divorced from the reality I experience every day.

Obama’s proposals for reform, and the variations discussed in recent congressional hearings would add billions to our national expenditures for health care and extrapolate savings, in the long term, through an emphasis on prevention, widespread use of health information technology, chronic disease management, outcome based payment reform (i.e. expanded pay-for-performance), and propagating research findings on cost effective disease management.

Unfortunately, extensive research has shown that although there is some prospect of benefit from these approaches , the benefit is likely to marginal , and many years in the coming.

A recent analysis in the Annals of Internal Medicine subtitled "Hope vs. Reality" emphasizes these points and concludes that to control cost we must "embrace price restraint, spending targets, and insurance regulation."

Nevertheless, from my seat as a primary care physician in clinical practice, I can’t embrace this diagnosis, either. It doesn’t fit with my experience. And the solution my experience suggests would require a simpler, but more fundamental reform than that proposed by President Obama or by Marmor and his colleagues in the Annals.

To illustrate this, I chose to go to the office one random morning and analyze each case I encountered in an effort to find opportunities and direction for cost control efforts.....

Late in the evening, home after finishing a short day at work (eight appointments, a dozen phone calls, medication refills, etc), getting my younger son off on a sleepover weekend, watching The San Francisco Giants win a rare 2-0 shutout, and tucking in my older son I returned to the task at hand.

It was difficult, in the hubbub of a busy clinic, to keep track of each patient visit and call for the purpose of this examination of possible routes towards heath care cost control, but I think what follows provides the gist of thoughts brought on by a rather ordinary day:

"I don’t know what I have to pay for with the insurance I’ve got," bemoaned my first patient, holding back sobs. "It’s a big shock for me, a big worry." The 22 year-old unemployed mother of a six week-old infant, was suffering from post-partum depression and topping the list of issues which had led her to see me was anxiety about health care costs, and stress in dealing with the hassles of her complex insurance. This kind of concern is no surprise. Indeed, the April 18 business section of the Las Vegas Sun headlines "Rising health care costs spur more anxiety than job loss."

Perhaps to treat that anxiety, Aetna is pushing in its advertising a new book, Navigating Your Health Benefits for Dummies. How ironic! Aetna, which is in the middle of a big campaign to sell more individual health policies, bare-boned policies which feature large deductibles and co-pays and offer their corporate sponsors fat profit margins, is using health insurance premiums to push a book that helps patients manage the complexities created by the insurers own activities! (Interestingly, this book is not listed on the Dummies.com website nor is it available elsewhere except through Aetna-connected sources.)

John Pizelle (names have been changed for confidentiality) , my next patient, spurred in by the fact that his wife had recently been treated for potentially serious disease, greeted me warmly, "How’s the economy treating you?!" His wife had recently lost her job and they were contemplating the possibility of securing health coverage through C.O.B.R.A., the option created by the federal government which "gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances."

He was considering becoming one of the only 10% of Americans eligible for COBRA benefits who actually enroll, as the qualifying circumstance, unemployment, makes most unable to afford to pay the premiums. Mr. Pizelle made his appointment to see me, fundamentally an unneeded one, because he was worried about what lurked in his health care future and was undertaking an individual cost-benefit analysis about the value of paying for COBRA.

Those who oppose making health coverage more widely available often express concern that lowering economic barriers to care might result in an excessive increase in visits to the doctor. Maybe, but the "Please-order-every-test-and-make-every-referral-because-I'm-about-to-lose-my-insurance" visits will surely decline.

Indeed, data on the frequency with which patients forego needed care, miss doses of medication, or otherwise avoid care which is their own best interest has revealed over and over again the economic wisdom of reducing barriers to care.

I am reminded about another patient of mine, a "non-compliant" diabetic whose lifetime of complications had cost tens (if not hundreds) of thousands of dollars, who returned from an extended trip overseas with his diabetes finally under control. "What happened?" I asked, incredulous. And he matter-of-factly replied, "Medicine is free in Tonga."

Of course nothing is "free." But in a system where a societal judgment has been made to pay for health care through a system of central financing, reducing barriers to care at the "retail" level, patients and their physicians make health care decisions based upon need, resulting in a greater focus on preventive care and leading to improved management of chronic conditions. As a study commissioned by the Robert Wood Johnson Foundation published in the scholarly journal Health Affairs concluded, fully insuring all Americans under such a plan would not increase overall health spending because increased costs from covering the underinsured and uninsured would be offset through the reduction in administrative costs.

The next two patients of my morning failed to show. One called, saying she was "too sick" to make it in. I spoke with her, finding her to be not really that ill, but in need of a prescription for an antibiotic for a sinus infection. My thoughts drifted to the possible role of the co-pay in preventing her visit and brought to mind how the structure of physician payment, based upon face-to-face encounters, may push up the costs of providing care. Paid in this way, physicians are encouraged to see patients whom they might have managed equally well over the phone or through an online interaction.

After two "physicals," the next two patients, one requiring a rather large excisional biopsy, the other (Mary) with a non-displaced distal radial fracture, pointed to the beneficial role of an extensive primary care infrastructure in the battle to reduce costs. As I removed the cyst from Mr. Martinez’ axillary fold I recalled my brother-in-law’s experience in New York City, a locale dominated by specialty care. He presented to his dermatologist (family physicians are few and far between in New York) with a small mole on his upper arm. Rather than remove it herself, biopsy a section, or conclude that it was benign (it was) based upon clinical features, she referred him to a plastic surgeon who, more than a thousand dollars later, removed the lesion.

Finally, arranging for Mary’s late Friday referral to the Emergency Room for splinting of her fracture (no orthopedists available for patients with her health coverage), I recalled the days when I used to manage such fractures and considered the systemic savings to be had if we operated within a system dominated by widely competent primary care providers working in a more integrated system which did not distinguish among patients based upon the source of their health benefit payment. Rather than Mary’s moving from me, to the emergency room, to the orthopedist, she might have gotten all her care in one place, saving resources for other public needs.

It’s clearly not so much my fees (or even those of my more richly rewarded specialist colleagues), but the associated costs of the care we direct and the increasingly complex, balkanized, and bureaucratic system within which we all operate which feels like the driver of the explosion in health care costs which threatens to sink business and government.

President Obama understands and has articulated the risk that uncontrolled costs impose on our government and society. But physicians understand best from where this risk derives and where we must turn.

A fundamental transformation of our health care system is required, away from the confusion and profit-maximizing bureaucratic buck passing of the private health insurance system, and towards a new system which is defined by centralized funding and universal enrollment of everyone living in this land. With this change we will waste no more resources on achieving a favorable risk selection, marketing, underwriting, investor relations, product development, nor profits. Providers will spend virtually no revenue on billing and we will all operate within a clear cut set of rules that applies to all patients.

It is a dream, but it is a dream that can be realized now, if we can only get going and act. Politics, and political change, has been described as the art of the possible. But what is possible only comes about when those who believe in the need for change act upon that belief. Possibilities can be created. Hope can lead to change.