The rigorous, evidence-based internal “system analysis” that Brent James advocates to improve quality has fallen prey to this reality. His method appears not only to cut unnecessary costs, but also to potentially lose the hospital money, thus threatening to upturn the innovative system. The article blames this perversity on fee-for-service payment. James suggests the answer is a fee-for-health system that would reward hospitals “trying to do the right thing.” An alternative approach currently gaining in popularity that attempts to align quality care with financial gain is “pay-for-performance.” This program is becoming increasingly popular but remains controversial due to relatively moderate improvements on quality and consequences that possibly increase health care disparities. Still, it relies less on change from within, generated by a group of doctors, and more on simple financial incentive; it is based on the ability of physicians’ interest in financial reward to influence their standard of care. Intermountain relies on a hospital committee to “woo” doctors into believing in evidence-based protocol. Although Intermountain appears to be successful in improving its quality, it may not survive its financial losses. Pay-for-performance has major flaws as well, but it may better understand how to control a doctor’s decisions: with money.