If it is true that objects in the mirror may be larger than they appear, perhaps the Federal Register publication on January 13, 2011, by the Centers for Medicare and Medicaid Services (CMS) of their proposed rule for Hospital Value-Based Purchasing should be taken seriously by rehabilitation physicians and hospitals, even though they are exempt from the Rule for the time being. The Rule is gaining ground, and we are almost certain to be next, which might even be a good thing, but it definitely deserves some attention. Public funds pay for 47.3% of health care in this country [1], so for years CMS has been talking about making sure it is getting its money’s worth. Commercial insurers write the checks for another 33.5% of health care [1], so they (and the large employers who cover ost of the costs themselves) are also highly interested in getting the most for their money. n policy circles, this concept is called value-based purchasing (VBP). Idealists attribute great powers to the concept of VBP. They believe it can root out edical error and raise practice standards while simultaneously promoting administrative mprovements and eliminating waste. Cynics think it is all about saving a buck, with little oncern for patient and physician individuality and preferences. Either way, VBP rests on he concept that it is possible to identify certain preferred behaviors or outcomes and adjust he health care payment system to increase the likelihood of their occurrence. Over recent ears, CMS has required community and academic hospitals to report their results on a umber of performance measures. But the Patient Protection and Affordable Care Act of 010 requires the Secretary of Health and Human Services to go beyond requiring a report nd actually establish a program to pay short-term acute care hospitals based on their erformance scores beginning in October 2012. So now CMS has the task of deciding which areas of performance it will reward and that s what the new Proposed Rule does. But do not think that high performance earns new onus money for a hospital. The VBP program can claim to be “budget neutral” because it unds itself with money withheld from the otherwise expected level of Medicare prospective ayment system payments. So VBP pits hospitals against each other to compete for money hat Congress had previously planned to pay for care anyway. Although inadequate ayments for health care services would obviously have serious ramifications, it is hard for ny purchaser to resist using the power of the economic transaction to influence the quality f the product. The new Proposed Rule would establish 17 specific clinical performance measures (eg, lood culture performed before administration of first antibiotic for pneumonia). In ggregate, these would account for 70% of a hospital’s score. The Proposed Rule also roposes that grades from the Hospital Consumer Assessment of Healthcare Providers and ystems survey of the patient experience with care would be calculated to account for the ther 30% of a hospital’s total score. Whether you label it customer service, patient atisfaction, or patient experience, the concept is that how the encounter “feels” to the atient is a matter of considerable importance. Those who pay for the care, including edicare, are not convinced that the services that they are currently buying hit the mark ith respect to meeting patients’ expectations, so they are proposing to establish specific nancial accountability. The Patient Protection and Affordable Care Act passed in 2010 (also known as Health eform) also sets the stage for the secretary to act by 2013 to create performance measures hat would apply to inpatient rehabilitation hospitals. Whatever political challenges this egislation faces based on the partisan divide between the House and the Senate, it is unlikely