More than half a decade after the influential report by the Institute of Medicine “Crossing the Quality Chasm: A New Health System for the 21st Century,”1 America's health care system continues to be riddled with quality problems. For example, adult and pediatric patients receive only about half of the health care services that are recommended.2,3 One factor contributing to this situation is receiving increasing attention: a reimbursement system that may actively discourage quality improvement (QI). Quality improvement may be discouraged because any financial rewards for improving health care quality accrue primarily to payers and patients, not to the health care providers who fund and implement them.4 Pay-for-performance programs are an attempt to correct this imbalance and provide direct incentives for quality to providers.5
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