Suboptimal health care quality is an urgent national concern.1 Recently, policy makers have sought to improve quality by providing bonus dollars to physicians whose patients achieve certain health goals.2 The privatized US health care system has engendered decentralized quality improvement approaches3 and an unintended consequence has been ambiguity regarding who is responsible for quality and the scope of stakeholders' obligations. For example, some pay-for-performance arrangements effectively pay physicians less if their patients with diabetes miss appointments and fail to take prescribed medications.4,5 Pay-for-performance also does not typically assess diagnostic skills or clinician empathy,3 traits that patients value highly.6 These measurement flaws have frustrated physicians5,7 and a backlash could derail potentially valuable improvement efforts.
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