In a commentary for New England Journal of Medicine, Karen E. Joynt Maddox, MD, MPH, of Washington University School of Medicine, outlines key principles for designing alternative payment models (APMs) to avoid harming vulnerable populations and penalizing the providers who care for them.
Alternative payment models (APMs) have the potential to improve care and control costs, but if they aren’t crafted carefully, they could cause harm for the most vulnerable populations, wrote Karen E. Joynt Maddox, MD, MPH, of Washington University School of Medicine, in a Perspective piece in New England Journal of Medicine.
The health industry is increasingly turning toward APMs for a way to include quality and cost targets in reimbursement, but the incentives of APMs may cause harm to patients in need by putting clinicians at risk for factors outside of their control.
“In the best-case scenario, clinicians will respond to APMs’ incentives by improving care coordination and integration,” Joynt Maddox wrote, but she also acknowledged that APMs provide incentives for clinicians to avoid caring for populations with higher-than-average medical and social needs. “Understanding APMs’ potential consequences for vulnerable populations is critical if we wish to maximize benefits and reduce harms.”
While the fee-for-service system provides little incentive to improve care for people with disabilities or people living in poverty, APMs can be used to focus attention on these groups, because “the highest-cost beneficiaries present the greatest opportunities for achieving savings,” Joynt Maddox explained.
However, results for APMs have been mixed, so far. The problem is that risk-adjustment methods still have trouble distinguishing poor-quality care from medical and social risk, such as poverty. In a graph, she showed that providers caring for more low-income patients were more likely to be penalized in the Hospital Readmission Reduction Program, the Hospital Value-Based Purchasing Program, the Hospital-Acquired Conditions Reduction Program, and the Physician Value-Based Payment Modifier. Only in the End-Stage Renal Disease Quality Incentive Program were the penalties similar.
Joynt Maddox outlined some key principles that policy makers can use to create payment models that avoid unnecessary harm to vulnerable populations and don’t penalize the providers who care for these populations:
“While some organizations may be driven by a moral imperative to address social determinants of health, financial incentives could persuade organizations that might not otherwise do so to focus on their neediest clients,” Joynt Maddox concluded. “However, if we introduce such incentives without close attention to how APMs affect providers who serve vulnerable populations, we risk causing more harm than good."
References
Joynt Maddox KE. Financial incentives and vulnerable populations—will alternative payment models help or hurt? N Engl J Med. 2018;378(11):977-979. doi: 10.1056/NEJMp1715455.
What We’re Reading: Abortion Privacy Rules; Alzheimer Drug Hurdles; Nursing Home Staffing Overhaul
April 23rd 2024New health privacy rules aim to protect patients and providers in an evolving abortion landscape; some physicians express concerns about efficacy, risks, and entrenched beliefs in treating Alzheimer disease; CMS addresses longstanding staffing deficits in nursing homes.
Read More
Oncology Onward: A Conversation With Thyme Care CEO and Cofounder Robin Shah
October 2nd 2023Robin Shah, CEO of Thyme Care, which he founded in 2020 with Bobby Green, MD, president and chief medical officer, joins hosts Emeline Aviki, MD, MBA, and Stephen Schleicher, MD, MBA, to discuss his evolution as an entrepreneur in oncology care innovation and his goal of positively changing how patients experience the cancer system.
Listen
Pegcetacoplan for PNH More Cost-Effective Than Anti-C5 Monoclonal Antibodies
April 18th 2024A cost-utility analysis conducted from the perspective of the Italian health system found that pegcetacoplan was more effective and less costly than 2 complement 5 (C5) inhibitors for the treatment of paroxysmal nocturnal hemoglobinuria (PNH).
Read More
Prices for care at hospital trauma centers vary across hospitals; drug shortages reached a record high during the first quarter of 2024; although 3 of the biggest makers of asthma inhalers pledged to cap out-of-pocket costs for some US patients at $35, these do not apply to daily inhalers used by the youngest kids with asthma.
Read More