NW Programs

"Programs" contains three sections: 1) The CMS national program, 2) International programs, and 3) P4P by state.

1)       The Centers for Medicare and Medicaid Services (CMS). CMS has embraced P4P as a way to both lower costs and improve care. In addition to their Physician Quality Reporting Initiative (PQRI) begun in 2007, CMS has developed and implemented numerous pilot and demonstration projects to investigate P4P in different settings. From the outset CMS undertook a rigorous effort, described by Kmetik (243), to develop quality measures. Click here to view the 200+ CMS measures. Various hospital-based CMS programs are outlined (43, 183, 208). Other CMS P4P demonstration projects are outlined in articles by Glendinning and Kauter (11, 116). The Physician Quality Reporting Initiative (PQRI) is described by Stulberg, (175), while Bagley (171) walks clinicians through participation in the PQRI. Articles by Wennberg (156, 157) highlight how Medicare can improve quality and reduce spending through P4P.

     The implementation of P4P by CMS has been rapid (56, 102, 225), but Glendinning (11) cautions to prioritize quality improvement over cost control, Trapp (56) suggests that sustaining P4P will be challenging, Aston (235) advises against setting quality thresholds too high, and Glendinning (240) points out that clinicians are disappointed with delays in feedback from CMS. The implementation of P4P by CMS has raised many political issues, some of which are discussed in this site’s "Politics and Law" section. A very controversial issue built into CMS is the use of negative incentives such as "nonpayment for 'never events'" discussed in "other performance based incentives." Many believe that the CMS P4P program will become, or should become, the template for private programs.

2)      International Programs. P4P is increasingly an international phenomenon. Manion (163) outlines case results of P4P in selected countries, while, Wilson (227) makes the case for learning from other countries to improve quality, and Majeed (154) suggests using P4P to compare physicians locally as well as globally. Cupples (284) advises against importing measures.  In comparing and contrasting P4P in the United States and abroad, P4P in the United States is comparatively under-regulated, decentralized with greater than 160 individual programs, almost exclusively administered by local insurers, lacking either risk adjustment or patient exceptions or both. Other countries that have robust P4P systems include the United Kingdom (see next paragraph), Australia (229, 253, 283), and New Zealand (201). Canada is gradually developing P4P at the provincial level (62, 63), and has additionally developed measures to help reduce queues and increase efficiency (298). The Netherlands aggressively redesigned their system of clinician reimbursement in 2006 to blend risk adjusted, capitated medical homes with bonus fee-for-service payments for complex patients, all in the context of mandatory quality improvement projects to qualify for higher reimbursement (122, 123). Custers (306), from the Netherlands, argues that market trends limit the ability of P4P to impact quality. Rubenstein (298) summarizes a P4P program in Argentina, and argues that P4P must be a part of a greater quality improvement project.

      In the United Kingdom (UK), the P4P program is named the Quality and Outcomes Framework (QOF). Authors (59, 184, 211) summarize P4P in the UK, and its importance as a tool for quality improvement. Doran (164) offers insights into the QOF based on data from 2004-2007. Specifically, Campbell (162) showed that P4P negatively affected relationships between doctors, nurses, and patients. Campbell (209) also showed modest acceleration of quality improvement in diabetes and asthma after QOF implementation. Doran discusses both the necessity of offering exclusion reporting (186), and showed that only small amounts of physicians have used exclusion reporting many times (194). Satin (242) argues that if the UK and New Zealand are capable of risk adjusting, all programs should find ways to risk adjust.


·      UK NHS: The Quality and Outcomes Framework:

·      Australia: Practice Incentives Program:

·      New Zealand:

View Dr. Satin's powerpoint presentation comparing and contrasting P4P in the US, UK, Australia, and New Zealand, with reference to Canada.

3)      P4P by State. Many states have begun to administer their own P4P state programs. Some states and state medical associations have published P4P reports detailing the P4P activities within their state. Some states and non governmental entities have begun to publicly report health outcomes within their state (e.g. Minnesota’s community measurement project ( The state-sponsored P4P programs are in addition to the CMS national P4P program and as of 2010, one could still participate in both programs simultaneously.

