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What is Engaged Benefit Design?

Engaged Benefit Design (EBD) is a new approach to healthcare benefits that provides resources and incentives for patients and their healthcare providers to make healthcare decisions based on patient values and medical evidence.

Coverage based on value (not cost)

For many chronic and preventive conditions where there is a best way to take care of the problem, there is no co-pay when you receive that care (No co-pay, high-value).  These screenings and treatments have strong scientific evidence to support their use. 

Some treatments may be appropriate for people in certain circumstances, but not others.  They are often expensive and require careful consideration.  Such treatments have an additional surcharge (Costs more, learn more).  The surcharge is intended to serve as a “speed bump” in the decision-making process sending a message to slow down, learn about all of your options, and then make a decision with your caregiver.  These services were chosen based on strong scientific evidence and with the scrutiny of Colorado medical experts.  

Free educational material is available to encourage consideration of alternatives before making a final decision. You may be eligible for a gift card or other incentive just for learning more about your options. 

Shared Decision-Making

Shared decision-making starts with a discussion between you and your healthcare provider about your health, your treatment options, the benefits and risks of those options, and your personal preferences and values.  It is the act of reaching an agreement together on the best strategy for treatment.  EBD’s goal is to create the conditions necessary to enable shared decision-making with your provider. 

To this end, your provider may write you a prescription for a Patient Decision Aid (PDA).  PDAs are evidence-based tools that make the options, benefits, and risks for medical decisions clearer.  They help patients consider their personal values and set the foundation for patients to make an informed choice in partnership with their clinician and loved ones.  PDAs are available in DVD and booklet format for you to review with important loved ones as you consider your treatment options.

Patient education is such an important part of the EBD approach that you may be eligible for a gift card or reward upon completion of a PDA when it is prescribed by your provider.

Click on the medical treatments below for more information.

No co-pay, high-value

Immunizations:

Immunizations have changed the face of disease. Infections like polio, diphtheria, whooping cough, influenza, and tetanus once caused an immense amount of suffering and death before vaccines for them were available. Vaccines can have side effects but they are usually mild and severe side effects are very rare. It is now clear that vaccines are not associated with autism. We now have safe and effective vaccines for many other diseases as well, including certain pneumonias, chicken pox, shingles, bacterial meningitis and a host of others. Vaccines are most effective when almost everyone is immunized. If low numbers of people are vaccinated, diseases can spread more easily and cause greater harm. It is clear that a neighborhood, a town, a city or the whole country will remain healthier if as many people receive vaccines as possible. Because of this, your health insurance covers the costs of approved vaccines at no cost.

 

Prenatal Care

Having a baby is one of the most important events in anyone’s life. Having a healthy baby is what every expectant parent hopes for. Many problems in pregnancy and childbirth can be prevented or treated when recognized early pregnancy. Because so many problems occurring in pregnancy can be prevented and because a healthy start in life affects health for many years to come, your insurance covers many services known to improve outcomes without payment when they are delivered.

 

 

Dental Care

Dental care is not typically covered by health insurance. Dental health, however, is important to overall heath. Some simple measures can have a great impact on health and quality of life including regular dental check-ups and fluoride treatments. Insurance which uses Engaged Benefits covers these simple services without cost because they are so important to overall health.

 

 

Contraception

Unintended pregnancies are frequent in the US accounting for a large portion of both live births and abortions. Planning a pregnancy can help a new family account for their finances and other obligations to assure adequate resources are available to grow their family. Avoiding unwanted pregnancies can reduce the number of abortions and unwanted children as well as reduce medical costs. The most effective forms of birth control (IUDs, contraceptive injections and implants) are covered without cost because they can help families plan how to grow, reduce the financial and emotional costs of unwanted pregnancy and save medical resources.

 

Hypertension

High blood pressure is a leading cause for a number of serious health problems including eye and kidney disease, heart attack and stroke. It causes little in the way of symptoms till complications occur and is sometimes call a silent killer. Fortunately, hypertension is treatable and complications can be prevented. Effective medications are available and changes in diet and lifestyle can contribute to improving your blood pressure. Insurance built with Engaged Benefit Design covers some doctor visits and medications as well as appropriate blood testing without cost. It also covers educational materials to help you understand and control your blood pressure.

If you have asthma, you know it can cause significant breathing problems. Asthma is a common cause for emergency room visits and hospitalizations for both children and adults that can often be prevented with proper use of medications. Insurance using Engaged Benefit Design covers services and medications for asthma to help you stay healthy and to avoid complications of asthma. It also covers educational resources to help you understand your asthma and to take control of it.

