Further, to be sustainable, cost management tools and monitoring structures should encourage and emphasize individual, professional, and organizational accountability. Detailed efforts to regulate prices, services, and other aspects of day-to-day health care delivery run two major risks. First, some health care practitioners and providers, health plans, and consumers may be preoccupied with manipulating the system rather than achieving more efficient and effective health services. Second, such manipulation may inspire ever more complex and voluminous rules that would ultimately defy sensible management or compliance by even the most well-intentioned participants. The current balance between delegation and regulation generates considerable tension and dissatisfaction, but some disagreement about the probable costs and benefits of any particular balance appears inevitable.

ELEMENTS OF A STRATEGY

As explained in the Preamble, the committee has not developed a comprehensive proposal for health care reform. It also has not formulated a comprehensive cost containment strategy to reduce the rate of increases in health care costs. One reason is that evidence about the effectiveness of specific tools supports a rather cautious view about their prospects for significantly limiting the rate of increase in health care costs or even achieving some ''once-and-for-all'' savings. Reforms should not overlook opportunities for such savings (and the associated shift to a lower trajectory of cost escalation), but they should avoid overselling strategies of modest or unproved effectiveness. (For reviews of the literature on the impact of cost containment strategies, see CBO, 1992a, 1992b; EBRI, 1991; IOM, 1989b, 1993b; Jencks and Schieber, 1991; Newhouse, 1992; Thorpe, 1992.)

Moreover, although some individual committee members had strong philosophical views about managed competition and other relatively sweeping prescriptions for controlling health care costs, the committee did not reach consensus on such prescriptions as part of this particular effort. For policymakers and the public at large, however, the next few months will bring an intense effort to forge, from contending views, an effective consensus about short-term and long-term strategies to reduce



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