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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Editor's note: By any measurable standard, Egypt is more vulnerable to violence and insurgency today than it had been before the Arab Spring. Since the overthrow of former President Mohammed Morsi in 2013, Egypt has seen shocking levels of repression. In Shadi Hamid's August 6 piece in Foreign Policy, Hamid makes the argument that the end result of the Egyptian coup turned out to be a gift to the Islamic State group.

Egyptian President Abdel Fattah al-Sisi came to power on a classic strongman platform. He was no liberal or democrat — and didn’t claim to be — but promised stability and security at a time when most Egyptians had grown exhausted from the uncertainties of the Arab Spring.

Increasingly, U.S. President Barack Obama’s administration seems to accept this premise. In the span of the past week, the United States has delivered eight F-16s to Egypt, relaunched the U.S.-Egypt “strategic dialogue,” and said it would resume “Bright Star,” the joint military exercise suspended after the military coup of July 3, 2013.

Sisi’s raison d’être of security and stability, however, has been undermined with each passing month. By any measurable standard, Egypt is more vulnerable to violence and insurgency today than it had been before. On July 1, as many as 64 soldiers were killed in coordinated attacks by Egypt’s Islamic State affiliate, which calls itself the Province of Sinai. It was the worst death toll in decades, and came just days after the country’s chief prosecutor, Hisham Barakat, was assassinated.

If this is what a “stability-first” approach looks like, Egypt’s future is dark indeed. Of course, it shouldn’t be surprising that the country is growing less secure: Since the overthrow of the Muslim Brotherhood’s Mohamed Morsi on July 3, 2013, Egypt has seen shocking levels of repression. On Aug. 14, 2013, it witnessed the worst mass killing in its modern history, with at least 800 killed in mere hours when security forces violently dispersed two pro-Morsi sit-ins in Cairo. WikiThawra, a project of the Egyptian Center for Economic and Social Rights, estimates that nearly 36,500 people were arrested or detained from the day of the coup through May 15, 2014 — one can only imagine how high that figure has grown a year later.

Since April 2015, meanwhile, at least 163 Egyptians have “disappeared.” As one prisoner recalled of his time at Azouli, a military jail which can’t be seen by civilians: “There is no documentation that says you are there. If you die at Azouli, no one would know.”

This repression, which targets not just Islamists but also secular and liberal opposition activists, makes the resort to violence and terror more likely among at least some Egyptians. There is a growing trend of academic literature pointing to the link between tyranny and terror: In a widely cited 2003 study, for example, academics Alan Krueger and Jitka Maleckova conclude, “The only variable that was consistently associated with the number of terrorists was the Freedom House index of political rights and civil liberties.”

Not all repression is created equal, however. I have argued that low-to-moderate levels of repression do not necessarily have a radicalizing effect. What we are seeing in Egypt today, however, is not your run-of-the-mill authoritarianism but something deeper and more frightening. This is eradication, driven, no less, by popular and populist sentiment.

The end result is that the Egyptian coup turned out to be a gift to the Islamic State. You don’t have to take my word for this: The jihadi group itself clearly thinks it benefited from Morsi’s overthrow. In its first statement after the coup, Islamic State spokesman Abu Mohamed al-Adnani, addressing the Muslim Brotherhood and other mainstream Islamists, says, “You have been exposed in Egypt.” He refers to “democracy” and the Brotherhood as “the two idols [which] have fallen.”

Of course, jihadis had long been making this argument, particularly after the Muslim Brotherhood in Iraq took part in successive U.S.-backed governments after the 2003 Iraq war. Al Qaeda and its ilk gleefully described the Muslim Brotherhood as al-Ikhwan al-Muflisun, or the Bankrupt Brotherhood — a play on its Arabic name. But while al Qaeda may have achieved a measure of sympathy in the Middle East after the Sept. 11 attacks, it was never, and never could be, a real threat to the Brotherhood’s model of political change. It was proficient at staging terrorist attacks but proved unable to carry its successes into the realm of governance. More importantly, al Qaeda’s vision for state building, to the extent that it had one, failed to capture the attention of the world or the imagination of tens of thousands of would-be fighters and fellow travelers.

