“P4P is here to stay and, given the lack of clear evidence supporting them, it is all the more important that physicians be active constituents in the development, implementation, and modification of metrics at a local and regional level,” Dr. Kansagara concluded.

Dr. Ricarda Milstein from Universität Hamburg and Hamburg Center for Health Economics in Germany, who reported similar findings in a review of 34 P4P programs in 14 OECD countries, told Reuters Health by email, “This paper confirms the already existing evidence that P4P performs below policy makers’ expectations. This evidence holds true irrespective of the program design and health care system. The lack of response to incentive payments may indicate that physicians are intrinsically rather than extrinsically motivated.”

“I personally am rather relieved by this finding,” she said. “It corrects a negative image of health providers that economists sometimes have – the greedy physician who is only in it for the money, to be blunt. If P4P were found to be more successful, we would see a boom of financial incentives which largely ignore its very worrisome side effects.”

“Policy makers should not make too much of a provider’s reimbursement conditional on P4P,” Dr. Milstein said. “It should be combined with other quality-enhancing policies, such as public reporting. Finally, there should be more analyses on the cost-effectiveness of P4P. I have the feeling that public reporting is just as effective as P4P, but much less costly.”

“Let me also point out that to my understanding, the peak of P4P is over,” she added. “We do see other countries to implement or expand P4P programs, such as Germany and Belgium. This, however, is more to the fact that the U.S. has it and that an OECD country is simply expected to have a P4P program because everyone has one, but not because of the overwhelming, great effect.”