P4P Program Research Articles

Household food security and dietary diversity in the context of an agricultural and market development program in Guatemala

WFP's Purchase for Progress (P4P) is a pilot program that enhances agricultural productivity and access to markets among low‐income farmers. We compared food security and dietary diversity between P4P beneficiaries and a control group. We evaluated household conditions, food security (ELCSA), and dietary diversity in 372 households (271 P4P; 101 control) using a cross‐sectional design and mixed‐methods. Most Significant Change methodology was used to characterize participants’ experiences. Education level (EL), number of children (NC), household quality (HQS), food security (FSS), carotenoid‐rich foods (VAS), and dietary diversity for households (HDDS), women (WDDS), children (IDDS), and normalized (HDDSn) were calculated. P4P participants were less food insecure (FSS=7.4±4.4, 9.2±3.1; p<0.01), and had increased dietary diversity (HDDS=8.9±1.8, 7.0±1.8; p<0.01), HDDSn, WDDS, IDDS, and VAS (p<0.01) than controls. For P4P, FSS was associated with EL (r=0.23, p<0.05); and HDDS with EL (r=0.23, p<0.05) and NC (r=−0.17). For controls, FSS was associated (p<0.05) with HDDS (r=0.53), HQS (r=0.61), and NC (r=−0.23). Women empowerment, intra‐household dynamics, higher crop productivity and technical knowledge were dominant themes among P4P beneficiaries. P4P program has a positive effect on food security and dietary diversity, which are perceived as important elements in improving livelihoods.Grant Funding Source: Ayre international research fellowship (JRL), Hatch (JEA), USDA‐ISE (WGH, NJE, and JEA)

성과연동지불제도의 확대 가능성 고찰

This paper investigates the possibility of expanding pay-for-performance (P4P) program as a provider payment system, in terms of financial, economical, and political sustainability. In order to expand the sustainable P4P, P4P should have usefulness in terms of economic value as well as efficiency in the financial aspects of health care. More importantly, the P4P would be politically sustainable only when both providers and consumers can accept. Korea's healthcare system seems to have logical ground for the P4P program financially and economically. However, how well the P4P can work remains to be proven in its implementation. After 43 tertiary hospitals applied the P4P program for acute myocardial infarction (AMI) and C-section in 2007, the number of hospitals adopting the P4P program for AMI and C-section has increased to 316 in 2011, and an incentive for hospitals applying the P4P has risen to 2% from 1% of health insurance benefits. This shows that the P4P program introduced by Health Insurance Review and Assessment Service is quite successful. In addition, people are aware of the need for improved P4P program and policy alternatives have been already made. Therefore, it is very important to come up with politically supportable strategies that can make providers and consumers accept the P4P program while maintaining the governance of the existing health insurance policy. To this end, there are some tasks to be considered. First, the expansion of the P4P program should be placed on the agenda of the Health Insurance Policy Review Committee, the highest decision-making body, and a separate agency for P4P planning should be established. Second, for more efficient P4P program, the processes of review and assessment, currently carried out separately, should be integrated into a single process. Third, infrastructure to measure the quality of medical services should be sharply expanded. Fourth, the current paradigm for the assessment should be changed. Lastly, a P4P program for consumers should be considered. Given that the consumers in Korea can use medical services freely, the National Health Insurance Corporation could initiate the P4P program for consumers as a means of controlling excessive use of medical services and adjusting consumer's moral hazard.

