Data and Outcomes

NW Data/Outcomes

"Data" contains three sections: 1) Studies of P4P programs, 2) Physician opinion, 3) News Articles/Commentaries.

1)      Studies of P4P programs. The basic question of whether P4P is successful in achieving better health outcomes is actually quite complex. The results vary based on the primary goal of the P4P program, most commonly quality improvement, which has proved to be challenging to measure. It is rare that programs actually decline in overall performance; so the rate of quality improvement is an important consideration as well. Additionally, a significant limitation for most studies is provider competition. If one hospital demonstrates improvement, market forces drive the other hospital to improve as well. Therefore, P4P projects are extremely difficult to provide control groups for (O'Reilly, 223). Perhaps this was best witnessed though by Tu, et al. (317 in the Other Performance Based Incentives section). Taking all this into account, most published studies show either a positive, or a partially positive result (36, 119, 182, 188, 189, 197, 269, 273, 316, 320). These studies were done in either hospitals and/or clinics, and a majority of these studies were done with measures based on acute myocardial infarction, congestive heart failure, and diabetes core measures. Literature analyzing multiple P4P trials shows at least some partial positive or positive results as well (18, 87, 115, 177, 197, 312) Meanwhile, mixed/neutral results were seen in two studies (87, 270), and no studies showing negative quality improvement (worsening care) after P4P implementation. When negative results are present, they are demonstrated in the form of unintended consequences, as well as moral and ethical challenges. To date, most unintended consequences are hypothetical, but still very much a threat to P4P, and are best found in the "Controversial Issues" section of this website. It is important to note that there is a wealth of literature regarding the link between performance metrics and desired outcomes without added financial incentives.  Because this website is dedicated to Pay for Performance, we have only included a few key articles from this area of research (51, 52, 120, 258)  Others point out that multiple factors that may contribute to achieving better P4P outcomes. For example: Armour (269) states bonuses directly to physicians will result in greater changes; Edwards (252) implies that long-term data tracking will help facilitate long-term change; Sinsky (141) provides an example of how information phrased to patients can vary their outcomes; Glickman (324) observed clinical guidelines to be more effective than administrative guidelines; and Vina (248) believes P4P will be more effective when it is one facet of a larger quality improvement project. Additionally, the AHRQ has reported (221) that improvement rates were slower from 2000-2005 than from 1994-2005, which may further make it difficult to judge effectiveness.

2)      Physician opinion. One way to measure negative effects and unintended consequences of P4P programs is to formally interview health care providers. This provides data regarding physician intent, physician consideration, and workplace environment. If physician's report any scheming, or firing patients to meet bonuses, programs may have to be halted. To date however, most physician's interviewed have stated a general positive attitude towards P4P (73, 165, 249, 300).  However, it is worthy to note that McDonald (165) reports a difference in perception between nurse and physician opinion because nurses have an increased workload, but do not share a part of the quality bonus.

3)      News Articles/Commentaries. Patient perception and acceptance of P4P is important. Patient perception of data and program outcomes will play a key role in the future as P4P is rapidly gaining a share in mainstream news and culture. Glendinning (36) provides an article of a positive story, while he (126) also provides an article with some skepticism. *We as authors are unable to track all news feeds and commentaries, as well as business literature, but will try to update if requested or a key mainstream article is published.

Key Articles: 85, 87, 115, 182, 188, 316

Authors' Opinion: Data thus far has been mostly positive.Most trials are not ideal for rigorous scientific investigations, and that could be detrimental in the eyes of some clinicians, yet satisfactory in others.  Meanwhile, most programs have only rewarded physicians for process measures, mainly because establishing a link to outcomes is difficult, and getting bonuses from outcomes of patients would be less convincing for many physicians approval. Therefore, the data is skewed towards programs that are highly unlikely to fail. This is probably the proper first steps for P4P programs because unintended consequences must be avoided, otherwise they could have severe repercussions in patient trust. Either way, there is much more work that must be done to research the effectiveness of P4P, and the United States offers a great chance to analyze many different P4P implementations.

Data Literature

(18)***Key Article***

Petersen LA, Woodard LCD, Urech T, Daw C, Sookanan S. Does Pay-for-Performance Improve the Quality of Health Care. Annals of Internal Medicine. 2006: 145(4) 265-272.

