Opportunity in austerity--a common agenda for medicine and public health.

395 this infrastructure would require a transfer of funds from specialists or hospitals to primary care, and it may be difficult for organizations to unilaterally alter the flow of funds to accomplish these aims. Moreover, although organizations may face strong incentives to control costs, specialist physicians who continue to be paid through the fee-for-service system and hospitals, which continue to receive DRG-based payments, face no such inherent incentives — and in fact will continue to benefit from practicing in much the same way as they do now. Over time, if global payments become the norm, there is likely to be a resurgence of subcapitation and budgets for particular specialties, and systems will be designed to provide similar incentives to specialists while also enhancing funding for primary care. In addition, ACOs and their aligned hospitals must share incentives to control hospital costs. This transition, however, is likely to be painful and prolonged under the current design of the programs. Certainly, adjustments to the fee schedule that limit specialist pay and divert funds to primary care will be helpful, but even more helpful would be upfront payments that organizations can use to invest in their caremanagement and primary care infrastructure to facilitate this transition without taking funds from specialists or hospitals, at least until they achieve surpluses that ensure the continuation of this funding stream. Tightly managed multispecialty or primary care groups without strong alignment with a hospital may be well positioned to manage this transition. The health care system is placing tremendous hope in changing incentives to control the everincreasing costs of care. Hybrid approaches such as ACOs that incorporate global incentives but continue to keep score using feefor-service payments will face serious challenges as they attempt to place increasing burdens on the already-stressed primary care system without providing additional resources for achieving the aims of global payments — slowed growth in costs and higher-quality care.