Is "Bundled" Medical Care a Good Idea? Re "The Arkansas Innovation" (Op-Ed, Sept. Despite Ezekiel J. Emanuel's implication, Arkansas isn't the only state to plan to substitute "bundled" medical payments for fee-for-service. Vermont, Massachusetts and Oregon have similar intentions. But without basic changes in the organization and delivery of care, it is doubtful that "bundled" payments can be successfully distributed among all the providers of care. A stifling supervisory bureaucracy interfering with medical care and endless disputes among providers and between providers and payers are almost certain to develop. Physicians are unlikely to accept such an arrangement, and nothing can succeed without their agreement. Eventually, they will accept a different health system in which a single public payer guarantees comprehensive care for all, and pays accountable multispecialty physician groups not by reimbursement for specific services but through prepaid budgets on a per capita basis. The writer, professor emeritus of medicine and social medicine at Harvard Medical School, is a former editor in chief of The New England Journal of Medicine. I wonder who determines the quality of the care. Is it the doctor "quarterback" who receives and distributes the global payment? The fewer dollars spent on tests and treatments, the more the doctor gets to keep. Is it the insurance company? The fewer dollars spent, the more the insurance company can keep as profit or, if nonprofit, use to reduce premiums to be competitive. Is it the patient, who in the absence of a disastrous outcome, has no way to judge quality? Successful systems using the described fixed payments rather than fee-for-service to doctors (V.A., Kaiser and so on) are centralized and can evaluate and control quality. It is unlikely that the state licensing board wishes to or has the resources to do this. That leaves the malpractice lawyers, who, even at their best, address individual errors and not systemic quality control. A single-payer or comprehensive medical care system with a primary mission to serve patients well that is subject to oversight would better reassure the citizens of Arkansas that they are receiving the best medical care we have to offer. The writer is clinical professor emeritus of medicine at Brown University. The bundling of patient care, combined with financial rewards to doctors with the lowest costs, and financial penalties to those with the highest costs, threatens to lead to minimal care for all patients. While we would like to believe that doctors enter medicine for idealistic reasons and always put the welfare of their patients first, it would require a saint to disregard the profit motive in his or her practice. As noted in the article, not all patients fit into neat treatment categories. Given that insurance companies are usually more interested in the bottom line than in providing care, it's not at all clear that "risk adjustment" will be easily obtained for those who need more than standard care. The writer is a retired social worker and psychoanalyst.