The Effect of Pay‐for‐Performance in Nursing Homes: Evidence from State Medicaid Programs

Pay-for-performance (P4P) is commonly used to improve health care quality in the United States and is expected to be frequently implemented under the Affordable Care Act. However, evidence supporting its use is mixed with few large-scale, rigorous evaluations of P4P. This study tests the effect of P4P on quality of care in a large-scale setting-the implementation of P4P for nursing homes by state Medicaid agencies. 2001-2009 nursing home Minimum Data Set and Online Survey, Certification, and Reporting (OSCAR) datasets. Between 2001 and 2009, eight state Medicaid agencies adopted P4P programs in nursing homes. We use a difference-in-differences approach to test for changes in nursing home quality under P4P, taking advantage of the variation in timing of implementation across these eight states and using nursing homes in the 42 non-P4P states plus Washington, DC as contemporaneous controls. Quality improvement under P4P was inconsistent. While three clinical quality measures (the percent of residents being physically restrained, in moderate to severe pain, and developed pressure sores) improved with the implementation of P4P in states with P4P compared with states without P4P, other targeted quality measures either did not change or worsened. Of the two structural measures of quality that were tied to payment (total number of deficiencies and nurse staffing) deficiency rates worsened slightly under P4P while staffing levels did not change. Medicaid-based P4P in nursing homes did not result in consistent improvements in nursing home quality. Expectations for improvement in nursing home care under P4P should be tempered.

An Examination of Pay‐for‐Performance in General Practice in Australia

This study examines the impact of Australia's pay-for-performance (P4P) program for general practitioners (GPs). The voluntary program pays GPs A$40 and A$100 in addition to fee-for-service payment for providing patients recommended diabetes and asthma treatment over a year, and A$35 for screening women for cervical cancer who have not been screened in 4years. Three approaches were used to triangulate the program's impact: (1) analysis of trends in national claims for incentivized services pre- and postprogram implementation; (2) fixed effects panel regression models examining the impact of GPs' P4P program participation on provision of incentivized services; and (3) in-depth interviews to explore GPs' perceptions of their own response to the program. There was a short-term increase in diabetes testing and cervical cancer screens after program implementation. The increase, however, was for all GPs. Neither signing onto the program nor claiming incentive payments was associated with increased diabetes testing or cervical cancer screening. GPs reported that the incentive did not influence their behavior, largely due to the modest payment and the complexity of tracking patients and claiming payment. Monitoring and evaluating P4P programs is essential, as programs may not spark the envisioned impact on quality improvement.

Medicare Readmission Rates Showed Meaningful Decline in 2012

Descriptive analysis of 30-day, all-cause hospital readmission rate patterns from 2007-2012. Medicare FFS beneficiaries experiencing at least one acute inpatient hospital stay. Using Chronic Condition Data Warehouse claims, we estimate unadjusted, monthly, readmission rates for the nation, within the Dartmouth Hospital Referral Regions (HRR), and compare participating and non-participating hospitals in the Partnership for Patients (P4P) program (overall and by number of inpatient beds at each facility). From 2007 through 2011, the national 30-day, all-cause, hospital readmission rate averaged 19 percent. During calendar year 2012, the readmission rate averaged 18.4 percent. Of the 306 HRRs, rates in 166 HRRs fell by between 1 and 5 percent, while rates dropped by more than 5 percent in 73 HRRs, with the largest reduction in Longview, Texas. Rates increased by more than 1 percent in only 30 HRRs, with the largest increase in Bloomington, Illinois. Readmission rates at hospitals participating in the P4P program have been, on average, consistently lower than the rates at non-participating hospitals within all size categories except for the very smallest and largest hospitals, but rates at both participant and non-participant hospitals fell in 2012. Although claims data are not yet final for 2012, our analysis indicates that hospital readmission rates for all Medicare FFS beneficiaries dropped noticeably during the year. The reasons behind the apparent reduction are not yet clear and merit further investigation.

