Listen now (26 mins) | Listen Now Over approximately the past decade the health care industry has become increasingly committed to financially incenting physicians and other clinicians, or tying performance to reimbursement. Commonly termed "pay for performance"(P4P), these arrangements are increasingly employed in the Medicare (i.e., under the Medicare Access and CHIP Reauthorization Act, or MACRA) and Medicaid programs and by commercial insurers, most notable accountable care models and bundled payment arrangements. One might assume because P4P models are now common there is research evidence that demonstrates they are effective in, again, improving care quality, patient outcomes and lowering spending growth. That is not the case. For example, a systematic review published by Cochrane in 2011 found "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care." Among other examples, for all the attention the Massachusetts' Alternative Quality Contracts (AQCs) have received since they were launched in 2009, it remains unclear if they have reduced spending or spending growth. Because P4P models have not proved out, payers and providers, for example, England's National Health Service and in the US the integrated, 12 hospital system, Geisinger Health, have substantially reduced incentive payments or are returning to paying providers straight salaries.