Over the past thirty years, we in the United States have had several rounds of
discussion and debate about health care reform, and various proposals for
more organized systems of care have played a key role in each of those debates.
After a widespread and serious push toward implementation of what Alain
Enthoven calls “delivery system health maintenance organizations” in the 1970s,
1980s, and early 1990s, our country has now spent the past several years moving
away from that model, in the interest of giving consumers greater choice of
providers.
It is not at all clear that our “back to the future” movement to fee-for-service
health care can deal with the continuing concern over health care costs. Furthermore,
we have learned much over the past few years about our deplorable
lack of consistently good quality and patient safety. An unorganized nonsystem
of health care delivery is ill-equipped to provide the focus and mechanisms for
quality improvement.