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Financial incentives and vulnerable populations - will alternative payment models help or hurt?

K.E. Joynt Maddox
N Engl J Med

There is broad agreement that fee-for-service reimbursement does too little to encourage the provision of efficient, high-value care. Consequently, Medicare and other payers are increasingly moving toward alternative payment models (APMs), which disrupt the fee-for-service system by incorporating quality and cost targets into reimbursement. Examples include accountable care organizations (ACOs), which hold providers responsible for meeting annual cost and quality targets, and bundled payment programs, which hold them responsible for meeting cost and quality targets during 30-, 60-, or 90-day care episodes.

In the best-case scenario, clinicians will respond to APMs’ incentives by improving care coordination and integration, which may particularly benefit vulnerable populations with higher-than-average medical and social needs. On the other hand, there may be incentives for clinicians to avoid caring for these groups, who are at risk for high costs or poor outcomes in part because of factors beyond clinicians’ control. Understanding APMs’ potential consequences for vulnerable populations is critical if we wish to maximize benefits and reduce harms.

Joynt Maddox KE. Financial incentives and vulnerable populations - will alternative payment models help or hurt? N Engl J Med. 2018;378(11):977-979. PMID: 29539282. DOI: 10.1056/NEJMp1715455.

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