P4P by Specialty

Below is a list of articles discussing the state of P4P within their specialty:

Ambulatory Care : 169

Cardiology : 213

Critical Care : 281

Emergency Medicine : 168

Gynecology : 181, 430

Oncology: 257

Orthopedics : 185

Otolaryngology : 39

Psychiatry : 288

Rheumatology: 422

Surgery : 19


P4P programs are rapidly expanding to include non-primary care specialties and subspecialties as both a system of quality improvement and of cost containment. For many specialties, it is no longer a question of embracing P4P. Rather, these specialties are addressing modes of engaging third party payers in discussions around P4P, quality improvement, and fair reimbursement. This section includes articles about the expansion of P4P measures to non-primary care specialties and sub-specialties. Much of the literature now addresses the need for specialty boards and societies to analyze their respective performance measures, and provide input into measure development. The earliest literature regarding P4P and non-primary care specialties resembles a warning call, whereby many peer-reviewed journal articles call for specific specialties to prepare to adopt P4P (39, 155, 181, 213). Bhattacharyya (185) argues that hospitals equipped with certain specialists will perform better on performance measures than hospitals without the ability to have certain specialities. Murphy (282) compares primary care physician attitude towards P4P vs. non-PCP attitude. Perhaps the most influential article is Glickman’s (168) critical analysis of nine current performance metrics in emergency medicine, finding that only 5/9 measures meet their criteria for appropriate measurement. But rather than deconstructing the inadequate measures, Glickman proposes two new measures and an emergency medicine research network for quality improvement. The tone of this work is reflective of the shift in attention of non-primary care specialties from debating the “if” of P4P, to debating the “how.”


P4P by Specialty Literature



(155) Ferris TG, Vogeil C, Marder J, Sennett CS, Campbell EG. Physician Specialty Societies And The Development Of Physician Performance Measures. Health Affairs. 2007: 26(6) 1712-1719.

PMID: 17978390


  • 31 specialty societies were selected and examined for their involvement in performance measure development.
  • They found only 35% of societies were involved in developing performance measures.
  • Findings suggest that physician specialty societies as a whole might not be ready to take on the next step in self-regulation, however committed leadership and external pressures will force societies to collaborate in the development of performance measures.

Significance to Literature

Specialty societies are not yet fully connected in guideline development for P4P.



***Key Article*** 

(282) Murphy KM, Nash DB. Nonprimary Care Physicians’ Views on Office-Based Quality Incentive and Improvement Programs. American Journal of Medical Quality. 2008: 23(6) 427-439.

PMID: 19001100


  • "While 41% of the total number of annual physician office visits are made to nonprimary care physicians, accounting for 70-80% national healthcare expenditures for all physicians services, historically the most common P4P programs are limited to primary care services." 
  • Authors summarize survey of physician attitudes towards quality incentive programs. For example, physicians traditionally favor payment schemes that avert risk.
  • 42% of respondents agreed or strongly agreed that quality incentive programs offer an opportunity to differentiate quality performance.
  • Physicians with fewer years of experience tended to favor quality improvement initiatives.
  • Studies examining the effect of financial incentives of physicians behavior in order to change phsyicians behavior, an incentive must account for 10% of the physician's annual income."
  • "Nonprimary care physicians had the most unfavorable views of public disclosure of quality performance."
  • Most physicians viewed current implementation of P4P as a means to decrease physician reimbursement.
  • Physicians who received information from their specialty society on clinical performance measures were more likely to view quality incentives more favorably.

Significance to Literature:

Nonprimary care physicians attitudes towards P4P differ signficantly from those of primary care physicians who currently participate in more extensively in P4P programs.


Ambulatory Care

(169) Brantes FD, Wickland PS, Williams JP. The Value of Ambulatory Care Measures: A review of Clinical and Financial Impact from an Employer/Payer Perspective. The American Journal of Managed Care. 2008:14(6) 360-368.

