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Background: Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain., Objective: The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation., Results: We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients., Conclusion: We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality.

The American Society of Internal Medicine is launching a campaign to attack the "hassle factor" in medicine, which, physicians say, damages patient care and undermines their decisionmaking process. In a white paper titled The Hassle Factor: America's Health Care System Strangling in Red Tape, the society outlines how government and private payer regulations are increasing costs, reducing access, and hurting patient care. The degree to which these regulations are driving physicians out of practice directly affects hospitals.