Author + information
- Eric C. Stecker, MD, MPH, FACC, Chair-Elect of ACC Science and Quality Committee,
- Lonny Reisman, MD, FACC,
- Larry A. Allen, MD, MHS, FACC and
- Ty J. Gluckman, MD, FACC
Over the last decade, as out-of-pocket costs have climbed, so too has patient responsibility for their health care. For the 153 million Americans with employer-sponsored insurance, the average individual deductible in 2019 reached $1,655 (more than double the amount a decade earlier), with 28% having deductibles that exceed $2,000 (1). Among those purchasing health insurance independent of their employer, average deductibles have skyrocketed to $4,328 for individuals and an astonishing $8,352 for families (2). For most patients, the out-of-pocket responsibility is even greater—over-the-counter medications, medical equipment, eye care, dental care, hearing, and more.
The growing financial pressure being faced by patients—which, of note, exists independent of the necessity or quality of the health care that is delivered—is rapidly eroding the fabric of our health care system. According to a 2018 survey, 64% of patients reported that they “delayed or neglected seeking medical care in the past year because of concern about high medical bills” (3). Not surprisingly, clinicians are challenged to provide proactive, personalized, guideline-directed care in an environment where patients are disincentivized to engage the health care system until catastrophe strikes.
To further explore the impact of insurance benefit design on the delivery of high-value care for the cardiovascular patient, the American College of Cardiology convened a multi-stakeholder summit in Washington, DC, in December 2019. Participants included leaders in health policy, clinical research and practice, managed care, patient advocacy, self-funded employer plans, industry, and data science. Focused on patients with atherosclerotic cardiovascular disease (ASCVD) and multiple comorbidities, the meeting sought to better understand how financial challenges associated with optimal treatment could best be overcome. The summit was divided into 3 sessions: the current state, the importance of data and informatics, and innovative plan designs.
While many insured patients with ASCVD are ostensibly “covered,” they often face high out-of-pocket costs, partly to ensure that they have “skin in the game.” An unintended consequence of this cost-sharing is that it indiscriminately limits use of all clinical services, including those that are both high-value and low-value. Beyond some preventive services, which are often exempt from deductibles, copays, and coinsurance, current health plan designs do not provide similar access to many of the evidence-based therapies known to reduce the risk of adverse cardiovascular events. Even for patients at highest risk, where use is likely to be most impactful, these therapies paradoxically remain subject to traditional non–value-based plan designs. As such, it is not the least bit surprising that patient adherence to recommended treatments is compromised and the promise of high-value care is lost for those who need it most.
Broad consensus was reached about the current state and the need for clinically nuanced plan designs as a replacement for today’s generally blunt approaches. There was felt to be a clear need for investment in how best to determine therapeutic value, both globally and for individuals. The fact that services understood to be lower value (i.e., interventions that lack strong evidence for use in a given patient) are often covered at the same level as those of higher value offers a potential means by which to offset costs associated with optimal care. This could be achieved if low-value services, such as those identified by the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, ceased to be covered. For example, decades of research have shown that pre-operative blood work and testing such as x-rays and electrocardiograms before low-risk surgeries provide minimal or no health benefits, contributing to the upwards of $340 billion per year that the United States spends on low-value care (4,5). Volume shifts from these services to high-value services could subsidize greater use of the diagnostic and therapeutic modalities known to benefit patients.
Time was also spent exploring the means by which varied data sources (e.g., clinically rich data sets, registries, genetic and other -omic data, administrative claims, and patient preferences) could be used to inform clinical practice. While such real-world data holds tremendous promise as a means to accelerate translation of clinical science to clinical practice, it was felt that that the benefits of these approaches may be limited because many patients are unable to afford recommended services. It was underscored, however, that technologies should be prioritized that make use of these data to help define dynamic, personalized plan designs that advance adherence to optimal care while simultaneously lessening the burden on caregivers and clinicians in undertaking unnecessary administrative tasks (e.g., prior authorization protocols).
The summit closed with discussion revolving around innovative means by which high-value services could be implemented without a commensurate increase in health care costs. Examples of adaptive plan designs were shared, which eliminate copays and coinsurance in high-risk patients receiving high-value care. These approaches are not associated with cost increases in the long-term, largely as a result of improved health outcomes and greater employee productivity. The adoption of such value-based care programs (that may incorporate downside risk for providers) cannot succeed without value-based insurance design that emphasizes out-of-pocket cost relief for patients adhering to guideline-directed care.
Attendees also acknowledged the critical role the American College of Cardiology can play in promulgating guidelines, providing tools for the translation of evidence to individualize patient care, and fostering relationships between academia, health systems, and industry. The College’s mission will be advanced by its engagement on the crucial topic of affordability of high-value services.
While the goals of access, affordability, and quality are laudable, they have not been sufficiently realized. Conflating access to insurance coverage with access to effective medical care has obfuscated the reality that many high-risk, “insured” patients remain unable to use critical, high-value services and treatments. As a consequence, health quality and equity continue to lag behind the underlying evidence. Ultimately, this results in avoidable medical costs being incurred, as the most vulnerable patients cannot avail themselves of evidence-based medical care. Rather than rationing care as many have suggested, perhaps creating dynamic, personalized insurance plan designs will help ensure access to low-cost, high-quality, and readily accessible health care.
- 2020 American College of Cardiology Foundation
- Kaiser Family Foundation
- eHealthInsurance Services Inc
- Mathews S.C.,
- Makary M.A.
- Fendrick A.M.
- Center for Value-Based Insurance Design