BACKGROUND: Health plans, self-insured employers, health plans, and provider organizations are currently introducing financial incentives that reward physicians for delivering high-quality medical care. Yet a review of existing research reveals virtually no empirical studies of the effect of direct, internal quality incentives on physician performance. Key-informant interviews with leaders of provider organizations should shed new light on evolving quality incentives within organizations. METHODS: Structured key-informant interviews with administrators and medical directors in 22 medical groups and 9 hospitals affiliated with 10 large, integrated health systems were conducted from July 2003 through January 2004. FINDINGS: Views on the role of financial incentives varied widely and were related to a number of other factors, including institutional culture, community context, organizational strategy and structure, organizational stability, quality measurement, nature and size of incentives, and the sustainability of interventions. DISCUSSION: These findings have implications for the acceptability and structure of financial incentives for quality directed to health care provider organizations. A set of considerations for the design and implementation of quality incentives relate to the incentives' scope, controllability, transparency, size, and orientation (individual or team), as well as the relationship between the extrinsic financial incentives and professionals' intrinsic motivation.