• The providers of health care prize their own autonomy and reimbursement rates more highly than the need to consistently deliver high-quality care to a wide range of populations and individuals. They seem blind to the case for re-engineering the system and reluctant to collaborate in a search for common ground.
• The payers of health care are captive to an ever-urgent business model that encourages both purchasers and providers of care to be more cost-conscious than caring. Lost along the way are better patient outcomes, improved community health and the trust of the public.
• The consumers of health care do not distinguish between the quantity and the quality of their own care. More is always better, so long as the co-pay is no more than 20 percent.

Closer to home is where the quality context becomes most real for patients and their families—when they go to the doctor, the hospital, the pharmacy. Here, the system is most puzzling, most disturbing and most harmful to the most people. Why? Because this is where our quality deficit is on full display and often obscures much of the actual good performed by the system and the people working in it. I’m sure each of our own families has experienced symptoms of this quality deficit.

For example, we provide too much care that is not necessary: 30 percent of kids with ear infections are given excessive antibiotics;(7) 20 to 50 percent of surgeries are not needed;(8) 50 percent of X-rays for back pain are unnecessary.(9) Or we provide too little of the care that is necessary: 45 percent of patients do not get the recommended care;(10) 40 percent who need care for chronic illnesses like diabetes or hypertension don’t get it; 50 percent of the elderly fail to receive the pneumococcal vaccine; 50 percent of heart attack victims fail to receive beta-blockers.(11)