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Invited Commentary
January 16, 2019

Accounting for Disparities in the Evaluation of Medicare Alternative Payment Plans: Lessons in Inequity

Author Affiliations
  • 1Yale School of Medicine, New Haven, Connecticut
  • 2Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 3Aga Khan University Medical College, Karachi, Pakistan
  • 4Deputy Editor, JAMA Surgery
JAMA Surg. 2019;154(5):400-401. doi:10.1001/jamasurg.2018.5243

In an effort to increase the value of care, the US Centers for Medicare and Medicaid Services (CMS) committed to changing 50% of its Medicare reimbursement to alternative payment plans by 2018. One strategy included the introduction of outcome-based pay-for-performance. As of fiscal year 2018 (October 2017), the approach included metrics for complications and mortality (Hospital Value-Based Purchasing Program and Hospital Acquired Condition Reduction Program) and readmissions (Hospital Readmissions Reduction Program [HRRP]). Within the HRRP, payments to hospitals are determined based on performance on 6 condition-specific metrics.1 Four address internal medicine hospitalizations for acute myocardial infarction, heart failure, pneumonia, and chronic obstructive pulmonary disease, while 2 address subspecialty surgical care for coronary artery bypass graft surgery and elective total hip/knee arthroplasty.1 Since the program’s inception in 2012, the HRRP has been criticized for unfairly penalizing hospitals that serve a higher proportion of racial/ethnic minority patients2,3 and dual-eligible patients,4 including those presenting to safety-net hospitals (SNHs).5 Recognition of this issue led to the announcement that in fiscal year 2019 (October 2018), the HRRP would begin evaluating hospitals within stratified peer groups defined based on the quintile of dual-eligible patients that a hospital treats.1

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