Fee-for-service payments encourage high-volume services rather than high-quality care. Alternative payment models (APMs) aim to realign financing to support high-value services.

The 2 main components of gastroenterologic care, procedures and chronic care management, call for a range of APMs. The first step for gastroenterologists is to identify the most important conditions and opportunities to improve care and reduce waste that do not require financial support.

We describe examples of delivery reforms and emerging APMs to accomplish these care improvements. A bundled payment for an episode of care, in which a provider is given a lump sum payment to cover the cost of services provided during the defined episode, can support better care for a discrete procedure such as a colonoscopy. Improved management of chronic conditions can be supported through a per-member, per-month (PMPM) payment to offer extended services and care coordination.

For complex chronic conditions such as inflammatory bowel disease, in which the gastroenterologist is the principal care coordinator, the PMPM payment could be given to a gastroenterology medical home. For conditions in which the gastroenterologist acts primarily as a consultant for primary care, such as noncomplex gastroesophageal reflux or hepatitis C, a PMPM payment can support effective care coordination in a medical neighborhood delivery model. Each APM can be supplemented with a shared savings component.

Gastroenterologists must engage with and be early leaders of these redesign discussions to be prepared for a time when APMs may be more prevalent and no longer voluntary.

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Editors’ Note: Turkey’s failed coup may lead to the worsening of Europe’s migration crisis, writes Jessica Brandt. That’s because it could lead to the dissolution of a recent pact between Brussels and Ankara over the plight of refugees arriving on the European Union’s shores. This post originally appeared on Vox.

Turkey’s recent failed coup may lead to the worsening of Europe’s migration crisis. That’s because it could lead to the dissolution of a recent pact between Brussels and Ankara over the plight of refugees arriving on the European Union’s shores. Even before the events of last weekend, the fate of the agreement was uncertain amid quarrels between the parties. Now its future is even more in doubt.

Last year, more than a million migrants and refugees crossed into Europe, roiling politics across the continent. It’s a crisis EU chief Donald Tusk has described as an “existential challenge.”

Under the terms of the deal, Turkey agreed to accept the “rapid return of all migrants not in need of international protection crossing from Turkey into Greece and to take back all irregular migrants intercepted in Turkish waters.” In other words, almost all refugees who cross into Greece are slated to be returned to Turkish soil.

In return, the EU pledged to speed up the allocation of €3 billion in aid to Turkey to help it house and care for refugees, “reenergize” Turkey's bid for membership in the EU, and lift visa restrictions on Turkish tourists and businessmen.

But the European Commission has conditioned changes to the visa restrictions on better governance in Turkey. In particular, it requires a change in President Recep Tayyip Erdoğan’s controversial anti-terror law, which he has used to crack down on journalists and critics. Erdoğan was already adamantly against narrowing the law to protect free speech. Having now overcome a determined coup attempt, he is even less likely to do so.

Instead, it appears probable that he will further clamp down on civil liberties, acting on his authoritarian instincts and retaliating against his detractors. On Sunday, he suggested that he might reintroduce the death penalty, a practice Turkey abolished in 2004 as part of its bid for EU membership. Doing so would widen the gap in political culture between Turkey and Europe and, as German Foreign Minister Frank-Walter Steinmeier asserted forcefully on Monday in Brussels, derail the already limited possibility of reigniting accession talks.

The pact has already been strongly opposed by the European left, and particularly by humanitarian and human rights groups. Rising authoritarianism in Turkey would only increase resistance to the deal, making implementation even harder, especially if those groups were to scale back their activities on the ground.

That would not be without precedent. The United Nations High Commissioner for Refugees, Doctors Without Borders, and the International Rescue Committee, among others, have suspended some of their activities in refugee centers because they do not want to be involved in implementing a deal that they describe as constituting the blanket expulsion of refugees from Turkey back to Greece.

[A] crackdown could also undermine the legal basis of the agreement.

Crucially, a crackdown could also undermine the legal basis of the agreement. One of the agreement’s key provisions is that individuals who cross from Turkey into Greece will be sent back across the Aegean to Turkey. That hinges on the notion that Turkey is a “safe third country” for migrants. A crackdown could prompt refugees to argue that it isn’t.

If that were the case, deporting them to Turkey could be seen as constituting “refoulement”—the forcible return of asylum seekers to a country where they are prone to be subjected to persecution—which is forbidden under both international and EU law.

That’s a problem, since some analysts believe worsening conditions in Turkey could lead even more people seeking refuge to journey onward to Europe. In the past, Erdoğan has threatened to “open the gates” and send refugees streaming into Europe when displeased with the level of financial assistance from Brussels earmarked for managing the crisis. Preoccupied by troubles at home, he may see stability as in his interest and resist taking aggressive steps that would cause an open breach.

