Over the last decade, many attempts have been made to simultaneously improve health care quality and reduce spending. A variety of methods have come and gone (or in some cases, come to stay, in specialized sectors such as managed care with its HMOs, gatekeepers and utilization review). Performance measurement and pay-for-performance (P4P) or Value-based Purchasing are the current rallying cries in health care reform and politics to achieve reduced spending and improved quality. It appears to be on the horizon for most, if not all, physicians in one form or another.