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In most years, the country gets a little bit richer. In the last decade, nearly all of the gains - more than 90% of economic growth - went toward offsetting the growth in health care spending.

The estimate, based on research by Michael Chernew, a health economist at Harvard University, is for 2000 through 2009, a period marked by sluggish growth overall. But it illustrates the growing burden that health care costs place on households as they struggle to get ahead.

"At some point, you get close to the cliff," said Dean Gruner, a physician and chief executive of ThedaCare in the Fox Valley. "And to me, we are pretty darn close."

The Supreme Court decision last month and the ongoing debate about health care reform don't change that. Nor do they change an economic reality: The United States must slow the rise in health care spending.

It won't be easy.

Health care spending grew an average of 2 percentage points faster than the economy from 1990 through 2010. But it also is growing faster than the economies of other industrialized countries. In other words, no country has figured out how to check the rise in spending.

What makes the problem more pressing in the United States is the country already spends a lot of money on health care - almost 50% more than any other industrialized country.

But nascent signs are appearing that the health care system is starting to get serious about providing better care at a lower cost.

They include an array of initiatives in the Affordable Care Act, the federal health care reform law, to make the health care system more efficient - although none is expected to slow the growth in spending in the near term.

The initiatives include putting more emphasis on primary care, increasing funding for research on which treatments work best, and creating an independent board designed to limit special interests' influence in Congress when determining what Medicare will pay for health care services.

"The act really took a whole bunch of ideas and put them into a law," said Brian Ewert, a physician and president and chief executive of Marshfield Clinic. "Some of them are probably really great ideas. Some of them probably aren't so great. We're going to be finding out between now and 2020."

By then, health care spending is projected to account for almost one-fifth of the U.S. economy, according to government estimates.

Fundamental change

To Gruner and others, the health care system must move away from its current system of paying hospitals and doctors based on the volume of services they provide.

"Nobody really knows how to do that yet," Gruner said.

So far, initiatives to test new ways of paying for health care have drawn the most attention. The goal is to give hospitals and doctors a financial incentive to provide better care at a lower cost by letting them share in the savings.

The experiments include "accountable care organizations," in which health systems or hospitals and doctors are accountable for the quality and cost of care provided to a specific group of patients.

Aurora Health Care, ProHealth Care and the Independent Physicians Network in the Milwaukee area are participating in the experiments. So, too, are ThedaCare, Bellin Health in Green Bay and Dean Clinic and St. Mary's Hospital in Madison.

Commercial health plans also are experimenting with new ways of paying hospitals and doctors.

Those experiments, Gruner said, are "exactly what we need in this country."

The initial results from similar experiments, though, have been disappointing, generally resulting in little or no reduction in costs - although they did improve the quality of care, according to a report from the Congressional Budget Office last year.

Marshfield an exception

The most notable exception was Marshfield Clinic, which consistently showed that it could improve quality while lowering costs in one of the experiments.

"This is not impossible - it is just hard," said Aaron McKethan, a health economist and visiting fellow at Brookings Institution.

There will be a learning curve, he said. And accountable care organizations will look much different five years from now.

"Any kind of innovation involves failure," McKethan said.

Old habits die hard

The obstacles to slowing the rise in spending are considerable.

Two of the biggest will be changing the behavior of patients and changing the practice patterns of physicians, said Peter Pruessing, an executive vice president at Froedtert Health.

Health care spending is concentrated - 5% of the population accounts for almost 50% of total spending and 20% accounts for 81%. And understandably, few people give any thought to costs when faced with a serious illness.

What's more, many people think that more care is better care. One result: Cries of rationing often accompany any talk of controlling costs.

Slowing the rise in health care spending also will entail changing the way medicine is practiced - and, in the process, influencing the hundreds of decisions that doctors make in a typical day.

"There is a heck of a lot of change that is required with this," Gruner said.

The potential savings could be significant, given how differing practice styles can increase costs.

