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Improving Value without Compromising Access for Vulnerable Patients

The rise in health-care costs has contributed to the push for value-based health-care (VBHC) reform. A recent JBJS-AOA Critical Issues article by Lin et al. examines the benefits of VBHC initiatives—and explores unintended consequences of reform, with a focus on joint arthroplasty. The authors discuss potential strategies to promote innovation and improve value without compromising access for vulnerable patients.  

Does Value-Based Care Threaten Joint Arthroplasty Access for Vulnerable Patient Populations? AOA Critical Issues 

From the article: 

“…there are many positive attributes of the VBHC initiatives. These programs align providers and health-care institutions, promoting innovation and proactive resource investment in factors that are important to achieve excellent outcomes, while decreasing or eliminating unnecessary and inefficient care. However, a major concern related to VBHC initiatives is that another strategy, referred to as either ‘cherry picking’ or ‘lemon dropping,’ allows providers and institutions to improve outcomes and/or decrease costs by shifting the population they care for to healthier patients and those with higher socioeconomic status and greater social support, while restricting access for less healthy patients and patients with lower socioeconomic status and less social support1.” 

The authors note that VBHC reform also puts pressure on health-care institutions to decrease access for higher-risk patients for purposes of fiscal survival.  

Improving preoperative patient optimization for better outcomes is part of the current landscape. However, Lin et al. point out that there are socioeconomic factors and medical comorbidities that are not modifiable. They say that even some conditions that are thought to be modifiable, such as obesity, are often not successfully modified. And the authors note that, even prior to VBHC initiatives, factors such as race and ethnicity were demonstrated to be associated with disparities in TJA utilization. 

Potential Solutions 

The authors outline possible solutions for maintaining the positives of VBHC while protecting vulnerable populations. Among these: 

  • Developing payment models based on clinical quality outcomes that are risk-adjusted relative to medical and socioeconomic risk factors.  
  • Rewarding surgeons for showing improvement “or sustained excellence in quality measures related to surgical protocols with appropriate risk adjustment.” In total joint arthroplasty, complications related to infection, dislocation, and periprosthetic fracture would be a focus. 
  • Adjusting payment to health-care facilities to support the appropriate discharge needs of patients, such as for elderly patients who may require greater resources following joint arthroplasty. 
  • Publicly committing to equity in patient care and obtaining training regarding unconscious bias. 
  • Advancing the use and effectiveness of personalized shared decision-making tools. These tools, note the authors, can help address bias in the sharing of medical information, promote patient engagement, and improve outcomes and health literacy of disadvantaged patients. 

The article by Lin et al. is available at

  1. Humbyrd CJ. The Ethics of Bundled Payments in Total Joint Replacement: “Cherry Picking” and “Lemon Dropping.” J Clin Ethics. 2018 Spring;29(1):62-8.

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