Journal of General Internal Medicine

, Volume 33, Issue 7, pp 1155–1166 | Cite as

Pay-for-Performance and Veteran Care in the VHA and the Community: a Systematic Review

  • Karli K. KondoEmail author
  • Jessica Wyse
  • Aaron Mendelson
  • Gabriella Beard
  • Michele Freeman
  • Allison Low
  • Devan Kansagara
Review Paper



Although pay-for-performance (P4P) strategies have been used by the Veterans Health Administration (VHA) for over a decade, the long-term benefits of P4P are unclear. The use of P4P is further complicated by the increased use of non-VHA healthcare providers as part of the Veterans Choice Program. We conducted a systematic review and key informant interviews to better understand the effectiveness and potential unintended consequences of P4P, as well as the implementation factors and design features important in both VHA and non-VHA/community settings.


We searched PubMed, PsycINFO, and CINAHL through March 2017 and reviewed reference lists. We included trials and observational studies of P4P targeting Veteran health. Two investigators abstracted data and assessed study quality. We interviewed VHA stakeholders to gain further insight.


The literature search yielded 1031 titles and abstracts, of which 30 studies met pre-specified inclusion criteria. Twenty-five examined P4P in VHA settings and 5 in community settings. There was no strong evidence supporting the effectiveness of P4P in VHA settings. Interviews with 17 key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in the VHA. Key informants’ views on P4P in community settings included the need to develop relationships with providers and health systems with records of strong performance, to improve coordination by targeting documentation and data sharing processes, and to troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population.


The evidence to support the effectiveness of P4P on Veteran health is limited. Key informants recognize the potential for unintended consequences, such as overtreatment in VHA settings, and suggest that implementation of P4P in the community focus on relationship building and target areas such as documentation and coordination of care.


Veterans pay for performance financial incentives implementation performance metrics systematic review 



We would like to acknowledge Rose Relevo for conducting literature searches and also the contributions of our stakeholders and Technical Expert Panel.

Prior Presentation

The contents of this manuscript have not been presented at any conference.


This project was funded by the US Department of Veterans Affairs, Veterans Health Administration (VHA) ESP Project #05-225.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4444_MOESM1_ESM.docx (162 kb)
ESM 1 (DOCX 161 kb)


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Copyright information

© Society of General Internal Medicine (This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply) 2018

Authors and Affiliations

  • Karli K. Kondo
    • 1
    • 2
    Email author
  • Jessica Wyse
    • 1
  • Aaron Mendelson
    • 2
  • Gabriella Beard
    • 1
  • Michele Freeman
    • 1
  • Allison Low
    • 1
  • Devan Kansagara
    • 1
    • 2
  1. 1.Portland VA Health Care System Evidence-based Synthesis ProgramPortlandUSA
  2. 2.Oregon Health and Science UniversityPortlandUSA

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