“…• Th e slippery slope, including demands for "risk compensation" for hard-to-achieve outcomes (Christianson, Knutson, and Mazze 2006;Nicholson et al 2008), paying for conditions not quite meeting bonus criteria (Weissert and Musliner 1992;Weissert et al 1983), meaningless but easy-to-measure outcomes (Christianson, Knutson, and Mazze 2006;Rosenthal et al 2004), paying for good outcomes that do not represent real change from baseline performance (McNamara 2006), or better record-keeping without real improvement in outcomes (Bell and Levinson 2007;Epstein 2007;Khanduja, Scales, and Adhikari 2009) • Th e "distortion eff ect" of care being pulled away from nonbonus patients (Beaulieu and Horrigan 2005;Christianson, Knutson, and Mazze 2006;de Bruin, Baan, and Struijs 2011;Mehrotra, Sorbero, and Damberg 2010) • Cream skimming as facilities become selective in the patients they choose to treat in order to win bonuses (Bachman 2006;Nicholson et al 2008;Petersen et al 2006;Rosenthal et al 2004;Teleki et al 2006;Young et al 2005) • Design failures such as bonuses tied to so many outcomes that staff are unable to keep track of everything or feel overwhelmed (Christianson, Knutson, and Mazze 2006;Harbaugh 2009;Smoldt and Cortese 2007), bonus targets outside provider control (Harbaugh 2009;Nicholson et al 2008;Young et al 2005), puny bonuses that do not motivate providers (Fagan et al 2010;Felt-Lisk, Grimm, and Petersen 2007;Nicholson et al 2008;Petersen et al 2006;Rosenthal et al 2004), competitive payments that only already excellent facilities can win…”