The concept of outcomes-based contracting today is far removed from the original intent, and, with a growing emphasis on disincentives for consumer non-achievement, has the chance to be a very real boomerang in the next 18 months. The implementation of the Affordable Care Act, in which accountable care vies for attention with the health insurance marketplace rollout, will complicate the problem and cause higher costs and lower health engagement.

When value-based benefit design (VBBD) was gaining speed in 2008, the darling of the discussions was the incentive. Pioneers large and small were highlighting their successes in engaging chronic care patients for better adherence to clinical protocols (exams, tests, refills) and the total cost of care for newly adherent patients helped to bend the cost curve down. Lost in much of the storytelling was the earlier focus on identifying the risk to the covered population, achieved mostly through health risk assessments that led to reconfiguring benefit designs and communication to achieve the outcomes of better care and cost control. VBBD, then, was an incentive-based component for health engagement, getting non-compliant beneficiaries to use appropriate care resources and stick to the plan.

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