Most sponsors to whom we spoke were not conducting formal evaluations of their hospital P4P programs (5/22). However, some noted anecdotal evidence of positive program impact. For example, some said hospitals have improved their quality improvement infrastructure (e.g., dedicated quality improvement staff, regular quality improvement meetings) in response to P4P. Other sponsors reported seeing improved performance scores for participating hospitals. There was significant interest in tracking ROI, but there was also a lack of knowledge about how to do this and general difficulty estimating the costs associated with program development, implementation, and ongoing administration. For the most part, sponsors were not monitoring for potential unintended consequences of their hospital P4P programs, such as reduced attention and decreased quality of care in unmeasured areas. Sponsors did, however, recognize the need to do this, especially as P4P programs become more widespread and the amount of money tied to the financial incentive increases.