Healthcare Executives are all Talking about Value Based Purchasing. Who is Talking About Its Ethics?!

Pay-For-Performance (P4P) provider reimbursement schemes came to prominence in the 1990s as health systems, insurers, and payors sought to establish clinician incentives to improve patient health outcomes and cut costs. P4P typically entailed direct enhancements to provider reimbursement. However, these incentives fell short of achieving robust, well-rounded improvements in patient health outcomes for many reasons: the narrow scope of some measures distracted from other important processes, achieving good process results frequently did not translate to improved outcomes, and gaming behavior among health systems often improved only documentation.
Using a novel literature search strategy focusing on the number of annual publications, we found that P4P is being replaced by value-based purchasing (VBP.) The goal of VBP is to address the shortcomings in classical P4P by providing reimbursement incentives and penalties that seek to align financial incentives with intrinsic motivators of enhancing patient outcomes. VBP financially rewards providers collectively rather than individually.
Conversations about reimbursement models must include their potential to exacerbate inequities. As a corollary of multi-generational and geographic health inequities, medically complex populations are profoundly affected by their sociopolitical drivers of health. Whereas P4P historically ignored these drivers, VBP aims for more holistic clinical measurements. Yet, ensuring a just accounting currently requires greater documentation and administrative overhead, for the very providers and populations who can least afford it.
This presentation explores several moral differences between P4P and VBP. We conclude that VBP shows promise for better protecting geographic and socioeconomic equity.

David Satin, MD – Associate Professor, Family Medicine, University of Minnesota Medical School; Mo Hicks, BA – Medical Student, General, University of Minnesota Medical School; Alex Conway, MD, MPH – Resident Physician, Family Medicine, Hillsboro Medical Center