Diabetes

Diabetes is a major cause of disabling complications and death. It can lead to kidney failure, blindness, painful nerve problems, heart attacks, stroke and amputations. People with poorly controlled diabetes die earlier and with more complications than those whose diabetes is well controlled. Controlling diabetes well also saves money. Diabetic control is facilitated by regular visits with a provider, regular monitoring and use of medicines that are proven to reduce complications. Because diabetes is so common, can cause such severe health problems and because there are proven ways to control it, health insurance designed with Engaged Benefit Design covers a specific set of medications, supplies and services to help people with diabetes to stay healthier. It also provides access to educational materials to help understand and manage diabetes.

Treatment for coronary artery disease

Coronary artery disease is the most common cause of death in our country. It is the cause of heart attacks and can lead to a substantial reduction in heart function. It can also be managed with medication, diet and lifestyle changes. Some medicines have been shown to significantly reduce the likelihood of future heart attack and death, even in people that have already suffered a heart attack. Because coronary artery disease is so common and has a major impact on health, insurance that uses Engaged Benefit Design covers office visits, medication and labs. Because diet and lifestyle are so important, it also covers educational materials to help people with coronary artery disease live longer, healthier lives.

 

Heart Failure

Heart failure does not mean the heart has failed but that it is weakened or otherwise affected in a way that decreases it’s ability to pump blood as effectively as it should.

The symptoms of heart failure are shortness of breath, fatigue, edema (swelling – usually in the legs), fluid in the lungs, rapid heartbeat, restlessness and anxiety, decreased ability to do daily activities and difficulty breathing when laying flat. It is also a common cause for hospitalization. Heart failure is treated with medications and lifestyle changes and can be managed effectively in most cases. Insurance that uses Engaged Benefit Design covers some office visits, medications and testing to keep you healthy. It also covers educational materials to help you understand and manage heart failure.

 

 

Depression

Depression is very common in the United States. It affects about 10% of people and causes difficulties with work life, home life and relationships. It robs many people of the opportunity to live a full satisfying life. It also interferes with the ability to manage difficulties including medical problems like diabetes and asthma. Fortunately, it is usually treatable and insurance that uses Engaged Benefit
Design covers some provider visits and medications to help those with depression get it under control. It also covers educational materials to help understand and manage depression.

Costs more, learn more

Weight Loss Surgery

Obesity is a growing problem in our country and around the world. It can lead to a number of health problems including diabetes, high blood pressure, premature arthritis, breathing problems during sleep and early death. If you are obese, you know how hard it can be to lose weight. You may be considering bariatric surgery, which has been shown to facilitate weight loss and improve obesity related health problems. But this surgery is life changing and can have profound effects on your lifestyle for the rest of your life. It also carries risks that are different from other methods of weight loss. Before making a decision about whether bariatric surgery makes sense for you, learn about all the risks as well as the benefits and be sure you understand what other options are available. Then discuss your preferences with your doctor to decide which is best for you.

 

Surgery for enlarged prostate

Most men, as they age, develop some enlargement of the prostate gland. It surrounds the tube that drains the bladder and can cause difficulties with urination including frequent trips to the bathroom overnight, trouble starting the flow of urine and persistent dribbling after urination. Surgical treatment for this condition has been available for years and works well to relieve symptoms but can have troubling side effects as well. There are several different surgical and non-surgical treatments now available for prostate enlargement. Before having surgery for this problem, it makes sense to understand all the choices you have, their risks and benefits and to make the decision together with your doctor to be sure the treatment you select is right for you.

 

 

Knee arthroscopy for osteoarthritis

When you have arthritis of the knee, and its associated pain, arthroscopy may sound like a good idea. It is a procedure that is performed frequently in the United States. During the operation, three small holes are made in the skin around the knee and small instruments are used to smooth the cartilage and wash out debris. Studies looking closely at the outcomes, however, don’t show evidence for benefit. One study even included "sham" surgery in which small incisions were made to mimic the real surgery. There was no greater improvement with arthroscopy than with the small incisions alone. Because there is no evidence that this operation is helpful, it is not covered by this insurance.

