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Experts urge shift from punitive penalties to proactive patient-safety payment models; patients propose an "earn-back" design
Summary
Experts at PTAC argued that current safety-oriented payment programs are largely retrospective and punitive and called for payment approaches that reward organizational safety capability. Patient advocates proposed a technology-enabled "earn-back" model that pairs patient-reported safety measures with performance-based reserves that providers can reclaim by showing improvement.
Dr. John Hollingsworth, a urologist and chief quality officer at UF Health, told the Physician-Focused Payment Model Technical Advisory Committee that the patient-safety field has moved from blaming individuals to recognizing system failures, but progress has stalled and many harms remain poorly captured by existing measures. "The absence of measurable harm is not necessarily the presence of safety," Hollingsworth said, arguing for more investment in leading indicators such as predictive surveillance, closed-loop communication, and diagnostic-safety infrastructure.
Dr. Jennifer Weiler, speaking from a provider perspective, outlined trade-offs in metric selection, the difficulty of consistent data capture (for example, inconsistent definitions for surgical-site infection) and a range of incentive mechanisms already in use—from gainsharing and grants to pay-for-reporting. She warned of predictable strategic responses to incentives, including patient selection and gaming, and emphasized the value of paying for data access and for concrete actions that improve care delivery.
Jimmy Blanton, who oversees quality and program improvement for Texas Medicaid and CHIP Services, described state-level efforts that pair measurement with directed payments. Texas, Blanton said, tracks potentially preventable complications and readmissions using software (Solventum, formerly 3M), operates a hospital quality-based payment program, and requires managed care organizations to move larger shares of reimbursement into alternate payment models. "We are one of the larger Medicaid programs, serving about 4.5 million people," he said, urging attention to risk adjustment and technical assistance for smaller and rural providers.
Patient advocate Sue Sheridan proposed a patient-centered "pivot/earn-back" model that draws on patient-reported outcome and experience measures (PROMs/PREMs) alongside clinical and cost domains. Sheridan described a two-sided approach in which a portion of payment is withheld into a reserve when benchmarks are missed and can be "earned back" if a provider demonstrates measurable safety improvements. The concept relies on automated patient reporting, AI-enabled triage, and existing levers such as quality improvement organizations and AHRQ tools to support systems seeking to recover withheld funds.
During Q&A, committee members debated whether patient safety requires a standalone mandatory payment model or whether safety elements should be embedded across existing APMs. Panelists noted that mandatory or all‑payer approaches reduce selection bias but are more difficult to implement at scale; others recommended a stepwise approach—embed safety measures in current models while piloting more ambitious programs. Across speakers there was strong agreement that data and interoperability gaps are a core barrier: better EHR/HIE connectivity, use of national sharing frameworks, and investments in measurement infrastructure were described as prerequisites for any model that aims to detect and prevent longitudinal safety threats.
The session ended with multiple presenters urging the committee to prioritize investments that build organizational capability and continuous learning systems rather than relying solely on marginal withholds or punitive penalties. Sheridan closed by urging committee members not to abandon the goal of improving patient safety, calling for courage and sustained action.