     This section is under construction on an ongoing basis. It will include both links to state P4P websites and literature describing state-specific P4P activities. If you are aware of state-specific P4P links to be included below, please submit it in the "Question/Comment" section of the homepage. If you are interested in any state-specific information, not limited to government-sponsored state programs, please type your state name into this website's search function.


Minnesota- See articles 23, 57, 60, 322
North Carolina- 102
Maine- 102
Pennsylvania- 102
Alabama- 102
Key Articles: 59, 162, 164, 171, 186, 60 (for Minnesota)

Authors' Opinion:  Navigating the CMS national program can be complex. Ongoing challenges include providing clinicians with timely reimbursement, performance feedback, and responsiveness to new clinical evidence or a change in the health care environment. Nevertheless, CMS likely has the most comprehensive and valid program in the United Sates. Additionally, we recommend that insurers be required to select from among the CMS measures, as these measures have gone through rigorous transparent development by content experts. Internationally, P4P is expanding quickly.  Most countries have government regulated programs, and this simplicity allows physicians to better understand the program and work to meet specific measures. Within the US, we anticipate a greater role for state-specific programs.


CMS National Program Literature

(11) Glendinning D. Medicare tests pay-for-performance: The AMA urges focus on quality improvement over cost control in the demonstration project. American Medical News. Feb. 21, 2005.



  • Article outlines the CMS P4P demonstration project in 10 large clinics by Medicare.

  • Addresses concerns, especially those regarding cost cutting reasoning.

  • Up front costs will be high, and it will take a lot of time to see dividends.

Significance to Literature:

  • AMA urges focus on quality improvement over cost control.

(31) Terry K. Score one for CMS. Medical Economics. June 16, 2006.



  • P4P was used by CMS to divert decreased compensation to physicians.

  • Reimbursement is expected to decrease in future years.

  • P4P in non-Primary care settings will be difficult.

Significance to Literature:

  • Outline political deal making over compensation between CMS and AMA.

(43) Abelson R. Bonus Pay By Medicare Lifts Quality. The New York Times January 25, 2007.



  • News article outlines a Medicare hospital experiment in 266 hospitals to determine effectiveness of incentives and public reporting.

  • Hospital outcomes improved, which supports idea of rewarding care, and “a step in the right direction.”

Significance to Literature:

  • January 2007 news article covering 3-year Medicare hospital based P4P experiment.

(56) Trapp D. Medicare quality reporting called a promising start. American Medical News. March 17, 2008.



  • 1/6 eligible physicians reported quality data to CMS, 50% will receive bonuses.

  • Experts worry that a 1.5% bonus is not enough for more growth.

Significance to Literature:

  • Sustaining and expanding CMS P4P will be difficult.

(102) Trapp D. Medicaid measures performance. American Medical News. August 6, 2007.



  • Documents growth of P4P in Medicaid.

  • Provides case examples of Alabama, Maine, and Pennsylvania

    • e.g. In North Carolina physicians as a whole have improved 20-25% on process measures such as flu shots.

  • Questions whether P4P is worth physicians’ time due to the amount of reimbursement.

Significance to literature:

  • Overview of some recent advances in Medicaid P4P.

(116) Kautter J, Pope GC, Trisolini M, Grund S. Medicare Physician Group Practice Demonstration Design: Quality and Efficiency Pay-for-Performance. Health Care Financing Review. 2007: 29(1) 15-29.



  • Paper outlines Medicare’s first Pay-for-Performance Physician Group Practice demonstration project from a business perspective.

  • Details who is participating, beneficiary assignment, measurements, performance payments, and reporting.

  • Supplies an outline of provider feedback about reason for participating and strategies for better care.

  • Outlines some of the benefits and challenges of P4P.

Significance to Literature:

  • Provides a business perspective of Medicare’s P4P demonstration project beginning in April, 2005, through publication of article in the fall, 2007.

(156) Wennberg JE, O’Connor AM, Collins ED, Weinstein JN. Extending The P4P Agenda, Part 1: How Medicare Can Improve Patient Decision Making And Reduce Unnecessary Care. Health Affairs. 2007: 26(1) 1564-1574.

