Year: 2020
Type: article
Abstract: We are at a critical juncture in value-based payment reform.In the decade since lawmakers created the Center for Medicare and Medicaid Innovation, we have seen the benefits of some new payment arrangements, but not others.To ensure that these results inform future policy agendas, policy makers can apply the principle of policy equipoise to existing evidence.1 Policy equipoise will help prioritize which payment models to test and when to do it using randomized designs to generate rigorous evidence.The concept of policy equipoise has a longstanding analogue in clinical medicine called clinical equipoise.For decades, clinical equipoise-true uncertainty about whether one treatment is better than another in a given situation-has guided clinical practice and research.2 Uncertainty about comparative efficacy allows practitioners to choose different treatments, pending additional research.In conducting those studies, equipoise serves as an ethical basis for deciding when to generate evidence using the gold standard of randomized clinical trials.Importantly, clinical equipoise evolves over time with medical evidence.For instance, decades ago, equivocality between percutaneous cardiac intervention and medical thrombolysis provided strong rationale for testing them head to head in the treatment of acute myocardial infarction.Percutaneous interventions have since emerged as the standard of care, and it would be unfathomable and unethical to compare the 2 treatments now, in 2020.Here, we use 2 prominent payment arrangements to illustrate the benefits of adapting the concept of policy equipoise to payment model evaluation. Pay For Performance: Absence of Policy EquipoiseFor decades, pay for performance (P4P) has been a cornerstone of payment reform.Numerous health care providers and insurers have used these arrangements to measure and financially reward (eg, via bonuses) or penalize (eg, via salary withholdings) providers based on performance on quality or utilization metrics.As a prominent example, Medicare continues to feature P4P at a national scale via the Merit-based Incentive Payment System (MIPS).Unfortunately, strong data supporting P4P are lacking.Under the Hospital Value-Based Purchasing Program, the payment arrangement did not improve a range of outcomes-an overall conclusion underscored by other inpatient and ambulatory programs.3,4 Though the effect of P4P can vary by context, the preponderance of data argues against the benefit of P4P in many settings.Given this absence of policy equipoise, policy makers can pursue several alternatives.First, they could test P4P in new settings where there is equipoise.For instance, there is less evidence for using P4P in specialty care, and more evaluations would clarify the benefit of P4P in this setting.Take cancer care as an example.Although early studies evaluating P4P in cancer care did not show expected results, a recent examination of the largest national cancer P4P program showed increased evidence-based prescribing.5 Second, policy makers could redesign P4P around the elements that are most likely to improve care.Currently, programs such as MIPS aggregate performance across a number of specific care processes-in the context of MIPS, across quality, electronic health record use, cost, and improvement activities.Future initiatives could involve creating programs that focus on specific elements that have not been well evaluated under the P4P construct, such as use of electronic health records to engage
Source: JAMA Health Forum
Language: Thai
Subfield: Economics and Econometrics
Domain: Social Sciences
Open Access status: hybrid
Estimated APC paid: $5,000
OpenAlex ID: W3096391350