Value-based insurance design, value-based purchasing, value-

based payment ? ?
&'()&*+,
value
)&,(,

volume-based outcome-based (P4P for outcomes/process) value-based

DRGCapitation: outcomes
/ outcomes

/
WHO ICER ($/DALY) 1-3 GDP per
Capita
NICE 20,000 30,000 per QALY
US$ 50,000-US$ 100,000/QALY
AU$ 42,000-AU$ 76,000/LYG
US$ 87,800/QALY

Value-based insurance Value-Based Payment Hospital Value-Based

design Modifier Purchasing
UM Mark Fendrick CMS CMS


2005 2015 2013




Medicare severity
diagnosis-related group
(MS-DRG) payments
2015 100 2% 2%
Total Performance
2016 10 Scores (TPS)value-based
2017 incentive payment
percentage
ACACMS 2%

(1) (1)
(ACSC)30
(25%)
(2) (20%)
(2)
(3) (30%)

a. (25%)
(
b. (5%)

(4)
COPD)
(25%)

ACOs, Bundled
payment, P4P [14]

Value-based insurance design()

1. Value-based insurance design (VBID) University of Michigan Mark
Fendrick 2001
benefit-based copay out of pocket



[1]
 2005 VBID one-size fits all
VBID (1)
(2)
[1]

2. VBID 0

3.
(1) 2010 Affordable Care Act
(HHS) VBID
cost-sharing
(2) 2013 CMS VBID

(3) 2014 Medicare Advantage Medicare
Medicaid plansMedigap plans [3]
(4) employee programs Connecticut, Oregon, Virginia, and New
Jersey .
4.
(1) 2013 Health Affairs 13 [4]
a. QualityVBID ( 3.0%)
out-of-pocket costs(copayment 0.5%-9.9%)
b. Medical expenditures 4
2 1
VBID 1
20.3%
c. Health service use (36), (5
), (13 )

(2) 2017 Health Affairs VBID [5]

Value-Based Payment Modifier()[6]
1. CMS Value-Based Payment Modifier
Value Modifier
(Medicare Physician Fee Schedule)
 2.
(1) (ACSC)30
(2) (
COPD)
3. 2015 100
(2013
2015 )
2016 10 2017
2018
Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and
Certified Registered Nurse Anesthetists

Hospital Value-Based Purchasing() )[7]

1. CMS 2013 Hospital Value-Based Purchasing Inpatient
Prospective Payment System (IPPS)
2.
(1) (Hospital Inpatient Quality Reporting (IQR)
Program)Hospital VBP Percentage Payment
Total Performance Scores (TPS)
(value-based incentive payment percentage)
Medicare fee-for-service
(2) Medicare severity diagnosis-related
group (MS-DRG) payments 2% 2%
Total Performance Scores (TPS)value-based incentive payment
percentage 2%
(3) [8]
a. (25%)
b. (20%)
c. (30%)
(25%)
(5%)
d. (25%)
 P4P, ACOs, Bundled payment
RAND 2014 [14]
1. VBP performance-based payment strategies

2. VBP models: (1) pay-for-performance programs, (2)
accountable care organizations (3) bundled payment programs.
3. (1) P4P
(2) ACOs 33
Benchmark (3)
Bundled payment

4.

P4P 49 P4P P4P


2
cost
HbA1c savings

mortality, readmission

initial hospitalizations

ACOs 6 ACOs
cost savings
Medicare FFSPioneer ACO
ACOs savings
CMS Pioneer ACO
FFS



 Bundled 3 value-based payment bundled
payment design payments (5%;
(59% to 100%) case $2,000)
19
bundled payment programs
10%
incentive formula

Reference
[1] Institute for health care policy & innovation, University of Michigan. VALUE-
BASED INSURANCE DESIGNRetrieved from
http://ihpi.umich.edu/initiatives/value-based-insurance-design Accessed at 2017/6/12
[2] Institute for health care policy & innovation, University of Michigan. (2015). Fed
to try out Value-Based Insurance DesignRetrieved from
http://ns.umich.edu/new/releases/23094-fed-to-try-out-value-based-insurance-design
Accessed at 2017/6/12
[3] Institute for health care policy & innovation, University of Michigan(2014).
Value-Based Insurance Design: Shifting the Health Care Cost Discussion from How
Much to How Well
[4] Lee, J. L., Maciejewski, M. L., Raju, S. S., Shrank, W. H., & Choudhry, N., K.
(2013). Value-based insurance design: quality improvement but no cost savings
Health Aff ;32(7):1251-1257
[5] Reed, M. E., Warton, E. M., Kim, E., Solomon, M. D., & Karter, A, J. (2017).
Value-Based Insurance Design Benefit Offsets Reductions In Medication Adherence
Associated With Switch To Deductible Plan. Health Aff ;36(3):516-523
[6] Centers for Medicare &Medicaid Services (CMS). (2017). Value-Based Payment
Modifier. Retrieved from https://www.cms.gov/medicare/medicare-fee-for-service-
payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html Accessed at
2017/6/12
[7] Centers for Medicare &Medicaid Services (CMS). (2017). Hospital Value-Based
Purchasing. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/hospital-value-based-
purchasing/index.html?redirect=/hospital-value-based-purchasing Accessed at
2017/6/13
[8] Centers for Medicare &Medicaid Services (CMS). (2017). Hospital Value-Based
Purchasing. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-
MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf
Accessed at 2017/6/13
[9] DRG 2017
. Retrieved from http://med.china.com.cn/archives/997.html Accessed at 2017/6/13
[10] Kevin W. Smith, Anupa Bir, Nikki L. B. Freeman, Benjamin C. Koethe, Julia
Cohen, and Timothy J. Day. (2017). Impact Of Health Care Delivery System
Innovations On Total Cost Of Care. Health Affairs, 36(3):509-515.
[11] Jeroen N. Strujis & Caroline A. Baan (2011). Integrating Care through Bundled
Payments Lessons from the Netherlands, New England Journal of Medicine,
364(11):990-1.
[12] Obama. B. (2016). United States health care reform progress to date and next
steps. The Journal of the American Medical Association; 316(5):525-532
[13] William C. Hsiao. (2011). State-Based Single-Payer Health Care A Solution
for the United States? New England Journal of Medicine; 364(13):1188-90.