Pay-for-performance in safety net settings: issues, opportunities, and challenges for the future.

A major trend among Medicaid programs is the adoption of pay-for-performance (P4P) programs, but little evidence exists about the impact of these programs on quality improvement. Our in-depth case investigation of P4P in two safety net settings suggests that such programs may have minimal short-term effect on quality improvement. Two potentially important barriers for P4P in safety net settings are limited motivational effects from financial incentives and complex patient care requirements. We did not uncover any opposition against P4P among providers, nor did we find any evidence that P4P programs may compromise quality of care through unintended consequences. Overall, study results point to opportunities to improve the design and implementation of P4P programs in safety net settings.