{"subscriber":false,"subscribedOffers":{}} Medicare Payment Incentives, Medicaid, And More | Health Affairs

From the Editor-In-Chief

Medicare Payment Incentives, Medicaid, And More

PUBLISHED:Free Accesshttps://doi.org/10.1377/hlthaff.2020.01540


As we continue to publish final versions of coronavirus disease 2019 (COVID-19) articles released earlier online, we also extend scholarship on other topics including payment incentives in Medicare, evolving Medicaid policy, and the roles of pharmaceuticals in the health system.

Medicare Payment

The following three papers are part of our Practice of Medicine series, which receives support from the Physicians Foundation. In 2017, the first year of Medicare’s Merit-based Incentive Payment System (MIPS), clinicians were evaluated across three categories: quality, advancing care information, and clinical process improvement activities. Nate Apathy and Jordan Everson find that 90 percent of clinicians easily met the low performance standards, but performance might not be as strong as it appears, as almost half of clinicians did not participate in at least one of the three categories.

Kenton Johnston and coauthors analyze 2019 MIPS data and find that clinicians serving populations with higher levels of social risk had lower overall MIPS scores and were more likely to receive a negative payment adjustment. The authors find that significant score and payment gaps remain even with the program’s Complex Payment Bonus, which is designed to offset the consequences of serving a higher-risk population.

Alexander Sandhu and coauthors focus on the portion of MIPS that evaluates clinicians on the basis of the risk-adjusted cost of each care episode. The existing MIPS risk-adjustment mechanism focuses exclusively on clinical conditions. The authors model various approaches to incorporating social risk but find that “adjusting for these social risk factors did not materially affect clinicians’ measure performance on cost.”

Medicare’s Bundled Payments for Care Improvement initiative sets target prices for hospitals for selected services and provides financial rewards to hospitals that deliver those services at a lower cost. Nicholas Berlin and colleagues analyze hospital performance and find that higher target prices were correlated with higher levels of voluntary hospital participation. They also find that reversion to the mean, a statistical phenomenon that has nothing to do with actual cost or quality, accounted for between one-third and two-thirds of the cost reductions reported by hospitals that entered the program with above-average costs.

Analyzing data related to patients with end-stage renal disease who moved from fee-for-service Medicare into a Medicare Advantage Special Needs Plan, Brian Powers and coauthors find that the move “was associated with lower all-cause mortality and utilization across the care continuum (acute, postacute, and home health).”


Jamie Daw and coauthors analyze survey data and find that low-income women in states that expanded Medicaid experienced a 10.1-percentage-point decrease in insurance churn across the preconception, delivery, and postpartum time points relative to those in nonexpansion states.

From June 2018 to April 2019 Arkansas required nonexempt Medicaid participants ages 30–49 to work or engage in work-related activities twenty hours a week to maintain coverage. Using telephone survey data, Benjamin Sommers and coauthors find significant confusion among the target population regarding program rules and “coverage losses associated with important negative impacts on medical debt and affordability of care without improving employment.”


Timothy Anderson and coauthors report that US teaching hospitals received nonresearch payments totaling $832 million in 2018 from biomedical companies. Although the majority of the value of payments was related to royalties, there were also “substantial payments for gifts and education, which raises concerns for institutional conflicts of interest.”

Christopher Auld and coauthors find that requiring physicians to receive prior authorization for OxyContin prescriptions in Manitoba, Canada, significantly decreased OxyContin prescriptions, especially for opioid-naive patients, with only modest substitution of other opioids.

Pre-exposure prophylaxis (PrEP) is highly effective in reducing HIV transmission. Stephen Bonett and colleagues find that the use of PrEP relative to underlying epidemiological need is “negatively associated with [laws that criminalize intentional HIV transmission] and positively associated with nondiscrimination laws for sexual and gender minorities.”

Between 1990 and 2015 US life expectancy increased by 3.3 years. Jason Buxbaum and coauthors find that innovations in public health and pharmaceuticals accounted for 44 percent and 35 percent of the increase, respectively. For specific causes of death, improvements related to ischemic heart disease, lung cancer, and stroke account for the greatest increases in life expectancy, whereas accidental poisoning or overdose and dementia, including Alzheimer disease, account for the greatest decrements.

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