For both parties, finding a stable, though imperfect, accommodation—as they were poised to do prior to the events of last weekend—is still the most promising path forward. Let’s hope the parties take it. Managing Europe’s migration crisis depends on it.

Twenty-five years ago, in March 1991, shaken by the fall of the Berlin Wall and the rise of nationalist-separatist movements in the Soviet Baltic and Caucasus republics, Mikhail Gorbachev held a historic referendum. He proposed the creation of a new union treaty to save the USSR. The gambit failed. Although a majority of the Soviet population voted yes, some key republics refused to participate. And so began the dissolution of the USSR, the event that current Russian President Vladimir Putin has called the “greatest geopolitical catastrophe” of the 20th century.

Today, in the wake of the referendum on leaving the European Union, British Prime Minister David Cameron seems to have put the United Kingdom on a similar, potentially catastrophic, path. Like the fall of the wall and the collapse of the Soviet Union, the fallout from Brexit could have momentous consequences. The U.K. is of course not the USSR, but there are historic links between Britain and Russia and structural parallels that are worth bearing in mind as the U.K. and the EU work out their divorce, and British leaders figure out what to do next, domestically and internationally.

A quick Russian history recap

The British and Russian empires formed at around the same time and frequently interacted. Queen Elizabeth I was pen pals with Ivan the Terrible. The union of the Scottish and English parliaments in 1707 that set the United Kingdom on its imperial trajectory coincided with the 1709 battle of Poltava, in which Peter the Great ousted the Swedes from the lands of modern Ukraine and began the consolidation of the Russian empire. The Russian imperial and British royal families intermarried, even as they jockeyed for influence in Central Asia and Afghanistan in the 19th century. The last Czar and his wife were respectively a distant cousin and granddaughter of British Queen Victoria. The Irish Easter Uprising and the Russian Revolution were both sparked by problems at home, imperial overstretch, and the shock of the World War I. 

Like the fall of the wall and the collapse of the Soviet Union, the fallout from Brexit could have momentous consequences.

Since the end of the Cold War, the U.K. and Russia have both had difficulty figuring out their post-imperial identities and roles. The U.K. in 2016 looks structurally a lot like the USSR in 1991, and England’s current identity crisis is reminiscent of Russia’s in the 1990s. After Gorbachev’s referendum failed to shore up the union, the Soviet Union was undermined by an attempted coup (in August 1991) and then dismantled by its national elites. In early December 1991, Boris Yeltsin, the flamboyant head of the Russian Federation, holed up in a hut deep in the Belarusian woods with the leaders of Ukraine and Belarus and conspired to replace the USSR with a new Commonwealth of Independent States (CIS). With Gorbachev and the Soviet Union gone by the end of December, the hangover set in. Boris Yeltsin was the first to rue the consequences of his actions. The CIS never gained traction as the basis for a new union led by Russia. 

The Ukrainians, Belarussians, and everyone else gained new states and new identities and used the CIS as a mechanism for divorce. Russians lost an empire, their geopolitical anchor, and their identity as the first among equals in the USSR. The Russian Federation was a rump state. And although ethnic Russians were 80 percent of the population, the forces of disintegration continued. Tatars, Chechens, and other indigenous peoples of the Russian Federation, with their own histories, seized or agitated for independence. Ethnic Russians were “left behind” in other republics. Historic territories were lost. Instead of presiding over a period of Russian independence, Boris Yeltsin muddled through a decade of economic collapse and political humiliation.

Separating the U.K. from Europe...could be as wrenching as pulling apart the USSR.

Is Britain laying the same trap?

Another Boris, the U.K.’s Boris Johnson, the former mayor of London and main political opponent of David Cameron, risks doing the same if he becomes U.K. prime minister in the next few months. Separating the U.K. from Europe institutionally, politically, and economically could be as wrenching as pulling apart the USSR. People will be left behind—EU citizens in the U.K., U.K. citizens in the EU––and will have to make hard choices about who they are, and where they want to live and work. The British pound has already plummeted. The prognoses for short- to medium-term economic dislocation have ranged from gloomy to dire. The U.K is a multi-ethnic state, with degrees of devolved power to its constituent parts, and deep political divides at the elite and popular levels. Scotland and Northern Ireland, along with Gibraltar (a contested territory with Spain), clearly voted to stay in the European Union. The prospect of a new Scottish referendum on independence, questions about the fate of the Irish peace process, and the format for continuing Gibraltar’s relationship with Spain, will all complicate the EU-U.K. divorce proceedings. 

Like Russia and the Russians, England and the English are in the throes of an identity crisis.

Like Russia and the Russians, England and the English are in the throes of an identity crisis. England is not ethnically homogeneous. In addition to hundreds of thousands of Irish citizens living in England, there are many more English people with Irish as well as Scottish ancestry––David Cameron’s name gives away his Scottish antecedents––as well as those with origins in the colonies of the old British empire. And there are the EU citizens who have drawn so much ire in the Brexit debate. 

