Sometimes Medpundit and I gravitate to the same issue. Today is such a day. The NY Times article is a must read . - Decade After Health Care Crisis, Soaring Costs Bring New Strains. I will excerpt from this long article and provide my own commentary. Then read Medpundit's view.

If the cost of coverage keeps going up, experts warn, even more Americans will join the ranks of the uninsured because they will be priced out of the market. Many health care analysts, their faith shaken in managed care, see no easy fixes.

Politicians in both parties are beginning to respond, but they are profoundly divided on the issue, a deadlock underscored last month by the Senate's inability to pass a prescription drug benefit for Medicare. As a result, the issue is expected to bubble throughout the fall elections.

The last decade saw a squeezing of health care costs. Every drop of easy decrease was accomplished. The next cuts will require a major change in thinking. Politics cannot solve this problem, because politicians do not address issues, they address constituencies.

The soaring costs are driven, in part, by the biomedical revolution of the past decade, which has produced an array of expensive new treatments for an aging population, from drugs to fight osteoporosis to high-tech heart pumps. The result is a health care system filled with great promise and inequity — such as wonder drugs that many of the nation's elderly must struggle to afford.

Dr. Janelle Walhout sees the paradox every day at the community clinic in Seattle where she works. "I've been thinking lately about the mismatch," Dr. Walhout said, "between how very high-tech medicine has become, with all these genetic tests for everything, mixing your medications like fine cocktails, and our patients, who can't afford them, can't understand it, can't get interpreters to explain it and are just not accessing those things."

These paragraphs outline the problem well. We can do so much more than we could. And we will be able to do even more. What is this progress worth? Should we set limits on health care expenditures? No one has good answers to these questions. Our society accepts inequities in legal care, automobiles, housing, but wants to deny those inequities in health care. If health care is special, if it is a right, then society must pay. If it is not a right, then we cannot be hypocritical about that decision. Declare it, and accept a multi-tiered system. But I do not think we really want to do that.

Spending on health care rose faster in 2000 than at any time since 1993, federal researchers reported this year. Spending on prescription drugs and hospital stays grew particularly fast, largely because of advances in technology and "the retreat from tightly managed care," said Paul Ginsberg, president of the Center for Studying Health System Change, a research organization.

That quote about retreating from tightly managed care really bothers me. The cost problems come from our ability to do more, with drugs and with procedures. No one was happy with tightly managed care - and medical care was worse.

Not surprisingly, doctors disagree. Dr. Richard Corlin, a former president of the American Medical Association, cited "advancing technology and an aging population," along with the rapid increases in the cost of malpractice insurance, as the primary reasons for the rising cost of care. The A.M.A. also notes that insurance companies are reaping higher profits.

And the AMA is correct. Physicians are making less money and health care costs are increasing. We have increased regulations (all of which cost much money), increased malpractice, more expensive drugs, more excellent technological advances - it has to cost more money.

Many health policy experts argue that tackling health care inflation will require a fundamental cultural shift in the American approach to medicine. They say doctors and patients must begin taking cost into account when making treatment decisions. They say Americans must limit themselves to treatments that are proven to work and accept the premise that more care does not necessarily mean better care.

"As a society, sooner or later we will have to determine whether there are some benefits that are too plain small to justify the cost," said David Eddy, an independent analyst who advises health care organizations, including the managed care industry. Americans, he said, "have an enormous tendency to use treatments if we think they work or if we hope work, even if there is no evidence that they do work."

In the 1990's, for instance, bone marrow transplants were widely used to treat aggressive breast cancer. Then studies showed it was no better than standard therapy. Hormone replacement therapy, prescribed to millions of American women, has now been discredited as a way to prevent heart disease and stroke.

Dr. Eddy says he believes a new government agency should be set up to take this kind of scientific literature into account, and then make recommendations about whether new treatments are worth the cost. But while health experts agree there is a critical need for independent evaluations of new technologies, they doubt such an agency will ever come into existence.

"It would be killed by all the lobbying groups," said Uwe Reinhardt, a health economist at Princeton University.

First, we have a such an agency - the Agency for Health Care and Quality (AHRQ), which receives a meager budget (relative to NIH), and which cannot do the studies needed because of lobbying groups. We do need more efficacy studies of many treatments. I have previously called for device manufacturers and pharmaceutical companies to fund these studies but not have any control over their design or execution . Such studies such be the litmus test for adoption of new treatments or diagnostic tests. We can do the studies. Unlike Medpundit I think we will have to involve subspecialists to do the studies properly. However, each study panel should have a heavy representation from generalists. Patients will only take cost into consideration when they share in the costs. Our health insurance system makes health care an entitlement. If it is - then let's pay, if it isn't let the patient participate in the costs.

Finally, let me suggest that the doctor patient relationship might actually help here. Physicians who have the appropriate amount of time with patients can take a more complete history, provide better prevention, more carefully select diagnostic tests, refer more appropriately. Our system has evolved over the past 10 years to shorter visits - and I believe the visit length leads to more expenses. We need to test this hypothesis. The system is trying to save money in the wrong places. The generalists should not be squeezed. They control much care, many expenses and can do a great job if given the tools and the time. This topic will recur often. And I will probably sound like a broken record.