<P> Pay for performance programs often target patients with serious and complex illnesses; such patients commonly interact with multiple healthcare providers and facilities . However, pilot programs now underway focus on simple indicators such as improvement in lab values or use of emergency services, avoiding areas of complexity such as multiple complications or several treating specialists . A 2007 study analyzing Medicare beneficiaries' healthcare visits showed that a median of two primary care physicians and five specialists provide care for a single patient . The authors doubt that pay - for - performance systems can accurately attribute responsibility for the outcome of care for such patients . The American College of Physicians Ethics has expressed concern: </P> <P> Pay - for - performance initiatives that provide incentives for good performance on a few specific elements of a single disease or condition may lead to neglect of other, potentially more important elements of care for that condition or a comorbid condition . The elderly patient with multiple chronic conditions is especially vulnerable to this unwanted effect of powerful incentives . </P> <P> Present pay - for - performance systems measure performance based on specified clinical measurements, such as reductions in glycohemoglobin (HbA1c) for patients with diabetes . Healthcare providers who are monitored by such limited criteria have a powerful incentive to deselect (dismiss or refuse to accept) patients whose outcome measures fall below the quality standard and therefore worsen the provider's assessment . Patients with low health literacy, inadequate financial resources to afford expensive medications or treatments, and ethnic groups traditionally subject to healthcare inequities may also be deselected by providers seeking improved performance measures . </P> <P> In Minnesota, Minnesota Community Measurement ranks providers on multiple categories such as patient experience and total cost of care and provides public reporting online to inform consumers . The service is designed to help purchasers make better decisions when seeking care and to provide feedback to providers for areas that need improvement . </P>

How could the impact of these departments on pay-for performance incentives be measured