"Pay-for-performance" as a quality improvement tool: perceptions and policy recommendations of physicians and program...

Although pay-for-performance (P4P) compensation is widespread, questions have arisen about its efficacy in improving health care quality and consequences for vulnerable patients.

To assess perceptions of general internists and P4P program leaders regarding how to implement fair and effective P4P.

Qualitative investigation using in-depth interviews with P4P program leaders and focus groups with general internists.

Internists emphasized a gradual and cautious approach to P4P implementation. They strongly recommended improving P4P measure validity and had detailed suggestions regarding how. Program leaders saw a need to implement perhaps imperfect programs but with continual improvement. Both groups advocated protecting vulnerable populations and made overlapping recommendations: improving measure validity; adjusting for patient characteristics; measuring improvements in quality (vs cutpoints); and providing incentives to physicians of vulnerable populations. Internists tended to favor explicit protections, while program leaders felt that P4P might inherently protect vulnerable patients by improving overall quality.

Internists favored gradual P4P implementation, while P4P leaders saw an immediate need for implementation with iterative improvement. Both groups recommended specific measures to protect vulnerable populations such as improving measure validity, assessing improvements in quality, and providing special incentives to physicians of vulnerable populations.