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.

Neither of the bills in the Senate nor the House do enough to bend the curve--at least in the direction of lowering cost. Health insurance reform in itself will not be sufficient to address the rising burden of health-care costs and utilization.

The administration understood the challenges to tackling health reform and instead decided to focus on health insurance reform as a means of addressing the issue. The Senate bill really does nothing to control health-care costs.

The first amendment I would propose is a tax credit to employers to encourage them to adopt solutions that will enable them to better hold insurance carriers more accountable.

Of course, the consumer is equally important -- the healthier we are the better off the system. The next amendment should create tax incentives for those who are truly interested in managing their health by enrolling in wellness and prevention. Nothing works better than financial rewards.

Lets stop making the people in first class pay for the folks in economy. its time to share responsibility for wealth and health

Some of the relatively low-cost, high-return ways to improve health and reduce health care cost increases are relatively unglamorous and do not involve big government programs. For example, at Pitney Bowes, we reduced the rate of seasonal influenza and other infectious diseases by having an aggressive outreach on seasonal immunizations and on hand-washing and other hygiene-focused practices, such as more frequent cleaning of surfaces on which viruses or bacteria reside and spread. The rate of hospital-acquired infections, which cost our health care system dearly, could be reduced significantly if all hospitals focused similarly on infectious disease prevention.

Another relatively low-cost area of focus, which pays both significant short and long term dividends, is more aggressive outreach on prenatal counseling and lifestyle modification. Today, government programs are predominantly focused on the medical interaction required close to the time the mother delivers. However, the real benefit of prenatal counseling is at much earlier points in the pregnancy, at points during which an intervention can reduce the incidence of low birth-weight, premature babies. At Pitney Bowes, we used a program called Great Expectations, which provided financial incentives to get expectant mothers to participate, and we achieved lower incidence of premature births.

Any investment in getting children and adolescents to adopt better living habits pays back handsomely. For example, increasing the price of tobacco products by 10 percent reduces the percentage of teenagers who start smoking by 4 percent as a number of studies summarized in 2004 by Professor John Taurus of the University of Illinois at Chicago shows.

We have to refocus our efforts on improving health, as opposed solely to increasing insurance access. If we do not solve the health and health care access problems, and only give everyone an insurance card, we are effectively rearranging the deck chairs on the Titanic.

I applaud the administration for shining a bright light on health reform. The government -- as buyer, regulator and leader -- must be a part of any solution. The political calculus has created a real sense of urgency to do something about this complex system which touches everyone and accounts for one sixth of our economy. The consequence however, through a lack of transparency and understanding, has reduced the public dialogue to be between "public insurance options" vs. "death panels." Framing the debate this way and consuming available public attention on "wedge" issues won't lead to a sustainable future system.

My attendance at an Institute of Medicine workshop this week in the midst of the buzz about the speech served as a stark reminder about the depth and breadth of the hard problems:

• Access (too many uninsured)
• Costs (growing faster than inflation)
• Demographics (aging populations driving up systemic costs)
• Quality (not enough -- as measured by comparative outcomes, disparity in care geographically)
• Worsening health (people dying because of a lack of focus on improving the care delivery process).

I was struck by the number of smart, passionate people representing the major stakeholders working together to drive change. Veterans of the process recognize that change is imperative but hard -- because the details matter. We are in this predicament because incentives, tax policies, government reimbursement schemes and increasing specialization and capability of medicine have led us here.

The president delivered an inspirational speech, laying out basic principles: everyone should have access, nobody with insurance will have to change it and cost growth must be slowed. Voters know there is no free lunch, and health is no different.

We can't achieve reform without educating the public. A sustainable system is not as simple as providing more access. Consumers are ultimately responsible for their health and their daily choices cost the system. We need to help them engage in their health differently, be wiser purchasers, and understand trade-offs. As long as they believe the price of care is their co-pay and continue to engage as they have, there won't be sustainable reform.

There are best practices at organizations like Geisinger that have re-invented care delivery and consumer engagement models. These leaders will tell you that success is about aligning incentives, understanding the details and making trade-offs.

The difficult work of figuring out the details and making hard choices is still ahead.

