The cost-effectiveness of value-based insurance design initiatives in managing cardiometabolic diseases: a systematic review

Healthcare systems are increasingly seeking cost-effective strategies to optimise value for money. Value-Based Insurance Design (VBID) presents a promising approach by aligning financial incentives with service value. By reducing out-of-pocket payments (OOP) for high-value care, VBID aims to improve efficiency, but its cost-effectiveness remains uncertain. Given the rising economic burden of cardiometabolic diseases, this systematic review evaluates VBID's cost-effectiveness from multiple perspectives. The analysis included a qualitative assessment of effectiveness and costs, as well as a descriptive evaluation of adherence elasticity to explore how variations in copayment levels influenced patient behaviour. Thirty studies met the inclusion criteria: nine focused on high-value services, others targeted specific populations or diseases, and 12 evaluated VBID initiatives in combination with disease management programmes. Findings indicate that whilst VBID generally improves patient adherence and reduces financial burdens, adherence sensitivity to price variations remains modest. Although insurers often incur additional pharmaceutical expenditures in anticipation of clinical cost-offsets, these trade-offs do not always materialise, resulting in uncertainty regarding the intervention's fiscal impact. Although these initiatives improve patient adherence, these gains do not consistently translate into better clinical outcomes, which are the key drivers through which VBID achieves substantial cost reductions.