The same cannot be said about the Islamic State, whose seemingly irrational apocalyptic vision coexists with an unusually pronounced interest in governance. As Yale University’s Andrew March and Mara Revkin laid out in considerable detail, the group has, in fact, developed fairly elaborate institutional structures. In the ideological and theological realms, the Islamic State is not just Baathist brutality in Islamic garb: Rather, it has articulated a policy toward Christian minorities based on a 7th-century pact, an approach to Islamic economic jurisprudence, and even a theory of international relations.

The Islamic State’s unlikely successes in governance undermine a key premise of mainstream Islamists — that because of their gradualism, pragmatism, and “competence,” they, rather than extremists, are better suited to delivering on bread-and-butter issues. In fact, the opposite appeared to be true: Brotherhood-style gradualism and a willingness to work through the democratic process hadn’t worked. One senior Brotherhood official told me, as we sat in a café on the outskirts of Istanbul, “If I look at the list of mistakes the Brotherhood made, this is the biggest one: trying to fix the system from inside gradually.”

Even those who otherwise abhor the Islamic State’s ideology might find themselves susceptible to the argument that violence “worked,” while peaceful participation didn’t. It’s an argument that the Islamic State and its affiliates have repeatedly tried to drive home: In one recruitment video, a young Egyptian man — a judge in one of the Islamic State’s sharia courts — tells the camera that “[Islamist groups that participate in elections] do not possess the military power or the means to defend the gains they have achieved through elections. After they win, they are put in prison, they are killed in the squares, as if they’d never even won … as if they had never campaigned for their candidates.”

Needless to say, this particular pitch wouldn’t have been possible in 2013, when Morsi was still in power, or even in 2012, when the Supreme Council of the Armed Forces was in charge. In short, the Egyptian coup — coupled with the subsequent massacres and never-ending crackdown — has given the arguments made by al Qaeda in the 2000s more power than ever before.

There’s no denying that violence surged following the coup. According to the Tahrir Institute for Middle East Policy, the month of the coup, July 2013, saw a massive uptick in violence, from 13 attacks the month before to 95 attacks. The number of attacks dipped in subsequent months — to 69 in August and 56 in September — but remained significantly higher than before the coup. The pre- and post-coup discrepancy becomes even more obvious when we zoom out further: From July 2013 to May 2015, there were a total of 1,223 attacks over 23 months, an average of 53.2 attacks per month. In the 23 months prior to June 2013, there were a mere 78 attacks, an average of 3.4 attacks per month.

If the coup had nothing or little to do with this, it would stand as one of the more remarkable coincidences in the recent history of Middle East politics. Of course, other variables may have contributed to this surge in violence. The flow of arms from Libya and the Islamic State’s growing international stature, for instance, would have played a destabilizing role no matter what happened with Egypt’s domestic politics. But neither of those developments can account for such a sharp increase in attacks over such a relatively short period of time. Civil conflict in Libya resulted in a more porous border and an increase in arms smuggling as early as 2012, while the Islamic State’s expansion didn’t register in a serious way in the broader region until the summer of 2014, when the group took over the Iraqi city of Mosul.

That leaves us with the coup and what it wrought — namely the Sisi regime’s increasingly repressive measures — as the key event that helped spark the wave of violence. How many people, who otherwise wouldn’t have taken up arms, took up arms because of the coup and the subsequent crackdown? Obviously, there is no way to know for sure. The strength of Ansar Beit al-Maqdis, the group that eventually pledged allegiance to the Islamic State and renamed itself Province of Sinai, is estimated to be in the thousands, so even a tiny increase of, say, 500 militants — representing 0.00055 percent of Egypt’s overall population — would have an outsized effect. Recruitment, however, takes time, so it is unlikely this would have mattered in the days immediately after the coup.

The more likely short-term explanation is that militants viewed the coup as an opportune moment to intensify their activities. They would have done so for two main reasons: First, the Egyptian military — an organization, like any other, with finite resources — was preoccupied with securing major urban centers and clamping down on the Brotherhood. Second, militants likely wagered that they could seize on the wave of Islamist anger and anti-military sentiment.

