PURPOSE: To describe the sources of tension within the health care system and methods for pursuing their solution. METHODS: Presentation of observations pertinent to patient, provider, and payer perspectives relevant to the cost, delivery, and quality of care and their impact on health. RESULTS: Societal forces, not just wealth, are major determinants of both health and the costs of health care. CONCLUSIONS: Tensions created by rising health care costs in the face of finite societal resources will increase in the years ahead. These can be resolved only by realizing new efficiencies in care, and prioritizing, through an explicit process, the care that is to be provided.
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