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“Come back and see us soon” is not what hospital staff say to patients these days. With policy makers and insurance payers taking aim at the high readmission rates of recently discharged patients, hospitals and clinicians have increasing financial incentives to manage the transition of care for patients from inpatient medical facilities back to the community. Successful patient interventions typically include multiple components, such as readmission risk assessments, discharge planning, medication reconciliation, follow-up appointment scheduling, patient education, coaching by dedicated clinicians, home health visits, and prompt follow-up visits with outpatient physicians.1 A recent meta-analysis of 50 multicomponent, quality improvement interventions found that readmissions fell by a mean of 12.1% among patients with heart failure and 6.3% among older adults.2 To financially reimburse outpatient physicians for their role in managing transitions from the medical facility to community settings, the Centers for Medicare and Medicaid Services introduced new transitional care management (TCM) payment codes in 2013. Outpatient physicians (or midlevel clinicians) billing for TCM services must satisfy the following 3 requirements: (1) contact the beneficiary within 2 days of discharge; (2) perform certain non–face-to-face services (eg, reviewing discharge summaries and diagnostic test results, providing education to caregivers and the beneficiary, and referring the beneficiary to other clinicians or resources); and (3) visit face-to-face with the beneficiary within 7 or 14 days of discharge, depending on the medical complexity.3 In this issue of JAMA Internal Medicine, Bindman and Cox3 used an observational study design to compare mortality and health care costs during the 31 to 60 days after an eligible discharge between Medicare beneficiaries who received TCM services and beneficiaries who did not receive TCM services. Those receiving TCM services had 0.6 percentage points lower mortality and 11% lower health care expenditures. Among individuals discharged from the hospital, receiving TCM services was associated with a lower probability of readmission. However, Bindman and Cox found that TCM services were seldom billed: claims for TCM services were associated with only 3.1% of eligible discharges in 2013 and 7.0% in 2015. Given that TCM services are associated with improvements in quality and reductions in health care costs, these services appear to represent high-value care that should be more widely used. Why has the uptake of these services by outpatient physicians been so limited? The likely explanation is that the organizational infrastructure and clinical processes necessary to optimally manage TCM services are still lacking despite recent efforts to reduce the number of readmissions. Moreover, there are many challenges to satisfying the specific TCM billing requirements, particularly the need for outpatient physicians to contact patients within 2 days of discharge. Patients, when hospitalized, are seldom treated by their outpatient physician, and direct communication between inpatient and outpatient physicians occurs for fewer than 20% of hospitalizations.4 Some patients do not have an outpatient physician for their ongoing medical treatment, while other patients do not have the names and contact information of their outpatient physician with them while they are hospitalized. Communication between inpatient and outpatient physicians may require several rounds of “telephone tag” and/or rapid completion and transmission of the discharge summary. Often, outpatient physicians first learn of the patient’s hospitalization at a follow-up visit, and the discharge summary is typically available at only 1 in 3 visits after discharge.4 Once the outpatient care team members are aware of a hospital discharge, they are required not only to contact the patient within 2 days after discharge but also to schedule an appointment for the patient to have a follow-up visit within 7 or 14 days. Given that the typical primary care appointment is scheduled more than 20 days in advance,5 outpatient physicians must be able to add postdischarge visits to schedules that are already full. Finally, the physician must remember to document and bill for the TCM services. Given these logistical challenges, the TCM payment may be insufficient for the clinical work performed or may be targeted to the wrong entity in the health care system. Research evidence indicates that physicians can and do respond to changes in payment policies that are targeted appropriately. The TCM payment covers multiple interactions between the clinician and the patient, but the payment is relatively small—an average reimbursement of $145 per postdischarge episode. In comparison, Bindman and Cox3 noted that the mean Medicare payment for a single office visit was $105. Even if $145 is sufficient to cover the marginal cost of each TCM service, clinicians may not deem it enough to warrant the workflow changes (ie, fixed costs) required to routinely deliver the TCM services. More important, the outpatient physician does not face any financial risk from readmission of a patient unless the physician is participating in an alternative payment model. Monetary reimbursement for TCM services is a small “carrot” for outpatient physicians; it provides a relatively small payment for an array of additional services. Hospitals face the larger “stick” of potential readmission penalties under the Hospital Readmission Reduction Program, which can sum to 3% of a Related article Transitional Care Management Services for Medicare Beneficiaries Invited Commentary