It was the best of times; it was the worst of tirnes ''~ A Tale of Two Cities Charles Dickens, 1859To paraphrase Dickens, it is the best of times, it is the worst of times. Dickens, of course, was writing about the French Revolution of 1789. I am referring to the American, and to some extent worldwide, health care revolution of the 1990s. Never has the health care system been equipped with such extraordinary and exciting physical and intellectual resources and abilities to prevent and treat disease than it is now--surely the best of times. Yet, not in recent memory, and perhaps never has there been so much attention paid and action taken to control health care expenditures. The speed and magnitude of the changes have left most health care organizations and providers reeling, uncertain, and afraid--surely the worst of times in the opinion of many. It is beyond rational debate that health care costs have grown well beyond society's desire or ability to pay for them. U.S. health care costs were $949.4 billion in 1994 and have increased from 5% of the gross domestic product (GDP) in 1960 to nearly 14% of the GDP in 1994, and if the same rate of increase is sustained, it will reach 30% of the GDP by 2020. And yet, as profound as cost containment has been, health care expenditures have not declined. It is just the rate of