No place like home--testing a new model of care delivery.

n engl j med 359;12 www.nejm.org september 18, 2008 1200 share this view that aligning provider incentives with payer goals will require organizational forms that can coordinate care more effectively than the fragmented current system.4 There are, fundamentally, no “new” methods of health care payment. Novel approaches such as those described here are new combinations of old ideas, with updated features such as improved risk adjustment. Economic theory, as others have long noted, suggests that such mixed payment models will function better than any single approach.5 Which recipe will yield the best balance of meaningful incentives for cost control and quality improvement, risk protection for providers, and selection incentives remains to be seen. The prospects for payment reform, however, hinge more on politics than on economics. Given that the two major goals of reform are to constrain spending growth and to move money from more intensive to less intensive settings — from doctors who carry endoscopes and scalpels to primary care physicians, for example — there will be substantial resistance to even the best-designed plans.