title: Aligning provider incentives to improve primary healthcare delivery in the United States.
abstract: BACKGROUND
  The United States (US) is reforming primary care delivery systems, including the implementation of 'patient-centered medical homes.' Alignment of provider incentives with desired outcomes will likely be important to the success of these delivery system reforms.
  
  
  METHODS
  This critical review uses a theoretical framework from game-theory models to discuss some of the dominant primary care provider payment models and how they create 'prisoner's dilemmas' that have stalled past reform efforts. It then uses this framework to illustrate, hypothetically, how advantages from different models could be blended together to encourage cooperation and improve the quality of primary care services delivered, thus providing an escape from current prisoner's dilemmas faced by providers.
  
  
  RESULTS
  Improvements in primary care delivery will largely hinge on blended payment mechanisms that can effectively combine the advantageous elements of fee-for-service, capitation, and incentive payments into a balanced equation that enables providers to escape the perverse financial incentives of current payment mechanisms and overcome collective action problems.
  
  
  CONCLUSIONS
  If balanced appropriately, a blend of guaranteed payment and selective incentives designed to encourage primary care providers to deliver high quality care, efficient and equitable care and to eliminate incentives towards over-servicing could reach outcomes leading to shared benefits for everyone involved.
authors.affiliation: Department of Family Medicine, Oregon Health and Science University, 3181 Sam Jackson Park Road, Mailcode: FM, Portland, OR 97239, USA.
authors.forename: J E
authors.initials: JE
authors.lastname: DeVoe
authors.affiliation: Saint Patrick Hospital, 500 West Broadway Street, Missoula, MT 59802, USA.
authors.forename: R
authors.initials: R
authors.lastname: Stenger