BOX 23-1

Common Themes

Cost and outcome challenges

  • Health cost excesses with personal, institutional, and national consequences

  • Health outcomes far short of expectations

  • Fragmented decision points, inconsistent principles, political distortions

Drivers of the shortfalls

  • Scientific uncertainty

  • Perverse economic and practice incentives

  • System fragmentation

  • Opacity as to cost, quality, outcomes

  • Changes in the population’s health status

  • Lack of patient engagement in decisions

  • Underinvestment in population health

Levers to address the drivers

  • Streamlined and harmonized health insurance regulation

  • Administrative simplification and consistency

  • Payment redesign to focus incentives on results and value

  • Quality and consistency in treatment, with a focus on the medically complex

  • Evidence that is timely, independent, and understandable

  • Transparency requirements as to cost, quality, and outcomes

  • Clinical records that are reliable, sharable, and secure

  • Data that are protected but accessible for continuous learning

  • Culture and activities framed by patient perspective

  • Medical liability reform

  • Prevention at the personal and population levels

that this very substantial variation in cost per beneficiary in Medicare is not correlated with overall health outcomes—and, in fact, that the opposite may be the case. Describing the relationship between growing healthcare costs and other sectors of the economy, he also discussed how increasing demands placed on states by Medicaid costs have crowded out other state priorities and limited growth in state appropriations for public education, putting, for example, public universities at risk and at clear competitive disadvantage with their private counterparts in faculty recruitment.

Health Outcomes Far Short of Expectations

Several participants also identified and underscored that not only do our high expenditure levels have a negative impact on families’ household

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