Résumé
Health systems undergo important transformations, triggered by budgetary pressure and rationalisation. In this context, France and Germany have introduced pay-for-performance (P4P) measures to provide financial incentives for providers meeting certain objectives. While there are similarities in both systems, the nature and timing of these policies differ, which we hypothesised to be related to differences in the collective organisation and institutionalisation of physicians. We used a comparative study design: the introduction of P4P in ambulatory care in France in 2009 and its potential introduction in Germany. We performed a literature review and semi-structured interviews of 23 actors. From an analytical perspective, we blended the approaches of public policy instruments, policy transfer and programmatic actors. We advance two main arguments. First, development of P4P in both countries is intrinsically linked to preceding policies as instruments prolonging the larger, long-term system transformations: the growing role of the State and statutory health insurance (SHI) in parallel to a fragmentation of the medical profession. It was embodied in France by the 2004 reform redefining the mission of SHI. In Germany, in addition, we emphasise the growing role of competition elements since the 1990s. This leads to our second argument: the prolongation of the long-term transformations did not lead to the same results in France and in Germany. In fact, P4P has seen a rapid uptake in France, facilitated by a relatively strong and proactive coalition led by SHI, which suggested that the reform be set within a coherent line of measures and ideas. Arguments of de-professionalization and ethics played a role in the ensuing discussions, with the majority of individual practitioners ultimately opting for P4P in balancing cognitive and material implications. A clear leadership role was assumed by the SHI director, by starting with P4P as individual contracts and then later integrating it in collective agreements. The cognitive focus was on cost containment via generic prescription, with SHI’s strategic goal of fostering IT in physician offices. Its backbone was a well-staffed strategy department scanning foreign experience. However, in the case of Germany, the picture is less clear, with many providers remaining reserved towards the idea of P4P and key actors uncertain about the net political gains. One major initiative for P4P in ambulatory care came from physician representatives in self-regulating bodies in a move to regain regulatory edge, hoping also to gain control over data or at least over data collection methods. Yet, it was rejected by its base over concerns about de-professionalization and the allocation of funds. It was followed by long technical debates about quality indicators that may be seen as delay tactics. The ensuing debate concerned issues over data and the balance of power among the self-regulating partners (physicians, SHI, hospitals). A P4P component will be introduced for hospital payment and is likely to yield advantages for SHI and private hospitals. In both countries, these developments challenge established patterns, pointing towards a “divergent convergence” of healthcare arrangements.