In this issue, Barry Greene has organized an important set of articles focused on how ambulatory care organizations have followed up on the Institute of Medicine landmark report, Crossing the Quality Chasm. This set of articles continues to build on the focus of the last issue of the journal, which ties together improvements in quality with changes in reimbursement.

National politicians have put healthcare delivery improvement and healthcare coverage for all at the top of the national agenda. While this is a welcome development, there is the perennial danger that we will simply engage in talk rather than in action resulting in improvement. Even worse, there is an even greater danger that action contemplated today in Congress will result in decrements in our healthcare system with less coverage for Americans.

The current Medicare Advantage debate in Congress is emblematic of the challenge for congressional leaders. On the one hand, consumers rightly do not trust health maintenance organizations (HMOs) (neither for-profit nor not-for-profit HMOs). Michael Moore's film "Sicko" told us the stories of "evil" Kaiser-a not-for-profit organization that arguably provides much better care than many private physicians. HMOs, on the other hand, have joined forces with traditional health insurance companies (Association Health Insurance Plans). Thus it is impossible to tell the difference between the few organizations that do provide coordinated care (ie, improved value or outcomes quality/payment) and the vast majority that are skimming the top with excessive administrative charges and provide virtually no coordinated care. With Democrats in control of Congress, Congress is finally shining a light on these health plans that provide little value.

The challenge that we have is to understand the intricacies of practical (ie, not single payer and/or "accountable" health partnerships; Crosson, 2005) payment system design. We must understand that the majority of plans providing little value will not be able to "play" if we implement a transparent, outcomes quality-driven payment system. The word "transparency" is thrown around so much today that it has come to have little meaning. For me, transparency means a clear link between payment and outcomes quality. The incentives and medical logic built into this linkage are not only open at the aggregate level, but the healthcare professional (or shall we even be so bold and call on the consumer!!), if he or she so chooses, can drill right down to the individual patient level. Unfortunately, the Democrats in Congress are likely to simply cut payments to Medicare Advantage Plans. Instead, Democrats should be emphasizing that proposed cuts might be moderated (but not eliminated) if Association Health Insurance Plan, the trade association for health insurers and health plans, went along with a law that would mandate complete transparency in dramatically improved payment methodologies. Such a compromise approach that fearless (they will have to fight against grassroots activists that are simply saying "cut" to Medicare Advantage plans) Democratic Congressional leaders might adopt would have the critical added benefit of illuminating all the added monetary payments that pharmaceuticals and technologies derive from already-existing Medicare programs. While we can never eliminate what is known as regulatory capture by, for example, device manufacturers, transparency and improved payment design would at least highlight the excesses of many of the feeders at the healthcare dinner table.

Without the emergence of national pragmatic fearless healthcare leaders, healthcare coverage for all is a nonstarter. However, to accomplish their goals, these leaders need to be able to compromise not just in a standard political manner but also need to hold on to a deck of cards that emphasizes transparency and expertise in payment system design. Implementation by truly fearless leaders of transparency, together with encouragement of true coordinated services, can free up the dollars to improve value and provide health coverage for all. Today these conversations are occurring in several states. Hopefully, the next election will see a new president committed to this brand of leadership. In this issue of the journal together with the recent and forthcoming issues, we will focus on payment system redesign as it pertains to ambulatory care-the key to cost control, the only way we can possibly move to healthcare coverage for all.

As always, we try to keep these discussions in perspective by having an up-to-date report from the Republic of Texas together with a Human Rights column from Physicians for Human Rights.

Norbert Goldfield, MD

Editor

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