Eliminate incentives that encourage underinvestment in low-income, high- risk patients
Health systems and providers that treat at-risk, low-income populations face many challenges in helping patients to achieve better health. These patients are often the sickest, poorest patients who have the most barriers to achieving good health. Emerging quality improvement policies and payment structures, such as accountable care organizations (ACOs), may unintentionally create perverse incentives for providers serving minority patients.vii At a time of health system transformation, when accommodation of new modes of financing and new delivery systems is taking place, some health systems may seek to minimize their financial risk. Monitoring for health system under-performance is required by Medicare and Medicaid managed care standards as well as by regulations recently published by the Centers for Medicare and Medicaid Services (CMS) for ACOs participating in Medicare’s shared savings program. Still, several problems may arise:
- The information needed to monitor health system performance in a comprehensive and timely fashion may not be available or accessible.
- Even when collected, the data may not be analyzed and actively used.
- Health systems may engage in selectively choosing to treat only those patients for whom providers can demonstrate the largest improvement with the least amount of effort. In doing so, providers would avoid serving the sickest and most costly populations – actions that could jeopardize access to quality health care for low-income, at-risk patients and serve to further exacerbate disparities in diabetes.
- Incentive systems that use "payment withholds" and thus payment penalties for providers who don't meet performance targets, may place providers who serve a significant number of vulnerable and complex patients at a significant and challenging financial disadvantage.
- Policies that penalize hospitals with high readmission rates may disproportionately punish at-risk communities, exert additional financial burdens on already stressed local health systems and could have the unintended consequence of increasing health disparities.