The association of clinical guideline adherence and pay-for-performance among patients with diabetes

BackgroundDiabetes mellitus management is one of the most challenging health care issues in Taiwan. To improve guideline adherence and the quality of diabetes care, the diabetes mellitus pay-for-performance (DM-P4P) program was introduced in 2001. This study examined the effects of the DM-P4P program on guideline adherence among patients with diabetes. MethodsThis cross-sectional study used National Health Insurance (NHI) claim data to assess guideline adherence among three groups of patients with diabetes: patients enrolled in the DM-P4P program, patients not enrolled but treated by DM-P4P-participating physicians, and patients treated by non-P4P physicians. Guideline adherence measures included hemoglobin A1c, blood glucose, lipid, serum creatinine, alanine transaminase, urinalysis, and eye examinations. Multiple logistic regression with generalized estimated equation approach were used to assess the effect of the DM-P4P program while controlling for patient and physician characteristics. ResultsA total of 520,804 patients were included in the analysis. Patients enrolled in the DM-P4P program were more likely to receive all of the guideline-recommended tests/examinations than patients treated by non-P4P physicians. Patients who were not enrolled in the program but who were treated by DM-P4P-participating physicians were more likely to receive three of the seven recommended tests/examinations than were those treated by non-P4P physicians. ConclusionWhen physicians participated in the P4P program, this increased the likelihood that patients would receive guideline-recommended tests or examinations. Increasing the DM-P4P participation rates for physicians and patients are important and worthwhile objectives that can assist in the effort to more effectively manage diabetes in the general population.

Provider and patient directed financial incentives to improve care and outcomes for patients with diabetes.

Incentive programs directed at both providers and patients have become increasingly widespread. Pay-for-performance (P4P) where providers receive financial incentives to carry out specific care or improve clinical outcomes has been widely implemented. The existing literature indicates they probably spur initial gains which then level off or partially revert if incentives are withdrawn. The literature also indicates that process measures are easier to influence through P4P programs but that intermediate outcomes such as glucose, blood pressure, and cholesterol control are harder to influence, and the long-term impact of P4P programs on health is largely unknown. Programs directed at patients show greater promise as a means to influence patient behavior and intermediate outcomes such as weight loss; however, the evidence for long-term effects are lacking. In combination, both patient and provider incentives are potentially powerful tools but whether they are cost-effective has yet to be determined.

LINK BETWEEN PAY FOR PERFORMANCE INCENTIVES AND PHYSICIAN PAYMENT MECHANISMS: EVIDENCE FROM THE DIABETES MANAGEMENT INCENTIVE IN ONTARIO

Pay for performance (P4P) incentives for physicians are generally designed as additional payments that can be paired with any existing payment mechanism such as a salary, fee-for-services and capitation. However, the link between the physician response to performance incentives and the existing payment mechanisms is still not well understood. In this article, we study this link using the recent primary care physician payment reform in Ontario as a natural experiment and the Diabetes Management Incentive as a case study. Using a comprehensive administrative data strategy and a difference-in-differences matching strategy, we find that physicians in a blended capitation model are more responsive to the Diabetes Management Incentive than physicians in an enhanced fee-for-service model. We show that this result implies that the optimal size of P4P incentives vary negatively with the degree of supply-side cost-sharing. These results have important implications for the design of P4P programs and the cost of their implementation.

PHP72 Making Money Work for Improvement of Patient Care: Success and Shortcomings of Pay-for-Performance Program in Taiwan

