Substantial scientific evidence accumulated from efforts of countless investigators demonstrates the potential benefits of delivering specific types of care under certain circumstances. On an increasing basis, the extent to which the health care delivered conforms to scientific evidence has provided a metric used by both insurers and health care consumers to judge service quality. Despite a host of efforts to promote the delivery of evidence-based care, however, actual rates of detection, treatment, and control often fall short of recommended levels. The obvious risk arising from this "treatment gap" is that health care consumers may not get the "right" care and others may get care that is clearly inferior or that has the potential for actual harm, if not the best possible outcomes.

A second factor driving the development of health policy is economics. Although health care expenditures in the United States have consumed an increasing proportion of the gross domestic product over the last several decades, several indicators of population health suggest that Americans do not get "value for money" in the health care they receive. Increased public awareness of the shortcomings of health care, whether considered in terms of treatment quality or value, has motivated the development and implementation of an array of initiatives to ensure that health care delivery better conforms to our understanding of evidence-based practice.

In this issue of QMHC, several groups explore the history, current experience, and potential implications of one approach to health care reimbursement about to be implemented on a broad scale: "pay for performance" or "P4P." Although not a single initiative, but rather a myriad of programs unified by a common performance-based reimbursement strategy, P4P attempts to narrow the treatment gap and promote the delivery of health care value, measured by indicators of quality, for money.

Jonah Stulberg describes a federally sponsored program, the Physician Quality Reporting Initiative (PQRI), which currently provides incentives to health care providers for reporting on the quality of the care they provide. While receipt of bonus payments through the PQRI requires only that a report be made, participating health care professionals may find this experience useful as they prepare for potentially more labor-intensive efforts under P4P in documenting and demonstrating the quality of care provided.

As the name suggests, P4P seeks to motivate the delivery of high-quality care through financial incentives. Marissa Hendrickson highlights a tension inherent in these objectives within the context of physicians' contract with society and a professional relationship based in trust. While P4P promotes a goal consistent with physicians' professional obligation to deliver care that is scientifically based and free of bias, Dr Hendrickson points out that the use of financial incentives in this pursuit is not without moral risk or potential damage to other objectives of medical professionalism.

Three articles raise important questions from different perspectives about the nature and origin of the measures used to indicate the presence of quality or care consistent with the evidence base. Darcey Terris and David Litaker highlight the difficulty of accurately and reliably assessing quality, given the presence of multiple influences on the delivery of care and its subsequent outcomes. These authors also point to further challenges that exist in the form of variable or absent infrastructure in many practice settings available to manage information and the reporting activities implied by participation in P4P programs. Brook Watts and colleagues use a different strategy by comparing 3 approaches to quality assessment applied to a best-case scenario, in which extensive qualitative and quantitative data characterizing the care delivery by an expert are available. Because ratings of quality vary substantially according to the measure used, this group advises caution when choosing a quality assessment approach. Finally, in his article examining the influence of the pharmaceutical industry, Johnie Rose describes several instances in which conflicts of interest among experts involved in guideline development and quality measurement have arisen. He concludes that in the presence of biased decision making driven by industry influence, the success of P4P in improving health care quality at an acceptable cost is unlikely.

Sharon Weyer, Sarah Bobiak, and Kurt Stange use an ecological analysis to reflect on the implications of a quality-driven focus. In their article, drawing from experience with primary care practices in northern Ohio over the last decade, they observe that quality improvement efforts focused on evidence-based recommendations appear to have been successful. A concurrent decline in patient satisfaction with care causes them to caution that implementation of P4P programs avoid creating an imbalance in the incentives of care based on what can be easily measured at the expense of the aspects of care valued by patients.

Given the recommendations of the recent Institute of Medicine report on P4P1 and the rapid expansion of the Medicare and other P4P programs, it is apparent that the United States is facing a fundamental change in current payment systems. We hope the articles in this special issue will serve as a foundation for further discussion of this important topic.

David G. Litaker, MD, PhD

Brook Watts, MD, MS

Issue Editors

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