PMID: 16908917


  • Summarizes 17 P4P effectiveness studies.

  • 5/6 studies of physician-level incentives showed partial or positive effects on quality.

  • 7/9 studies of provider group-level incentives showed partial or positive effects on quality.

  • 1/2 studies of payment-system level incentives showed a positive effect on access to care. While the other showed negative effect on access to care for the sickest patients.

  • 4 studies suggest unintended effects.

Significance to Literature:

  • In 2006, P4P appeared to have some initial positive outcomes and some unintended effects. Ongoing monitoring is recommended.

(36) Glendinning D. “Pay-for-quality” pilot project gets high marks. American Medical News. July 24/31, 2006.



  • HealthSpring insurer setup a Pay-for-Quality system with Sumner Medical Group in Tennessee to coordinate the care of 1,200 patients.

  • Offered rewards (up to 20%) to track Medicare patients.

  • Programs successful, as measured by 10% drop in hospital admissions and 19% decline in ER visits.

  • The program will be tried in 12 more markets.

Significance to Literature:

  • An example of a success in P4P programs.

(51) Bradley EH, et al. Hospital Quality for Acute Myocardial Infarction. JAMA. 2006: 296(1) 72-78.

PMID: 16820549


  • Authors sought to determine correlation between current process measures for acute MIs and 30-day post-MI mortality rates.

  • Found moderately strong correlations between some measures pertaining to pharmaceutical treatments and survival.

  • However, only 6% of hospital-level variation correlated with acute MI mortality rates; risk standardization was far more important in predicting 30-day mortality.

Significance to Literature:

  • CMS and JCAHO acute MI core process measures in 2002-2003 capture only a small proportion of the variation in the hospitals’ risk standardized short term mortality rates.

(52) Shojania et al. Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control. JAMA. 2006: 296(4) 427-440.

PMID: 16868301


  • A meta-regression analysis done across 66 trials investigating type 2 diabetes interventions, using HbA1C as the outcome standard.

  • Found team-based approach and case management produced the most effective outcome gains.

Significance to Literature:

  • While most QI strategies produced small to modest changes, team-based approaches and case management show the greatest improvements.

(73) Physicians have positive attitudes about pay-for-quality programs, but are ambivalent about certain program features. AHRQ September, 2007. No. 325.



  • Recent survey of primary care physicians in California and Massachusetts:

    • Many physicians think positively of P4P, but report negatively about their understanding of the details of programs.

  • Many doctors think P4P can improve quality care.

Significance to Literature:

  • In September 2007 physicians in Massachusetts and California were “neither disaffected from nor fully engaged in P4Q (Pay-for-Quality) programs.”

(85)***Key Article***

Rosenthal MB, Landon BE, Normand SLT, Frank RG, Epstein AM. Pay for Performance in Commercial HMO’s. NEJM. 2006: 355:18 1895-1902.

PMID: 17079763


  • Outlines the usage of P4P in 2006:

    • More than 50% of HMO’s using P4P, representing over 80% of persons enrolled.

  • Of the 126 health plans with P4P programs 90% reimburse physician, and 38% reimburse hospitals.

  • Matching patients with primary care providers was highly associated with use of P4P.

Significance to Literature:

  • Offers a comprehensive overview of the growth of P4P in commercial HMOs in 2006 and recommends CMS leverage their early experience.

(87)***Key Article***

Glickman et. al. Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial Infarction. JAMA. 2007: 297(21): 2373-2380.

PMID: 17551130


  • Seeks to answer what, if any, is the incremental benefit of P4P, and if there were any adverse effects from P4P.

  • An observational study of 105,383 patients with acute non-ST segment elevation myocardial infarction was completed to test effectiveness of P4P vs. non-P4P hospital process and outcomes.

  • Study showed no statistical difference in quality of care or outcomes between hospitals participating in P4P and hospitals not participating in P4P.

  • However, both groups did show a 5.2% increase in absolute improvement in meeting process based CRUSADE guidelines.

  • It was also noted that no adverse effects were observed due to P4P.

