Pay-for-virtue: an option to improve pay-for-performance?jep_1722 894..898 Stephen Buetow PhD 1 and Vikki Entwistle PhD 2 1 Associate Professor, Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand 2 Professor, Social Dimensions of Health Institute, University of Dundee, Dundee, UK Keywords health care, incentive, motivation, physician incentive plans, quality assurance, reimbursement, virtues Correspondence Associate Professor Stephen A. Buetow Department of General Practice and Primary Health Care University of Auckland Tamaki Campus Private Bag 92019 Auckland 1142 New Zealand E-mail: s.buetow@auckland.ac.nz Funding: None. Accepted for publication: 14 June 2011 doi:10.1111/j.1365-2753.2011.01722.x Abstract Pay-for-performance schemes reward standardized professional behaviours associated with effective care. However, they neglect the significance of virtue and devalue and erode professional motivation based on virtue. Pay for training to cultivate virtue, and/or pay- for-virtue, may mitigate these dangers. Although virtue is typically considered its own reward, and the assessment of virtue is problematic, pay-for-virtue could involve (1) stringent checks on the appropriateness of the standardized care currently rewarded by pay-for-performance for individual patients or (2) pay for indicators of virtue. These indicators could be based on virtues identified from a framework of universal virtues and through logical inferences from features of practice. It is possible that pay-for-virtue could ultimately strengthen health professionals’ intrinsic motivation for good practice, but this and the broader effects of pay-for-virtue would need careful investigation. Introduction A good health professional ideally provides the right forms of health care for the right reasons. Current systems for paying health provider organizations and health professionals offer financial reasons for and against some particular forms of health care pro- vision [1]. For example, fee-for-service payments encourage pro- fessionals to sell more care rather than necessarily better care, while capitation payments create financial incentives to reduce the number of interventions that patients receive [1]. Pay-for-performance makes supplemental payments for certain health care behaviours in order to try to reduce inappropriate variations in health care delivery and outcomes, cut spiralling health care costs and extrinsically motivate and reward (or not) the content of performance by professionals against preset standards. Typical standards set targets for indicators of particular health care behaviours (e.g. prescriptions of statins for high cholesterol) or patient health status (e.g. blood pressure levels) assessed across the patient population that the provider serves. The standards are sup- posed to be designed (and revised) to stimulate ongoing improve- ments in the quality of health care provision and in resource use. Our concerns are that pay-for-performance emphasizes and buys standardized behaviours and particular health consequences while ignoring or downplaying the need to attend appropriately to variations between individual patients. More generally and more fundamentally, it can tend to undermine what is often understood as professionalism in medicine by neglecting the need to support and strengthen virtue among individual health professionals. Virtue in an individual is usually understood to depend on the possession or command of an integrated set of more specific virtues. Virtues are positive character traits, qualities or disposi- tions, such as humanity, in which the core values of health profes- sionals are embedded [2]. They are relatively stable and largely unconscious determinants of goal-directed performance. The virtue of wisdom, for example, underpins and integrates recogni- tion of what is right, or good, in particular circumstances. It helps to safeguard professional autonomy and pride while protecting the dignity and broader interests of patients. Virtue is also necessary in order to grow and be self-aware of the motivation that comes from inside to act well [3]. Pay-for-performance does not directly assess or financially reward professional motivation. The current schemes focus on Journal of Evaluation in Clinical Practice ISSN 1365-2753 © 2011 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 17 (2011) 894–898 894