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American medicine remains, at least arguably, the best in the world. The United States leads the world in laboratory and clinical research, producing far more new scientific discoveries than any other country. Americans continue to lead the world in Nobel Prizes in medicine. People come from all over the world for education and to train in leading American centers of excellence.Despite the excellent quality of American medicine at its best, there are tremendous areas of concern over the quality of medical care as delivered in the United States. A substantial proportion of the American people remain uninsured. There is concern that many people—perhaps most—are not meeting guidelines for control of blood pressure, serum lipids, and diabetes. There is concern that we as a society have not done a good enough job at seeking value. We fail to provide adequate care in some areas while lavishing resources in others. Finally, there is concern over the ability of society to continue to afford the care that is being offered. The Institute of Medicine has called for a medical care system that offers care that is safe, effective, patient centered, timely, efficient, and equitable.1 These various goals should be mutually achievable, but we seem to be a long way from realizing them.A major problem that our society faces is the increasing cost of medical care. Since 1980, the percentage of gross national product devoted to medical care has increased from 13% and is expected to reach 17% by 2010 (Figure 1).2 There are multiple drivers of this problem, including the aging population and technological advancement. These twin drivers will place an increasing burden on Medicare, the principal form of insurance for the elderly.3 Medicare is composed of two parts: part A, or Medicare Hospital Insurance …

Is a Paradigm Shift in US Healthcare Reimbursement Inevitable?