Are value-based payments and equity at odds with one another? Early evidence on APM participation certainly seemed so, with greater participation in affluent areas. In what may be one of the first examples of an APM improving equity, we found that Medicare's CJR program actually mitigated disparities in post-surgical complications after hip/knee replacement for dual eligibles (vs. non-duals). This is welcome news with the upcoming TEAM model in 2026 that will once again scale bundles nationally on a mandatory basis. Important context however is that this does not suggest VBP or bundles are uniformly good for equity. For example, there is some evidence that hospitals in CJR were more likely to avoid surgery on Black beneficiaries. So we must interpret this new promising evidence on reduced SES outcome disparities in the context of the broader evidence. Austin Kilaru Joshua M. Liao The Parity Center https://lnkd.in/etMGw9-M
Robert Bowman
4mo
Last November, University of Pittsburgh and Harvard researchers published a major study in Annals of Internal Medicine showing that a Medicare pay-for-performance program did not improve quality or reduce cost and, to make matters worse, it actually penalized doctors for caring for the poorest and sickest patients because their “quality scores” suffered. In December, Ankur Gupta and colleagues reported that a Medicare program that rewards and punishes hospitals based on arbitrary limits on the number of hospital admissions of heart failure patients may have increased death rates. reading Kip Sullivan is a good idea because of numerous MedPAC references https://www.statnews.com/2018/01/30/pay-for-performance-doctors-hospitals/
Robert Bowman
4mo
The evidence against performance based designs Readmissions top penalties 14% for the remaining fewer hospitals in 2621 counties packed with disparities and poor outcomes inherently plus drivers of those outcomes as compared to 5% average and 3% for urban hospitals Star Ratings - even a cursory review of the 1 star hospitals indicates that they are paid less and facing numerous higher complexity areas including populations inherently lower in outcomes ACO Shared Savings - dumping populations with higher costs and worst outcomes is important - and excluding certain physicians is a good mechanism. Kaiser excluded mental health patients and has been fined for this situation that will improve costs and outcomes
Robert Horne
4mo
Can you define what you mean by equity in this instance? I haven't heard Dually-Eligible people (as a legal category under federal law) used in reference to equity. Also seeing different uses of it in the comments below. A bit confused but nothing insight can't fix. Your post raises questions as to how this might impact a whole range of policy-related laws (ex. Medicare and Medicaid) at the federal and state level hence the question. Thank you in advance. Hope you are well.
Robert Bowman
4mo
These articles at The Health Care Blog are particularly relevant to past MedPAC irregularities Readmissions Obsessive Measurement Disorder - great review! Medical Home failed all 3 times Readmissions harming heart patients ACOs and insurance - Anyone paying attention to the research knew even before 2012 that ACOs wouldn’t cut costs for a general population (as opposed to a small slice of the population that is very sick). The Physician Group Practice Demonstration, which was widely seen as the first test of the ACO concept, raised Medicare spending. According to the final evaluation of the demonstration, the ten participating ACOs raised Medicare’s costs by 1.2 percent over the five years the demonstration ran (2005-2010), and it might have been worse if the ACOs hadn’t upcoded. [2] This failure to cut costs occurred despite the fact that the ten participating “group practices”/ACOs were very experienced in managing risk. Sloppy Risk Adjustment and Attribution guarantee that MACRA won't work The Mess that is MACRA Poor ACO study articles https://thehealthcareblog.com/blog/tag/kip-sullivan/
Julia Doherty
3mo
Important research. But sadly not surprising If a model is not designed with equity as a priority outcome.
Chief Medical Officer - Medicare, Aetna/CVS Health | Faculty, Yale Med + Kellogg | Physician Executive, Health Innovator + Social Entrepreneur | Investor, Advisor + Board Director
4moI would argue, from the brick and mortar world, that full-risk value models have been very helpful in advancing equity in two domains: A) access in marginalized communities (https://www.modernhealthcare.com/opinion/oak-street-health-value-based-healthcare-providers-primary-care-access) and B) clinical outcomes (see Humana's recent work at Academy health). The trick is that we need to mover these from the exception to the rule...