Abstract
As industrialized countries around the world encounter rising health care costs with little to show in quality and health outcome improvements, they increasingly are turning to pay-for-performance mechanisms to align provider action with quality, equity, and efficiency goals. The primary objective of most pay-for-performance schemes is to improve quality of care, and the logic of linking financial rewards to quality and performance metrics makes sense. However, despite broad international experience with pay-for-performance, evidence of its impact is limited, frequently conflicting, focuses largely on improvements in the provision and structure of care rather than health outcomes, and tends to generate more questions than it does answers.