Pay-for-performance in orthopedics: implications for clinical practice.

The United States health care system currently faces many challenges, including rising costs and variable quality. Health care purchasers and payers are demanding increased transparency and accountability for their health care dollars. Pay-for-performance (P4P) initiatives, which seek to link provider reimbursement to measures of quality and efficiency, have been introduced by both private and government payers. Despite their appeal over current provider reimbursement systems, which reward volume and intensity of services rather than quality and efficiency, P4P programs face numerous challenges in their implementation, including difficulty defining and measuring quality, high costs associated with collecting and analyzing performance data, problems with risk adjustment, lack of additional funding to reward quality, unintended consequences of provider gaming and patient deselection, and impact on low-tier, low-quality providers. Future efforts should involve collaboration among providers, payers, and policy makers to ensure that P4P programs are implemented safely and effectively.