Journal of General Internal Medicine

, Volume 29, Issue 1, pp 127–132 | Cite as

Sustainability of Quality Improvement Following Removal of Pay-for-Performance Incentives

  • Justin K. BenzerEmail author
  • Gary J. Young
  • James F. BurgessJr
  • Errol Baker
  • David C. Mohr
  • Martin P. Charns
  • Peter J. Kaboli
Original Research



Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed.


To investigate sustainability of performance levels following removal of performance-based incentives.


Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010.


VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Bonuses are distributed based on the attainment of these performance goals.


Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives.


Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained.


This is a quasi-experimental study without a comparison group; causal conclusions are limited.


The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare’s value-based purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives.


inpatients physician incentive plans quality improvement quality indicators reimbursement incentive salaries  fringe benefits 



The work reported herein was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (IIR 08-067-1) and an Investigator Award in Health Policy to Gary Young from the Robert Wood Johnson Foundation. The authors had full access to and take full responsibility for the integrity of the data. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The authors would like to thank Terry Duncan for consultation on implementing time series models in MPLUS.

Conflict of Interest

The authors declare that they do not have any conflicts of interest.

Supplementary material

11606_2013_2572_MOESM1_ESM.pdf (191 kb)
ESM 1 (PDF 191 kb)
11606_2013_2572_MOESM2_ESM.pdf (172 kb)
ESM 2 (PDF 171 kb)


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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Justin K. Benzer
    • 1
    • 2
    Email author
  • Gary J. Young
    • 1
    • 3
  • James F. BurgessJr
    • 1
    • 2
  • Errol Baker
    • 1
    • 2
  • David C. Mohr
    • 1
    • 2
  • Martin P. Charns
    • 1
    • 2
  • Peter J. Kaboli
    • 4
    • 5
  1. 1.Center for Organization, Leadership, and Management Research (COLMR) at the VA Boston Healthcare System (152 M)BostonUSA
  2. 2.Boston University School of Public HealthBostonUSA
  3. 3.Northeastern University Center for Health Policy and Healthcare ResearchBostonUSA
  4. 4.Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare SystemIowa CityUSA
  5. 5.Department of Internal Medicine, University of Iowa Carver College of MedicineIowa CityUSA

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