Why Did Most French GPs Choose Not to Join the Voluntary National Pay-for-Performance Program?

Background: In 2009, a voluntary pay for performance (P4P) scheme for primary care physicians was introduced in France through the 'Contract for Improving Individual Practice' (CAPI).Although the contract could be interrupted at any time and without any penalty, two-thirds of French general practitioners chose not to participate. We studied what factors motivated general practitioners not to subscribe to the P4P contract, and particularly their perception of the ethical risks that may be associated with adhering to a CAPI. Method: A cross-sectional survey among French general practitioners using an online questionnaire based on focus group discussion results. Descriptive and multivariate statistical analyses with logistic regression. Results: A sample of 1,016 respondents, representative of French GPs. The variables that were associated with the probability of not signing a CAPI were "discomfort that patients were not informed of the signing of a P4P contract by their doctors'' (OR=8.24, 95% CI=4.61-14.71), "the risk of conflicts of interest'' (OR = 4.50, 95% CI = 2.42-8.35), "perceptions by patients that doctors may risk breaching professional ethics'' (OR=4. 35, 95% CI=2.43-7.80) and "the risk of excluding the poorest patients'' (OR=2.66, 95% CI=1.53-4.63). Conclusion: The perception of ethical risks associated with P4P may have hampered its success. Although the CAPI was extended to all GPs in 2012, our results question the relevance of the program itself by shedding light on potential adverse effects.