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Although fee-for-service payments may encourage volume without rewarding quality, bundled payments may incentivize providers to avoid patients more prone to complications. Is one a rock, and the other a hard place? Charles L. Nelson, MD, Professor and Chief of Adult Reconstruction at the University of Pennsylvania, discusses how surgical decisions are made, and how this process may favor those patients least likely to be re-hospitalized, marginalizing people with comorbidities such as obesity. Dr Nelson also argues that it is inequitable for patients not to receive the resources that they need, particularly when they may not be in a position to advocate for themselves. He makes the case that payments need to be adjusted to reflect clinical complexity and to mitigate the impact of social determinants. With Bill Finerfrock.

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