Significance to literature:

  • 3-year analysis of hospital based P4P showed no benefits or adverse effects directly attributable to P4P programs.

(110) Landon BE et. al. Quality of Care for the Treatment of Acute Medical Conditions in US Hospitals. Archives of Internal Medicine. 2006: 166 2511-2517.

PMID: 17159018


  • Analysis of CMS and JCAHO performance data from 4,000 for-profit and not-for-profit hospitals in 2004.

  • Authors found that for profit hospitals had worse results, while not-for-profit hospitals had better results mainly attributable to investments in nurse staffing and technology.

  • Overall, 75.9% of patients hospitalized for acute MI, CHF, and/or pneumonia received recommended care.

Significance to Literature:

  • Care is influenced by payment model.

(115)***Key article***

Rosenthal MB, Landon BE, Howitt K, Song HSR, Epstein AM. Climbing Up The Pay-For-Performance Learning Curve: Where Are The Early Adopters Now? Health Affairs. 2007: 26(6) 1674-1682.

PMID: 17978386


  • Authors tracked 27 P4P programs across the United States that began prior to 2003, 24 of which still remained in 2007.

  • They found P4P is still mainly in primary care, but slowly expanding to other specialties as measures grow.

  • P4P programs sponsors cited measurement issues as the largest barrier to the inclusion of specialists.

  • Identifies risk adjustment as one of the next key issues.

  • Outcomes thus far have been positive, with possibly few negative side effects.

  • Also details a list of areas where improvement can be made:

    • Primary recommendation is the involvement of more physicians and hospitals.

Significance to Literature:

  • Tracks the progress of many prominent P4P programs over 3 years.

(119) Gilmore AS, et. al. Patient Outcomes and Evidence-Based Medicine in a Preferred Provider Organization Setting: A Six-Year Evaluation of a Physician Pay-for-Performance Program. Health Services Research 2007: 42(6) 2140-2159.

PMID: 17995557


  • An observational study of a Blue Cross Blue Shield of Hawaii P4P program over a six year period comparing physicians who did or did not participate in the program.

  • Article analyzes total patients, quality indicators, performance measurements, and possible drawbacks/limitations.

  • Odds ratio for patients to receive recommended care from program-participating providers was 1.06-1.27 as compared to non-program participating providers.

Significance to Literature:

  • A positive case report of a P4P program over six years.

(120) Werner RM, Bradlow ET. Relationship Between Medicare’s Hospital Compare Performance Measures and Mortality Rates. JAMA. 2006: 296(22) 2694-2702.

PMID: 17164455


  • 3,657 hospitals were analyzed comparing mortality rates for acute myocardial infarctions, pneumonia, and heart failure between hospitals performing in the 25th percentile vs. those performing in the 75th percentile.

  • Outcomes were similar for these two groups.

  • However, outcomes were risk-adjusted for comorbidities, age, race, ZIP-code level median income and education, sex, insurance status, and whether the admission was emergent or elective.

  • Although these results are statistically significant, the authors are careful to make sure that this should not discourage current efforts to improve quality.

  • Authors urge development of performance measures more tightly linked to outcomes.

Significance to Literature:

  • Performance as reported in Hospital Compare is not strongly linked to better patient outcomes when risk adjusted for medical and social factors.

  • Hospital performance measures should be redesigned to better correlate with outcomes.

(126) Glendinning D. No quality benefit seen in Medicare pay pilot. American Medical News. June 25, 2007.



  • Article is a follow up of the June 6 JAMA article about performance outcomes of acute MI care in P4P vs. non-P4P hospitals.(120)

  • Results raise skepticism about P4P because P4P hospitals showed no significant gains in quality of care over non-P4P hospitals.

  • However, many remain optimistic, including CMS, who renewed the P4P pilot program for 3 more years.

  • Competition created by P4P and public reporting will move hospitals towards better care, which should be the ultimate goal.

Significance to Literature:

  • News article summarizing the disappointing results of Medicare’s Hospital Compare published in JAMA, June 6th, 2007.

(141) Sinsky CA, Foreman-Hoffman V, Cram P. The Impact of Expressions of Treatment Efficacy and Out-of-pocket Expenses on Patient and Physician Interest in Osteoporosis Treatment: Implications for Pay-for-performance Programs. Journal of General Internal Medicine. 2007: 23(2) 164-168.

