general pay-for- performance plans, hoping that these would improve the quality of care and outcomes of their study populations, or to propose global payment and shared savings plans, believing that these plans ’ indirect incentives would support the care management and preventive measures that could improve care and reduce disparities in health outcomes. The linkage of payment reform to dis- parities reduction was generally not strong. Most applicants aimed to im- prove the care and outcomes of a vulner- able population without specifically studying reduction in disparities, per- haps because most of their patients were from that vulnerable population. Thus, the Finding Answers national program office subsequently provided technical assistance to grantees about examining disparities explicitly and refining inter- ventions to address the root causes of these disparities. Most applicants did not address how they would try to optimize intrinsic and extrinsic motivation. Much of the exist- ing evidence cautions that using exter- nal motivators (such as financial incen- tives) alone is unlikely to be the best way to reduce disparities, as only a lim- ited number of processes of care and outcomes can be incentivized, and negative unintended consequences are possible. 22 – 24 In particular, concerns have been raised about how pay-for- performance could lead to gaming of financial incentives, distraction from important quality-of-care goals that are difficult to measure, a reduction in in- trinsic motivation to reduce disparities, decreased provider and staff morale, and harm to social relations and team- work. 25 It may be important to reinforce intrinsic motivation while implement- ing financial incentives, removing dis- incentives to achieving health equity, or both. Clearly, payment systems will need to be designed very carefully to maximize positive effects and prevent unintended negative consequences. It is probably necessary to tailor ap- proaches to specific situations and people. 7,8,26 Payment reform might also need to be viewed within the context of enabling ( “ can do ” ) and motivating ( “ will do ” ) factors. Enabling factors include having the resources necessary to reduce health disparities. 25 Motivating factors include the desire to reduce disparities. The types of payment reform that address enabling factors (for example, mecha- nisms to fund community health work- ers and intensive care management — services either not reimbursed or under- reimbursed in traditional fee-for-service payment) might differ from the ones that address the motivation of individu- al providers. For example, early experi- ence with safety-net ACOs suggests that systems need capital and financial flexi- bility up front to make the delivery sys- tem innovations necessary to improve care and reduce costs. 15 Moreover, it will be important to clarify which combina- tions of payment and care delivery re- form are likely to be most effective and synergistic.
- Fall '19
- Med Care