P4P by Specialty


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

Ambulatory Care : 169

Cardiology : 213451

Critical Care : 281

Emergency Medicine : 168

Gynecology : 181430

Oncology: 257

Orthopedics : 185441454455456457458459460461

Otolaryngology : 39

Pediatrics: 364452

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 certain specialties to prepare to adopt P4P (39155181213). Bhattacharyya (185) argues that hospitals equipped with certain specialists will perform better on performance measures than hospitals without the ability to have certain specialties. 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 physicians' 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 significantly 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.



(451) Farmer et al. Existing and Emerging Payment and Delivery Reforms in Cardiology. JAMA Cardiol.2017 Feb 1;2(2):210-217. doi: 10.1001/jamacardio.2016.3965.

PMID: 27851858


  • Authors summarize each of the existing payment model categories (as defined by the Department of Health and Human Surfaces) including: 1) Fee-for-service (FFS) 2)  FFS with links to quality 3) Alternative Payment Models (APMs) built on a FFS architecture 4) Population-based payments
  • Examples of 4 new payment models involving cardiology are used to illustrate the changing reimbursement landscape
    • Physician Group Incentive Model  (PGIP)
      • Blue Cross Blue Shield of Michigan came up with the PGIP in 2005 which provides periodic performance reporting while associating both primary care and specialty payment to population-level outcomes
    • Acute Myocardial Infarction Episode Payment Model
      • CMS announced this first mandatory APM for cardiac conditions in July 2016 and it includes an acute myocardial infarction bundled payment for all Medicare services in the 90 days following discharge
    • MD Value Care
      • This is a physician-led ACO initiated in 2014 because participants wished to remain independent and succeed in the rapidly changing payment landscape. The ACO, with its 14,000 beneficiaries and 5 PCP groups, participates in Medicare’s Shared Savings Program
    • Henry Ford Physician Network (HFPN)
      • The HFPN was started in 2010 as a commercial ACO which focuses on administratively driven value strategies. The group also participates in PGIP and was chosen to participate in Medicare’s Net Generation ACO program
  • Authors also note that the complexity and administrative burden of emerging payment models has resulted in accelerated hospital acquisition of cardiology practices, noting that hospital ownership tripled from 8% to 24% from 2007 to 2012

Significance to Literature:

Cardiologists must acknowledge FFS has generated perverse incentives, but early novel payment models have not performed as well as many had hoped. Participation in APMs will soon become unavoidable for cardiologists and early involvement will help clinicians “to develop expertise in new care pathways during a period of relatively low risk.”



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 are 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.



(441) Kamal RN1; Hand Surgery Quality Consortium. Quality and Value in an Evolving Health Care Landscape. J Hand Surg Am. 2016 Jul;41(7):794-9. doi: 10.1016/j.jhsa.2016.05.016.

PMID: 27374791


  • The focus on how to define and measure quality while providing cost-efficient care has recently been increasing in orthopedics with the implementation of patient-reported outcome measures to evaluate total joint arthroplasty by hip and knee surgeons
  • However, the author argues that hand surgery is unique within orthopedic subspecialties
    • Hand surgery is heterogeneous with general, orthopedic, and plastic surgeons all treating patients “from the shoulder to the fingertips”
    • A wide variety of procedures makes it difficult to come up with the clinically-relevant “cross-cutting” outcome measures payers ask for
    • There is strong influence of psychosocial factors  and coping strategies on patient-reported outcomes in hand surgery as symptoms and limitations may still persist
  • As hand surgeons prepare for value-based health care they should ask:
    • How do we balance adopting innovative payment models without affecting research efforts?
    • How do we leverage a value-based model to benefit all stakeholders?
    • How do we best use value-based incentives to motivate research and quality improvement without potentially devaluing the physician-patient relationship?

Significance to Literature:

“Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models”



(454) Goldman, A. H., & Kates, S. (2017). Pay-for-performance in orthopedics: How we got here and where we are going. Current Reviews in Musculoskeletal Medicine, 10(2), 212-217.

