The European Journal of Health Economics

, Volume 13, Issue 6, pp 755–767 | Cite as

Economic evaluation of pay-for-performance in health care: a systematic review

  • Martin EmmertEmail author
  • Frank Eijkenaar
  • Heike Kemter
  • Adelheid Susanne Esslinger
  • Oliver Schöffski
Original Paper



Pay-for-performance (P4P) intents to stimulate both more effective and more efficient health care delivery. To date, evidence on whether P4P itself is an efficient method has not been systematically analyzed.


To identify and analyze the existing literature regarding economic evaluation of P4P.

Data sources

English, German, Spanish, and Turkish language literature were searched in the following databases: Business Source Complete, the Cochrane Library, Econlit, ISI web of knowledge, Medline (via PubMed), and PsycInfo (January 2000–April 2010).

Study selection

Articles published in peer-reviewed journals and describing economic evaluations of P4P initiatives. Full economic evaluations, considering costs and consequences of the P4P intervention simultaneously, were the prime focus. Additionally, comparative partial evaluations were included if costs were described and the study allows for an assessment of consequences. Both experimental and observational studies were considered.


In total, nine studies could be identified. Three studies could be regarded as full economic evaluations, and six studies were classified as partial economic evaluations. Based on the full economic evaluations, P4P efficiency could not be demonstrated. Partial economic evaluations showed mixed results, but several flaws limit their significance. Ranges of costs and consequences were typically narrow, and programs differed considerably in design. Methodological quality assessment showed scores between 32% and 65%.


The results show that evidence on the efficiency of P4P is scarce and inconclusive. P4P efficiency could not be demonstrated. The small number and variability of included studies limit the strength of our conclusions. More research addressing P4P efficiency is needed.


Pay-for-performance P4P Economic evaluation Efficiency ROI Cost-effectiveness 

JEL Classification

I11 I12 J33 



The authors are grateful to Frauke Hübsch and Collin Devin Maddox for their support and comments on earlier drafts. We would like to thank Professor Michael Drummond for his helpful recommendation regarding the study quality appraisal.

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

10198_2011_329_MOESM1_ESM.pdf (236 kb)
Supplementary material 1 (PDF 237 kb)


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Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Martin Emmert
    • 1
    Email author
  • Frank Eijkenaar
    • 2
  • Heike Kemter
    • 1
  • Adelheid Susanne Esslinger
    • 3
  • Oliver Schöffski
    • 1
  1. 1.Chair of Health Business Administration, Institute of Management (IFM), School of Business and EconomicsFriedrich-Alexander-University Erlangen-NurembergNurembergGermany
  2. 2.Institute of Health Policy and ManagementErasmus University RotterdamRotterdamThe Netherlands
  3. 3.Chair of Strategic ManagementFriedrich-Alexander-University Erlangen-NurembergNurembergGermany

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