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Journal Article


Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences



The Issue

Pay-for-performance programs could have unintended consequences: such incentives could encourage physicians to avoid sicker patients, they could exacerbate health disparities, and they could lead to the neglect of care not targeted by performance measures. Commonwealth Fund–supported researchers interviewed primary care physicians in England and California to gauge whether pay-for-performance programs have produced unintended consequences.

What the Study Found

English physicians were much more likely than California physicians to report that the incentive program changed their office visits, mostly citing the large number of measures being tracked and the resulting reliance on prompts from electronic medical records. California physicians were more likely to express resentment of the program, particularly their inability to exclude particular patients from the performance calculations. While assessment of English physicians is based on data extracted from their medical records, Californian physicians are assessed by third-party data collection, which contributes to their lack of buy-in to the performance programs.


 The findings suggest that unintended consequences of pay-for-performance programs are related to their design and implementation—factors that should be attended to when developing incentive programs, the authors say.

Publication Details



R. McDonald and M. Roland, "Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences," Annals of Family Medicine, March/April 2009 7(2):121–27.