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Pay for Performance in Five States: Lessons for the Nursing Home Sector


  • Edward Alan Miller is associate professor of gerontology and public policy at the University of Massachusetts Boston and adjunct associate professor of health services, policy, and practice at Brown University. He received his doctorate in political science and health services research from the University of Michigan. His research focuses on understanding the determinants and effects of federal and state policies affecting vulnerable populations, including the elderly, veterans, and mentally ill. E-mail:
  • Julia Doherty is senior research director at L&M Policy Research, LLC. She has 25 years of experience in health care management, policy, and research. She has recruited and managed technical advisory panels to support projects in a variety of research areas, conducted hundreds of stakeholder interviews with representatives across health sectors, and advised stakeholders as they worked to improve health care quality and delivery throughout a fragmented health care system. E-mail:
  • Pamela Nadash is assistant professor of gerontology at the University of Massachusetts Boston. She received her doctorate in public health and political science from Columbia University. Her research centers on helping people with long-term care needs to live in the community. This includes specializations in long-term care policy, comparative health policy, consumer choice in health and long-term supportive services, and integrated care models. E-mail:


Pay for performance (P4P) aims to use reimbursement to incentivize providers to deliver high-quality services. This article examines P4P in five Medicaid nursing home programs: Iowa, Minnesota, Oklahoma, Utah, and Vermont. It describes each program and draws lessons regarding program participation, financing, measurement, administration, and development. Findings highlight the importance of obtaining stakeholder input, both initially and on an ongoing basis. Findings also highlight the need to provide opportunities for acceptance and learning by phasing in programs slowly, beginning with performance measurement, followed by public reporting and, finally, by introducing P4P incentives. Funding P4P using new appropriations, incorporating multiple quality measures and domains, and relying on existing data sources when possible were deemed important; so, too, was allowing programs to evolve over time to account for innovations in quality measurement.