A s health care professionals, we marvel at the complexity of the human body-extraordinary when its systems perform in concert, devastating when disease or disorder invades. One malfunction within the body-not making insulin, for example-may lead to serious problems such as blindness, peripheral nerve damage, and heart disease. Our job is to bring the entire human body back into balance so the patient can lead a full, productive life. A similar holistic approach should be used to examine the way we provide health care in the United States. Like a person suffering from a debilitating disease, health care in the United States is ailing. There are many signs that it is in serious trouble. PROBLEMS WITH THE HEALTH CARE SYSTEM Lack of Quality and Safety. Nearly one half of physician care is not based on best practices. 1 Also, at least 98,000 Americans die of a medical error each year. 2 The Uninsured. The number of uninsured or underinsured people in America is rising. In 2004, nearly 46 million people were uninsured, according to the US Census Bureau (www.census.gov/hhes/www/hlthins/hlthin04/hlth04asc .html). Public Unease. Surveys have increasingly found that more Americans are worried about their health care costs than about losing their jobs, paying their mortgages, losing money in the stock market, or being victims of a terrorist attack. Among those who currently have insurance, more than one third report that they are very worried that their health plan will be more concerned about money than about what is best for them. 3 Rising Costs. With the exception of the mid-1990s, health insurance premium increases have generally exceeded the rate of increase in the Consumer Price Index, as well as worker earnings. 4 An October 2005 study from the Kaiser Family Foundation reported that the percentage of employers offering health coverage decreased from 69% to 60% in just 5 years. 5 Some companies, such as General Motors, are finding it difficult to compete globally when

Despite efforts to develop methods for measuring the quality of medical care, no satisfactory mechanism has been established. Our study, using hypertension as a clinical model, evaluated process and outcomes separately and then compared the two. Physician adherence to an extensive process list varied substantially from established criteria. No statistically significant association was detected between process and outcome. Regression analysis examined the relation between outcome diastolic pressure and 12 predictive variables that included patient satisfaction and social class. The only statistically significant variables (P less than 0.05) related to outcome blood pressure were age, initial blood pressure and weight. The inability to identify a relation between various process items and outcome suggests that, in determining a successful outcome for hypertensive patients, the selective use of process by the physician may be more effective than adherence to a rigid criteria list.

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If patients are to be at the center of health care, then providers should work diligently to better organize the delivery system. In this Perspective, two Mayo Clinic leaders provide their views on why it is necessary for physicians and hospitals to set aside their differences and work together for the good of their patients. They cite successful enterprises nationwide that combine hospital and physician control. T h e s e v e n t e e n t h -c e n t u ry poet John Donne points out a simple truth that can guide our country as it undertakes the difficult task of reforming the health care system: No one is self-sufficient. Physicians need hospitals; hospitals need physicians. And, most of all, patients need their providers to work together. A 2006 Commonwealth Fund survey found that more than 40 percent of Americans have experienced "poorly coordinated, inefficient or unsafe care" at some point during the past two years. The survey also found that, across the board, adults endorse the importance of wellcoordinated care. 1 Integration will also help us reach a common vision articulated by the Institute of Medicine: health care that is safe, effective, efficient, timely, equitable, and patient centered. 2 Some have proposed that health care be offered in a "focused factory" setting-a carveout facility where physicians focus on providing heart care, for example. 3 We believe that this approach is inadequate for patients with complex, multisystem health problems. In Remaking Health Care in America, Stephen Shortell, a leading health services researcher who has dedicated his career to studying organized delivery systems, and his colleagues ask, "How are the needs of a mother with breast cancer who cares for a mother-in-law with chronic obstructive pulmonary disease and has a child at home with attention deficit disorder served by a focused factory?" 4 At medicine's best, health professionals create teams of experts that deliver appropriate care to patients throughout their lifetimes. They share a common electronic record; they consult with one another; they provide the care that is appropriate and no more. When providers aren't working together, they provide uncoordinated, expensive, unsafe, and substandard care. Unfortunately, this is common in the United States. Studies show that w 6 8 5 D e c e m b e r 2 0 0 6 P e r s p e c t i v e s