Patients with disabilities or living in poverty have poorer health outcomes and higher costs. Theoretically, alternative payment models (APMs) could encourage providers to better coordinate care for vulnerable populations and improve their outcomes—but they also have the potential to harm these patients, according to Karen Joynt Maddox, MD, MPH, assistant professor of medicine at Washington University in St. Louis.

Writing in the New England Journal of Medicine, Maddox said clinicians may have incentives in APMs to avoid high-risk patients thanks to risk adjustment which doesn’t separate lower quality care from socioeconomic risk.

“As a result, hospitals or clinics with a high proportion of poor patients may lose money under APMs through no fault of their own,” Maddox wrote. “Particularly in programs with a high level of downside financial risk, there is a powerful incentive for clinicians to avoid providing care for high-risk patients, which could have meaningful consequences for access to care.”

Some APMs, however, have shown evidence of helping this population. In the Medicare Shared Savings Program, for example, organizations which earned shared savings were more likely to serve a higher proportion of disabled or dual-eligible patients.

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