Looking back over the past year of health-care legislation, I would make the following observations:
• The Obama Administration made remarkable progress on health information technology, prevention and wellness and health-care quality in the February 2009, stimulus legislation.
• Although the House and Senate health-care reform bills were not bipartisan and some of the compromises were not particularly good ones, I am pleased that the Senate discarded the public option, the logic for which was never compelling.
• Relative to what the bills attempted to accomplish, the goal of enabling universal health insurance would be achieved. However, there are some structural flaws in the design of the insurance systems that, if not corrected, will put our country at serious financial risk.
• Structural health-care payment and delivery reform could avoid a financial crisis, but it is not clear that any level of government has the political will to tackle these issues, and they were addressed in these bills. Raising taxes to fund health insurance will cripple the economy, and cutting Medicare payments in our existing flawed system will simply drive doctors and other providers out of the system, which will create shortages. At this stage, it is unclear how we will create universal insurance that is affordable and financially sustainable.
• I commend Senators Harkin and Dodd and their colleagues for some excellent work on prevention and wellness. I also believe that the foundation has been laid for supporting more community health centers, a vital tool for health care delivery. Nevertheless, the good pieces of the legislation are relatively under-developed nuggets, not full-blown health care transformation solutions.

Politically, this legislation went as far as Congress could probably go, but much remains to be done.

The Business Roundtable's latest report, Health Care Reform: Creating a Sustainable Health Care Marketplace, estimates that per-employee health-care costs will grow from about $10,000 in 2009 to over $28,000 in 2019. With the legislative proposals' tactics for cost-containment, the 2019 number would be around $25,000. That's not much of a cost-bend over a decade. Money is being wasted in the system, both clinically and administratively.

What's missing from health reform is a bolder, more comprehensive approach to managing costs. If the U.S. wants to reach universal coverage -- a goal embraced by most Americans, in theory -- it can only be done in a sustainable, responsible way by more directly dealing with costs.

While cost-containment is a theme in Senator Reid's bill, I'd like to see more forceful language in the areas of rewarding adherence to evidence-based medicine, and doing more than piloting programs for changing payments to providers. As electronic medical records penetrate physicians' practices, we'll be able to better measure quality and outcomes and pay providers based on this quantitative evidence of quality.

At the same time, a final bill should have innovative, transparent incentives that motivate Americans to live more healthfully, bolstered by an infrastructure that brings transparency to pricing, quality and outcomes information for providers and plans.

Accountability for both providers and patients will underpin a sustainable health system. But Congress isn't acting as boldly as it should.

There's a long road ahead for health-care reform -- five bills to be merged and countless hours of debate still to come. A lot could change over the course of the next few months, and the content of the final reform bill is likely to vary from any of these individual bills. The question we need to keep asking ourselves is whether reform will drive the kind of wholesale transformation needed for the industry and consumers -- the kind we've seen in banking, travel and other service industries. Ten years ago, we wouldn't have imagined that people would do so many things themselves. Technology and business model innovation enabled new types of services -- putting consumers in charge, dramatically changing engagement and economics. Imagine the possibilities for new services in health.

Taking this into account, what's needed is a new 'health delivery' framework that drives value, rewards experimentation, puts consumers in charge, and enables innovation--essentially changing the attitudes, beliefs, and behaviors of everyone involved in health delivery. We all have to be prepared to work together in different ways.

We have an opportunity now to move the traditional healthcare business model in a new direction:

At the end of the day, the ultimate success of health-care reform will depend as much on how we will work together and change our behaviors as on the legislation ultimately passed by Congress and signed by President Obama. I applaud the administration for shining the light on health care as it has never been done before.

If the 35 percent tax is going to be passed on to consumers, I am definitely against that. However, it is clear that there are efficiencies built into other versions of health-care reform legislation with electronic medical records and meaningful use of health information technology. And it is clear that the ultimate benefit of electronic records will go mostly to the insurance companies; therefore, I think the tax on them is appropriate.

As a matter of fact, since the insurance companies will benefit the most with the added resources of health information technology, they should be paying largely for the set up, education and maintenance of electronic health records in physicians offices. That way, physicians can more efficiently provide services to the increased numbers of patients in the most need of medical help.

President Obama should move the conversation to health-care reform rather than health-cost reform. Costs will never be controlled until we control and systematize the underlying infrastructure of fragmented, disassociated care. Identify and articulate specific activities such as:
1. Standardize the electronic medical record so every patient's chart can be accessed electronically from any computer with permission.
2. Implement tort reform
3. Fix the Employee Retirement Income Security Act (ERISA)
4. Fix the Emergency Medical Treatment & Labor Act (EMTALA)
5. Pull apart the fake number of "48 million" uninsured (the real number is closer to 10 million hard-core uninsured.)
6. Address the access problem before requiring the current broken provider structure to absorb millions of new patients. By that, I mean turn primary care over to nurse practitioners, nurse midwives and physician assistants and encourage current primary care doctors to go on into specialty care.
7. Stop assuming that only doctors can increase access to care or be heads of medical homes (which should be called health care homes) There will never be enough doctors. Utilize and incentivize other health-care providers to increase access to care and provide scholarship support and assistance so that the debt load of doctors, nurses and other providers is not staggering.
8. Allow health insurance to be purchased across states so that consumers can comparison shop for better prices and for increased opportunities for choice and competition.
9. "Right-size" regulations and get rid of state-by-state impediments to practice for non-physician providers. Federal pre-emption might be the only solution.
10. Go slowly. Identify areas of consensus that are fixable and fix those first.