PMID: 18163191


  • Study demonstrates that osteoporosis treatment compliance of both physician and patient is higher when data is presented as a relative risk, and not absolute risk.

  • This is important to consider as P4P is attempting to link compliance to reimbursement.

  • Study also found that patients become less and less likely to be compliant with prescription drugs as out-of-pocket expenses increase.

Significance to Literature:

  • Thinking about disease risk in absolute vs. relative terms and out-of-pocket costs of interventions to patients play major roles in determining whether patients and providers follow CPGs.

(165) McDonald R, Harrison S, Checkland K. Incentives and control in primary health care: findings from English pay-for-performance case studies. Journal of Health Organization and Management. 2008: 22(1) 48-62.

PMID: 18488519


  • In-depth qualitative case study of two GP clinics in England seeking to find perceptions of control after P4P implementation.

  • Overall attitudes towards P4P were positive. However nurses expressed more discontent with increase surveillance, insufficient wage increases for workload, and negative consequences for patient-centered care.

  • Discontent was observed with more intensive surveillance.

Significance to Literature:

  • Highlights differences between physician and nurse experiences with England’s Quality and Outcome Framework (QOF) P4P program and concludes that intense surveillance may have the potential to constrain clinical practice.

(177) Schatz M. Does pay-for-performance influence the quality of care? Current Opinion in Allergy and Clinical Immunology. 2008: 8 213-221.

PMI: 18560295


  • A review, by a Kaiser Permanente of California physician, of 7 randomized control studies and 15 nonrandomized control studies of P4P programs dating back as far as 1990.

  • 14 out of 15 nonrandomized studies showed at least some positive results, and less than half of the randomized studies showed positive results.

Significance to Literature:

  • P4P can improve quality markers, but not always.

(182)***Key Article***

Pearson SD, Schneider EC, Kleinman KP, Coltin KL, Singer JA. The Impact of Pay-for-Performance on Health Care Quality in Massachusetts, 2001-2003. Health Affairs. 2008: 27(4) 1167-1176.

PMID: 18607052


  • Study in Massachusetts of statewide quality measurements and reporting systems from 2001-2003 to evaluate the performance impact of P4P by five major commercial health plans.

  • Overall strategy was to compare change in HEDIS performance over three years between incentivized physicians and non-incentivized physicians.

  • Improvement trends were similar throughout many HEDIS measures amongst incentivized physicians and their comparison group. Substantial improvement of HEDIS measures was seen across the board.

  • However, one P4P contract with a single medical group was associated with superior improvement for diabetes care.

  • The size of incentive did not show a relationship to magnitude of improvement.

Significance to Literature:

  • P4P can be viewed as an integral part of recent positive changes in medical practice, but current studies lack the ability to show direct effectiveness of P4P.

(188)***Key Article***

Mandel KE, Kotagal UR. Pay for Performance Alone Cannot Drive Quality. Archives of Pediatric Adolescent Medicine. 2007: 161(7) 650-655

PMID: 17606827


  • Analysis of the impact of P4P within the asthma improvement collaborative amongst 44 pediatric practices in Cincinnati, OH.

  • Anthem Blue Cross Blue Shield gave practice-based rewards that were tiered based on performance, with the maximum potential to earn 7% fee increase.

  • 43 practices qualified for bonuses,

    • 3 received a 2% increase

    • 13 a 4% increase

    • 2 a 5% increase

    • 14 a 5% increase

    • 11 a 7% increase

  • Overall, the percentage of the population receiving perfect care went from 4% to 88%

  • Provided 5 key design principles P4P programs should embrace for sustainable success.

Significance to Literature:

  • P4P, when coupled with robust approaches to quality improvement, can be a catalyst to accelerate sustainable transformation among providers.”

(189) Millett C, Gray J, Saxena S, Netuveli G, Majeed A. Impact of pay-for-performance incentive on support for smoking cessation and on smoking prevalence among people with diabetes. Journal of the Canadian Medical Association. 2007: 176(12) 1705-1710.



