What do you get when you combine today’s limited comparative effectiveness research with aggressive value-based insurance design? A risky and expensive proposition for patients, that’s what. I’m a fan of the value-based insurance design concept, which rewards patients and healthcare providers for using the most effective care, even if it’s more expensive. But when private insurers use it to fleece patients in a bait-and-switch scheme, it’s another matter entirely.

First, let’s take a look at the current state of comparative effectiveness research. Disruptive Women in Healthcare has a succinct post on the subject, summarizing a recent JAMA analysis of comparative effectiveness research (CER) studies. Did you know that only 32% of evaluated medication studies met the basic criteria for CER? Worse, only 19% focused on safety (efficacy was the overwhelming focus) and a mere 2% included consideration of cost-effectiveness.

But it gets worse. Not even 50% of the studies used active comparisons to current therapies. Of those studies, less than 25% used non-inferiority analysis to allow apples-to-apples comparison of different therapies. Simply put, is the therapy under consideration at least as effective as what is already on the market? Seems a no-brainer to ask that question of any new therapy, but apparently the giant cash machine that masquerades as US medical innovation doesn’t have a brain.

Now, take this disappointing state of affairs and combine it with an enterprising private health insurer. What results is a value-based insurance design plan that puts patients’ physical and financial wellbeing at risk. Regence Blue Cross Blue Shield in Portland, OR, has designed a plan that provides free care to effectively manage common diseases, such as diabetes, asthma, depression, and heart disease – that’s the good part. The bad is doubled deductibles and co-pays, and paying up to half the cost of an ER visit or hospitalization (up to $1,500 individual/$3,000 family), for general emergencies, cardiac bypass surgery or stent placement, hysterectomies, hip or knee replacements, and other expensive medical care.

Think about that for a moment. BCBS wants you, the patient, to think really hard before seeking emergency services. It also wants you to question your cardiologist about the need for heart surgery. It’s your life on the line, and BCBS throws an expensive wrench into your decision-making process. Isn’t there enough of that in our current healthcare mess? Worse, this plan is intended for steel mill workers – not upper income earners. BCBS chose these procedures because of perceived overuse. But instead of incentivizing physicians to use them less, BCBS is punishing patients who agree (as they usually do) to their physician’s treatment plan.

I’m all for offering patients reduced cost or free services to most effectively manage their conditions. A typical annual bill for asthma medications can be $10,000, and diabetes and heart medications are just as expensive. Still, managing these diseases is much cheaper than treating them as they progress. When it comes to managing overused tests and treatments, though, modify provider behavior first. Pay physicians less for doing low-value procedures.

Remember our current CER limitations? Public outcry during health reform efforts was all about not expanding CER because of the potential “death panel” effect from the federal government. Well, guess what? Private insurers aren’t waiting for CER confirmation in high-cost areas. They don’t need to, because in the current healthcare market patients have few if any insurance choices. Without either a public plan or effective CER funding, patients are left to bear the risk of their own “death panels” – otherwise known as their personal budgets.

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