Unless the above happens, it is very unlikely that health-care reform will occur and all we will be doing is blaming each other for the out-of-control costs.

Seniors, especially those with Medicare, will benefit from an improved system that will not change access to their providers of choice. You will have better patient service, better quality, and better coordination of your care.

More specifically, new health information technology available under a reformed system will bring the use of medical information up-to-speed with your clinician's ability to diagnosis and treat you. For example, you will not have to fill out your information by hand every time you see your doctor or someone you are referred to. You will be able to make an appointment over the Internet or by phone. Your doctor will be able to confirm the visit with you and even remind you that the visit is scheduled. Any laboratory test or X-rays will be available to you, your doctor or any clinicians you approve to help manage your care 24/7.

Your doctor and her staff will have more time to spend with you because they have less paperwork to fill out by hand. Your doctor will be able to ensure you got your flu shot after a review of your electronic record that shows that your lung doctor gave it to you three weeks ago. Your laboratory tests and X-ray results ordered by the lung doctor are available for your doctor to review. She, therefore, does not need to repeat these tests, saving you valuable time and the health system money. Your prescriptions are ordered by computer and all you have to do is drive by the pharmacy to pick them up on your way home. By the way, the pharmaceutical ordering system is safer because the pharmacist did not have to decipher your doctor's handwriting.

As a primary care doctor, your physician is paid a little bit more for coordinating your care and is able to spend more time with you trying to resolve that nagging backache on this visit instead of making a second appointment. More time saved. She also has access to new scientific breakthroughs, which helps her better manage your lung problem thanks to the new medical effectiveness research the administration and Congress approved. In addition, your costs are lower because you are no longer paying as much for prescription drugs.

Same physician, better service, improved care coordination, enhanced safety and quality, and lower prescription drug costs. Seniors will benefit.

The best thing we can do to rein in health-care costs is to invest in keeping people healthy instead of waiting for them to be sick or injured. For example, if someone is very obese and is at risk of getting diabetes, heart disease, high blood pressure and back pain, a doctor cannot be reimbursed for helping them lose weight in the Medicare system -- the patient must be diagnosed with a disease first. That's like saying that we wait until the roof leaks and ruins our living room furniture before we repair a hole in the roof. It costs more to wait longer.

We also need to pay an integrated care team for getting a good result, not for activity. Most manufacturing companies used to pay workers by the piece until they discovered that piecework produced a high volume of defective parts or products. Today, we pay doctors and hospitals more based on the volume of work they do, not its quality. That has to change.

There's a lot of waste because we do not transfer medical records information. Think about ATMs today vs. what you had to do 35 years ago. At that time, you either had to have a bank account everywhere you lived, worked or traveled, or you had to buy expensive travelers checks and convert them to cash. Today, you can go to any bank machine and get cash, no matter where your bank account is.

Medical records are where cash withdrawals were 35 years ago. The technology is available to achieve the same ease of use of medical records as we have with bank debit cards, but the government needs to bring everyone together and drive for transferable electronic medical information.

When you defuse a bomb, you have to approach the problem carefully, thoughtfully and systematically so the bomb doesn't go off with injuries and unintended consequences.

In President Obama's remarks to the American Medical Association on Monday, the cost of health care being a threat to our economy (his words: a "ticking bomb") was rightfully raised -- and so were the many challenges of a system not designed to support consumer involvement, physician empowerment, preventive care and so on.

What's troubling is the approach to defusing this bomb. I fear that we may just be pulling at wires -- electronic health records, Medicare advantage plans, generic drugs and asking wealthy Medicare recipients to subsidize the system to make it economically viable. If we were to implement these proposals, would the root cause of the problem -- our health-care non-system -- be addressed?

I don't think so. Defusing this bomb requires an understanding of its engineering -- how we got into this mess. The "big red wire" that needs to be clipped first is the fee-for-service payment system driven by the government today through Medicare reimbursement decisions. Until that's addressed, the ticking bomb won't be stopped.

And it's certainly not about electronic health records. Feeding them to thousands of doctors through the stimulus package won't engender the change needed: improving patient health and paying doctors for new services that deliver better health outcomes at the same or lower cost. We can't attain the promised benefits of health IT without compensating physician innovation from volume to value. As much as health IT has the potential to help doctors with best practices and cut "waste", we need the right policy solutions to bring greater transparency to what patients purchase and the quality of those services...as illustrated through this story about colonoscopy pricing.

Raising taxes, cutting benefits or some combination will buy us more time--but won't address the core problems in the system nor improve its economic viability. Until we do that, we won't realize value--as measured by better health outcomes for every dollar we spend on health.