Knee replacement surgery

Knee replacement surgery is effective at relieving pain from arthritis and has a success rate of nearly 90% in doing so. It may have significant complications including blood clots, infections, heart problems and death but these are very infrequent. There are, however, many non-surgical treatments for arthritis of the knee and there are other operations that may be more appropriate for some people. Because deciding on knee replacement surgery is not always straightforward and because different approaches may be right for different people, there is a higher co-payment for this operation so that people are encouraged to learn more and find the treatment that is right for them.

Hip replacement surgery

Hip replacement is an effective treatment for pain caused by arthritis of the hip and 90% of people have most or all of their pain relieved. As with all operations it carries risks. People with hip replacements may need to limit some of their activities, especially running and jumping. Infrequently, the new hip can become dislocated. There are many other treatments for arthritis of the hip and, while it is very effective for many people, it may not be the right choice for others. Because hip replacement surgery involves a large operation with some risk and because there are other alternatives for treatments, your insurance requires a higher co-payment to encourage you to learn more and make the decision that is best for you. It also covers use of a DVD and booklet that can provide you with the information you need to know.

 

Hysterectomy for bleeding or fibroids

Hysterectomies are one of the most common operations performed and are frequently done for abnormal bleeding or for fibroids. 1 in 4 women will develop fibroids that sometimes cause significant symptoms. Uterine bleeding can have many causes, some of which are serious and require surgical treatment, but most do not. Whether surgery is appropriate in a particular circumstance depends on many things including the goals and feeling of the woman considering it. For both of these conditions, there is more than one type of surgery and there are non-surgical treatments as well. To receive the treatment that is right for you, learn more about your options and take part with your doctor in making the right decision for you.

 

MRI for low back pain

When you have pain in the low back, it may seem reasonable to get an MRI to see what is going on inside.But there can be problems using MRI scans when there is no evidence of spinal cord or nerve involvement causing your pain.In 100 people with no pain at all, MRI scans find “abnormalities” in 30 of them.If you have back pain and an MRI shows an abnormality, the odds are it is unrelated to the pain.If the scan is done to decide whether surgery should be done, it can result in unnecessary operations which can lead to complications and may not improve your symptoms.If you have low back pain, it is worth understanding all the facts before you have an MRI scan.

Screening CT scans

It has been popular to undergo CT Scans to screen for illness that has no symptoms in an effort to identify cancers and other problems at an early stage when they are more treatable.  This makes sense at first glance but it can also create problems.  First, CT scans can expose you to a significant amount of radiation.  No one knows exactly how much harm this may cause, but it is likely that over time, CT scans done too frequently will cause cancer in some people.  There is new evidence that CT scans of the lungs can reduce deaths from lung cancer.  But the study did not answer questions about how much harm may be caused. Finding non-cancer changes in the lungs can lead to invasive testing like biopsies that can cause harm.  It will be a while before we know if CT screening for lung cancer results in more harm or benefit.  Because there is a real risk to make things worse rather than better, insurance using Engaged Health Benefit Design does not cover screening CT scans.  This may change as more studies are available that answer questions about both harms and benefits.

Coronary CT angiography outside the emergency room

Coronary CT angiography uses a CT scan done after putting x-ray dye into a vein.  It produces a very detailed picture of the heart and the coronary arteries in 3 dimensions.  Because the test is not invasive (other than putting an IV in), and because it is very sensitive in finding coronary artery disease, it has been used to test people who have no symptoms but may be at risk for having blocked arteries to the heart.  Sounds good, but in a study of 1,000 people who had the test and 1,000 who did not, the main difference was in how many had further testing and invasive treatment like angioplasty or bypass surgery. There was no difference in how many had heart attacks over the following 18 months.  The only place where there is clear evidence that the test is useful is in the emergency room to evaluate people who are having chest pain that may be due to heart disease.  That is why insurance using Engaged Health Benefit Design only covers the test in the emergency room.

Coronary Calcium Scoring

Coronary Calcium Scoring uses a CT scanner to identify calcium in the coronary arteries.  If a lot of calcium is present, there is a higher likelihood that there are narrowings in the arteries, but the test does not tell you where they are.  It has been used to help identify people who are more likely to have coronary artery disease so they can be treated more aggressively.  Studies, however, have not found that the test is useful in changing treatment since almost everyone with a high score also has other risk factors for coronary artery disease like diabetes, high blood pressure or high cholesterol.  Because we already know these problems should be treated, and because of the exposure to radiation and the cost of the test, insurance using Engaged Health Benefit Design does not cover it.

