This comprehensive review summarizes the financial issues and challenges facing efforts to improve health care quality. The authors examine four case studies to explore the financial and clinical implications of quality improvements. The cases include management of high-cost pharmaceuticals, diabetes management, smoking cessation, and wellness programs in the workplace. Through this discussion, costs and benefits are weighed for each of four prominent stakeholders with frequently conflicting interests: providers, purchasers and employers, individual patients, and society. The authors share the differing perspectives of the stakeholders to demonstrate how intimately tied a “business case” is to sustaining various interventions. They recommend policy changes to support necessary prioritization of financial incentives to achieve the highest quality of care. Readers will gain significant insight into the complexities and balancing act between financial incentives and quality.