all members being in a non-TN plan, scheduled admissions to hospitals on the nonpreferred tier would drop by 7.6 percentage points while those to middle and preferred tier hospitals would rise by 0.9 and 6.6 percentage points, respectively. Chapter 3. Normative Assessments of Value-Based Insurance Design and Tiered Provider Networks. When health insurers implement new insurance designs, the quality, accessibility, and cost of health care may be affected. In this chapter, I assess the normative implications of employing the insurance designs examined in chapters 1 and 2. While VBID programs and TN plans both seek to promote value, the use of these insurance designs may implicate a range of ethical issues. Thus, to the extent that VBID and TN initiatives are less efficient than they could be, certain individuals or groups may be harmed (in the sense of being made worse off than they otherwise should be). Moreover, when VBID programs and TN plans are implemented, the distributions of health care benefits and burdens will be impacted, which can lead to inequities (if the insurance design unfairly affects one or more groups disproportionately relative to others). After identifying various ways in which harms and inequities may arise in the contexts of VBID and TN initiatives, I propose policies and practices to help mitigate these concerns.