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For decades, policy makers have struggled to improve care and control costs for medically complex and socially vulnerable populations, particularly individuals dually eligible for Medicare and Medicaid. Dual-eligible beneficiaries experience high rates of chronic illness, disability, and unmet social needs, and they account for a disproportionate share of Medicare and Medicaid spending. Despite sustained efforts to shift payment from volume to value, performance-based models have often yielded uneven results among providers serving these populations.
In Medicare’s Accountable Care Organization (ACO) programs, organizations caring for higher proportions of racial and ethnic minority beneficiaries and socially vulnerable patients have faced greater challenges achieving savings and sustaining participation. These patterns highlight a central dilemma in value-based payment: without careful risk adjustment and benchmarking, models designed to reward quality of care and efficiency may disadvantage providers serving communities with concentrated social risk.