Pay for performance (P4P)—tying monetary rewards to measures of health care quality—is a payment strategy being embraced by a variety of payers and policy makers nationally and internationally. In this issue of the Archives of Pediatrics & Adolescent Medicine, Garner et al1 describe a cluster randomized study of 29 substance abuse treatment sites to examine whether a provider-level piece-rate P4P program was effective at improving adolescent substance abuse treatment structures, processes, and outcomes. This P4P program targeted care related to the Adolescent Community Reinforcement Approach (A-CRA), an approach to adolescent substance abuse treatment that has been shown to be effective at reducing cannabis use among teens. In the P4P program, therapists could earn $50 for each month that they demonstrated competence with the A-CRA program as judged by digital recordings of their sessions with patients and $200 for each patient who received at least 10 or 12 specific A-CRA “procedures” (eg, asking for description of common [substance abuse] episode, discussing the importance of a satisfying social life, and checking on the progress of treatment goals). Garner et al found that, in adjusted analyses, therapists randomized to the P4P arm of the intervention were significantly more likely to demonstrate A-CRA competence and deliver recommended A-CRA care processes than those in the usual care arm. However, differences in care processes did not necessarily translate into desired changes in outcomes: patients receiving care from treatment centers and therapists in the P4P arm of the study were not any more likely to remain in remission than patients who were not.