PMID: 18554074


  • Economic and clinical literature review of 62 quality metrics used in primary care P4P.
  • Of the top 20 metrics based on clinical and economic support, 16 were found to be cost-saving in the short-term.
  • Many primary care measures may have little clinical evidence beyond expert opinion.

Significance to Literature:

Systematic clinical and economic evaluation of 62 ambulatory care measures.



(213) Brush et al. American College of Cardiology 2006 Principles to Guide Physician Pay-for-Performance: A Report of the American College of Cardiology Work Group on Pay for Performance (A Joint Working Group of the ACC Quality Strategy Direction Committee and the ACC Advocacy Committee. Journal of the American College of Cardiology. 2006: 48 2603-2609.

PMID: 17174211


  • First official policy statement and position from the American College of Cardiology (ACC) about P4P.
  • Lists 12 guiding principles that P4P programs must embrace, including:
    • Measures based on evidence, and backed by specialty committees.
    • A business case must be made for widespread implementation.
    • Reward improvement and sustained high performance, and rewards must be positive, no negative punishments.
    • Risk-adjustment and benchmarking should be embraced concepts.
    • Encourage collaboration.
    • Audit data, and set targets through a national consensus process, and data should not be collected from claims data.
    • Incentives must be aligned to result in improvement.

Significance to Literature:

The ACC’s official P4P policy statement.



Critical Care

(281) Khanduja K, Scales DC, Adhikari NKJ. Pay for performance in the intensive care unit—Opportunity or threat? Critical Care Medicine. 2009: 37(3) 852-858.

PMID: 19237887


  • No study to date has examined incentives for intensivists.  However, the ICU is a likely target for future quality measures.
  • Group-directed P4P incentives is most likely to be effective.
  • Authors suggest numerous potential quality measures for ICU care.
  • Points out that death may not be a bad outcome for all ICU patients.

Significance to Literature:

ICU P4P programs may soon be considered, professional societies should be involved in the measure development.



Emergency Medicine

***Key Article***

(168) Glickman SW, Schulman KA, Peterson ED, Hocker MB, Cairns CB. Evidence-Based Perspectives on Pay for Performance and Quality of Patient Care and Outcomes in Emergency Medicine. Annals of Emergency Medicine. 2008: 51(5) 622-631.

PMID: 18358566


  • Article reviews the 9 emergency care performance metrics and grades them based on the American College of Cardiology and American Heart Association criteria for selection of performance measures to improve quality.
  • 5 of the 9 emergency measures meet all four of the criteria.
  • Authors suggest 2 new performance measures that should be used.
  • Quality improvement initiatives in emergency medicine would benefit greatly from large research networks.

Significance to Literature:

Overview of the P4P measures in Emergency medicine.




(181) Erekson EA, Sung VW, Myers DL. Pay for Performance: what the urogynecologist should know. Journal of Internal Urogynecology. 2008: 19, 1039-1041.

PMID: 18629563


  • As a subspecialty, urogynecology must prepare for P4P.
  • Outlines current outcome measurement schemes that might be used to measure quality performance and P4P reimbursement in urogynecology.
  • Offers advice for developing P4P measures, and some possible challenges the subspecialty faces with implementation.

Significance to Literature:

Subspecialties need to begin preparing for P4P.


(430) Hale DS. Pay for Performance - Are You Prepared? Female Pelvic Med Reconstr Surg. 2016 May-Jun;22(3):123-5. doi: 10.1097/SPV.0000000000000234.

PMID: 26825402


  • Quality summary of the history of quality reporting and incentive-based reimbursement from its initiation with the Tax Relief and Health Care Act of 2006 to what lies ahead with the signing of MACRA in 2015
  • Author expresses concern that while policy makers understand the changes implemented by the Physician Quality Reporting System (PQRS) and now MACRA, clinicians do not
    • A 2013 poll of American Urogynecologic Society (AUGS) members showed that only 20% knew what PQRS was; which is troubling because penalties for data collection went into effect in the same year
  • Acceptable outcome measures are not available for many specialties, including urogynecology, and measure development cannot be acquired at the speed CMS has been demanding
  • Two studies in the same journal issue focused on the practice patterns of highly successful urogynecologic surgeons represent the response to National Quality Forum (NQF) for more data to support new quality measures

Significance to Literature:

Subspecialty physicians need to be actively engaged in quality measure development and APMs instead of ignoring the policy changes, letting others dictate policy and pay




(257) O’Reilly KB. Doctors catalysts for pay-for-performance program. American Medical News. December 25, 2006.

