When I was at the IHI conference in Nashville a few weeks ago, I sat in on a half-day "learning lab" called, "What Does it Take to Transform Healthcare?" Taught by three physicians with vastly different backgrounds—private practice in Oregon, an Alaska native medical system (which I'll post about separately soon), and a Swedish county health system—the session didn't really strive to answer the big questions so much as to encourage participants to go home and think hard about them. Who should make decisions about our health care system? What are the goals of reform? Who sets them and do they reflect the shared values of a community? Why does fixing health care take so long, and why is it so hard? I'm not going to try to sum it all up here, because it was a pretty open-ended exercise, but I wanted to touch on a few points that stuck with me and hope they aren't too disjointed out of the context of this discussion.

One was the "hype cycle." This idea (adapted from Gartner Research) isn't unique to health care quality, but we get all excited about one trend or innovation, our expectations are wildly inflated, then we crash. At some point, hope and disappointment should find some kind of equilibrium at the "plateau of productivity." But sometimes we just move on to the next big thing—consumer-directed health care, pay for performance, electronic medical records, patient-centered medical homes or whatever. Maybe we need less of the next big thing and more of a medley of sensible middle-sized things, all tempered by more realistic expectations. (MedPAC, to its credit, has been recommending a mixture of innovations, not a magic bullet).

The three presenters—Douglas Eby, MD, MPH Vice President of Medical Services, Southcentral Foundation Alaska Native Medical Center in Anchorage, Göran Henriks, chief of learning and innovation in Jonkoping County, Sweden, and Charles M. Kilo, MD, MPH executive director, The Trust for Healthcare Excellence and a primary care practitioner at GreenField Health in Portland, Oregon—also encouraged the group to think about what health care should really aim to accomplish. The Triple Aim in IHI lingo, "The Best Care, for the Whole Population, at the Lowest Cost." Kilo outlined it this way:

1. The objective (purpose) of our health system is health as measured at the individual, family and community levels.
2. Individual and community health are public assets. Universal access to basic health services is essential to the well-being of our workforce and our communities.
3. Public resources should be allocated in a way that maximizes health across the population.
4. Decision-making about the expenditure of public resources should be evidence-based and transparent.
5. Health services should be coordinated, integrated, and organized within the community to provide longitudinal care for comprehensive mental and physical health

The group (more or less) concurred that we can't reach those goals simply through finance reform. Moving money around within the system won't work in isolation, won't necessarily reform or repair a system —although it can help move the system in a desired direction, such as toward a more integrated delivery system.

The group didn't come up with any shattering conclusions. Except that there's a lot more to be done. And that we may be entering an era in which we can do it.