Pay-for-Performance (P4P) program was introduced in Taiwan in 2001 for treatment of breast cancer (BC), diabetes mellitus (DM), tuberculosis (TB), asthma, and cervical cancer. Although P4P is increasingly being implemented, there remains insufficient evidence to support the belief that the P4P incentive design improved the outcomes of care. Embase® and MEDLINE® were searched from 2001-2012 using the key terms “pay-for-performance” and “P4P” for studies published in English. Of the 1413 screened, 14 studies assessing P4P program in Taiwan were identified. Studies assessing P4P in patients with asthma and cervical cancer were not retrieved. The BC-P4P enrolees received better quality care (p=0.001), resulting in better 5-year overall survival (odds ratio [OR]: 5.99; p=0.003) and less recurrence (OR: 2.70; p=0.002) when compared to non-enrolees. The effect was more pronounced in low-volume hospitals (OR: 1.38; [95%CI: 1.08 - 1.77]) and non-medical centres (OR: 1.62; [95%CI: 1.24 - 2.11]). Among TB-P4P enrolees, cure rate within 12 months of treatment significantly increased (OR, 1.338; [95%CI: 1.159 - 1.544]), whereas default rate from treatment significantly decreased (OR, 0.904; [95%CI: 0.702 - 0.973]) compared to non-P4P enrolees. In DM-P4P enrolees, the cost of diabetes-related physician visits was higher (5731 NT$/patient), however, costs of diabetes-related hospitalisations (-5099 NT$/patient) and overall expenditures on health services (-10 543 NT$/patient) were considerably lower compared to non-enrolees. Hospitals in cities with low-income levels were more likely to participate in P4P programs compared to hospitals in high-income level cities (OR: 4.53; [95%CI: 2.87 - 7.16]). The results illustrated that older patients and patients with high co-morbidity/severity were prone to be excluded from P4P programs. Patients enrolled in the P4P program received a better quality of care and demonstrated better outcomes than the non-enrolled patients. However, benefit of P4P can be extended by including older patients and those with higher disease severity and co-morbidities.

Managing Pay for Performance: Aligning Social Science Research with Budget Predictability

Managers and policymakers are seeking practical guidelines for assessing the outcomes of emerging pay-for-performance (P4P) programs. Evaluations of P4P programs published to date are mixed-some are confusing-and methodological problems with them are common. This article first identifies and summarizes obstacles to implementing effective P4P programs. Second, it describes results from social science research going back several decades to support evidence-based P4P best practices. Among the findings from this research, the zero-sum and "earn it back" P4P incentive systems have important drawbacks and may be counterproductive, neither reducing health system costs nor improving quality. The research suggests that punishing participants for low performance may further reduce individuals' performance, especially when involvement is required. We suggest that optimal P4P systems are those that reward all participants for performance improvements. Third, the article links P4P design to budgetary considerations. P4P program designs that provide incentives while improving quality and reducing costs are critical if budget neutrality is a priority for the organization and its resources are limited. In these types of P4P designs, cost calculations are straightforward: The greater the participation, the higher the savings. The article concludes by recommending an evidence-based P4P approach for practitioners that can be implemented without large upfront investment. More research on this topic is also advised.

Impact of a pay for performance program to improve diabetes care in the safety net

ObjectiveTo evaluate the impact of a “piece-rate” pay for performance (P4P) program aimed at improving diabetes care processes, outcomes and related healthcare utilization for patients enrolled in a not-for-profit Medicaid-focused managed care plan. MethodsTo evaluate Hudson Health Plan's P4P program in New York (2003–2007), we conducted: (1) a case-comparison difference-in-difference study using plan-level administrative data; (2) a patient-level claims data analysis; and (3) a cross-sectional survey. ResultsThe case-comparison study found that diabetes care processes (e.g., HbA1c, lipid, and dilated eye exam rates) and outcomes (e.g., LDL-C<100mg/dL) did not improve significantly over the study period. Claims analysis showed that younger adults had significantly increased odds (OR 3.50–3.56, p<0.001) of using emergency and hospital-based services and similarly decreased odds of receiving recommended care process (OR 0.22–0.36, p<0.01–0.001). Survey study indicated that practices lack fundamental quality improvement infrastructures and training. ConclusionsRecent health legislation mandates the use of P4P incentives in government programs that disproportionately care for patients with lower socioeconomic or minority backgrounds (e.g., Medicaid, Veterans Health Administration, and Tricare). More research is needed in order to understand how to tailor P4P programs for vulnerable care settings.

