BackgroundPay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.MethodsThe systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.ResultsOne hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.ConclusionsP4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

Growing optimism over the promise of "pay for performance" to improve the quality of health care may have been given further impetus following publication of the first study to assess the effects of quality incentives in a large health plan. With support from The Commonwealth Fund, researchers examining a payforperformance program implemented by PacifiCare Health Systems-one of the nation's largest health plans-found that for one of three clinical quality measures studied, a physician network that was offered bonus payments outperformed another network that was not.

Integration of care is emerging as a central challenge of health care delivery, particularly for patients with multiple, complex chronic conditions. The authors argue that the concept of "integrated patient care" would benefit from further clarification regarding (a) the object of integration and (b) its essential components, particularly when constructing measures.To address these issues, the authors propose a definition of integrated patient care that distinguishes it from integrated delivery organizations, acknowledging that integrated organizational structures and processes may fail to produce integrated patient care. The definition emphasizes patients' central role as active participants in managing their own health by including patient centeredness as a key element of integrated patient care. Measures based on the proposed definition will enable empirical assessment of the potential relationships between the integration of organizations, the integration of patient care, and patient outcomes, providing valuable guidance to health systems reformers.

Spending on direct-to-consumer advertising has continued to increase in recent years in spite of the criticisms leveled against it. Our findings suggest that calls for a moratorium on such advertising for new drugs would represent a dramatic departure from current practices.

Although the use of direct-to-consumer advertising has grown disproportionately to other forms of promotion, it continues to account for a small proportion of total promotional efforts. Nevertheless, physicians must assist patients in evaluating health-related information obtained through direct advertising.

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Paying health care providers to meet quality goals is an idea with widespread appeal, given the common perception that quality of care in the United States remains unacceptably low despite a decade of benchmarking and public reporting. There has been little critical analysis of the design of the current generation of quality incentive programs. In this paper we examine public reports of paying for quality over the past five years and assess each of the identified programs in terms of key design features, including the market share of payers, the structure of the reward system, the amount of revenue at stake, and the targeted domains of health care quality. D e l i v e r i n g h i g h -q ua l i t y c a r e in the current U.S. health care system does not always pay.1 In the case of many aspects of clinical quality, the widespread use of fee-for-service payment fails to promote or even discourages optimal treatment. For example, an effective chronic care management program may lead to lower revenues for providers, since quality improvement activities are not billable and acute care visits are reduced as a result. Increasingly, however, individual purchasers and coalitions as well as health plans have implemented pay-for-performance systems to reward providers for delivering highquality care and to motivate quality improvement.To understand the importance of these incipient "pay-for-performance" efforts, we describe the prevalence and structure of these initiatives as they are now being adopted in the U.S. health care system. We focus on specific design elements identified using key lessons from the literature on the impact of financial incentives on behavior and quality improvement.2 These include the market leverage of spon-

Despite more than a decade of bench-marking and public reporting of quality problems in the health care sector, changes in medical practice have been slow to materialize. To accelerate quality improvement, many private and public payers have begun to offer financial incentives to physicians and hospitals based on their performance on clinical and service quality measures. The authors review the empirical literature on paying for quality in health care and comparable interventions in other sectors. They find little evidence to support the effectiveness of paying for quality. The absence of findings for an effect may be attributable to the small size of the bonuses studied and the fact that payers often accounted for only a fraction of the targeted provider's panel. Even in non-health settings, however, where the institutional features are more favorable to a positive impact, the literature contains mixed results on the effectiveness of analogous pay-for-performance schemes.