Current HVBP Value Weights Do Not Reflect Preferences of Medicare Beneficiaries


Using data from a wide-ranging survey of Medicare enrollees, investigators found that using value weights from participants would have a negative impact on smaller, rural hospitals.

The Center for Medicare and Medicaid Services’ (CMS) approach of weighting the 4 quality domains in the Hospital Value-Based Purchasing (HVBP) program do not reflect the preferences of Medicare beneficiaries and disadvantaged smaller, lower-volume, rural hospitals, according to the authors of a new study published in the Journal of the American Medical Association.

Responses from the participants of the study were collected between March 15 and 29 in 2022, with the target population including preidentified panelists who confirmed they were enrolled in Medicare; researchers used an online survey format that included a discrete choice experiment (DCE) to estimate the weights of beneficiary values, the study authors wrote.

Survey respondents were given a choice between 2 hospitals based on domains of quality from the HVBP and asked to imagine they needed to choose a hospital to receive care. They were then asked to indicate which hospital they preferred, with their choices being assessed thereafter, according to the study authors.

In total, 1835 eligible Medicare beneficiaries were invited to participate, and 1025 individuals completed the survey. Due to the sampling strategy of the study, there was a higher proportion of beneficiaries who identified as Black or African-American, Asian, and Hispanic, the researchers wrote.

The results of the study showed that clinical outcomes received the highest weight (49%; coefficient range, -1.89 to 1.36), followed by safety (22%; coefficient range, -0.88 to 0.58), patient experience (21%; coefficient range, -0.75 to 0.65), and Medicare spending per patient (8%; coefficient range, -0.24 to 0.24).

After linking payment and performance data for 2752 hospitals and more than $80 billion in payments, the study authors found that using beneficiary value weights would result in a reallocation of $86 billion.

Further, the investigators found that nearly double the amount of hospitals would see a payment reduction instead of a payment increase when utilizing beneficiary value weights (1830 vs 922 hospitals), yet the net decrease in incentive was smaller (mean [SD], −$46,978 [$71,211]; median [IQR], −$24,628 [−$53,507 to −$9562]) than the comparable increase (mean [SD], $93,243 [$190,654]; median [IQR], $35,358 [$9906 to $97,348]).

Additionally, the hospitals that saw a net reduction were more likely to be in less populated areas, have fewer hospital beds and admissions, and serve less-complex-patients, the investigators explained. “Our results suggest that beneficiaries do not value all domains equally and, instead, place greater weight on clinical outcomes, primarily at the expense of efficiency,” the study authors wrote.

Notably, the researchers considered whether hospitals respond to incentives to improve quality of care based on patient values; a 2020 review found that the HVBP program led to limited improvements in quality of care, perhaps due to the incentives offered to hospitals being too small to make a difference in a hospital’s decisions.

The investigators discussed how utilizing value weights is a way perspectives of beneficiary values can be incorporated into the design of value-based programs, noting that they could also inform decisions about the quality domains and the selection of measures used to evaluate them.

Despite these positives, there are concerns that the HVBP program could potentially establish or exacerbate disparities in care. The researchers discussed whether establishing health equity as an explicit objective of value-based payment reforms and tying equity to payments would help remedy this problem.

“Our findings suggest that using beneficiary value weights has important implications from an equity perspective and would disadvantage smaller, lower volume, nonteaching, non–safety-net hospitals located in more deprived areas that serve less-complex patients (eg, rural hospitals),” the study authors wrote.


Trenaman L, Harrison M, Hoch J S. Medicare beneficiaries’ perspectives on the quality of hospital care and their implications for value-based payment. JAMA Netw Open.2023;6(6):e2319047. doi:10.1001/jamanetworkopen.2023.19047

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