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H e a l t h c a r e t h a t i s s t r u c t u r e d t o a c c o m m o -date the sensitivities and demands of human biology will look different from health care that is organized to meet the requirements of stockholders and quarterly profits. Structure implies function in the corporate environment as decidedly as it does in the natural world. A health plan constructed for financial profit measures success quarterly. A health plan created to accommodate the needs of human biology, on the other hand, adopts the perspective of a life span; its success is best expressed in health outcomes and quality of life. Members ought to be able to trust that their HMO is primarily focusing on their health. Yet advocates of nonprofit HMOs have not succeeded in calling attention to their differences from for-profit organizations. Most surveys indicate that people do not understand or care about the distinction. One reason is that the not-for profits have done little to translate the relationship of trust that they have established with their members into market advantage, preferring instead to maintain an ivory-tower existence and to refrain from arguing the merits of their status.Nevertheless, the achievements of managed care in improving the health status of communities can be traced directly to the not-for-

The Patient Protection and Affordable Care Act establishes a new Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services (CMS). The center is intended to enhance the CMS's role in promoting much-needed improvements in payment and service delivery. Lessons from the Medicare Health Support Program, a chronic care pilot program that ran between 2005 and 2008, illustrate the value of drawing on experience in planning for the center and future pilot programs. The lessons include the importance of strong leadership; collaboration and flexibility to foster innovation; receptivity of beneficiaries to care management; and the need for timely data on patients' status. The lessons also highlight pitfalls to be avoided in planning future pilot programs, such as flawed strategies for selecting populations to target when testing payment and service delivery reforms.

D e f i n i n g a n d m e a s u r i n g q u a l i t y w i t h o u t paying attention to cost is not feasible in the real world, where the issue is what quality can be achieved at a defined cost. Purchasers of health benefits have clearly shown that they can effectively use prepayment ("capitation" of the plan) to leverage wider benefits (e.g., preventive services and drugs), at lower cost both to themselves and their subscribers, while imposing extensive requirements for documentation of performance, including structural, process, and outcomes quality indicators. No other funding mechanism has been able to achieve this level of value, or "cost-adjusted quality." Indemnity financing has all but disappeared. Even if we could agree on the definitions and measurements of quality, comparisons of prepayment and indemnity are no longer relevant. Prepayment by purchasers clearly extracts greater value from plans, end of story! When health plans, in turn, purchase services, they link financial and nonfinancial incentives, like various risk arrangements (e.g., capitation), benefit designs, copayments, network structures, bonus incentives, and utilization controls, in order to change the behavior of both providers and patients. The research that was reviewed by the conference participants fails to demonstrate an unequivocal increase or decrease in the