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Association of practice-level social and medical risk with performance in the Medicare Physician Value-Based Payment Modifier Program

Institute Faculty Scholar, Karen E. Joynt Maddox, MD, MPH, led a project published in JAMA aimed at determining whether there is an association between the social and medical risk of patients treated at physician practices and their performance in Medicare’s Physician Value-Based Payment Modifier (VM) Program.

The Physician VM program is the first national mandatory pay-for-performance program for physician practices. Under this program, physician practices receive penalties or bonuses based on the quality and costs of care they provide. However, there had been no prior studies examining practice factors associated with performance in this program.  Because many have been concerned that the VM program might have unintended consequences for practice serving the most socially and medically at-risk patients, the study sought to answer three questions:

  • What are the patient, practice, and clinician characteristics of large physician practices that serve a disproportionate share of medically or socially high-risk patients?
  • How did these high-risk practices perform on quality and cost performance metrics included in the Physician VM Program?
  • What implications did any performance differences have on payment?

The study found that practices that served more socially high-risk patients had lower quality of care and lower costs, while those practices serving more medically high-risk patients had lower quality and higher costs for care. Such patterns were associated with fewer bonuses and more penalties for both groups of high-risk practices.

If these performance patterns persist through the growth of other value-based payment programs, such as the Merit-based Incentive Payment System (MIPS), practices that disproportionately serve high-risk patients may be at risk of receiving more financial penalties.

Moving forward, it will be critical to learn more about what underlies these patterns and find ways to address them, in order to ensure that these programs help, rather than hurt, the quality of care of medically underserved populations.

Read the full investigation outline published on August 1, 2017 by JAMA Network.