PMID: 28389971


  • Review of 2013-2016 literature regarding how the P4P is shaping orthopedics
  • Identified “value” in orthopedics as a critical issue to be defined
  • Accurate risk calculators are needed for specific orthopedic procedures like Total Joint Arthroplasty
  • Patient satisfaction plays a large role in P4P rubrics, and satisfaction can be influenced by demographic factors out of the control of the treating physician

Significance to Literature:

As P4P is implemented in orthopedics, value of care, quality/risk stratification, and patient satisfaction are key areas of current research.



(455) Morris, B. J., Richards, J. E., Archer, K. R., Lasater, M., Rabalais, D., Sethi, M. K., et al. (2014). Improving patient satisfaction in the orthopaedic trauma population. Journal of Orthopaedic Trauma, 28(4), e80-4.

DOI: 24158181


  • Orthopedic trauma patient satisfaction difficult to accurately assess given high acuity traumatic injuries inhibiting ability to form patient-physician rapport
  • Studied impact of providing patients with attending orthopedic trauma surgeon biosketch card including picture, brief synopsis of educational background, specialty, surgical interests, and research interests
  • Patients receiving biosketch card of his or her attending orthopedic surgeon showed significant improvements in patient satisfaction

Significance to Literature:

Attending physician biosketch cards can increase inpatient satisfaction in an orthopedic trauma patient population.



(456) Freehill, M. T., Mannava, S., & Safran, M. R. (2014). Outcomes evaluation of the athletic elbow.Sports Medicine and Arthroscopy Review, 22(3), e25-32.

PMID: 25077753


  • Evaluating orthopedic surgery outcomes in high-level athletic populations is difficult using standard outcome metrics due to good overall health and high baseline function
  • Manuscript reviewed five most clinically relevant outcome measures for sports-related elbow outcomes
  • Kerlan-Jobe Orthopedic Clinic score is the only outcome tool validated for elbow injuries in the overhead athlete

Significance to Literature:

Both validating outcome measures for specific orthopedic interventions (e.g. elbow surgery) and considering elite athlete populations are relevant challenges for P4P models to be successful in orthopedics.



(457) Edelstein, A. I., Kwasny, M. J., Suleiman, L. I., Khakhkhar, R. H., Moore, M. A., Beal, M. D., et al. (2015). Can the American College of Surgeons risk calculator predict 30-day complications after knee and hip arthroplasty? The Journal of Arthroplasty, 30(9 Suppl), 5-10.

PMID: 26165953


  • Risk stratification of total hip (THA) and knee (TKA) arthroplasty patients is essential for accurate P4P assessment
  • ACS-NSQIP universal risk calculator does not predict complications on an individual basis suggesting need for arthroplasty-specific risk calculator to better inform risk adjusted quality comparisons

Significance to Literature:

Current common orthopedic risk calculators are not sufficiently patient specific to be used for total joint arthroplasty risk adjustment in P4P.



(458) Regan, D. K., Manoli, A.,3rd, Hutzler, L., Konda, S. R., & Egol, K. A. (2015). Impact of diabetes mellitus on surgical quality measures after ankle fracture surgery: Implications for "value-based" compensation and "pay for performance". Journal of Orthopaedic Trauma, 29(12), e483-6.

PMID: 26595598


  • Evaluated impact of diabetes mellitus (DM) and associated complications after open reduction internal fixation (ORIF) of an ankle fracture
  • Mean length of stay, in-hospital mortality rates, and total hospital costs were significantly greater for the DM cohort than non-DM cohort following ankle ORIF

Significance to Literature:

Testing the effect of co-morbidities on orthopedic outcome measures can provide risk-adjustment guidance for P4P.



(459) Shih, T., Nicholas, L. H., Thumma, J. R., Birkmeyer, J. D., & Dimick, J. B. (2014). Does pay-for-performance improve surgical outcomes? an evaluation of phase 2 of the premier hospital quality incentive demonstration. Annals of Surgery, 259(4), 677-681.

