"how can we provide a health care system that is accessible, cost-effective, and of high quality?"

The 1999 UCLA Health Care Symposium will address the current state of health care in California and the challenges that lie ahead. We will look to address possible solutions to the crisis at hand: how can we provide a health care system that is accessible, cost effective, and of high quality? As we have seen in the past, California has consistently been a frontier for major health care reform. Such reform has been highlighted by the predominant shift from a fee-for-service health care industry to one that is governed by managed care organizations. The changes implemented in California have often acted as catalysts and, at times, blueprints for reform elsewhere in the nation. For this reason, an objective evaluation and an educated appraisal of the challenges facing health care delivery today are imperative to meet the needs of tomorrow's patients.

The transition from the traditional fee-for-service (FFS) to managed care health care delivery has impacted no other state as extensively as in California. In fact, well over 55% of all Californians and 90% of employer-insured Californians are members of an HMO or PPO plan. California "represents the state of the art in prepaid managed care," whereas many areas of the U.S. health care markets are just entering the early phases of managed care. Thus, it is time to consider the role California plays in leading other states into the Managed Care Era and to assess the advantages, shortcomings and the challenges that await in the near future. Does Californian Health Care Delivery represent the model system for the rest of the United States? More importantly, is the system meeting the needs of Californians by providing a solution to the health care crisis -- by providing health care that is accessible, cost-effective, and of high quality? If not, how can we change health care delivery to meet these needs?

Approximately 40 million Americans have little or no access to health care. This problem may be attributed to the cost inflation under the traditional FFS system, mediated by uncoordinated abuse of the freedom this system provided by insurance companies, other third party payers, and certain physicians. In addition, the shift to managed care as the primary means of health care delivery in Southern California is the product of a variety of sociological, technological, and economical transformations that have occurred in the 20^th century. Such transformations have necessitated a more accessible, cost-effective, and comprehensive health care system for all, regardless of prior or present health, social, and economic status. A shift from FFS to prepaid managed care in California is not only a product of social and market forces, but is also seen as a step closer towards cost-effective health care delivery.

Managed care systems, such as Health Maintenance Organizations (HMOs), have solved some of the shortcomings of the traditional FFS model. They have proven to be more cost-effective and provide greater accessibility to some populations. These systems also encourage a greater emphasis on preventive care and routine check-ups that are not normally covered in the traditional FFS system. Managed care proponents claim that more efficient and cost-effective care can be provided through the use of "utilization management reviews," which advocate discharge planning, case management, and less expensive alternatives. This is promised without any subsequent loss in the quality of care provided to patients.

Nonetheless, managed care systems also have serious shortcomings. For example, this model places new limitations on patients' freedom in terms of selecting their desired services and/or physicians. In addition, the preoccupation with cost may create lower quality health care, which may jeopardize the integrity of the doctor-patient relationship and restrain physicians from providing adequate care as they deem necessary. The ultimate concern is that health care is being provided by corporations that are more concerned with the financial interest of their stockholders rather than patient care. Thus we are challenged with new questions: Will cost be maintained at the expense of patient care? And will physicians' autonomy in treating patients the best way possible be compromised?

As we dawn upon a new millenium, we may need to consider alternative systems or reforms that will eliminate some of the problems associated with the existing form of health care delivery -- managed care. The history of health care delivery in this country has been one of "resolutions that create problems which requires new solutions." Are we once again stepping into this vicious cycle with a managed care system in place of FFS? As health care providers, we are challenged with a number of difficult questions: Is the concept of having a quality, cost-effective, and accessible health care delivery system just a myth, or can we reach this goal? What are the necessary reforms and how can they be achieved? Whose job and responsibility is it to deal with our current problems and who should be the decision-makers leading the future of this country's health care delivery system?