PMID: 17978377


  • CMS should extend its pay-for-performance to a shared-decision-making process, as Medicare should support informed patient choice as the standard of practice for preference-sensitive care.

  • Article proposes strategies to address the three major barriers to rapid adoption of informed patient choice.

Significance to Literature:

  • Article addresses conflicts at the intersection of P4P and patient choice.

(157) Wennberg JE, Fisher ES, Skinner JS, Bonner KK. Extending The P4P Agenda, Part 2: How Medicare Can Reduce Waste and Improve The Care Of The Chronically Ill. Health Affairs: 2007: 26(6) 1575-1585.

PMID: 17978378


  • CMS should use P4P to ensure that within ten years all severe chronically ill patients have access to accountable health care organizations providing evidence-based care.

  • Outlines strategies to reform the treatment of the chronically ill:

    • Develop a research program for chronic care.

    • Share the savings realized with providers.

    • Use P4P to transition to cost-effective care for chronic care patients.

    • Implement a non-participation penalty.

Significance to Literature:

  • P4P can be utilized to appropriately manage chronic illness cost effectively.

(171)***Key article***

Bagley, B. Measuring for Medicare: The Physician Quality Reporting Initiative. Family Practice Management. June, 2007. 37-40.



  • Offers an overview on how the process of collecting and reporting data for the Physician Quality Reporting Initiative (PQRI) works, and how a clinic can participate.

  • Also points out that participating may not only provide monetary rewards, but also more consistent care, and more active quality improvement.

Significance to Literature:

  • Walks clinicians through participation in the CMS PQRI.

(175) Stulberg J. The Physician Quality Reporting Initiative—A Gateway to Pay for Performance: What Every Health Care Professional Should Know. Quality Management in Health Care. 2008: 17(1) 2-8.

PMID: 18204372


  • Article examines PQRI, its key features, and discusses its possible implications

  • PQRI, a nationwide CMS quality measurement reporting program, will provide important groundwork for quality improvement if health care professional choose to report data.

  • PQRI is low-risk because it rewards for reporting only, and does not penalize for poor results.

  • PQRI affects individual Medicare providers.

Significance to Literature:

  • Overview of PQRI sponsored by CMS.

(183) Huff C. Good is Never Enough for P4P. Hospitals and Health Networks. 2008: 82(6) 26-32.

PMID: 18666732


  • Hospitals in Medicare’s P4P demonstration project are working harder to continue to raise quality scores.

  • 4 case studies are discussed in the article that outlines hospitals efforts to improve quality of care.

Significance to Literature:

  • There is much debate about the direct effectiveness of P4P, but it is unquestionable that reporting hospitals in the demonstration project are improving.

(205) Milgate K, Cheng SB. Pay-for-Performance: The MedPAC Perspective. Health Affairs. 25(2) 413-419.

PMID: 16522581


  • Article describes rationale for MedPAC backing of CMS use of quality incentives.

  • Issues that CMS must address include how rewards should be distributed, the evolution of the measures, and the number, type, and relative weights of the measures.

Significance to Literature:

  • Although CMS faces many challenges with P4P, choosing P4P was a step towards improving quality care.

(208) Grossbart SR. What’s the Return? Assessing the Effect of “Pay-for-Performance” Initiatives on the Quality of Care Delivery. Medical Care Research Review. 2006: 63 29S-48S.

PMID: 16688923


  • Author analyzes the effects of the CMS P4P Premier demonstration project in a multi-hospital healthcare system (4 hospitals), while comparing 3 clinical areas against a similar hospital (6 hospitals) system not participating in the CMS program.

  • Study compared acute myocardial infarction, pneumonia, and heart failure guidelines followed over a 1 year time span.

  • Although both groups had performance improvement gains, the group participating in Premier’s demonstration project improved more. (89.7% vs. 85.6% composite quality scores, p<.001)

  • Participating hospitals were noted as collaborating amongst each other to report trends that worked and did not work.

  • It was also noted that leadership and hospital communications helped the new P4P program function well.

Significance to Literature:

  • The CMS premier project seems to aid quality improvement in both participating and non-participating hospitals, but more so in participating hospitals.

