Figure 1 Health care in the United States, circa 1981.

self and one's health. The final value involves improving the quality of patient care outcomes.

The system is moving faster now than even the most aggressive prognosticators thought possible as recently as two or three years ago. By the end of this decade, I believe that in most major markets of this country, 90–95 percent of the population will be enrolled in some sort of integrated system, not owned necessarily all in a single place, but integrated in the sense of long-term contracts or exclusive contracts. Already, in northern California; Portland, Oregon; Seattle, Washington; and the Twin Cities, such patterns of organization are emerging.

The nature of the integration is almost unimportant; horizontal or vertical integration is almost unimportant. However, the size of the system is critical. How the systems come together is something for consultants and attorneys to work on, not something that will have anything ultimately to do with the health of the nation.

This integration is occurring in three phases. Let me focus on one dimension of each, because in each of the three phases there is a cost-control and system value-added dimension that presses severely on health professionals and their work.

The first stage is assembly—the cobbling together of systems. That is going on right now. To try to make sense out of this and then project into the future is foolish because, next year, someone will buy the system on which that analysis is based and the analysis will be useless. In this first phase, limiting access and reducing fees are essentially the means of controlling