The state of Maryland has implemented a payment model for hospitals which caps revenue and attempts to regulate volume. The initial attraction was, if hospitals knew what there operating budget would be and if there were able to reduce cost, than the difference would be profit that could be reallocated for improvements, personel, or overall growth. Now approximately 5 % was assigned to quality metrics The regulatory body,HSCRC, also has the ability to readjust based on inflation, volume shift and failure to meet quality metrics. To note, if a hospital exceeds its volume threshold than that excess is paid at 50% which, for most hospital, is below cost. The other issue is that most hospitals are part of a system but are viewed by HSCRC independently. Now as hospitals will shift volume for a variety of reasons, i.e. too complicated, too costly, the receiving hospital is potentially exceeding budget and volume and the sending hospital may or may not be with in their financial corridor. Now, you may ask yourself, why doesn’t HSCRC realize this. The answer is the transfer is defended by the institutions as the right thing for the patient. So now let me explain the conundrum. Since the introduction of this payment model, most hospitals have figured out the game and volume is not your friend. Most hospitals continue to struggle with controlling volume especially tertiary hospitals. So, the response by these facilities is to use elective volume as its flux. They will ask surgeons to shift volume when a hospital is at risk for too much volume or if a hospital, within its system, needs volume. As you can imagine, this is very disruptive to patients and employees. When volume is needed at a sister hospital, the hospital that is above threshold is asked to close ORs ( this lowers expense) and the employees and doctors are asked to shift to the other hospital to provide volume. As you can imagine, this is not what the doctors or employees signed up for. So as ask for your help is solving this conundrum.