Pay for performance in health care Methods and approaches

By Jerry Cromwell, Michael Trisolini, Gregory Pope, Janet Mitchell, Leslie Greenwald

This book provides a balanced assessment of pay for performance (P4P), addressing both its promise and its shortcomings. P4P programs have become widespread in health care in just the past decade and have generated a great deal of enthusiasm in health policy circles and among legislators, despite limited evidence of their effectiveness. On a positive note, this movement has developed and tested many new types of health care payment systems and has stimulated much new thinking about how to improve quality of care and reduce the costs of health care. The current interest in P4P echoes earlier enthusiasms in health policy—such as those for capitation and managed care in the 1990s—that failed to live up to their early promise. The fate of P4P is not yet certain, but we can learn a number of lessons from experiences with P4P to date, and ways to improve the designs of P4P programs are becoming apparent. We anticipate that a “second generation” of P4P programs can now be developed that can have greater impact and be better integrated with other interventions to improve the quality of care and reduce costs.


Cromwell, J., Trisolini, M., Pope, G., Mitchell, J., & Greenwald, L. (Eds.) (2011). Pay for performance in health care: Methods and approaches. (RTI Press Publication No. BK-0002-1103). Research Triangle Park, NC: RTI Press.

© 2019 RTI International. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.


Jerry CromwellJerry Cromwell, PhD, has more than 35 years of experience conducting federally funded technical and evaluation projects in health economics. Major fields include Medicare hospital and physician payment systems and productivity gains, disease management evaluations, federal-state Medicaid public finance, physician participation in publicly funded health programs, reimbursement of anesthesia services, and disparities in access to complex health technologies. His technical expertise includes actuarial estimation of hospital inpatient and outpatient payment rates, quasi-experimental design of payment reform demonstrations, quantification of breadth and depth of state Medicaid insurance coverage and physician work effort, and econometric analysis of business cycle effects on Medicaid eligibility. He has sat on AHCPR, VA, and OTA health care study sections and testified before Congress on Medicare and Medicaid payment reforms. He is the founder and past president of Health Economics Research, which was acquired by RTI in 2002.

Michael TrisoliniMichael G. Trisolini, PhD, MBA, is the director of RTI International’s Heath Care Quality and Outcomes Program. Dr. Trisolini has more than 27 years of experience in health services research and management. His research focuses on quality-of-care measurement, quality improvement programs, pay for performance, value-based purchasing, and health information technology. He has a BA from Oberlin College, an MBA from Harvard University, and a PhD from Brandeis University.

Gregory PopeGregory C. Pope, MS, directs RTI’s Health Care Financing and Payment program. Mr. Pope is a health economist whose primary research interest is health plan and provider payment in the US Medicare program, including pay for performance, accountable care organizations, and risk adjustment.

Janet MitchellJanet B. Mitchell, PhD, heads RTI’s Social Policy, Health, and Economics Research unit. She received her doctorate from the Heller School at Brandeis University in 1976. She has studied physician payment under Medicare and Medicaid for many years and conducted the seminal work on bundling inpatient physician services (physician diagnosis-related groups).

Leslie GreenwaldLeslie M. Greenwald, PhD, is a principal scientist at RTI International. Her research interests include Medicare program policy, health care costs and payment, managed care, and health care reform. Dr. Greenwald received a BA from Dartmouth College and an MPA and PhD from the University of Virginia.

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