Let’s face it, providersw and plans will respond to others on this one. For example, Barry points out that plans stepped back from aggressively managing care and limiting their provider networks. We didn’t do that because we thought it was a good idea. We did it because employers, government and consumers - our customers and our overseers - told us to. Until they can stomach something other than very modest changes, we will be somewhat limited in our ability - at least on the plan side - to deliver significant reforms. Sigh.

I think the reason costs are out of control are three fold:

-a totally outmoded, grossly inefficient delivery system designed 100+ years ago to rely on physician memory, compliant patients, office visits and hospital care

-we can’t decide as a society whether healthcare is a right or privilege and who should pay, so the system has devolved to the chaos of diverse self interests. Payers and providers long ago spun into their own internally-focused, costly orbits of turf guarding and quarterly profits

-a dysfunctional market where the patient isn’t viewed as a paying customer, resulting in perverse financial incentives and rushed interactions vs. healing relationships.

Why not draw a line in the sand that asks for commitments from payers, providers, and employers to establish common ground and results that are SIMPLE, complete, and easy to understand. A common purpose that re-focuses us on why we’re here in the first place. An example of such common ground might be: Care that heals, enables and delights at the lowest possible cost. Every time.

I can attest from vast experience that of the hundreds of thousands of healthcare encounters that happen every day, those that heal (not just medicate), enable and delight at the lowest possible cost are rare indeed. A commitment to common ground among payers, providers and employers that patients also understand, could begin to establish a common national purpose and mobilize far more innovation.

Your emphasis on the centrality of controlling costs is spot on. The one point I would disagree with is calling cost containment an economic issue, in contrast to expanding coverage, which is typically seen as a moral issue. The degree to which ever-expanding health care costs eat away at wages for employees and other social goods like education is at least as much of a moral issue as expanding coverage. Paradoxically, letting health care consume so much of our national wealth actually reduces overall health and well being, by starving other sectors that contribute as much to population health as health care does.

As for more general impediments to healthcare reform that focus on taking cost out of the system, I think the diagnosis is straightforward. Namely, everyone wants to solve the problem at someone else’s expense. Nobody wants to give up anything themselves. Consider the following:

1. Consumers resist eliminating or sharply curtailing the favorable tax treatment currently afforded employer provided health insurance. They are also reluctant to accept sensible limits on end of life care.

2. Doctors resist price and quality transparency, P4P, and working with hospitals to offer bundled payments for an entire episode of care connected with expensive surgical procedures.

3. Hospitals resist price and quality transparency and P4P as well. They also are reluctant to practice less aggressively, especially at the end of life, because doing so would reduce their revenue. Both hospitals and doctors are reluctant to pay for electronic records because they think the benefits will mostly accrue to payers and patients.

4. Lawyers don’t want to give up the current jury based medical malpractice system in favor of health courts, arbitration or some other sensible alternative that would remove juries from medical dispute resolution.

5. Insurers often require confidentiality agreements that preclude doctors and hospitals from disclosing how much they are actually paid for various procedures. Insurers have also backed away from serious attempts to manage care as opposed to just manage reimbursement and focus on risk selection.

6. Drug and device manufacturers resist comparative effectiveness research because it would probably reduce demand for many of their newer, more expensive products that are little or no better than established treatments.

When every interest group steps forward with serious proposals that would cost it money or power in the short term in exchange for a better and more sustainable healthcare system in the long term, we might finally start to make some progress. We all have to give up something and the sooner we accept that, the better.