Since the start of the pay-for-performance and the patient protection and affordable care act (aca), there has been intense pressure on the healthcare sector to improve quality of care while reducing expenses, specifically related to pharmacy. the stress has been exacerbated by expensive specialty medications, egregious price increases for some sole-source drug products, and the escalation of generic drug prices. identify the strategic fundamentals of the problem and what mistakes were made in either the planning or implementation of the pay-for-performance and the patient protection/aca.