Is Value Based Purchasing getting it right?

Value Based Purchasing (VBP) is the program CMS uses to financially reward and punish hospitals based on the quality of the care the hospitals provide and their ability to cut costs.  Two stories from Kaiser Health News highlight the stakes involved for the hospitals and the details of the evaluation process.

Like many Pay for Performance (P4P) programs, the concerns with VBP lie less in the concept- no one is against better outcomes and accountability- and more in the details and assumptions contained in how quality is measured and addressed. 

A Health Affairs blog post by Woolhandler and Ariely, for example takes on the P4P assumption that the underling issue in the failure to provide better care is motivation:
“The quality improvement literature has pinpointed many causes of quality breeches in medical care: fatigue; poorly designed workflow and care systems; undue commercial influence; knowledge gaps; memory lapses; reliance on inappropriate heuristics; poor interpersonal skills and insufficient teamwork, to name just a few.  But ‘not trying’ is rarely cited.  Yet P4P implicitly blames lack of motivation for poor quality care.”
With the 2015 changes in the VBP program new questions arise about acuity and quality measurement.  An article in Modern Health Care highlights this concern:

“’If a patient has a lot of complex problems, current methodologies could penalize physicians for getting involved in the care,’ said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a Pittsburgh-based not-for-profit focused on the quality and affordability of U.S. healthcare services. The approach does not distinguish between an over-treated patient and one who legitimately needs more care. As a result, physicians may be penalized if they take on sicker patients, he said (emphasis added).”

The fear of course is that the professional responsibility of the doctor could be compromised by incentives that could potentially lead to gaming the system.

There seems to be at least two issues with VBP and P4P in health care.  The first is a technical question:  Do the measurements used accurately measure what they claim to measure?  The same Modern Health Care article, for example, question the validity of some of the VBP metrics.

But the second issue is somewhat more complicated:  How does measuring quality affect the nature of the healthcare delivery system,  what assumptions do different P4P programs and VBP bring to the analysis of the health care crisis, and finally how do these different P4P programs and VBP challenge and enlarge the professional responsibly of the doctor?

These are not technical issues at all, but rather critical questions about the role of doctors in a changing health care delivery system.