As in the case of the USSR and Russia where all roads led (and still lead) to Moscow, London dominates the U.K.’s population, politics, and economics. London is a global city that is as much a magnet for international migration as a center of finance and business. London voted to remain in Europe. The rest of England, London’s far flung, neglected, and resentful hinterland, voted to leave the EU—and perhaps also to leave London. At the end of the divorce process, without careful attention from politicians in London, England could find itself the rump successor state to the United Kingdom. If so, another great imperial state will have consigned itself to the “dust heap of history” by tying its future to a referendum. 

Editors’ Note: The odds of wringing short-term concessions from Cuba's proud and nationalist leaders are stacked against Obama, Richard Feinberg and Ted Piccone believe. They argue the trip should be judged by its ability to expand constituencies in both countries who want a more open and prosperous Cuba. This post originally appeared on Huffington Post.

President Obama's decision to make a historic visit to Cuba later this month is about more than U.S. politics or business opportunities on the island. It's a bold bet that

presidential diplomacy can secure a new normal in U.S.-Cuba relations after over five decades of hostilities, embargoes and gridlock.

Based on our years of analysis and policymaking in and out of government, we believe the odds of wringing short-term concessions from Cuba's proud and nationalist leaders are stacked against Obama. We also believe, however, that that is the wrong metric. Rather, this trip should be judged by its ability to expand constituencies in both countries who want a more open and prosperous Cuba.

To that end, Obama should draw on his extraordinary rhetorical skills to paint a vision for both Cubans and Americans of a future attractive enough to persuade the island's citizens, especially its ambitious and talented millennials to remain on the island and for the resourceful Cuban American diaspora to invest in that vision. This promise of a Cuban renaissance should include one where citizens freely exercise their chosen professions, engage directly with a transparent and accountable government, have access to the global internet, and travel abroad routinely for family and business purposes.

To help shape such a future, the U.S. delegation should engage not only with Cuba's historic revolutionaries but also with its next generations of public and private leaders from across Cuban society. The White House can also use the visit to leverage Obama's immense popularity on the island to speak directly to the Cuban people about their aspirations for a brighter future.

Given the longstanding feuds between our two countries, however, it will take longer than a year or two to unwind the accumulated distrust and build support for this new normalcy. On the U.S. side, major sectors have swung clearly in favor of normalization - business and agricultural interests, human rights and religious groups, and the broad swath of U.S. citizens keen to know Cuba after decades of isolation. Even majorities of Cuban-Americans and Hispanic voters favor engagement over the embargo.

These constituencies, however, are not yet strong enough to persuade Congress to lift the embargo. And Havana has done little so far to address the major sticking points in Washington's list of legitimate grievances, particularly in the key areas of human rights and economic reforms.

On the Cuban side, Raúl Castro recognizes that Cuba's ability to protect the social gains of the revolution depends on normalizing its participation in the global economy. Its economy badly needs the injection of U.S. commerce, professional exchanges and tourism that would flow readily once the embargo is lifted. Family-run businesses, farmers, young people and professionals in sectors like software and biotechnology also stand to gain from these changes.

Notably, many of those fighting for a more pluralistic Cuba applaud Obama's decision to declaw the embargo as a political shield for government hard-liners; it helps their cause for a more honest debate at home about how to reform Cuba's outdated model of state-centric development and to make government more accountable to its citizens.

The visit offers both presidents a rare opportunity to demonstrate to these various stakeholders that change is not one-sided but a mutual accommodation. There is nothing like a presidential visit to move bureaucracies and catalyze action.

For example, the visit could accelerate progress toward easing the embargo. Already, new rules encourage trade with the emerging private sector and with some state-owned enterprises. Cuba should now take steps to facilitate such commerce and stop insisting that all sanctions be lifted first.

As important, the two sides should expedite resolution of outstanding U.S. property claims dating back to the early 1960s, a key congressional condition for lifting sanctions. Prompt resolution of these cases would automatically create powerful constituencies in the United States for repealing the embargo and signal to foreign investors that Cuba is prepared to respect property rights and the rule of law. They could also demonstrate a willingness to resolve longstanding claims for compensation for citizens killed in hostilities during the Cold War.

In anticipation of next month's Cuban Communist Party Congress, President Castro can detail his plans to decentralize power, empower the legislature and reform the electoral system.

The precise timing of Obama's visit - just one month before the Party Congress - may signal that Raúl Castro and his pragmatic followers welcome a friendly nudge to recharge the reform process they launched in 2008. It also underscores how little time remains before Americans elect a new president who could reverse steps taken so far with the stroke of a pen. That is the kind of marriage of short and long-term interests that allow wise presidents to make history, and the ultimate test for assessing whether the Obamas' trip is serious business, or just family fun.