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"Hop up on the table, Honey." mThat's how an x-ray technician addressed my 89-year-old mother-in-law in 2001, when we took her for knee x-rays. Mom, who had advanced osteoporosis and arthritis as well as confusion and heart problems, had long since given up hopping. When it became obvious that she needed assistance, the technician grabbed her arm -- as if pulling on another sore appendage would magically raise the rest of her onto the table. It didn't. This incident has become our personal mantra for expressing what is wrong with America's health care system. Having helped our four parents during their final years and having both had cancer ourselves as well as other medical problems, we have had experiences with five nursing homes, two personal care facilities and a half dozen hospitals. We've lost count of the doctors, drugstores and health insurance plans. All of us have had health insurance, though some policies were better than others. Nonetheless, we have experienced incident after incident demonstrating the waste, ignorance and apathy which is rampant in the system. Unable to list them all, I have been heretofore reluctant to write about a handful of them lest the reader be persuaded that the problem is with only that hospital, only that nursing home or only that doctor. There is, however, an increasing crisis of confusion, mismanagement and ill-preparedness which is at the core of our healthcare system. We are all familiar at least with the trend line if not the specifics for healthcare costs. According to WhiteHouse.gov, "The United States spends over $2.2 trillion on health care each year-almost $8,000 per person." That's sixteen percent of the economy. Healthcare costs are projected to increase to almost twenty percent ($4 trillion a year) by 2017. Meanwhile forty-six million Americans are without health insurance (14,000 more each day), premiums and co-pays are rising and more reasons are used to refuse coverage both to those willing to pay and thos

"Hop up on the table, Honey." mThat's how an x-ray technician addressed my 89-year-old mother-in-law in 2001, when we took her for knee x-rays. Mom, who had advanced osteoporosis and arthritis as well as confusion and heart problems, had long since given up hopping. When it became obvious that she needed assistance, the technician grabbed her arm -- as if pulling on another sore appendage would magically raise the rest of her onto the table. It didn't. This incident has become our personal mantra for expressing what is wrong with America's health care system. Having helped our four parents during their final years and having both had cancer ourselves as well as other medical problems, we have had experiences with five nursing homes, two personal care facilities and a half dozen hospitals. We've lost count of the doctors, drugstores and health insurance plans. All of us have had health insurance, though some policies were better than others. Nonetheless, we have experienced incident after incident demonstrating the waste, ignorance and apathy which is rampant in the system. Unable to list them all, I have been heretofore reluctant to write about a handful of them lest the reader be persuaded that the problem is with only that hospital, only that nursing home or only that doctor. There is, however, an increasing crisis of confusion, mismanagement and ill-preparedness which is at the core of our healthcare system. We are all familiar at least with the trend line if not the specifics for healthcare costs. According to WhiteHouse.gov, "The United States spends over $2.2 trillion on health care each year-almost $8,000 per person." That's sixteen percent of the economy. Healthcare costs are projected to increase to almost twenty percent ($4 trillion a year) by 2017. Meanwhile forty-six million Americans are without health insurance (14,000 more each day), premiums and co-pays are rising and more reasons are used to refuse coverage both to those willing to pay and thos

Patient Centered Learning: The solution is to permit alternatives to rigid institutions, utilize free internet programs, and have medical students assist practicing physicians by assisting practicing physicians in taking patient histories. These students would offer valuable, free services to doctors. At the same time, they would have a vivid learning experience by spending several hours each day interacting with actual patients. The Cost Of Medical Education Would Be Negligible. The expense of healthcare is directly proportional to the cost of the doctor's education. With the institutional bottleneck gone, there would be a greater number of doctors, and the cost of healthcare would plummet.

The AARP just met with the leadership of the Mayo Clinic, one of the most outstanding medical institutions in the country. They provide excellent care at a cost that is less than most other parts of the healthcare system - and with improved outcomes. We asked them about their secret to success.\n\nMayo has an electronic medical record and all their patients have their information online. The physicians are on salary, so there's no incentive to order unnecessary tests or procedures, and Mayo has an ethic of patient-centered care, with a long history of attracting the best people and rewarding them.\n\nIf Mayo can do it, why can't everyone else? The AARP believes that the potential is there for most communities to have excellent care - we must emulate the care delivery of institutions like the Mayo Clinic, and put in place payment and information systems that will coordinate care management better. It's a big job and will take some investment, but we have many opportunities to do a better job than we're doing today.

McAllen TX is one of the most expensive health-care markets in the country. Only Miami-which has much higher labor and living costs-spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

Can health care organizations and physicians be incented to deliver the highest quality, safest, most reliable, most patient-centric care at the lowest possible cost without Atul Gawande reading the findings of the Dartmouth Atlas into the Congressional Record? I think they can, if they have a strong hospitalist program.

Full-text PDF, policy white paper from Brookings Institute

Accountable care organizations (ACOs) represent a critical step away from volume-driven health care payment and toward better health and better care at lower cost.

Given the success of the coverage expansion, Massachusetts policymakers are turning to the next phase of health reform - reigning in health care costs.

*In West Chester, Community Volunteers in Medicine treated 332 patients in February, up 26% from February 2008. The cost of care was up 21%. At the same time, the clinic was about $100,000 behind in fundraising for its $1.8 million annual budget. *Ohio's 40 free clinics treated 56,000 uninsured patients in 2008, up from 43,000 in 2007. Marjorie Frazier, executive director of the Ohio Association of Free Clinics, expects the number to increase in 2009. In January, one clinic in Cleveland closed because it lacked funding. Ohio, one of the few states that helps pay for free clinics' operations, is cutting funding. Its two-year allocation for 2008 and 2009 was $2.1 million; for 2010 and 2011, proposed funding is $1.5 million. *California's 800 community health centers saw increases of up to 20% in uninsured patients in the past six months. The state, facing a $42 billion budget shortfall, is eliminating payments for some services for poor adults, including dental care. As a result, the centers will lay off 1,000 dentists and other staff, leaving as many as 400,000 people without dental care, says Chris Patterson, spokesman for the California Primary Care Association.

Providers, payers, and patients - do what is in their best interest without concern for cost or effectiveness. This focus is appealing in the short run but leads to a destructive endgame.

Dr. Fisher is a professor of medicine and of community and family medicine, Dr. Bynum an assistant professor of medicine and of community and family medicine, and Dr. Skinner a professor of economics and of community and family medicine at Dartmouth Medical School, Lebanon, NH, where Dr. Fisher also directs the Center for Health Policy Research, Dartmouth Institute for Health Policy and Clinical Practice.

Why Paying for Health Care Reform Is Difficult and Essential - Numbers and Rules. In a short few paragraphs, Dr. Aaron elegantly simplifies and quantifies why finding the $1 trillion for universal coverage is so difficult. He concludes, realistically, soberly,

Understanding High Value Care and Reducing Unwarranted Variation in Health Care Delivery: A Collaborative Project of the Mayo Clinic, Intermountain Health Care and The Center for the Evaluative Clinical Sciences

Analysis & report regarding health spending in the current (2008-09) economic crisis. Health Update No. 7, produced by the International Coordination Group for Health (ICGH)