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Pay for quality: how much pay for how much quality?

2014 The US healthcare system is evolving. Historically, providers earned compensation based upon the volume of services that they delivered. As pointed out in a recent Journal of Comparative Effectiveness Research article, ‘provider payment incentives have long been viewed as an important factor driving decisions about the types of care that patients receive’ [1]. In a fee-for-service environment, providers have incentives to deliver more services. However, that system is evolving, with a variety of models being used ranging from fixed fees for major surgical procedures like hip replacement (including prehospital and posthospital services) to Accountable Care Organizations financially responsible for large populations and longitudinal care. These alternative payment models shift volume-based reimbursement to payment for either a specified bundle of services, a clinically defined episode of care or an entire year of care. Accordingly, hospitals have economic responsibility for rehospitalizations that might occur within a defined time period, and physicians need to manage a population of patients within a budget. In this evolution, fee-for-service incentives that may lead to overuse shift to possibilities of underuse. Will patients with low back pain still undergo MRI scanning when necessary? Will patients with hard to control diabetes receive insulin pumps? And will patients with rheumatoid arthritis be prescribed biologic therapy