Antiretroviral Drug Recommendations for HIV Treatment and Prevention

Abstract

In Reply We agree with Dr Donzelli that reforming health care payment is an essential step in reducing the delivery of lowvalue services. This is core to our argument around the economic forces that guide the de-adoption of low-value care. 1 Within this realm of economic levers, Donzelli makes an important distinction between pay-for-performance and payfor-health models, noting some inconsistent results from the former. Although there is evidence that targeted payment policies can reduce the provision of low-value care, 2 we agree that more holistic value-based payment models are needed. Our understanding of how to best pay for health continues to evolve and requires precise measurement of and alignment around the definition of health. One approach raised by Donzelli is to move toward risk-adjusted capitated payments, an approach already used at scale within the Medicare Advantage program. There is also some evidence to suggest that other global payment structures influence the provision of low-value services. 3 As the adoption of value-based payment continues to grow, it will be important to rigorously evaluate the impact on low-value care.Donzelli states that "low-value care for patients and society can be high value for the producers, hospitals, and physicians selling it." This important point is sometimes left unacknowledged and identifies trade-offs that must be addressed when seeking widespread de-adoption of low-value care. Here, value-based payment can also play an important role by allocating health care spending to the highest-value services and offsetting potential financial losses. In our own efforts, we have found that value-based payment redirects attention to highvalue services, reallocates savings to increase benefits and reduce out-of-pocket costs for patients, and can actually increase payments to primary care providers. 4 Donzelli also notes that "health authorities should…issue firm recommendations highlighting the health risks and costs of low-value services" instead of simply noting that there is insufficient evidence to cover a service. We agree that when evidence is conclusive, it is essential to clearly communicate health risks and costs. Unfortunately, there is often truly insufficient evidence on the value of many common clinical services. 5 Increased attention to building an evidence base around low-value care is a prerequisite for the effective use of downstream economic levers. 1