During the next few years, some portion of physician reimbursement will be increasingly based on the quality and efficiency of service, a practice commonly referred to as pay for performance (P4P). Performance benchmarks are the discrete parameters of structure, process, or outcome metrics whose attainment defines good quality care. Private payers are already rewarding primary care physicians for practices that adhere to quality standards, are efficient, involve information technology, and result in high patient satisfaction. The Centers for Medicare and Medicaid Services will have completed the development of performance measures to be used in Medicare payment strategies for all specialties by the end of 2006 and anticipates phasing in the program fully by 2008. This article describes P4P, its importance to the ACR, the organizations involved in developing it, the ACR's activities to date, and the steps the ACR must take to ensure that radiologists are remunerated fairly as physician payment becomes based, in part, on performance.