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Why A Massachusetts Health Plan Waives Out-of-Pocket Expenses For Chronic Conditions

by AHIP

January 4, 2018

Financial obstacles can make it hard to effectively manage chronic conditions. Patients and doctors in  Massachusetts have support, thanks to Neighborhood Health Plan’s (NHP) new comprehensive benefit design, called Care Complement. The program also offers affordable alternatives to opioids for chronic pain. NHP is a Massachusetts-based not-for-profit health plan with more than 380,000 members.


AHIP spoke with Dr. Anton Dodek, chief medical officer at NHP, to learn more about how Care Complement benefits its members.

What is the most innovative feature of your program?

Dr. Anton Dodek: We are proud that NHP is the first health plan in the nation to offer such a comprehensive set of benefits designed to proactively address the health needs of key populations. Our program waives out-of-pocket expenses for certain treatments relating to chronic conditions and chronic pain. By removing financial barriers and offering alternative methods for managing these conditions, NHP aims to encourage healthy behaviors and mitigate long-term complications.

We are confident that this innovative approach will also help employers to achieve cost savings, as complications from chronic conditions can be very expensive over time. With Care Complement, employers can deploy strategies to help improve overall health and quality of life for their employees, and minimize the incidence of these complications.

Can you share some of the ways that Care Complement helps members to manage health problems before they arise?

Dodek: Helping our members to stay healthy is the primary goal of this new program—especially those managing chronic conditions. To do so, the program offers no copays for 11 common prescription medications that treat conditions like high cholesterol, diabetes, high blood pressure, heart disease, and depression. In addition, the program waives cost sharing associated with cardiac rehabilitation therapy and screenings to prevent diabetes complications.

By eliminating cost sharing, we hope that members will be encouraged to work with their doctors to manage their conditions optimally and proactively, which will result in healthier outcomes in the long run.

What are Neighborhood Health Plan’s goals for the program? How does it make life easier for people with chronic health problems?

Dodek: The Care Complement program reflects NHP’s member-centric approach, and our efforts to give our members access to the right care at the right time. NHP set out to remove the barrier of out-of-pocket expenses for more effective patient care, so that patients and their doctors can think differently about how to better manage chronic conditions together, resulting in improved health outcomes.

In addition, Care Complement also addresses the ongoing opioid epidemic. We are waiving costs for comprehensive alternatives to opioids, which can lead to substance use disorders and which claim about 100 lives every month in Massachusetts alone. These alternatives include waiving cost sharing for medication-assisted therapies (MAT), as well as expenses for recovery coaches.

What are some alternative methods for managing pain that patients can access through Care Complement?

Dodek: The Care Complement program gives members who suffer from acute or chronic pain access to drug-free, pain management treatments at no out-of-pocket cost. This is especially important, because it gives chronic pain sufferers an effective and affordable alternative to powerful prescription drugs, including opioids. With Care Complement, we support doctors with the resources needed to help determine if their patients would benefit from alternative pain management treatments, such as physical therapy/occupational therapy sessions, chiropractic visits, and acupuncture visits.

How big of an impact do financial barriers have on treatment adherence and health outcomes?

Dodek: With certain chronic conditions, such as diabetes, there are often many recommended services to fully control the condition and reduce the risk of complications. For diabetes, these recommendations include an annual routine eye exam, diabetic education, and nutritional counseling. Each of these office visits typically require a co-payment from the member, and can create a barrier to receiving care. By eliminating the out-of-pocket costs for these appointments, we encourage healthy behaviors that can lead to better health outcomes.

In the short term, this could mean fewer hospital admissions and emergency room visits. In the long term, it could lead to less complications relating to these types of chronic illnesses.