The promise of health reform - providing the best possible care to all Americans - cannot be achieved without reining in cost. But to do so will require a fundamental restructuring of our health care system. We need a paradigm shift.

First, there is a broader shift in culture which must occur. We need to create a culture of promoting health and wellness and it must start early in life. Transforming our disease care system into a health care system involves schools, communities, and parenting as much as it does doctors, nurses, and pharmacists. Part of this shift is about educating people (including health professionals) about good nutrition and physical exercise. But this is only part of the puzzle.

As a physician, I care for many patients who have a reasonably good sense of what is good for them. But they are living in a world which often makes the right choices difficult. We can make the right choices easier by thinking about to make healthy foods more accessible, affordable, and identifiable. We can facilitate the right choices by rethinking how we design our work settings and communities in ways that promote physical activity. Prevention is at the core of health and wellness. We know that preventing illness costs less in dollars and human suffering than treating disease. We need to ensure that we have a health care system that builds on this principle.

Second, our health care system must reward the outcomes we wish to see. If we seek to promote health, we should reward healthy outcomes. Currently, we spend most of our money paying for office visits, medications, and procedures; we reward health care consumption. But we also know that more consumption doesn't mean better outcomes. If that were true, America would have the best health care outcomes in the world (we don't - in fact, far from it). Rewarding good outcomes increases the likelihood that we'll generate good outcomes. It also encourages physicians, hospitals, and other stakeholders to think creatively about enhancing health outcomes instead of focusing on utilization of services.

Third, the delivery system needs to be lean and efficient. This is where technology and coordination of care are critical. As a physician, I have lost track of the number of times I have seen expensive studies repeated because we couldn't find the original results from another hospital in a timely manner. Integrated medical records that connect institutions while rigorously protecting patient confidentiality can help us avoid these situations. My colleagues and I have also spent countless hours searching for critical patient information and deciphering handwriting in paper charts (which are still used by the majority of American medical practices). When you consider the hundreds or thousands of dollars that a single unnecessary imaging test can cost, it's easy to see how integrated information and communication systems could create valuable savings. It's also easy to see how electronic records can save time while preventing errors that result from manual transcription. If physicians and nurses could take the time they spend searching for information and invest that time in talking to patients, I believe that would be more satisfying for patients and practitioners.

Transforming an institution as large and entrenched as health care is not easy. It will be uncomfortable at times and will require tough choices. But it is what we need to do if we are serious about reining in cost and providing Americans with the health care they deserve.

Yes, it is possible to substantially rein in costs to "bend the cost curve." There are many proven techniques to do this. However, preventing things from happening continues to be undervalued even though we know it significantly reduces future costs. By making wise investments now and choosing program and policy options that move the system toward prevention, we can reduce our spending in the future and give greater value to the health system. Two methods that accomplish this include:

• Change the system to provide care as far upstream as possible by enhancing provider reimbursement for primary care, prevention and early intervention, as well as utilizing more allied health providers and physician extenders to provide care. This will reduce costs by identifying problems early and then managing them to reduce or eliminate the need for more costly care in the future.

• Invest in and utilize more community-based interventions that have been shown to save money. A study by the Trust for America's Health showed that for every "$10 per person per year invested in proven community-based disease prevention programs saved more than $2.8 billion annually in health care costs in one to 2 years, more than $16 billion annually within 5 years, and nearly $18 billion annually in 10 to 20 years (in 2004 dollars)."

That's real savings. Unfortunately the Congressional Budget Office, the scorekeeper for Congress, has not designed a methodology to fully capture and credit this benefit. This needs to be corrected if the true costs savings are to be captured.

Prevention measures are the most proven and effective way of keeping costs low and improving Americans' health. Yet, it seems these measures are at the front of the line to get eliminated in the rush to "cut costs" from the health-care reform package. Prevention measures didn't even get the respect of a cost score from the Congressional Budget Office. This is a totally backwards way of thinking.

A report released last year by the Trust for America's Health showed that for every dollar we invest in prevention, we save $5.60. If we invested $10 per person in prevention, we would save $16 billion nationwide within five years. That is an astounding rate of return -- not only in dollars, but in health, peace of mind and improved worker productivity.