(225) Glendinning D. Doctors still can try for bonuses as Medicare expands quality reporting. American Medical News. May 26, 2008.



  • CMS has expanded its quality measures from 74 to 119.

  • CMS will also begin to allow data submission on qualified registries.

  • Article outlines milestones as CMS rolls out its program.

Significance to Literature:

  • CMS expands its quality reporting program in 2008.

(235) Aston G. Practices hit Medicare P4P quality targets, but bonuses still fall short. American Medical News. September 8, 2008.



  • After the second year of the PGPD, all 10 groups met performance measurements in 25 of the 27 measures, and 5 practices achieved the goals of all 27 measures.

  • However, only four groups received performance bonuses because CMS requires savings to exceed 2% when compared with the community control group in order to payout.

  • The AMA has expressed concerns that the current project is too focused on cost savings, and not quality improvement.

Significance to Literature:

  • It will be difficult to persuade physician groups if the bar for receiving payments is too high.

(240) Glendinning D. Medicare rated as poor performer during debut of pay-for-reporting. American Medical News. November 17, 2008.



  • Physicians and the AMA are disappointed with the lack of support and feedback provided by CMS. Only 20% of surveyed physicians were able to download their 2007 feedback reports which told doctors whether or not they qualify for certain bonuses.

Significance to Literature:

  • A major change in CMS is needed to get physicians quicker feedback that they can use to improve their care.

(243) Kmetik K. PCPI: What you should know about Consortium performance measures. The Journal of Family Practice. 2007: 56(10A) 8A-12A.



  • Helps explain how many common P4P measures were developed for The Physician Consortium for Performance Improvement (PCPI).

  • Hundreds of physicians from all fields worked in measure-development work groups to develop guidelines with the highest level of evidence and strongest clinician recommendation.

  • Measures were open for public input, scrutinized by professionals, and re-edited numerous times before final implementation.

Significance to Literature:

  • Measures designed for the PCPI were agreed upon after much rigorous labor and debate.


(303) Glendinning D. CMS touts hospital demo as proof of pay-for-performance promise. American Medical News. February 19, 2007.




  • 30 Quality measures saw an average of 12% improvement in the first two years of the P4P hospital demo.
  • The next step is either a mandatory pay-for-reporting, or CMS may decide to make the leap to linking all measured quality scores to reimbursement.


Significance to Literature:

  • It will be an important step in the CMS program to decide which program to make mandatory, pay-for-reporting or P4P.

International Program Literature

(59) ***Key Article***

Mannion, R, Davies H. Payment for performance in health care. British Medical Journal. 2008: 336 306-308.

PMID: 18258966


  • Financial reward is a key factor in the success of P4P.

  • Article addresses the good vs. bad of both high and low financial reward.

  • Evaluation of P4P has not been able to keep up with implementation.

  • Preliminary evaluations of the quality and outcomes framework show benefits and adverse consequences.

Significance to Literature:

  • Summary of P4P in the United Kingdom in February 2008.

(62) Landon BE. Is Pay-for-Performance Moving North? P4P Prospects in the Canadian Healthcare System. Healthcare Papers. 2006: 6(4) 24-33.

PMID: 16825854


  • Canada has yet to implement a P4P system.

  • Compares P4P potential in United States, United Kingdom, and Canada.

  • Discusses proposal for regional level P4P.

Significance to Literature:

  • International comparisons of P4P potential, focusing on Canada.

(63) Pink GH et al. The Authors Respond. Healthcare Papers. 2006: 6(4) 72-74.


  • Authors point out that there are several P4P initiatives underway in Canada at the provincial level.

  • Canadian P4P must utilize regional differences, and Canadian infrastructure to collect data, and learn from other industries.

  • P4P should support a variety of measures.

Significance to Literature:

  • Summarizes Canadian P4P themes emerging from several commentaries.

(122) Knottnerus JA, Velden GHMT. Dutch Doctors and Their Patients—Effects of Health Care Reform in the Netherlands. NEJM. Perspective. 2007: 357(24) 2424-2426.

PMID: 18077806


  • In 2006, the Netherlands implemented a new healthcare system, assigning medical primary care physicians to all citizens with mandatory insurance.