  • A longitudinal study of prevalence of offering smoking cessation advice and smoking cessation in diabetes patients from 2003 and in 2005 after P4P was implemented in the UK.

  • In those two years, smoking prevalence decreased from 20.0% to 16.2% and cessation advice given increased from 48.0% to 83.5%.

Significance to Literature:

  • The implementation of P4P in the UK seemed to correlate with a substantial increase in smoking cessation advice and smoking cessation amongst diabetes patients.

(197) Rosenthal MB, Frank RG, Li Z, Epstein AM. Early Experience With Pay-for-Performance. From Concept to Practice. JAMA. 2005: 294(14) 1788-1793.

PMID: 16219882


  • Addresses paying physicians according to performance improvement vs. overall performance scores.

  • Evaluated two quality improvement programs from July 2003-April 2004, one utilized P4P in California, the other was a similar demographic not using incentive payments.

  • Of the three like processes measured, the California P4P program demonstrated greater quality improvement in cervical cancer screenings.

  • Improvement occurred in all three areas in both groups.

  • Physician groups whose performance was initially the lowest improved the most.

Significance to Literature:

  • Incentivizing physicians may prove little gain in quality for the total dollars spent.

(221) O’Reilly KB. U.S. report finds sluggish increases in quality of care. American Medical News. April 28, 2008.



  • The rate of health care improvement was slower from 2000-2005 than 1994-2005 according to the Agency for Healthcare Research and Quality (AHRQ).

  • Additionally health disparities among racial and ethnic groups for multiple medical conditions were relatively unchanged from 2005-2007.

Significance to Literature:

  • According to AHRQ, quality of care is improving at slower rates than the 1990's.

(223) O’Reilly KB. P4P found to have little impact on care quality. American Medical News. August 4, 2008.



  • A recent report in Health Affairs shows that P4P programs had made little impact on quality. Citing small bonuses as a potential barrier.

  • This is inconsistent with a study from 2006 in the Annals of Internal Medicine that found 17 P4P programs with at least a partial positive effect on care.

Significance to Literature:

  • There are few evaluations [of P4P programs] that have a comparison group of any kind.”

(247) Brantes FSd. D’Andrea G. Physicians Respond to Pay-for-Performance Incentives: Larger Incentives Yield Greater Participation. The American Journal of Managed Care. 2009: 15(5) 305-310.

PMID: 19435398


  • Authored by the CEO of Bridges to Excellence, the company that designed the program studied in the paper.
  • Study of data from Bridges to Excellence looking to determine the extent to which the size of the financial incentive influences physician participation.
  • Physicians increase participation in a linear fashion as the potential reward increases.
  • Physicians were more willing to participate sooner if incentives were individual rather than group incentives.


Significance to Literature:

  • The greater the reward, the more likely physicians will be to participate in P4P programs.

(248) Vina ER, Rhew DC, Weingarten SR, Weingarten JB, Chang JT. Relationship Between Organizational Factors and Performance Among Pay-for-Performance Hospitals. Journal of General Internal Medicine. 2009: 24(7) 833-840.

PMID: 19415390


  • Study aimed to find the key organizational factors associated with higher performance by interviewing executives in hospital administration.
  • Top performing hospitals were more likely to utilize clinical pathways for treatments, multidisciplinary teams, order sets for treatment, and computer physician order entry.
  • Top performing hospitals were also more likely to have adequate human resources for quality improvement projects and an organizational culture which promoted quality improvement.


Significance to Literature:

  • P4P is most likely to be successful when implemented as part of a larger quality improvement initiative.

(249) Leas BF, Goldfarb NI, Browne RC, Kerorack M, Nash DB. Ambulatory Quality Improvement in Academic Medical Centers: A Changing Landscape. American Journal of Medical Quality. 2009: 24(4) 287-94.

PMID: 19411626


  • Compares a survey of Academic Centers ambulatory quality improvement infrastructure published in 2004 with a current survey conducted in 2006.
  • Institutional support for quality initiatives and sustained improvement substanially increased between the two surverys.
  • More than half of surveryed Academic Medical Centers (AMCs) reported already participating in commercial quality improvement initiatives, and two thirds expected further expansion in quality improvement programs.
  • In contrast, less than half of AMCs planned to participate in public reporting programs.