Healthcare organizations’ attitudes toward pay-for-performance in Korea

This study was conducted to assess views of healthcare organizations on pay-for-performance (P4P) in terms of its design, possible effects, and unintended consequences. This is a cross-sectional, self-administered, internet-based survey. Eligible healthcare organizations were 3605 organizations in Korea. Healthcare organizations of 522, including 31 tertiary teaching hospitals, 182 general hospitals, 158 hospitals, and 152 clinics, were participated in this survey. Rates of awareness and support of P4P, preferred P4P program design, and possible effects and unintended consequences resulting from the P4P program were identified. There were variations in the awareness and support from the type of healthcare organization. The preferred design was quite different from the current design of the P4P program. They believed that the P4P program would not have a significant economic impact on their organizations, but that the P4P program could stimulate positive changes in their practice behaviors. They also showed considerable concerns about unintended consequences. P4P implementing agency such as HIRA in Korea should make an effort to improve healthcare organizations’ understanding of the program. Also, HIRA could take into consideration of reflecting their reasonable opinions regarding its design components and unintended consequences.

Assessment of a pay-for-performance program in primary care designed by target users

Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects. To assess changes in performance after introducing a participatory P4P program. An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark. Quality indicators for clinical care (process and outcome) and patient experience. We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement. A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral Health Care

We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics. We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization. Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval=1.39, 2.14) after the P4P program implementation compared with pre-program implementation. Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.

Design choices made by target users for a pay-for-performance program in primary care: an action research approach

BackgroundInternational interest in pay-for-performance (P4P) initiatives to improve quality of health care is growing. Current programs vary in the methods of performance measurement, appraisal and reimbursement. One may assume that involvement of health care professionals in the goal setting and methods of quality measurement and subsequent payment schemes may enhance their commitment to and motivation for P4P programs and therefore the impact of these programs. We developed a P4P program in which the target users were involved in decisions about the P4P methods.MethodsFor the development of the P4P program a framework was used which distinguished three main components: performance measurement, appraisal and reimbursement. Based on this framework design choices were discussed in two panels of target users using an adapted Delphi procedure. The target users were 65 general practices and two health insurance companies in the South of the Netherlands.ResultsPerformance measurement was linked to the Dutch accreditation program based on three domains (clinical care, practice management and patient experience). The general practice was chosen as unit of assessment. Relative standards were set at the 25th percentile of group performance. The incentive for clinical care was set twice as high as the one for practice management and patient experience. Quality scores were to be calculated separately for all three domains, and for both the quality level and the improvement of performance. The incentive for quality level was set thrice as high as the one for the improvement of performance. For reimbursement, quality scores were divided into seven levels. A practice with a quality score in the lowest group was not supposed to receive a bonus. The additional payment grew proportionally for each extra group. The bonus aimed at was on average 5% to 10% of the practice income.ConclusionsDesigning a P4P program for primary care with involvement of the target users gave us an insight into their motives, which can help others who need to discuss similar programs. The resulting program is in line with target users' views and assessments of relevance and applicability. This may enhance their commitment to the program as was indicated by the growing number of voluntary participants after a successfully performed field test during the procedure. The elements of our framework can be very helpful for others who are developing or evaluating a P4P program.

Paying for Prevention: Associations between Pay for Performance and Cessation Counseling in Primary Care Practices

To examine associations between pay for performance (P4P) and recommended cessation counseling among primary care practices (PCPs). Cross-sectional survey of 89 PCPs participating in a joint Robert Wood Johnson Foundation (RWJF)-Agency for Healthcare Research and Quality (AHRQ) health promotion initiative. 100% response rate from PCPs participating in the RWJF-AHRQ initiative. Survey data on cessation counseling, practice involvement with P4P, practice size, public reporting of performance, practice competition, linkages with community resources, integration of evidence-based guidelines, patient recommendations for cessation, and state-specific smoking rates. Logistic regression was used to examine associations between practice involvement with P4P and cessation counseling offered by PCPs. Practice characteristics, including size and availability of other cessation services, were included in the analysis. Practices that were involved with P4P had greater odds of offering recommended cessation counseling (odds ratio [OR] = 27.6, p < .01). Practices that linked patients to community resources, experienced greater competition, and were larger in size also provided more counseling (p < .05). Publicly reporting performance information and being located in states with higher smoking rates were associated with decreased odds of offering counseling support (p < .10). Findings suggest that P4P is associated with recommended counseling for smoking cessation. Study limitations include small sample size and unavailability of information on the magnitude of P4P incentives and program design. Further analysis considering these programmatic details is warranted.