  • Over and above the standard capitated payment system, the new system adds fee-for-service payments for more complicated patients.

  • Consumers have responsibility to select the right health plan for self.

  • Physicians must demonstrate their engagement in quality-improvement to obtain financial compensation.

    • This has already benefited general practitioners in low-income areas because it allows for greater compensation for more complex cases.

  • Task force exist that prepares professional guidelines and performance indicators

Significance to Literature:

  • New Dutch system aims to promote primary care through enhanced payments for more complicated patients.

(123) Enthoven AC, Ven WPMMVD. Going Dutch—Managed-Competition Health Insurance in the Netherlands. NEJM. 2007: 357(24) 2421-2423.

PMID: 18077805


  • After 20 years of research, in 2006 a new Dutch healthcare system was realized.

  • Mandatory insurance for all citizens, most insurers are private, but are heavily regulated.

  • Risk equalization is a pre-condition of the new system and is based on which patients are predicted to cost more.

  • Individuals and employers must contribute to a risk equalization fund.

  • The “Dutch model” was first designed and proposed for the United States, and similar proposals exist today.

Significance to Literature:

  • Risk-adjusted capitated medical homes may be a necessary component for P4P.

  • It took the Dutch 20 years of research and a homogenous population to accurately risk-adjust a capitated primary care panel of patients.

(149) Hawkes N. How do we get the measure of patient care? British Medical Journal. 2008: 336 249.

PMID: 18244995


  • Author agrees with movement to measure quality through process-based measurements.

  • Article outlines Patient Reported Outcome Measures (PROMs), which will help assess quality in care from the patients perspective post-operation.

  • Author warns because of the high number of patients needed to comply, the system, “will add to the noise, without contributing much to the signal.”

Significance to Literature:

  • Article argues against using death or specific outcome measures in P4P. Suggests limitation of using PROMs in P4P.

(154) Majeed A, Lester H, Bindman A. Improving the quality of care with performance indicators. British Medical Journal. Analysis. 2007: 335 916-918.

PMID: 17974688


  • Gives reasoning behind P4P, and why measuring performance is important.

  • Although public reporting does not seem to play a role in how patients choose their general practice physician, public reporting does encourage providers to improve quality.

  • Author recommends that internationally accepted data standards and coding would allow for large amounts of data, and comparisons of quality across countries.

Significance to Literature:

  • Outlines the use of P4P for quality comparisons from the individual clinician to the international level.

(162) ***Key Article***

Campbell SM, McDonald R, Lester H. The Experience of Pay for Performance in English Family Practice: A Qualitative Study. Annals of Family Medicine. 2008: 6(3) 228-234.

PMID: 18474885


  • Interviewed 20 nurses and 21 family doctors across England to explore beliefs and concerns about changes to service as a result of P4P between 2004-2007.

  • Many doctors and nurses acknowledged that nurses have become the primary provider of health care for patients with chronic disease, however most P4P reimbursements go to doctors.

  • The QOF achieved objectives:

    • Improved disease specific processes of patient care

    • Increased primary care physician income

    • Improved data capture

  • Lists unintended consequences including:

    • Dual QOF-patient agenda within consultations

    • Potential deskilling of doctors

    • Decline in doctor/patient continuity of care

    • Resentment by team member not benefiting financially

    • Concerns about an ongoing culture of performance monitoring

Significance to Literature:

  • British family doctors and nurses surveyed believe that despite benefits, P4P negatively affects relationships between doctors, nurses, and patients.

(163) Mannion R, Davies HT. Incentives in health systems: developing theory, investigating practice. Journal of Health Organization and Management. 2008: 22(1) 5-10.

PMID: 18488515


  • Provides and a definition and an overview of P4P.

  • Highlights recent findings/results in other countries.

  • Need to move beyond case accounts of on-the-surface-successful implementation of P4P schemes to more theoretically driven and analytic evaluations of such schemes in all their diversity.”

Significance to Literature:

  • Overview of P4P case results in many countries.

(164) ***Key Article***

Doran T. Lessons from Early Experience with Pay for Performance. Journal Disease Management and Health Outcomes. 2008: 16(2) 69-77.