Significance to Literature:

  • AMCs report an expanded capacity to participate in P4P programs as part of quality improvement programs.


(252) Edwards, FH. How one medical specialty society’s use of measures and reporting dramatically improved patient care. The Journal of Family Practice. 2008: 57(10a) S6-S9.



  • The Society of Thoracic Surgeons has kept a national database of performance statistics for 20 years with over 3 million patients, which has helped quality improvement initiatives for thoracic surgeons.
  • Risk adjustment has been a critical piece.
  • Physicians can sort through the data to find out where they rank amongst their colleagues.
  • “Database feedback lead to reduced CABG operative mortality from 1994-2003, in contrast to an expected increase due to heightened risks.”
  • The Society has urged congress to fund similar projects for the future.


Significance to Literature:

  • P4P must accurately measure data over a long period of time. This Society has shown that longitudinal performance data can be used to save lives.

(258) Fonarow et al. Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure. JAMA. 2007: 297(1) 61-70.

PMID: 17200476


  • Article assesses the link between the 5 performance measures in hospitalized heart failure patients and mortality risk.
  • 54% of heart failure patients met all five performance measures/indicators upon leaving the hospital.
  • None of the five quality indicators were associated with decreased 60 and 90 day mortality rates. Only ACE inhibitors or ARB’s were associated with improvements in the combined mortality/rehospitalization rates.
  • Authors also noted that Beta blockers (not one of the performance measures) demonstrated decreased mortality and rehospitalization in heart failure patients.


Significance to Literature:

  • Performance measures ought to be strongly associated with improved clinical outcomes prior to large scare dissemination.

(268) Young GJ, et al. Effects of Paying Physicians Based on their Relative Performance for Quality. Journal of General Internal Medicine. 2007: 22 872-876.

PMID: 17443360


  • Retrospective analysis of an incentive program in which physicians had a financial risk; they could gain or lose income.
  • Study took place 3 years pre-incentive and 3 years post-incentive allowing the authors to estimate practice pattern changes over time.
  • 5% of all PCP’s salaries were withheld and placed in an incentive pool that was then redistributed according to a sliding scale of relative performance in clinical quality, patient satisfaction, and practice efficiency.
  • There was no difference in pre and post intervention trends as all areas were improving at the same rate, with one exception: there was a modest 1 time improvement in physician adherence for diabetic eye exams.  


Significance to Literature:

  • Study demonstrates only a modest effect in improving provider adherence to quality measures.

(269) Armour BS, et al. The Influence of Year-end Bonuses on Colorectal Cancer Screening. The American Journal of Managed Care. 2004: 10(9) 617-624.

PMID: 15515994


  • Retrospective study using managed care plan claims from 2000 and 2001 which sought to examine explicit financial incentives to improve colorectal screenings in patients 50 years or older.
  • A $10,000 increase in income raises the probability of flexible sigmoidoscopy or colonoscopy screening approximately 2%.
  • Bonuses are more effective when targeted to individual physicians as opposed to a physician group.


Significance to Literature:

  • Cash bonuses to individual physicians can modestly increase screening of commercially insured patients.


(270) Forsberg E, Axelsson R, Arnetz B. Financial incentives in health care. The impact of performance-based reimbursement. Health Policy. 2001: 58 243-262.

PMID: 11641002


  • Swedish study comparing performance-based reimbursement (PBR) in one county with 10 traditionally reimbursed counties.
  • PBR focused on cost contaiment rather than quality improvement.
  • PBR resulted in greater cost awareness and shorter length of hospital stay, but a strong cost awareness was found to be a negative predictor of quality care.


Significance to Literature:

  • Swedish physicians found both positive and negative effects of performance reimbursement aimed at cost containment.


(273) Robeznieks A. California Pay for Performance Program Achieving Results. Metro Doctors. September/October, 2005.



  • Discusses the results of the Integrated Healthcare Association (IHA) P4P program in California which used 14 clinical markers and paid a total of $40 million dollars in bonuses.
  • P4P here was not designed to lower cost, but rather to improve quality.
  • IHA saw improvement statewide in all 14 clinical quality indicators.


