When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average.

To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients.

Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics.

Fee-for-service Medicare.

Random 20% sample of beneficiaries.

Hospitalization for ambulatory care–sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality.

No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores.

Observational design and administrative data.

The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities.

The Laura and John Arnold Foundation and National Institute on Aging.

当风险调整不足且激励措施薄弱时，按绩效付费计划（例如由Medicare和Medicaid Services中心实施的基于价值的支付修改器（Value Modifier [VM]））可能会导致医疗保健差距扩大而无法改善平均表现。

评估VM暴露与质量和支出指标上的绩效之间的关联，并评估针对其他患者特征进行调整对服务于高风险患者和低风险患者的绩效差异的影响。

根据执业规模，逐步不连续性分析和2014年Medicare索赔利用VM的逐步使用，以估算与100名或100名以上的临床医生接受完整VM激励措施（奖励和罚款）相关的实践绩效差异。有10名或10名以上临床医生的做法受到部分奖励（仅限奖金）。对2015年的索赔进行了重复分析，以评估与第二年接触超过100名或更多临床医生的门槛相关的绩效差异。在标准Medicare调整与针对其他患者特征的调整之后，评估了为高风险患者和低风险患者提供服务的实践之间的性能差异。

收费医疗保险。

随机抽取20％的受益人样本。

因非卧床护理敏感病情住院，全天30天再入院，医疗保险支出和死亡率。

在任何一年中，在实践规模与质量或支出指标的绩效之间的关系中，在10位或更多或100位或100位以上的临床医生的阈值上均未发现统计学上的显着不连续性。在医疗补助患者的最高和最低四分位数与分层疾病类别评分中，针对其他患者特征的调整将性能差异缩小了9.2％至67.9％。

观测设计和行政数据。

VM与计划措施的性能差异无关。为更高风险的患者和为更低风险的患者提供服务的实践之间的绩效差异受到其他调整的影响很大，这表明Medicare的按绩效付费计划可能会加剧医疗保健差异。

劳拉和约翰·阿诺德基金会和国家老龄研究所。