 

 

 

 

Surgery for Carotid Artery Disease

 

Stroke is a common cause of disability and death. The best option you have to avoid it is to eat right, treat your blood pressure if it is high and keep your cholesterol down. Strokes have many causes and one of them is disease in the carotid arteries, which carry blood from the heart to the brain. For most people with a narrowing of the carotid artery that is not causing symptoms, a surgical operation to remove the narrowing carries a risk and has little benefit. If the narrowing is severe and has caused symptoms, surgery to remove the narrowing (carotid endarterectomy) reduces the risk of stroke. However, if the narrowing has not caused any symptoms the risk of stroke is not very high. Although this low risk can be lowered further by surgery, the surgery itself can sometimes cause a stroke or death. The overall effect of surgery is a small benefit.Increased narrowing, advanced age, male sex and recent transient ischemic attack (TIA) or stroke are associated with increasing benefit from surgery. Patients with lesser degrees of narrowing were harmed.Because making a decision about having this surgery is complex, insurance using Engaged Benefit Design increases the cost of the surgery and provides educational material to encourage you to learn about the risks and benefits and to have a discussion with your doctor about what is right for you.

Invasive treatments for angina (pain from clogged heart arteries)

Coronary artery disease is a common and serious problem in the United States.  It kills more people here than anything else. It can cause heart attacks, heart failure and chest pain when you exert yourself (angina). Over the years, doctors have developed procedures to open narrowed and blocked arteries that supply life-giving blood to the heart muscle. If you are having a heart attack, opening the problem blood vessel with a small balloon (angioplasty) can save your life and preserve heart function. Angioplasty is also commonly used to treat chest pain (angina) caused by narrowed arteries supplying the heart and to open blood vessels that have already caused a heart attack. Interestingly, research has clearly shown that this procedure does nothing to prolong life or prevent heart attacks unless you are having one at the time or have especially severe blockages. It controls angina in a few more people than medication does (though most peoples’ pain is controlled with medication alone), but is invasive and can cause complications. It is also very expensive. In spite of this knowledge, most people who get angioplasty feel that it will prevent heart attacks and lengthen their life even though evidence from well-done research lets us know it won’t. For many people, angioplasty involves risks, discomfort and high expense that do not improve their symptoms or improve their long-term outlook for good health. The more you know, the better your choices will be.

 

 

Lumbar discectomy

Herniated discs in the lower spine may be associated with pain in some people and none in others.If a disc is causing pain that extends into the leg, often called sciatica, there are several ways to treat it.These range from simple exercises and medication, to injections into the spine, to spine surgery.Most people get better without surgery and it’s risks, but some people may get better faster with surgery.It is good to understand all the treatments, their risks and benefits and what may work best for you.Different treatments may make more sense for different people even if the problem is the same.

Surgery for lumbar spinal stenosis

Spinal stenosis refers to a condition in which the canal that the spinal nerves to the leg pass through becomes narrowed.This can irritate the nerves and cause pain extending into the legs.Having spinal stenosis on an MRI scan does not always mean it is causing your symptoms.If your symptoms are related to spinal stenosis, they may resolve more quickly with surgery, but there are risks and 1 in 5 people do not benefit.As time goes by, the difference in improvement between people who have surgery and those who don’t becomes smaller because symptoms frequently improve without an operation.Knowing all the facts will help you decide what will work best for you.

Vertebroplasty and Kyphoplasty

Vertebroplasty and Kyphoplasty are procedures used when a vertebra collapses. Vertebrae are the bones that make up the spine and can collapse as the result of an injury or from osteoporosis. This is called a vertebral compression fracture. The procedure involves placing a needle into the bone cavity and re-expanding it with a special balloon. The space is then filled with medical cement to keep the vertebra at it’s normal height. Some studies suggest that the procedure may reduce pain but most do not. Even in studies that suggest it is effective in pain control, the difference between those who had the procedure and those that didn’t is almost gone by one year. Because these procedures have risks and little evidence that they are helpful, they are not covered by this insurance.

Endoscopy for gastroesophageal reflux

Heartburn (also called gastroesophageal reflux disease or GERD) is very common in the US. Maybe it is our diet or the level of stress most of us live with. Some medications can aggravate it. If you are obese, drink alcohol or coffee or if you smoke, you are more likely to have symptoms. Endoscopy (esophagogastroduodenoscopy or EGD) is often used to look at the junction of the esophagus or swallowing tube and the stomach. There is no evidence that this is needed unless you have tried maximum medication therapy and have failed. Because heartburn of the usual severity can be treated quite effectively without an EGD, it costs more with this insurance.