Pay-for-performance programs are now firmly ensconced in the payment systems of US public and private insurers across the spectrum. More than half of commercial health maintenance organizations are using pay-for-performance, and recent legislation requires Centers for Medicare & Medicaid Services (CMS) to adopt this approach for Medicare.1 As commercial programs have evolved during the last 5 years, the categories of providers (clinicians, hospitals, and other health care facilities), numbers of measures, and dollar amounts at risk have increased. In addition, acceptance of performance measurement among physicians and organized medicine has broadened, with the American Medical Association committing to the US Congress in February 2006 that it would develop more than 100 performance measures by the end of 2006.2
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