  • Evidence of long-term benefits and harms of the UK’s QOF P4P schemes is beginning to emerge, better health outcomes must be observed to continue P4P.

  • Early reports from the UK are encouraging.

  • Author lists 10 characteristics of successful P4P schemes, and discusses 3 risks associated with P4P that must be examined.

Significance to Literature:

  • Provides insights, based on data from 2004-2007, about successful and unsuccessful elements of the United Kingdom’s QOF P4P program.

(184) Ashworth M, Millett C. Quality Improvement in UK Primary Care: The Role of Financial Incentives. Journal of Ambulatory Care Management. 2008: 31(3) 220-225.

PMID: 18574380


  • Article outlines the inception of QOF, its initial outcomes, and how QOF rewards physicians.

  • Discusses QOF as a research tool, and the future directions of QOF.

Significance to Literature:

  • After a short period of time, QOF has become an instrumental tool to improving quality in the UK, and its role will grow in the coming years.

(186) ***Key Article***

Doran T, Fullwood C, Reeves D, Gravelle H, Roland M. Exclusion of Patients from Pay-for-Performance Targets by English Physicians. NEJM. 2008: 359(3) 274-284.

PMID: 18635432


  • Article first discusses the three approaches to avoiding inappropriate treatment of patients when a quality indicator does not apply when other considerations must take precedence:

    • 1. Risk-adjust

    • 2. Maximum achievement thresholds

    • 3. Exception reporting

  • Analysis of data from exception reporting in the UK, including financial gain analysis, and the effect of the characteristics of patients and medical practices.

  • The median rate of exceptions in 2005-2006 was 5.3%

  • Authors conclude that exception reporting has brought substantial benefits to P4P in the UK, and there is little evidence of gaming the system.

  • Exceptions accounted for about 1.5% of the cost of the P4P program in the UK.

  • Discusses the arguments for and against exception reporting.

Significance to Literature:

  • Exclusion of patients is necessary in P4P, this demonstrates a successful attempt to do so.

(194) Doran T, et al. Pay-for-Performance Programs in Family Practices in the United Kingdom. NEJM. 355(4) 375-384.

PMID: 16870916


  • Analyzed data from the NHS from April 2004-March 2005 about the use of clinical indicators amongst the entire population, and determined the extent to which exception reporting utilized.

  • Exception reporting was not extensive, but it was the strongest predictor of achievement. A 1% increase in exception reporting correlated with .31% increase in reported achievements.

  • Exception reporting was high in only a small amount of practices.

Significance to Literature:

  • A small number of practices appear to have achieved high scores by excluding a large number of patients by exception reporting.

(201) Perkins R, Seddon M. Quality Improvement in New Zealand healthcare. Part 5: measurement for monitoring and controlling performance—the quest for external accountability. The New Zealand Medical Journal. 119(1241).

PMID: 16964301


  • The key audience for report cards and public reporting seems to be provider organisations, not patients or the public at large.

  • Performance data is very complex, and that must be recognized when using performance indicators.

  • All performance indicators give rise to some form of perverse or unintended consequence. Article lists some of these possible consequences.

Significance to Literature:

  • Serious pitfalls of performance indicators must be addressed in New Zealand’s performance indicators and public report cards.

(209) Campbell S, et al. Quality of Primary Care in England with the Introduction of Pay for Performance. NEJM. 2007: 357(2) 181-190.

PMID: 17625132


  • Study of 42 physicians practices in England tracking performance indicators from 1998, 2003 (both pre-P4P), and 2005 (with P4P). Authors compared trends in 30 indicators with financial incentives, and 17 indicators without.

  • The quality of performance for indicators with financial incentives in coronary heart disease, type 2 diabetes, and asthma was substantially higher than those performance indicators without incentives.

  • However, scores did not differ significantly from trend rate predicted performance scores.

Significance to Literature:

  • Results show modest acceleration of quality improvement for diabetes and asthma.

(211) Roland M. Linking Physicians’ Pay to the Quality of Care—A Major Experiment in the United Kingdom. NEJM. 2004: 351(14) 1448-1454.

