The corresponding literature contains six sections:

Website Authors' Opinion

It is not easy to measure the effects of P4P on most controversial issues. However, Shen (241) did an excellent job of clearly showing that P4P led to patient selection. More studies of this nature are necessary to control the expansion of P4P. Perhaps the most intimate ethical issue centers on the doctor-patient relationship. The importance of this relationship cannot be underestimated, and must not falter as P4P changes the delivery of care. Because measures are changing constantly, there must be a way for P4P program developers to streamline evidence changes into programs. Furthermore, it is vital to the success of P4P to find ways to risk adjust and combat disparities. Other countries have found ways, and risk adjustment should be a mandatory aspect at this time in the United States.  All of these controversies should not scare clinicians away P4P, rather they should suggest alternative plan opportunities to help solve these controversies.


Authors' Opinion Literature


(241) Shen Y. Selection Incentives in a Performance-Based Contracting System. Health Services Research. 2003: 38(2) 535-552.

PMID: 12785560


  • Author investigated whether a P4P program provided incentives for a nonprofit substance abuse treatment center to treat less severe clients.
  • P4P was implemented in the study group (OSA) but not in the control group (Medicaid).
  • Prior to the implementation of P4P the study group had 11% more severe cases than the control group, whereas after three years of P4P, the study group had 28.5% fewer severe cases than the control group.
  • Study identifies “the selection effect” as just one unintended consequence of P4P.

Significance to Literature:

First study to show major selection bias likely resulting from the implementation of a P4P program.