Problem · Problems created by solution paths

Targets and quality metrics invite gaming

Wait-time guarantees, quality bonuses, and spending targets can be gamed: re-labeling referral dates, avoiding sick patients, or upcoding.

Evidence

NHS England's waiting-list targets have been associated with documented gaming.
Sources: NHS England (2025)

Who's affected

Who is hurt

People with ongoing or specialist care needs: Gaming wait-time and quality measures undermines their intended protection.

Who gains while it lasts

Hospitals, clinics, and care organizations: They can benefit by changing referral dates, avoiding sick patients, or upcoding.

Under your mix of paths

Paths that create or worsen it

Paths that fix or soften it

Using your saved plan. 0 paths picked.Edit all picks

Root causes

Rewards tied to measurable proxies

Open questions

How should metrics be audited and designed to resist gaming?

Caused or worsened by these paths

This problem only matters if one of these paths is chosen.

Regulated multi-payer: everyone must have a non-profit or tightly regulated planTens of millions of people have no coverageRejected

Plans may avoid sick people unless risk adjustment counters that incentive.

Fix Medicare Advantage paymentsMedicare Advantage overpayments and coding intensityChosen

Plans adapt to coding reforms, and previous reforms only partly closed the payment gap.

Capitation for primary care and integrated systemsU.S. prices are far higher than in other countriesChosen

Fixed payments per enrollee create an incentive to avoid sick patients rather than provide their costly care.

Stepped care and integration into primary careMental health care is hard to getChosen

Outcome targets in stepped mental health care can be gamed.

Legal wait-time guaranteesLonger waits if demand grows faster than capacityChosen

A care deadline can encourage gaming of referral dates.

Regional administrators under national rulesOne payer becomes one targetChosen

Making regional administrators compete on integrity metrics puts those measures at the center of performance comparisons.

Hold the single payer to service standardsLosing the choice of health plan and insurer competitionChosen

Published call-wait, claim-time, and appeal measures can be gamed rather than reflect service accurately.

Risk adjustment plus outcome monitoringPaying a fixed amount per patient rewards doing lessChosen

Higher payments for sicker patients create a risk of upcoding.

Shift spending toward primary careWorse outcomes than peer countries despite the highest spendingChosen

Primary care spending targets can be met by relabeling costs.

Solution paths (2)

Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.

Independent audits and few, simple measuresChosen

Keep a short list of hard-to-game measures (outcomes, patient-reported) and audit them.

+Targets and quality metrics invite gaming

−Leaves less complete or useful data
−Adds paperwork, coordination, or complexity

Report measures publicly without tying pay to themRejected

Publish data for transparency but don't attach bonuses, removing the incentive to game.

+Targets and quality metrics invite gaming
+About $1 trillion a year in administrative cost

−Weakens incentives for desired behavior
−Leaves less complete or useful data