Ansar Beit al-Maqdis exploited the “narrative” of the local Sinai population, which was already predisposed to distrust state institutions after years of economic neglect and heavy-handed security policies. Not surprisingly, then, residents were more likely to oppose the coup than most other Egyptians. The founders of Ansar Beit al-Maqdis, many of whom hail from North Sinai, knew this as well as anyone. The jihadi group, before pledging allegiance to the Islamic State in November 2014, was almost entirely focused on police and military targets, and would generally couch such attacks as “revenge for the security forces’ suppression of Islamist dissidents.”

Electoral results from 2011 to 2014 offer additional insight into patterns of political support in the Sinai. South Sinai has generally been more pro-regime and less supportive of militant activity, due in part to its economic dependence on the tourism industry. North Sinai, however, is a different story: In each of the four major electoral contests during the transition period, voters there supported Islamist positions and candidates at a significantly higher percentage than the national average. For example, in the 2012 presidential election, 61.5 percent of North Sinai voters cast their ballots for Morsi, compared to 51.7 percent nationally.

While the coup and its brutal aftermath contributed to a sustained increase in monthly attacks — as well as an increase in the lethality of attacks — we still see considerable variation in militant activity. From November 2013 to July 2014, for example, there is a dip, with the monthly average falling to about 22 attacks per month. Yet, even at this lower point, the average number of attacks is still more than 640 percent above the monthly pre-coup average. Starting in January 2015, militant activity jumps up sharply again to 107 attacks, from only nine in December. Again, there are any number of factors that could have played a role in this new surge in violence, but there is only one factor that changes dramatically during this period and that can account for such an unusual uptick in attacks: the military’s hasty creation of a “security zone” along the border with Gaza.

On Oct. 24, 2014, at least 33 Egyptian soldiers were killed, in what was, until then, the deadliest attack on security personnel since the coup. Ansar Beit al-Maqdis claimed responsibility. In response, Egyptian authorities moved to establish a buffer zone, forcing up to 10,000 residents to evacuate their homes, some with only 48 hours notice. The Egyptians military’s narrow security lens and harsh tactics have, in effect, further alienated local residents and helped fuel the insurgency. Shortly after the army began “relocating” villages, the number of attacks increased once again, but this time to previously unheard-of levels. The first five months of 2015 saw an average of 114.6 attacks, with an all-time high of 138 attacks in May.

This is not to say that the creation of a buffer zone transformed people into ideological hard-liners in a matter of weeks, but, rather, that groups like the Islamic State seek to exploit local grievances and depend on local sympathy to stage successful attacks. Zack Gold, a researcher who specializes on the Sinai, wrote that due to the army’s scorched-earth tactics, “whole swaths of North Sinai civilization no longer exist.” One resident of the border town of Rafah, after learning his home would be destroyed, said: “I won’t lie. I’m more afraid of the army than the jihadis. When you’re oppressed, anyone who fights your oppression gets your sympathy.” Another Sinai resident, according to journalist Mohannad Sabry, said that after 90 percent of his village was destroyed in a security campaign, around 40 people took up arms, where through 2013, he knew of only five Ansar Beit al-Maqdis members in the village.

It might be hard to imagine why the Egyptian army would appear so intent on alienating the very citizens whose help it needs to defeat the insurgency. Yet, this appears to be Sisi’s approach to conflict resolution across the country — more state power, more control, and more repression. As the saying goes, when all you have is a hammer, everything looks like a nail. Because authoritarian regimes are forged and sustained by force, they are perhaps the worst candidates to develop a nuanced, holistic counterinsurgency strategy.

Then again, Egypt starts from a different set of assumptions than the United States does. At the most basic level, the Egyptian government fails the first test of counterterrorism, which requires correctly identifying who the actual terrorists are. It continues to act as if the Islamic State and the Muslim Brotherhood are interchangeable — something that no Western intelligence agency takes seriously. As a result, Egypt has made itself a burden. The Egyptian regime is not — and, more importantly, cannot be — a reliable counterterrorism partner. This is no accident of circumstance. Hoping and claiming to fight terrorism, Egypt, however unwittingly, is fueling an insurgency.