Higher Stakes for Physicians and Patients Figure 1. Higher Stakes Require Higher Rigor Tiered or Limited Networks Consumer-Directed Health Plans Public Reporting of Performance Physician Pay-for-Performance Quality Improvement Programs Higher Accuracy and Methodological Rigor Required Figure 2. The Win–Lose Cycle Payers Plans Develop mechanisms to reduce costs. Practitioners seek loopholes, alternatives. Providers withhold innovations, ideas. They spend time imagining how to beat the system. No feedback loop. Costs dip briefly, then escalate. Source: H. B. Beckman, Rochester Individual Practice Association, Mar. 2004.