We sympathize with the sentiments expressed by Dr. Miller. One of us is a practicing physician and is aware of the extra burden imposed by many performance measurement programs with unclear patient benefits. Evidence suggests, however, that the proliferation, measurement, and dissemination of quality information have a substantial impact on measured areas of quality. Indeed, one measure (β-blocker use after a myocardial infarction) has been retired because performance has approached perfection (1). It is highly unlikely that performance on this measure and others would be so high if a spotlight had not been aimed at them. Although pay-for-performance and other programs have been shown to have a generally small impact over short periods, their cumulative effects over time remain unknown. The hope is that better use of population health management techniques and electronic resources, such as electronic health records and decision support, will improve the capacity of physician organizations to achieve higher-quality care.

Although space constraints prohibit us from addressing each of Dr. Miller's questions, we comment on a few key points. First, given recent evidence that the quality of care produced by the U.S. health care system is suboptimal, we believe not only that limited resources should be directed toward improving care but that this investment should be much more substantial (2–4). Second, we disagree that these programs are at the root of the current primary care crisis. In fact, the United Kingdom has instituted a broad pay-for-performance program that includes substantial additional resources directed toward general practitioners, in part to stabilize the primary care workforce. Like Dr. Miller, we hope that onerous utilization management tools and requests used by health plans will diminish with time as the interconnectedness of the health care system is improved. Nonetheless, it is unlikely that these programs will disappear while there is still substantial evidence of overuse and variations in use that cannot be explained by clinical need. Some of these other issues have been discussed in other papers (5). Despite these problems, we believe that increased measurement and transparency are required for improving health systems.