Opportunities to Address Health Disparities in Performance-Based Accountability and Payment Programs

Disparities in health care and health outcomes are a pressing policy problem in the United States. Recent attention has focused on the role of social risk factors in disparities in health care quality and the ramifications of not accounting for social risk factors in value-based payment and accountability initiatives. In this issue of JAMA Health Forum, Meyers and colleagues report findings from a study in which they constructed simulated star ratings for Medicare Advantage health plans (ie, contracts). These simulated star ratings were based on 22 Medicare Advantage quality measures estimated for subgroups of enrollees in each contract, specifically those who were Black, Hispanic, or White individuals, and those with low or high socioeconomic status (SES). The authors found lower simulated star ratings associated with low SES among Black and Hispanic enrollees compared with high SES and White enrollees. As in prior studies, they found variation in performance and disparities by the sociodemographic composition of contract enrollees. The authors also report estimated contract-level associations in performance across subgroups that likely understate true associations, being attenuated by the limited reliability of some measurements.

The study by Meyers and colleagues adds to the growing body of studies describing quality-performance disparities for individuals with greater burdens of social risk factors. The authors found evidence of disparities in 1 of the largest quality-incentive programs in the United States, consistent with prior findings reported by Joynt and colleagues in 9 federal performance-based payment systems. The evidence prompts consideration of potential actions to address disparities in the context of performance accountability and value-based payment programs. We propose a 4-part approach to aligning measurement, reporting, and incentive payments with equity goals in such programs. Each component addresses a different facet of this pressing problem, and their complementary effects may offset the limitations that each component might have in isolation.