A programme of financially structured incentives for practitioners and providers in exchange or as reward for the achievement of certain benchmarks of performance. The hope is that by offering positive rewards – both for reaching thresholds of performance and for making continuous strides in improving the quality of health care – high quality health care will be delivered on a consistent basis. This approach acknowledges the reality that financial rewards are among the most powerful tools for bringing about behaviour change. These incentive programmes are largely untested. Pay-for-performance programmes are operating in a complex reimbursement environment that often creates – by omission or commission – barriers to reaching the goal of consistent, high quality care for all patients. For example, payment systems frequently do not recognise the nuances of care delivery, nor do they always pay fairly for important aspects of care, such as activities that support patient education, continuity of care, or integration of services. One pitfall of these programmes is that the financial incentives may discourage providers from treating severely ill patients in order to improve their outcome reporting. Incentives can also inadvertently discourage providers from ordering potentially life-saving procedures in order to save costs.