Elimination of the Out-of-Pocket Charge for Children's Primary Care Visits: An Application of Value-Based Insurance Design

ObjectiveTo evaluate the impact of a value-based insurance design for primary care among children.Study designA retrospective analysis of health care claims data on 25 950 children (<18 years of age) was conducted. Individuals were enrolled in a large employer's health plans when zero out-of-pocket cost for primary care physician visits was implemented. A rigorous propensity score matching process was used to generate a control group of equal size from a database of other employer-sponsored insurees. Multivariate difference-in-differences models estimated the effect of zero out-of-pocket cost on 21 health services and cost outcomes 24 months after intervention.ResultsZero out-of-pocket cost for primary care was associated with significant increases (P < .01) in primary care physician visits (+32 per 100 children), as well as decreases in emergency department (−5 per 100 children) and specialist physician visits (−12 per 100 children). The number of prescription drug fills also declined (−20 per 100 children), yet medication adherence for 3 chronic conditions was unaffected. The receipt of well child visits and 4 recommended vaccinations were all significantly (P < .05) greater under the new plan design feature. Employer costs for primary care increased significantly (P < .01) in association with greater utilization ($29 per child), but specialist visit costs declined (−$12 per child) and total health care costs per child did not exhibit a statistically significant increase.ConclusionThis novel application of value-based insurance design warrants broader deployment and assessment of its longer term outcomes. As with recommended preventive services, policymakers should consider exempting primary care from health insurance cost-sharing.