title: The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review.
abstract: BACKGROUND
  The benefits of pay-for-performance (P4P) programs are uncertain.
  
  
  OBJECTIVE
  To update and expand a prior review examining the effects of P4P programs targeted at the physician, group, managerial, or institutional level on process-of-care and patient outcomes in ambulatory and inpatient settings.
  
  
  METHODS
  PubMed from June 2007 to October 2016; MEDLINE, PsycINFO, CINAHL, Business Economics and Theory, Business Source Elite, Scopus, Faculty of 1000, and Gartner Research from June 2007 to February 2016.
  
  
  METHODS
  Trials and observational studies in ambulatory and inpatient settings reporting process-of-care, health, or utilization outcomes.
  
  
  METHODS
  Two investigators extracted data, assessed study quality, and graded the strength of the evidence.
  
  
  RESULTS
  Among 69 studies, 58 were in ambulatory settings, 52 reported process-of-care outcomes, and 38 reported patient outcomes. Low-strength evidence suggested that P4P programs in ambulatory settings may improve process-of-care outcomes over the short term (2 to 3 years), whereas data on longer-term effects were limited. Many of the positive studies were conducted in the United Kingdom, where incentives were larger than in the United States. The largest improvements were seen in areas where baseline performance was poor. There was no consistent effect of P4P on intermediate health outcomes (low-strength evidence) and insufficient evidence to characterize any effect on patient health outcomes. In the hospital setting, there was low-strength evidence that P4P had little or no effect on patient health outcomes and a positive effect on reducing hospital readmissions.
  
  
  CONCLUSIONS
  Few methodologically rigorous studies; heterogeneous population and program characteristics and incentive targets.
  
  
  CONCLUSIONS
  Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.
  
  
  BACKGROUND
  U.S. Department of Veterans Affairs.
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Aaron
authors.initials: A
authors.lastname: Mendelson
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Karli
authors.initials: K
authors.lastname: Kondo
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Damberg
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Allison
authors.initials: A
authors.lastname: Low
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Makalapua
authors.initials: M
authors.lastname: Motúapuaka
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Michele
authors.initials: M
authors.lastname: Freeman
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Maya
authors.initials: M
authors.lastname: O'Neil
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Rose
authors.initials: R
authors.lastname: Relevo
authors.affiliation: From VA Portland Health Care System, and Oregon Health & Science University, Portland, Oregon, and RAND Corporation, Santa Monica, California.
authors.forename: Devan
authors.initials: D
authors.lastname: Kansagara
mesh_terms: D000553:Ambulatory Care / Q000592:standards* / Q000706:statistics & numerical data; D006761:Hospitals / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D011787:Quality of Health Care / Q000191:economics*; D012052:Reimbursement, Incentive