The whole idea behind bundled payments is to transfer clinical and financial risk to providers (“Tying it together,” May 3, p. 31). Depending on the identity of the “at-risk” provider group and their interim basis of payment, however, incentives may still not be aligned to cause individual practitioners or institutions to fully consider the impact of their care management decisions on the overall cost of an episode of care. Global and budgeted capitation agreements were also meant to incent individual physicians and hospitals to consider the financial ramifications of their clinical decisionmaking. For those treating more of the “garden variety” type of patient, the incentives generally worked in favor of at-risk groups; for groups treating patients having a higher illness burden, the results were often devastating. I am assuming that the proponents of accountable care organizations and medical homes have factored the cost of high-acuity patients and catastrophic care into their financial calculus when establishing these types of care constructs. The reality is that while the potential exists to reduce the long-term medical cost trend through more judicious care management, we are a long way from that ideal future.
Jonathan B. PomazonIndependent healthcaredevelopment executiveBeverly, Mass.