Differences in patient reports on the quality of care in a diabetes pay-for-performance program between 1 year enrolled and newly enrolled patients

This study aimed to assess the quality of care from the perspective of patients who participated in the diabetes pay-for-performance (P4P) program in Taiwan. A cross-sectional telephone interview to measure the quality of care for patients with diabetes mellitus. A stratified sampling according to the level and region of the health-care providers in Taiwan. A total of 1796 patients with diabetes mellitus responded to the telephone survey. The patients were divided into two groups according to the length of time they had participated in the program: (1) the case group, who had received comprehensive care for at least 1 year and (2) the control group, who were newly enrolled in the diabetes mellitus P4P program for <3 months. The compliance of diabetes self-care and the level of satisfaction with the quality of care from the perspective of the patients. After controlling for the characteristics of the health-care providers involved, pattern of diabetes treatment, self-reported health status and other patient characteristics, the case group performed better in exercise, had regular medication and better foot care and showed overall compliance with diabetes self-care and perceived better quality of care than the control group. The patients who had received comprehensive care for 1 year showed better compliance with self-care and were more satisfied with the quality of care they had received. The P4P program appears to be associated with this enhanced care.

Pay for Performance in Health Care

Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.

Pay-For-Performance Programs to Reduce Racial/Ethnic Disparities: What Might Different Designs Achieve?

Pay-for-performance (P4P) programs may have unintended effects on racial/ethnic disparities. We used patient-level quality scores from the Hospital Quality Alliance and ranked hospitals by overall quality and by racial/ethnic disparities. We then modeled the effects of different P4P designs on national disparity scores. The models using overall quality to rank hospitals resulted in modest reductions in national disparity scores, although these were smaller than the reductions that were found from programs using disparities to rank hospitals. These results suggest that many hospitals treat Whites and minorities equitably. Nevertheless, in order to maximize both improvements in quality and reductions in national disparities, P4P programs should consider an approach that considers both overall quality and reductions in disparities when setting incentives.

The Reliability of Medical Group Performance Measurement in a Single Insurer’s Pay for Performance Program

Most public reporting and pay for performance (P4P) programs in the United States continue to be organized and implemented by single insurers. Adequate medical group-level reliability on clinical care process measures is possible in multistakeholder initiatives because patient samples can be pooled across payers. However, the extent to which reliable measurement is achievable in single insurer P4P initiatives remains unclear. This study uses 7 years (2001 to 2007) of patient-level clinical care process data from an insurer in Washington State involving 20 medical groups. Eight clinical care process measures were analyzed. We compared the medical group-level reliability and resulting sample size requirements for each of the 8 measures using unadjusted and adjusted binary mixed models. The relation of baseline intraclass correlation coefficients (ICCs) and medical group performance change over time was examined for each clinical care process measure. Only 45% of all medical group measurements (group-years for all observations) had sufficient sample sizes to achieve reliable estimates of group performance. Measures with the largest deficiencies in patient samples per group included appropriate asthma treatment and low-density lipoprotein screening for patients with coronary artery disease. There was an inconsistent relationship between the size of baseline ICCs and medical group performance improvement over time. Unreliable performance measurement is an important consequence of the prevailing organization and implementation of public reporting and P4P programs in the US. Multi-payer collaborations may be an important vehicle for ensuring reliable medical group performance measurement and comparisons on clinical care process measures.