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indicate better care, but that providers may try to treat on an outpatient basis when the patient should really be readmitted. Chen, Chung, Lin, and Lai (2011) investigated patient characteristics when providers could determine who was enrolled in pay-for-performance programs. Results showed that older diabetics, ones with multiple comorbidities, or ones that hadmore severe disease processes were excluded, implying that providers may choose not to treat more difficult patients, if given the option. Himmelstein, Ariely, and Woolhandler (2014) pointedout that monetary motivation may lead otherwise ethical individuals to falsify data so that measurements are distorted.Pay for Performance and the Affordable Care ActWhile ACA expanded healthcare services in the United States to include preventive and primary care, its implications for P4P systems are indicative of how nurses and physicians confront legal restrictions and other professional limitations within a specific scope ofpractice. For example, Lathrop and Hodnicki (2014) noted how ACA provided multiple opportunities for nurses and physicians to improve direct patient care as well as act as advocates for patients. However, most of the legal restrictions and professional limitations presented by ACA reduce leadership potential for most practicing nurses and physicians. Berkowitz (2016)
PAY FOR PERFORMANCE9argued concurrently that most P4P systems developed after ACA became federal law function as metrics for measuring the quality of payment systems. Whether P4P systems reimburse healthcare providers and institutions for improvements to the quality of care depends on whether nurses and physicians rely on a single evidence-based approach designed for improving health outcomes in patients. Furthermore, Dogra and Dorman (2016) acknowledged how ACA reinforces the linkages between the ability to pay and patient health outcomes. Although some healthcare providers may receive reimbursement payments from Medicare and Medicaid services, most of the P4P systems enacted post-ACA indicate a misalignment between patient expectations and outcomes.In a similar vein, Naci and Soumerai (2016) found that ACA created many problems that required nurses and physicians to correct performance issues that held serious implications for improving the quality of care among patients defined as too costly for stakeholders in the healthcare system to maintain. P4P systems are part and parcel of ACA to such an extent that many of their components—e.g., Accountable Care Organizations (ACOs), patient-centered medical homes, and health information technologies (HITs)—reinforce gaps between patient expectations and outcomes. Meanwhile, the studies linking ACA and P4P systems present historical biases that suggest a lack of correlation between the impact of policies before and after their enactment. Whereas some historical events may create incentives to improve the quality of care delivered by nurses and physicians, others open the door for questioning whether their impacts are as remarkable as originally intended. Moreover, the