Fair point about KPI gaming, and it's a real problem in value-based care. But the fix in Issue #3 (commercial reference pricing at 200% of Medicare) is a price cap, not a quality incentive structure, so it doesn't directly create the risk-avoidance problem you're describing.
Montana Medicaid has used 200% Medicare reference pricing since 2015. Published evaluations haven't shown measurable quality deterioration or patient-selection effects in that program. The RAND Round 5.1 study underlying the savings estimate controlled for case mix, so it's comparing equivalent procedures at equivalent acuity. Risk adjustment is still genuinely hard at the individual level, and the concern is well-founded for P4P schemes. It's a separate question from whether commercial payers should pay 254% of Medicare rates for the same surgery at the same hospital.
Medicare Advantage is a clusterfuck from start to finish (denying more claims than Medicare while also costing taxpayers more), precisely because it tries to micro-manage KPIs.
If you want to look at them done correctly, look at the FEP program. High-level KPIs that are difficult to game (without actually improving service & outcomes) tied to financial incentivizes.
We have already seen it with things like Medicare Advantage plans doing sign-up meetings on the second floor of buildings without elevators etc.