It is common these days for efforts to be made to create or offer the “business case” for desired health care reforms. This is an appropriate and much needed measure against creating initiatives because they seem correct or the right thing to do in the moment. Business cases are typically made demonstrating improvement in quality, more effective use of a resource, cost savings, enhancement of the consumer experience or expanded access. The key to making a good business case is demonstrating real and quantifiable outcomes toward a desired future state.

Growth of the pharmacy profession in recent years makes perfect sense given the trends that are driving health care in the US. Fifty years of proliferation of basic and translational biomedical research programs, in both the public and private sectors, has created an enormous infrastructure for research and intellectual capital that are unparalleled anywhere else in the world. This capacity has produced a massive rise of pharmacological agents that effectively address acute maladies, prevent the onset of chronic conditions and manage them once they emerge.

Over the past year I have been engaged in dozens of conversations with nursing leaders who at some point or another come to question the state of "nursing professionalism" in today's health care system. Most of these comments seem to point to a general lack of responsibility, knowledge of nursing practice, and commitment on the part of many of those in nursing. These observations come primarily from the service sector and from leaders who are responsible for delivering on the growing demands for safer practice environments, higher patient satisfaction, and more efficient operations. The concept of nursing professionalism is an important but poorly understood issue that merits broader consideration and ongoing conversation. Here are some thoughts on where to start.

One of the critical elements missing from effective health care reform is a context for reframing the large-scale aspects of finance, delivery, public health, information, and other essential elements in comprising a health care system. We have much more experience and success in improving on what we have, particularly in reshaping the micro-systems in which care is delivered and organized. Still, without a larger framework for these changes, we are at times unable to push through necessary systems change when dealing with something as large as the US health care system. Several years ago, I presented the concept of a health commons at the University of New Mexico and I would like to revisit it as one set of ideas that may facilitate a discussion of the essential elements of a reframed health care system.

The November/December issue of the journal Health Affairs contains a number of articles about the current health care challenges and where we might be headed next. What seems to be missing is an overarching driver to direct us to the future. Are we moving to a more government-controlled system or will it be more driven by the consumer? Will individual professional groups stretch their independence or will teams become the fashion? Will the system continue to grow or will the necessity for controlling cost finally limit its size and determine its shape? Will technology solve all of the problems or will it generate a cost basis, which will eventually sink the system?

There is a growing chorus of calls for enlarging the size and number of the health schools of the nation. For three reasons we should give these calls special attention. First, the size of the US population will grow by over 40% by 2050, and during that time it will diversify to such an extent that many areas will be non-majority. Second, and more immediate, as the current population ages it will likely demand more care services which will put more pressure on a system that's already overtaxed. Finally, this aging population contains many health professionals of the Baby Boom generation who will soon begin to leave or slow down their practice, which will change the way care has traditionally been provided.

The rising cost of health care has become the elephant in the room in which all health care discussions take place. While the health care establishment worries about the quality and safety of care, the numbers of professionals to provide service, the availability of faculty, dwindling research dollars, and compensation for professionals, those who consume and purchase care struggle to figure out how to pay for the costly system that we have built. Health care in the U.S. constitutes sixteen percent of the Gross Domestic Product, which is three times what we spend on education. It is more expensive than health care in any other nation; twice as much as some nations whose citizens somehow live just as long as us. Health care is also growing two to three times faster than the rest of the economy. Traditional purchasers of health benefits, mainly businesses, are reacting by shirking the responsibility in order to remain competitive in an increasingly global market, one in which competitors pay a fraction of our health care costs.

Now that Hurricane Katrina has conducted the national emergency preparedness test and found us wanting, it is time to think differently about some of the ways we prepare for national emergencies. One of the most heartening dimensions of this tragedy for me has been the stories from health professional colleagues regarding their own actions to assist with first response, secondary care, and resettlement. No one was charged with organizing this response. As professionals with skills saw the tragedy develop, they made personal sacrifices to be where they were needed most and the response unfolded. I hope someone studies the value of this impact; if they do, I think they will find it vital to saving lives and essential to returning daily life back to something close to normal.

Economists abhor transaction costs associated with carrying or producing a unit of something valuable that involves more than one firm. There are the costs of the contract negotiation, work rules, monitoring of the contract, transporting material, ensuring system integration, and making sure that the process of production runs smoothly. Much of the productivity gains of the past two decades have come from using information technology to remove layers of unneeded management, making information more transparent and speeding transactions along the process of making a product or service valuable. A major challenge facing health care is that it is beset with enormous transaction costs that lead to higher costs and also to poor performance in quality and patient safety.

Across all of the health professions we face a daunting challenge: how can we change the dominant practice model to become more adaptive to the access, quality, and price demands of, patients, payers and the public, while simultaneously operating the old model at full speed in order to make ends meet? The lack of regulatory and financial incentives does not encourage the needed change. If that were not enough, there are few clinicians who are skilled in such transformations and the experience base gets thinner the smaller the organization or practice is.