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Background: In 2009, a voluntary pay for performance (P4P) scheme for primary care physicians was introduced in France through the 'Contract for Improving Individual Practice' (CAPI). Although the contract could be interrupted at any time and without any penalty, two-thirds of French general practitioners chose not to participate. We studied what factors motivated general practitioners not to subscribe to the P4P contract, and particularly their perception of the ethical risks that may be associated with adhering to a CAPI., Method: A cross-sectional survey among French general practitioners using an online questionnaire based on focus group discussion results. Descriptive and multivariate statistical analyses with logistic regression., Results: A sample of 1,016 respondents, representative of French GPs. The variables that were associated with the probability of not signing a CAPI were "discomfort that patients were not informed of the signing of a P4P contract by their doctors" (OR = 8.24, 95% CI = 4.61-14.71), "the risk of conflicts of interest" (OR = 4.50, 95% CI = 2.42-8.35), "perceptions by patients that doctors may risk breaching professional ethics" (OR = 4. 35, 95% CI = 2.43-7.80) and "the risk of excluding the poorest patients" (OR = 2.66, 95% CI = 1.53-4.63)., Conclusion: The perception of ethical risks associated with P4P may have hampered its success. Although the CAPI was extended to all GPs in 2012, our results question the relevance of the program itself by shedding light on potential adverse effects.

Context In France, a new payment for performance (P4P) scheme for primary care physicians was introduced in 2QQ9 through the 'Contract for Improving Individual Practice' programme. Its objective was to reduce healthcare expenditures while enhancing improvement in guidelines' observance. Nevertheless, in all countries where the scheme was implemented, it raised several concerns in the domain of professional ethics. Objective To draw out in France the ethical tensions arising in the general practitioner's (GP) profession linked to the introduction of P4P. Method Qualitative research using two focus groups: first one with a sample of GPs who joined P4P and second one with those who did not. All collective interviews were recorded and fully transcribed. An inductive analysis of thematic content with construction of categories was conducted. All the data were triangulated. Results All participants agreed that conflicts of interest were a real issue, leading to the resurgence of doctor's dirigisme, which could be detrimental for patient's autonomy. GPs who did not join P4P believed that the scheme would lead to patient's selection while those who joined P4P did not. The level of the maximal bonus of the P4P was considered low by all GPs. This was considered as an offense by non-participating GPs, whereas for participating ones, this low level minimised the risk of patient's selection. Conclusion This work identified several areas of ethical tension, some being different from those previously described in other countries. The authors discuss the potential impact of institutional contexts and variability of implementation processes on shaping these differences. [ABSTRACT FROM AUTHOR]