PMID: 15459308


  • Detailed summary of the Quality and Outcomes Framework, P4P in the United Kingdom.

Significance to Literature:

  • Objective overview of the P4P program in the United Kingdom in 2004.

(227) Wilson JF. Lessons for Health Care Could Be Found Abroad. Annals of Internal Medicine. 2007: 146(6) 473-476.

PMID: 17371900


  • In 2001, the Organization for Economic Co-operation and Development (OECD) launched the Health Care Quality Indicator (HCQI) project, a 23 country collaboration, to formalize data collection and reporting worldwide in hopes of using the data to learn ways to improve quality care across countries.

  • Countries include UK, US, Canada, Australia, Denmark, France, Germany, Japan, Mexico, and the Netherlands.

  • The use of EMRs will greatly help data collection.

Significance to Literature:

  • Learning from other countries will be an important way to improve quality of care, and P4P programs.

(229) Duckett S, et al. Pay for Performance in Australia: Queenland’s new Clinical Practice Improvement Payment. Journal of Health Services Research & Policy. 2008: 13(3)174-177.

PMID: 18573767


  • Queensland, Australia is implementing a new P4P system called Clinical Practice Improvement Payment system (CPIP) that rewards hospitals for achievement of clinical process indicators.

  • Physician skepticism reinforces the importance of clinician involvement in measurement development.

  • CPIP is not universally endorsed, however, Australia is now making a concerted effort to involve physicians about measurement development.

Significance to Literature:

  • P4P in Australia appears to be gaining widespread, if somewhat reluctant, acceptance.”

(242) Satin DJ. Paying Physicians and Protecting the Poor. Minnesota Medicine. Commentary. 2006 Apr;89(4):42-4. 

PMID: 16681283


  • Adjust performance goals to account for the socioeconomic status of patients and allow for limited exceptions to the program.”

  • P4P programs must realize that patients have many determinants of health, and that as little as 10% of their health status can be based on their health provision.

  • P4P in New Zealand and the United Kingdom have devised ways to risk adjust.

Significance to Literature:

  • P4P programs must risk adjust in order to accurately assess physician performance.

(253) Smylie J, Anderson I, Ratima M, Anderson M. Indigenous health performance measurement systems in Canada, Australia, and New Zealand. The Lancet. Viewpoint.  2006: 367 2029-2031.

PMID: 16782494


  • Article discusses how performance measurements may be troublesome in indigenous populations in Canada, Australia, and New Zealand.
  • Primarily, indicators are nationwide quality markers, and not good markers of quality within indigenous communities possibly due to different health beliefs.
  • Authors suggest that performance markers should be set by local communities, in hopes of engaging health care communities most effectively.


Significance to Literature:

  • Suggest unique approach to quality improvement for indigenous peoples.

(283) Scott IA. Pay for performance programs in Australia: a need for guiding principles. Australian Health Review. 2008: 32(4) 740-749.

PMID: 18980570


Paper outlines 10 principles for success for P4P programs derived from a review of published trials, program evaluations, and position statements:

   1. Formulate rationale and business case

   2. Use established evidence-based performance measures

   3. Use rigorous and verifiable methods of data collection and analysis
   4. Define performance targets using absolute and relative thresholds
   5. Use rewards that are sufficient, equitable, and transparent

   6. Address appropriateness of provider responses and avoid perverse incentives.

   7. Implement governance procedures which incorporate communication and feedback strategies

   8. Use existing structures to implement P4P programs.

   9. Attribute credit for performance to participants in ways that foster population-based perspectives
   10. Invest in outcomes and health service research


Significance to Literature:

  • Overview of literature suggestions for P4P program implementation

(284) Cupples ME, Byrne MC, Smith SM, Leathem CS, Murphy AW. Secondary prevention of cardiovascular disease in different primary healthcare systems with and without pay-for-performance. Heart. 2008: 94 1594-1600.

