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Open Access Highly Accessed Research article

Pay-for-performance in disease management: a systematic review of the literature

Simone R de Bruin*, Caroline A Baan and Jeroen N Struijs

Author Affiliations

National Institute for Public Health and the Environment, Centre for Prevention and Health Services Research, P.O. Box 1, 3720 BA Bilthoven, The Netherlands

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BMC Health Services Research 2011, 11:272  doi:10.1186/1472-6963-11-272

Published: 14 October 2011



Pay-for-performance (P4P) is increasingly implemented in the healthcare system to encourage improvements in healthcare quality. P4P is a payment model that rewards healthcare providers for meeting pre-established targets for delivery of healthcare services by financial incentives. Based on their performance, healthcare providers receive either additional or reduced payment. Currently, little is known about P4P schemes intending to improve delivery of chronic care through disease management. The objectives of this paper are therefore to provide an overview of P4P schemes used to stimulate delivery of chronic care through disease management and to provide insight into their effects on healthcare quality and costs.


A systematic PubMed search was performed for English language papers published between 2000 and 2010 describing P4P schemes related to the implementation of disease management. Wagner's chronic care model was used to make disease management operational.


Eight P4P schemes were identified, introduced in the USA (n = 6), Germany (n = 1), and Australia (n = 1). Five P4P schemes were part of a larger scheme of interventions to improve quality of care, whereas three P4P schemes were solely implemented. Most financial incentives were rewards, selective, and granted on the basis of absolute performance. More variation was found in incented entities and the basis for providing incentives. Information about motivation, certainty, size, frequency, and duration of the financial incentives was generally limited. Five studies were identified that evaluated the effects of P4P on healthcare quality. Most studies showed positive effects of P4P on healthcare quality. No studies were found that evaluated the effects of P4P on healthcare costs.


The number of P4P schemes to encourage disease management is limited. Hardly any information is available about the effects of such schemes on healthcare quality and costs.