In 2005, the Commonwealth Fund, a highly respected health policy group, commissioned a survey of health care opinion leaders. The leaders identified pay for performance (P4P), the notion that the provision of better care should result in more payment, as the single most promising approach to improving the performance of the US health care system.1 The enthusiasm behind P4P was driven by a simple concept: people and institutions respond to incentives. If incentives are created that promote quality and efficiency, better care should occur. However, the intervening years have not been kind to the advocates of P4P. Since that 2005 survey, the preponderance of the evidence that has emerged suggests that P4P, at least as currently conceived, is not working.2
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