• J Frank Wharam, Michael K Paasche-Orlow, Neil J Farber, Christine Sinsky, Lisa Rucker, Kimberly J Rask, M Kathleen Figaro, Clarence Braddock, Michael J Barry, and Daniel P Sulmasy.
• Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02114, USA. jwharam@partners.org
• J Gen Intern Med. 2009 Jul 1; 24 (7): 854859854-9.

BackgroundPay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain.ObjectiveThe Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation.ResultsWe conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients.ConclusionWe propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality.

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