Significance to Literature:

  • Early (published 2005) success story of one P4P program.


(300) Damberg CL, Raube K, Teleki SS, Cruz ED. Taking Stock of Pay-For-Performance: A Candid Assessment From The Front Lines. Health Affairs. 2009: 28(2) 517-525.

PMID: 19276011


  • Authors interviewed a non-randomized sample of 35 physician organizations participating in California’s Integrated Healthcare Association’s statewide P4P program.
  • Authors presented many results based on physicians experience with P4P in their clinic:
    • 25/31 believe that P4P has increased accountability for quality, improved data collection, and created greater organizational focus for QI projects.
    • Some groups were quoted as saying P4P “isn’t worth the trouble.”
    • 9 gave examples of negative consequences, however >66% reported more positives than negatives created.
    • 23 reported believe P4P was either very important or important.
    • There was widespread support for increasing incentives
    • Health plans stated P4P program had not met original goals yet.


Significance to Literature:

  • Provides insight and advice from physician organizations in one of the biggest P4P programs in the country.

(312) Mehrotra A. Damberg CL, Sorbero ME, Teleki SS. Pay for Performance in the Hospital Setting: What is the State of the Evidence? American Journal of Medical Quality. 2009: 24(1) 19-28.

PMID: 19073941



  • Article outlines 3 hospital based P4P programs and its effects on quality improvement by analyzing 8 published studies.
  • Authors found that participating hospitals had a 2- to 4- percentage point greater improvement than control hospitals when present in studies.
  • Authors question the need for monetary incentive if hospitals demonstrate that quality can be raised through public reporting mechanisms.


Significance to Literature:

  •  P4P programs in hospitals are thus far limited, yet studies do show positive outcomes for existing programs, and few published unintended consequences.

(316)***Key Article***

Foels T, Hewner S. Integrating Pay for Performance with Educational Strategies to Improve Diabetes Care. Population Health Management. 2009: 12 121-129.

PMID: 19534576



  •  Study aimed to assess improvement of diabetes care after P4P and inspirational support implementation
  • Assessed nine processed measures over 4.5 years, 
  • Results suggested that inspirational support and P4P produced an accelerated performance trajectory.
  • "Once providers are aware of gaps in their performance, they often are extremely interested in strategies that will help close the gaps."


Significance to Literature:

  •  Positive P4P outcome with emphasis on teaching the clinician how to provide better care.

(320)***Key Article***

Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of Pay for Performance on Quality of Primary Care in England. NEJM. 361(4) 368-378.

PMID: 19625717


  • Time-series analysis of 42 family practices in the United Kingdom of the clinical quality scores pre- (1998 and 2003) and post- (2005 and 2007) P4P (QOF) implementation in 2004.
  • Measured clinical care in coronary heart disease, asthma, and diabetes. Measured patients' perceptions in communication with physicians, access to care, and continuity of care.
  • Clinical quality of care increased for diabetes and asthma from 2003 to 2005, but by 2007 improvement had slowed. While improvement for heart disease was marginal from 2003 to 2005, and similar in 2007 compared to 2005.
  • Patients' perceptions of care regarding access and interpersonal aspects remained similar throughout,while continuity of care decreased immediately following P4P implementation, but remained steady at a reduced level in 2007.
  • Structure of P4P program did not reward for further improvement once targets had been achieved.
  • Meanwhile, two non-incentivized quality of care measures decreased in both asthma and heart disease treatment.


Significance to Literature:

  • Once quality targets were met, quality improvement was slowed, while quality of care for non-incentivized conditions decreased.

(324) Glickman SW, et al. Alternative Pay-for-Performance Scoring Methods: Implications for Quality Improvement and Patient Outcomes. Medical Care. 2009: 47(10) 1062-1068.

PMID: 19648833



  • Analysis of AMI and heart failure measures comparing the mortality association between administrative versus clinical measure adherence.
  • Authors found clinical activities were associated with higher survival rates, rather than administrative process measures.
  • Therefore, it may be more beneficial to design incentives and spend limited financial resources on implementing measures that affect clinical activities.


Significance to Literature:

  • Measures more associated with better patient outcomes should be more targeted by quality improvement initiatives.