<P> Present pay - for - performance systems measure performance based on specified clinical measurements, such as reductions in glycohemoglobin (HbA1c) for patients with diabetes . Healthcare providers who are monitored by such limited criteria have a powerful incentive to deselect (dismiss or refuse to accept) patients whose outcome measures fall below the quality standard and therefore worsen the provider's assessment . Patients with low health literacy, inadequate financial resources to afford expensive medications or treatments, and ethnic groups traditionally subject to healthcare inequities may also be deselected by providers seeking improved performance measures . </P> <P> In Minnesota, Minnesota Community Measurement ranks providers on multiple categories such as patient experience and total cost of care and provides public reporting online to inform consumers . The service is designed to help purchasers make better decisions when seeking care and to provide feedback to providers for areas that need improvement . </P>

When did the concept of value based purchasing start