Table 1.

Elements of the P4P program, design options and choices

Component	Elements	Design options	Design choices P4P program
Performance measurement	Performance indicators
	Domains, subjects and indicators	Selection of:- Clinical care (diabetes, asthma, COPD, cardiovascular risk management, influenza vaccination, cervical cancer screening, prescribing acid suppressive drugs and antibiotics)- Practice management (infrastructure, team, information, quality and safety)- Patient experience (experience with general practitioner and organisation of care)	Selected indicators for:- Clinical care: diabetes (n = 9), asthma (n = 4), COPD (n = 5), cardiovascular risk management (n = 9), influenza vaccination (n = 2), cervical cancer screening (n = 1), prescribing antibiotics (n = 2)- Practice management: infrastructure (n = 7), team (n = 8), information (n = 3), quality and safety (n = 4)- Patient experience: experience with general practitioner (n = 16) and organisation of care (n = 11)
	Period of data collection	Data collection for all three domains each year vs. a trimmed-down version of the program	At baseline measurement of clinical care, practice management, patient experience; In following years only clinical care and patient experience
Appraisal	Unit of assessment	Individual GP vs. general practice vs. larger organisational unit	General practice
	Performance standards	• Absolute vs. relative standards • Same standards vs. different standards for indicators/subjects	• A relative standard set at the 25th percentile of group performance • Different standards for indicators
	Analysis and interpretation of performance data
	Weighing the domains	Different weights vs. same weight	Clinical care : practice management : patient experience 2:1:1
	Weighing the indicators	Different weights vs. same weight	Same weight for all indicators
	Calculations	• Separate scores for each domain vs. one overall domain-score • Calculations for quality level and/or improvement of performance	• Separate scores for each domain • Calculations for both quality level and improvement of performance
	Weighing the quality scores	Different weights vs. same weight for quality level and improvement of performance	Quality level : improvement of performance 3:1
	Differentiation of quality scores	4 levels vs. 5-7 levels vs. 8-10 levels	7 levels
	Feedback	• Benchmark: median vs. best practice (75th or 90th percentile) vs. a combination • Risk adjustment: indirect vs. direct correction • One-step procedure vs. two-step procedure	• 25th percentile, median, 75th percentile • No risk adjustment • Two-step procedure
Reimbursement	Financial rewards
	Payment	Money vs. human resources vs. sabbatical leave vs. a combination	Money
	Size of the bonus	5000 Euros to 10000 Euros (5-10% practice income) on average per practice (depending on practice size) → appropriate or not?	5000 Euros to 10000 Euros on average per practice (depending on practice size)Baseline: A maximum of euro 6.89 on average per patient*Following years: A maximum of euro 2.88 on average per patient*
	Spending the bonus	No obligations vs. obligations (spending for practice with or without pre-set goal) vs. a combination	No obligations

* A patient whose health insurance company was a sponsor of the P4P program