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Value-Based Insurance: Extra Fee For Imaging?

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What would happen to your business if health-insurance plans started adding a $100 surcharge for such “overused” services as MRI and other advanced imaging?

Some employer-provided insurance plans are moving to a so-called value-based design. The idea is that consumers should pay less in out-of-pocket costs for the medical services that are most valuable for their health but pay more for procedures that are deemed to be overused or of lesser value for their health.

In a Kaiser Health News article, Michelle Andrews gives the example of the health-insurance plans provided to Oregon public-education employees and their dependents. The plans offer free preventive care and low-cost or free generic drugs for managing chronic conditions. But, as of October, plan participants are being charged more for services that the state Educators Benefit Board has determined are overused or “preference sensitive” to patient choice.

So patients now pay an extra $100 for advanced imaging tests and sleep studies. They pay an extra $500 for spinal surgery, knee and shoulder arthroscopy, hip and knee replacement, and upper endoscopy exams.

Regarding free preventive services, Niteesh Choudhry, MD, PhD, an assistant professor at Harvard Medical School, says, “It’s all in keeping with the idea that some things are so valuable to health care that there should be no barriers to their use.” Dr. Choudhry is the lead author of two articles in the November issue of Health Affairs, which is devoted to the topic of “designing insurance to improve value in health care.”

Those “free” services may actually save insurers money. Programs to head off obesity or heart disease, for example, might be much cheaper than treating the health complications that can arise from such conditions.

But to really reduce costs, some experts also advise financial disincentives for medical services that are considered to have lower value. And consumers might not be too upset, says Marge Ginsburg, executive director of the Center for Healthcare Decisions, a nonprofit organization in Sacramento, California, that studies how consumers make health-care choices.

They’re open to “the idea that, yes, it’s still available to you, but it’s going to cost you more,” she says. Outright denials of service under the plan are another story. “People are really unhappy if you draw a line in the sand,” she says.

(A personal note: As someone who has undergone surgery on each knee, I certainly had a “preference” not to be cut into. But if I wanted to resume my normal activities, I didn’t have a choice. Though I might not have been thrilled about it, I would have paid the extra $500. Or more.)

Related seminar: The Business of Radiology


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