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Health systems, physicians, and health plans in Springfield are entrenched in value-based care models under a state-driven care delivery transformation initiative that supports the move from fee-for-service payments toward alternative payment arrangements. These programs, which aim to reduce the cost of care and improve quality, tend to emphasize drug adherence, given the link between outcomes and adherence. However, a focus on pharmaceutical spend makes health systems and physicians more likely to hold down costs by using generic drugs. The MassHealth Medicaid program also drives reform, as it moved most members into accountable care organizations that are responsible for total cost of care. Successful outcomes could spur more alternative payment arrangements featuring downside risk among health systems.