New Value-Based Insurance Plan Helps Consumers Who Use Healthcare the Most

As the healthcare industry struggles to address rising costs and increased enrollment of people with chronic conditions in high-deductible health plans, attention is turning to value-based benefit design options. Altarum has released its outline for a new value-based insurance design model that it will test at pilot sites across the country.

Altarum created the Medical Episode Spending Allowance (MESA) plan with support from the Robert Wood Johnson Foundation. The model is well suited to people with chronic diseases or serious health conditions who use the most healthcare. In comparison, the use of high-deductible health plans with health savings accounts has helped lower the cost of care, but can hurt patients with chronic conditions who need more care.

“Employers and consumers are looking for alternatives to increasingly unaffordable health coverage, and finding a solution that works is essential,” François de Brantes, vice president and director of Altarum’s Center for Payment Innovation, said in a statement. “That’s what our MESA Blueprint is all about. By turning the high deductible health plan on its head, the MESA plan significantly reduces the potential for people with on-going illnesses from foregoing needed care.”

MESA is based on a reference pricing model, which sets a price for services and anything above that price is paid for by the consumer. According to Altarum, the model encourages consumers to seek out high-value care and providers. Members in a MESA plan only pay out of pocket when their cost of care exceeds the allowance for an episode of care, and when they use network providers in risk-based models of care, they could potentially have no out-of-pocket costs.

Through MESA, consumers will also have access to tools to help them make financially savvy choices with tools to research procedures, identify providers in their area, and view cost and quality ratings for providers. MESA also identifies Potentially Avoidable Complications, which are a significant driver of cost and a reliable indicator of quality, according to the MESA blueprint.

A. Mark Fendrick, MD, director of the University of Michigan Center for Value-Based Insurance Design and co-editor-in-chief of The American Journal of Managed Care^®, explained that MESA, and health insurance innovations like it, align consumer and provider incentives on quality and cost.

“Strategies that reduce the patients’ out-of-pocket cost burden for clinically indicated services provided by high performing clinicians are necessary and important strategies to achieve the Triple Aim,” Fendrick said.

MESA will be tested at select pilot sites throughout the United States, although none have been chosen yet. Sites that are interested in becoming pilots should have current engagement in and familiarity with alternative payment models, according to Altarum.

“MESA provides a comprehensive plan that marries payment reform with benefits reform, provider engagement with consumer engagement, and physician accountability for costs of care with patient accountability for managing their health and costs of care,” said Emmy Ganos, program officer at the Robert Wood Johnson Foundation. “Many of the concepts aren’t new—they are tried and tested—but their combination is, quite simply, a better solution.”