at present these usually reward discrete episodes of care in the future payment mechanisms are increasingly likely to reward bundles of care or indeed a whole year of care for people with complex needs it will be interesting to see whether health systems can respond to these new pressures and whether appropriate organizations will arise to manage the challenges of integrating care for such patients experience in the us with the new accountable care organizations responsible for the costs and quality of health care for a defined population with a minimum size of people will be of great interest in this respect shortell et al