The care provided by the 10% of physicians with the most costly practice styles - those most likely to order more tests, prescribe more expensive drugs, schedule more office visits - will cost 40% to 60% more than the median for physicians in the same specialty in the same area treating the same condition, according to the Medicare Payment Advisory Commission, an independent agency that advises Congress.

At the same time, as health policy analysts have noted, it is easier to identify unneeded care in hindsight than when making decisions about a person in front of you.

But the current system also rewards physicians for doing more, and slowing the rise in spending could mean less money for specialists.

"Nobody wants to take a pay cut," said Coreen Dicus-Johnson, senior vice president of physician and revenue operations at Wheaton Franciscan.

Doctors will listen

But physicians want to help make the health care system more efficient, she said. They also are more willing to accept feedback on how they practice.

Greater acceptance of clinical guidelines - once derided as "cookbook medicine" because it places more emphasis initially on following standard protocols than a doctor's intuition - is an example of that.

Another is the Choosing Wisely campaign launched in April by the ABIM Foundation. In that campaign, nine physician groups each identified five commonly used tests or procedures in their specialties that are often unnecessary or inappropriate - such as bone density tests for low-risk women under 65. Eight other specialty societies will be putting out their own lists this fall.

It also can be seen in initiatives such as the Wisconsin Health Information Organization, which is aggregating and analyzing insurance claims data with the goal of gauging the cost and quality of care provided by physicians.

"The world is moving to rewarding quality and clinical patient outcomes," said Jim Dietsche, chief financial officer of Bellin Health.

Information tech crucial

Advances in information technology also could help health systems slow the rise in costs.

The move toward electronic health records in place of paper charts will enable the organizations to focus on managing the care of patients with chronic disease, such as diabetes and heart failure, who account for a large share of health care spending. The information systems also could help standardize care by identifying physicians who consistently diverge from clinical guidelines.

"We can spot variation much more quickly," Dietsche said.

Wisconsin ranks high for health care quality in national surveys, and many of its health systems have been at the forefront of efforts to improve quality. But the Dartmouth Atlas of Health Care and initial data from the Wisconsin Health Information Organization have shown significant variation in how medicine is practiced within the state.

That, too, suggests the challenge ahead.

The need to reduce costs and improve quality is well recognized, said John Raymond, a physician and chief executive of the Medical College of Wisconsin.

But, he said, "It will take many years."

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WHAT DRIVES COSTS UP?

Factors driving the growth in health care spending are varied and often interrelated. Among them:

Technology: Advances in medical technology, such as new drugs, medical devices, diagnostic tools and procedures, may account for one-half or more of the long-term growth in spending.

Price increases: Price increases have been much more of a factor in rising spending than increases in the volume of services.

Income: Wealthier countries tend to spend more on health care, though by one estimate, the United States spends 23% more on health care than would be expected based on its wealth.

Chronic diseases and lifestyle: Increases in chronic diseases, such as diabetes and heart disease, often stemming from lifestyle, contribute to the growth in health care spending.

Insurance coverage: Insurance coverage gives consumer little incentive to shop for the most effective care at the lowest price, a problem compounded by the lack of information on prices and what treatments work best. It also can encourage the use of more medical services than needed.

Aging of the population: The aging of the population is a minor factor in rising health care costs, though it will have a small but steady effect in coming years.

Medical malpractice: By one estimate, medical malpractice, including defensive medicine, accounts for 2.4% of total health care spending, or $55.6 billion in 2008 dollars. Other studies also have found that medical malpractice is a relatively small factor in total spending.

Inefficiency: By some estimates, 20% or more of total health care spending stems from various forms of inefficiency or waste, including unnecessary or inappropriate care, lack of coordination in a fragmented system, high administrative costs, prices set too high or too low relative to their true cost, and fraud and abuse.

Joe Taschler of the Journal Sentinel staff contributed to this report.