Link: http://www.ama-assn.org/amednews/2006/12/25/prsc1225.htm 


  • A group of 20 oncologists developed their own P4P program for their cancer treatments in Spokane, WA.
  • Instead of letting insurers develop the P4P plan, this was developed by physicians to insure that cancer regimens continue to be appropriate.

Significance to Literature:

Landmark P4P program developed independently by physicians, yet maintained and financed by the insurance company. Results unknown.




(185) Bhattacharyya T, Mehta P, Freiberg AA. Hospital Characteristics Associated with Success in a Pay-for-Performance Program in Orthopedic Surgery. Journal of Bone and Joint Surgery. 2008: 90 1240-1243.

PMID: 18519316


  • Analysis of hospital characteristics associated with success in the CMS/Premier Hospital Quality Incentive Demonstration for total hip and knee arthroplasty.
  • Top performing hospitals were located in the Midwest and were teaching hospitals. Meanwhile, the size of the hospital and revenue were not associated with top performance in hip and knee replacements.
  • Orthopedic specialization was the strongest predictor of top performance.

Significance to Literature:

Hospitals that are more capable of specializing will perform better on performance measures related to specialty fields.




(39) Cognetti DM, Reiter D, The implications of “pay-for-performance” reimbursement for Otolaryngology—Head and Neck Surgery. Journal of Otolaryngology-Head and Neck Surgery. 2006: 134 1036-1042.

PMID: 16730552


  • Presents timeline demonstrating accelerating pace of P4P initiatives.
  • Specialties must “ready and prepare” for P4P.
  • Specialists should sit on P4P boards to help determine their field's measures.

Significance to Literature:

Call for medical specialties to prepare for P4P.




(288) Bremer RW, Scholle SH, Keyser D, Hourtsinger JVK, Pincus HA. Pay for Performance in Behavioral Health. Psychiatric Services. 2008: 59 1419-1429.

PMID: 19033169


  • Effort to identify P4P programs in behavioral health. Chart of the programs is detailed.
  • Overall, there is less consensus on a common set of quality improvement strategies and measures in behavioral health care.
  • 24 specific P4P programs were found for behavioral health issues.
  • Authors discuss preliminary lessons learned from behavioral P4P programs already in place.

Significance to Literature:

P4P in behavioral fields is relatively behind when assessing gross amount of available programs and measures.



(422) Harrison et al. Incentives in Rheumatology: the Potential Contribution of Physician Responses to Financial Incentives, Public Reporting, and Treatment Guidelines to Health Care Sustainability. Curr Rheumatol Rep. 2016 Jul;18(7):42. doi: 10.1007/s11926-016-0596-6.

PMID: 27240436


  • Narrative review of which P4P incentives exist and how they influence rheumatology
  • Analysis of current indicators for osteoporosis and rheumatoid arthritis in both the Affordable Care Act and the UK Quality and Outcomes Framework
  • There is limited evidence for the success of incentives to improve quality of rheumatology care, and all currently focus on process measures
  • Authors indicate “reporting variation in the quality and level of provision of rheumatology services appears to be a good way to identify opportunities for cost control”

Significance to Literature:

Review of current evidence and case studies for incentives which could impact “the future of incentive schemes in rheumatology”




(19) Russell, Thomas R. The future of surgical reimbursement: quality care, pay for performance, and outcome measures. The American Journal of Surgery. 2006: 301-304.

PMID: 16490535


  • Surgeon that believes surgery should embrace P4P.
  • If surgeons don’t take up responsibility of quality improvement, others will force it upon them.

Significance to Literature:

Commentary on the positive potential of P4P in surgery



Back to Top