PMID: 18701532


  • Analyzes baseline cardiovascular care in the United Kingdom (P4P) versus Northern Ireland (No P4P). Assesses how P4P may factor into the quality of care.
  • A strong, publicly funded healthcare systems, like Northern Ireland's, may manage risk factors well, but patients still have less healthy lifestyles and poorer quality of life. In contrast, the United Kingdom has a mixed healthcare economy, and relatively healthier lifestyles.
  • Prevention measures may have different impacts on populations depending on the nature of the healthcare system.


Significance to Literature:

  • One cannot simply import successful P4P measures from another healthcare system and expect similar results.

(293) Rubenstein A, et al. A Multimodal Strategy Based on Pay-Per-Performance to Improve Quality of Care of Family Practitioners in Argentina. Journal of Ambulatory Care Management. 2009: 32(2) 103-114.

PMID: 19305222


  • Reports results after 2 years of instituting a Quality Improvement program in Buenos Aires that utilizes P4P, teamwork, continuous education, and audit and feedback.
  • Primary Care groups earn up to a 1000 points in the system from a complex set of indicators made up of each of the five categories above.
  • A significant improvement in all indicators related to clinical effectiveness was achieved.
  • A ceiling effect of scores was observed.


Significance to Literature:

  • P4P as being only one part of a QI program may be another way to utilize financial incentives.

(298) Babic M. Pay-for-performance planned for SMH. March 3, 2009.




  • In Canada, Surrey Memorial Hospital is beginning a P4P program that aims to reduce wait times in the hospital.
  • The hospital will receive bonus payments for getting patients either discharged or admitted in less than certain allotted amounts of time.


Significance to Literature:

  • P4P is being used to reduce waiting times and improve efficiency.

(306) Custers T, Arah OA, Klanzinga NS. Is there a business case for quality in The Netherlands? A critical analysis of the recent reforms of the health care system. Health Policy. 2007: 82 226-239.

PMID: 17070956



  • Analysis of new reimbursement program in the Netherlands.
  • Authors argue that new P4P program only advocates efficiency, and not bettering quality of care.
  • Discussion of the free market environment of healthcare and its limitations.


Significance to Literature:

  • The current market trends in healthcare limit the ability of P4P to impact quality of care provided.

P4P by State Literature

(23) Smith D. Pawlenty says new health care plan will ‘transform system.’ Minneapolis Star Tribune. August 1, 2006.


  • Article briefly outlines a new Minnesota health plan called Qcare.

  • Qcare is a state P4P system that sets standards for optimal care.

Significance to Literature:

  • One of many state P4P programs.

(57) Smith S. 2007 quality scores stall. Minnesota Medical Association: Quality review. Winter, 2008.



  • In 2007, outcome scores did not increase in Minnesota for the first time in 4 years.

  • Thought to be because of increasing numbers of participating physicians; results no longer reflect only the most advanced practices.

  • Also thought to be because of possible ceiling effect. “Lots of groups have done the easy things to improve quality.”

Significance to Literature:

  • Statewide report of sustained P4P over four years with possible ceiling effect.

(60)***Key article in MN***

Schierman B. A Review of Pay for Performance in Minnesota. Minnesota Medical Association. November, 2007.




  • Document outlines 9 different P4P plans in Minnesota

  • Offers charts comparing the P4P programs.

  • Evaluates programs’ alignment with MMA principles August, 2007.

  • Suggests recommendations for P4P in Minnesota.

Significance to Literature:

  • In-depth analysis of P4P in Minnesota through November 2007.


(322) Vinz C, Foreman J, Bonneville S. Minnesota's Baskets-of-Care Project: Scope, Component, and Measurement. Minnesota Medicine. 2010



  • Discusses the process the Minnesota department of health took, including seeking input from 140+ stakeholders and contracted with the Institute for Clinical Systems Improvement (ICSI) to create 8 baskets of care payments.
  • Further gives an in depth look at patient qualifications for each basket and its associated recommended quality measures. Baskets include:
    • Asthma care for children
    • Diabetes
    • Prediabetes
    • Acute episode of low back pain
    • Obstetric care
    • Preventive care for adults
    • Preventive care for children
    • Total knee replacement
  • Provides insight into the current implementation in baskets of care and directs readers to a how-to guide at


Significance to Literature:

  •  Offers overview of one of many new bundled payments pilot projects.