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July 28, 1993

Three Battles to Watch in the 1990s

Author Affiliations

Duke University Durham, NC

JAMA. 1993;270(4):520-526. doi:10.1001/jama.1993.03510040124050

HOWEVER the debate on national health care reform comes out, and whatever strategies are eventually used to achieve the seemingly incompatible goals of providing universal access, improving quality, and controlling costs, one thing is certain: The day-to-day decisions of those who actually provide health care will be put under ever-increasing stress. Reform will not solve the problems that have been causing the pressure on physician decision making over the last decade; it will rely on further pressure to solve the problems.

We know this will occur for several reasons. Begin with the fact that of the three main goals of health care reform— access, quality, and cost—the driving force is cost. To be more precise, the driving force is the rate of increase in costs—the fact that health care costs have been rising at about twice the rate of inflation. It is this feature of health care that has transformed

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