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Value-based Medicare payments augment health care disparities instead of improving them, JAMA article contends

Feb 25, 2018

Although paying physicians based on the quality of the care they provide rather than on a fee-for-service basis seems like it would help eliminate disparities in care, it may instead be exacerbating those disparities, according to an article published online Feb. 21 in JAMA.

The author, Rita Rubin, points out that the problem, according to health policy researchers, is twofold: there’s a lack of evidence about the best methods for evaluating care quality, and the measures currently being used do not take into consideration differences in patients’ socioeconomic and health status. As a result, quality scores can be skewed in favor of physician practices that serve patients who have higher incomes, higher levels of education and less-complex health issues.
Consequently, physicians who care for poorer and sicker patients are penalized—even if the care they provide is of equivalent quality.

Dr. J. Michael McWilliams, a professor of health care policy at Harvard Medical School, said this might lead some physician practices to cherry-pick patients who try harder to stay healthy and therefore have better outcomes, making it seem as though their physicians provide better care.

Dr. Williams also expressed concern that pay-for-performance incentives might discourage large health care organizations from opening or acquiring practices in economically disadvantaged areas.

Rubin cited multiple studies to support the argument that Medicare’s performance-based payment programs are having the unintended effect of disproportionately penalizing practices that serve low-income patients, making it more difficult for them to serve their patients well.

She also wrote that adjusting for practices’ case-mix might minimize the problem but acknowledged that it would be “easier said than done.” And, Dr. Donald Berwick, a former administrator of the Centers for Medicare and Medicaid Services (CMS), said providers could still game the system by manipulating the data—for example, by coding patient visits as more complex than they really were.

When the Merit-based Incentive Payment System begins adjusting payments in 2020 based on the proportion of a practice’s patients who are eligible for Medicaid, as well as Medicare, it will be a step in the right direction, according to Melinda Buntin, who chairs the Department of Health Policy at Vanderbilt University’s School of Medicine.

Dr. Berwick agreed that pay-for-performance strategies “on the whole may well have aggravated disparities [in care],” and said that no matter what approach Medicare takes toward paying physicians, it cannot be counted on to eliminate those disparities.


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