For many PPOs benefit design issues are either the responsibility of an employer/purchaser or another type of payers. The role of the PPO clinical leadership may be to bring best practice information on benefit design to the payer. There is increasing information that benefit design can support best practices in diabetes care management. For example, many payers are experimenting (or have results of effectiveness) with approaches that could include patient and provider incentives and new reimbursement models. Payer strategies around diabetes could include:

• Benefit incentives to encourage patients to adopt healthy lifestyles
• Reduced co-pays for essential diabetes-related services and medications
• Coverage of support services such as counseling by a pharmacist or diabetes educator

This section includes samples of web resources to share with payers:

National Business Coalition On Health “Promoting Consumerism Through Responsible Health Care Benefit Design” http://www.nbch.org/resources/
policypapers/health_benefit_design.pdf

Other useful resources with case studies on employer adoption of innovative benefit design include:

Issue Brief: Benefit Design Innovations: Implications for Consumer-Directed Health  Care” http://www.hschange.com/CONTENT/913/913.pdf

A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage http://www.businessgrouphealth.org/benefitstopics/topics/
purchasers/condition_specific.cfm

Center for Value Based Insurance Design 

http://www.sph.umich.edu/vbidcenter/index.htm

Talking Points for PPOs on Benefit Design for Diabetes

• Value based benefit design is an emerging approach designed to reduce costs or increase incentives for essential treatments for chronic disease, including diabetes. Pitney Bowes and other large employer have found better treatment compliance and outcomes with this approach.
  
  
• Pitney Bowes developed a model to improve appropriate use of medications by employees.  They lowered diabetes pharmacy costs and carefully monitored utilization, pharmacy, and disability costs.  Pharmacy costs went up, emergency room cost went down, and company health spending trend held at 8.1% during the experiment; benchmark companies increased 12-15%.   See article at:
  http://www.ajmc.com/files/articlefiles/A169_07april_Berger_
  S55toS58.pdf
  
  
• Studies show that when co-pays for essential medications (like diabetes drugs) go up, patient use, adherence, and persistence go down.  Emergency room use goes up when long term medication compliance goes down.  The net effect is no cost savings and poorer health outcomes.  See: http://content.nejm.org/cgi/content/abstract/354/22/2349