As a purely political point, prevention is also overwhelmingly popular. A study released in June by The Robert Wood Johnson Foundation and the Trust for America's Health showed that "more than three-quarters of Americans (76 percent) support increasing funding for prevention programs that provide people with information and resources and creating policies that help people make healthier choices. Investing in prevention is popular across the political spectrum, with 86 percent of Democrats, 71 percent of Republicans, and 70 percent of Independents supporting investing more in prevention."

Prevention measures must also recognize that where we live affects how we live. To be truly healthy, Americans need access to fresh food, clean air, and safe places to play. Some places are starting to understand that. Take the city of Richmond, Calif., for example. They are looking beyond the usual avenues to ensure healthy residents. They are, of course, doing the much-needed work of expanding access to health clinics and medical services. But they're also making sure all residents have access to fresh, healthy food; clean, reliable public transportation, affordable, well-kept housing; and safe, nearby parks. The early returns are promising and should be replicated.

As we work for better prevention measures, we also must remember that health inequities have put low-income communities and communities of color most at risk. By bringing prevention to all communities, we can make a tremendous difference in the lives of millions of Americans.

I believe strongly in individual mandates for health insurance, with subsidies for low-income people. I recognize that mandate enforcement is a big challenge, and, as we all know, even though automobile insurance is mandatory for those driving a car, there are a significant number of uninsured motorists.

While enforceable individual mandates will certainly contribute to the pool of money needed to provide affordable universal care, the main reason I believe that everyone should be required to purchase health insurance is that individuals who have and pay for health insurance, even in a nominal amount, feel a greater stake in taking care of their health and in the quality of the health care they receive. They focus on getting preventive screenings and immunizations. They take care of infectious diseases earlier and more aggressively, and they monitor what they spend more carefully.

With universal participation in health insurance programs, we also can reward those who take better care of themselves with lower health insurance premiums. Without mandatory health insurance, we are giving up a major tool for encouraging people to take better care of their health. I believe no one should be denied health insurance or be forced to pay more because of medical conditions over which they have no control. At the same time, we must reward good behaviors and penalize bad ones, particularly with respect to preventable chronic diseases.

The economic rationale for a mandate (individual, employer-based or a hybrid) is based on avoiding adverse selection: consumers will logically opt out of the system if they feel their personal health (past predicting future) is better than average and insurance companies will overprice the product, expecting only the highest-risk customers to enroll. In the absence of some mandate, the individual insurance market devolves to the current state: many individuals rationally choosing to be uninsured, not because they don't value health insurance, but because they refuse to overpay for the offered product.

But beyond the economics of this mandate, there is a cultural change that might follow. Perhaps if everyone knows that they will always need to be insured (rather than planning for that day in the future when they anticipate the "need"), they will become more informed consumers. Perhaps they will also take health preservation and illness prevention more seriously. Perhaps our health-care providers will find greater motivation to incorporate preventive measures in their day-to-day delivery of care. And with more healthy risks in the insurance pool, perhaps we will actually stand a better chance of truly preventing disease and/or detecting it at a stage when we can affect positive change.

While some of the narrative bears proof-of-concept, there is little risk and a huge potential reward. Mandates are a necessity if we can make this work.

As a family practitioner in the United Kingdom, I have often attended meetings to learn about other health-care systems. The advantages of the commercially-run providers in the States are frequently quoted, including the improvements in "customer" care, involvement of the consumer, better communication and enhanced choice.

Yesterday, I attended a meeting in England presented by a research doctor who had spent a year in California. The doctor started a pilot program in this country based on the Kaiser Permanente system of predictive models. By looking at the highest risk patients and maximizing the preventive treatments, hospital admissions had been substantially reduced. Both the patient and the public purse would benefit if this could be replicated in the United Kingdom.

This lesson has been driven from a commercially-based system of care in the U.S. to reduce inefficiency in the United Kingdom's state-funded system. We hope to reduce the number of revolving-door patients who are in and out of acute medical units and who run the risk of hospital-acquired infections and other avoidable complications.