PMID: 24368657


  • Manuscript evaluated whether 2006 changes in incentive design in P4P program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals
  • Examined discharge data for patients who underwent CABG, hip replacement, and knee replacement
  • Premier HQID did not improve surgical outcomes

Significance to Literature:

P4P models may not improve surgical outcomes.



(460) Bhattacharyya, T., Iorio, R., & Healy, W. L. (2002). Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. The Journal of Bone and Joint Surgery.American Volume, 84-A(4), 562-572.

PMID: 11940616


  • Orthopedic surgeons operate on a diverse patient population, many of which who have ongoing medical problems
  • Study obtained hospital records to identify rate of mortality and evaluate risk factors for mortality after orthopedic surgery
  • Mortality rate was highest in patients older than seventy and 50% of all deaths occurred after operative treatment of hip fractures

Significance to Literature:

Studies identifying mortality risk factors can help risk adjust P4P in orthopedic surgery.



(461) Tsai, Y. S., Kung, P. T., Ku, M. C., Wang, Y. H., & Tsai, W. C. (2018). Effects of pay for performance on risk incidence of infection and of revision after total knee arthroplasty in type 2 diabetic patients: A nationwide matched cohort study. PloS One, 13(11), e0206797.

PMID: 30388167


  • Total knee arthoplasty (TKA) on the rise as worldwide population ages and diabetic patients are known to face greater risks of TKA postoperative infection or revision
  • Investigated if diabetic patient participation in P4P programs influences incidence rate of TKA postoperative infection or revision
  • Joining P4P lowered risk of postoperative infection and significantly lowered the risk of revision
  • Other factors impacting risk of postoperative infection or revision included being young and male, having multiple comorbidities, and receiving care at regional or public hospitals

Significance to Literature:

P4P may lower the rate of post-operative complications for certain orthopedic patient populations.




(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.




(364) Gleeson S, Kelleher K, Gardner W. Evaluating a Pay-for-Performance Program for Medicaid Children in an Accountable Care Organization. JAMA Pediatr. 2016 Mar 1;170(3):259-66. doi: 10.1001/jamapediatrics.2015.3809.

PMID: 26810378


  • Retrospective cohort study conducted from January 1, 2010 to December 31, 2013 to determine if P4P improved physician performance within the context of a pediatric accountable care organization (ACO) serving Medicaid children in Ohio
  • Physicians were divided into three groups:
    • Community physicians who received P4P incentives
    • Non-incentivized community physicians
    • Non-incentivized hospital physicians
  • Among the 21 quality measures (14 subject to incentives) examined, incentivized community physicians showed greater performance improvement than non-incentivized community physicians in 5 incentivized and 2 non-incentivized measures
  • Hospital non-incentivized physicians had greater performance improvements on 8/14 incentivized measures and 1/7 non-incentivized measures

Significance to Literature:

P4P alone in a pediatric ACO appears to result in modest performance improvement, but “other interventions at the disposal of the ACO may have been more effective.”



(452) Chien AT, Song Z, Chernew ME, et al. Two-Year Impact of the Alternative Quality Contract on Pediatric Health Care Quality and Spending. Pediatrics. 2014;133(1):96-104. doi:10.1542/peds.2012-3440.

PMID: 24366988


  • Studied a commercially-insured pediatric population enrolled in Blue Cross Blue Shield Massachusetts (BCBSMA) to determine an Alternative Quality Contract (AQC)’s effect on pediatric quality and spending in its first two years
  • Compared quality and spending pre (2006–2008) and post (2009–2010) AQC implementation, adjusting analyses for age, gender, health risk score, and secular trends
  • Special focus on Children with Special Health Care Needs (CSHCN)
  • Found that “the AQC had on average a significant, positive, and small effect on pediatric preventive care quality measures tied to P4P and that CSHCN experienced significantly greater increases in performance than non-CSHCN on those preventive measures”
  • The AQC did not affect measures not tied to P4P and had no significant effect on spending for children

Significance to Literature:

This large Alternative Quality Contract was effective in improving preventative pediatric care, with particularly significant benefits for CSHCN, but global budget arrangements need to better target care processes and outcomes to make a more significant impact on health care spending.




(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