Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program
By Lena M. Chen, MD, MS; Arnold M. Epstein, MD, MA5; E. John Orav, PhD; et al
JAMA, August 1, 2017
From the Introduction
Ambulatory pay-for-performance programs provide incentives for physician practices to improve the care they deliver. The Medicare Physician Value-Based Payment Modifier (PVBM) Program, which launched in 2015, will be the largest mandatory pay-for-performance program for physicians when fully phased in. Under this program, physician practices receive penalties or bonuses (from −1% to 10% of Medicare payments in 2015) based on the quality and costs of care. The PVBM Program serves as a precursor to the Medicare Quality Payment Program, which will launch in 2019, apply to clinicians and practices, and measure performance across a broader array of metrics. Clinicians eligible in the PVBM Program include physicians, nurse practitioners, and physician assistants.
Despite the growth of ambulatory pay-for-performance programs, there is concern about unintended consequences, including disproportionately penalizing practices that care for complex patients. Prior studies have shown that patients with high levels of medical risk as well as patients with social risk factors, such as those dually enrolled in Medicare and Medicaid, have worse quality outcomes. Thus, it is possible that physician practices that care for these high-risk populations will fare poorly in pay-for-performance programs.
Question: Was there an association between the social or medical risk of patients treated at physician practices and performance during the first year of the Medicare Physician Value-Based Payment Modifier Program?
Findings: Practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for high-risk practices.
Meaning: As value-based payment programs continue to increase in size and scope, practices that disproportionately serve high-risk patients may be at particular risk of receiving financial penalties.
By Don McCanne, M.D.
Rather than being smart and actually improving our health care system by enacting a single payer program, the bureaucrats and policy community have fixated on magical solutions that supposedly would improve quality and reduce costs by paying for value instead of volume. One of these programs is the Medicare Physician Value-Based Payment Modifier Program (PVBM).
Under PVBM, “Practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for high-risk practices.”
We are penalizing physicians who take care of more socially high-risk patients and more medically high-risk patients!
Value instead of volume? Our greatest problem with volume is that we are not giving enough care to people who are uninsured or under-insured. And value? Experience in Canada has shown that bringing in patients who need care tends to displace some of the care that is of little value.
So let’s get smart. Let’s enact and implement a single payer national health program. That would bring us much more value than these rinky-dink programs such as PVBM.
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