This article was originally published as a "Delaware Voice" article in the News Journal on October 13, 2014. Delaware and the Christiana Care Health Systems feted Dr. Donald Berwick, former head of Medicare and Medicaid Services and a major author of the Affordable Care Act, last year and his "Triple Aim" of increased access to health care, increased quality of outcomes, and lower cost. Delaware is facing a "Triple Threat" of poor access to care, mediocre outcomes and excessive costs of Medicaid. In response to the disparities between soaring health care spending and lagging health care outcomes in Delaware, the state Department of Health and Social Services has led a team effort to respond. The details of the results are found in Choose Health Delaware: Delawares State Health Care Innovation Plan, which is the result of the Health Care Commissions work touting the "Triple Goal," raising Delaware to the top of healthiest states, with the best outcomes with a 6 percent lowering of cost. All laudable goals. I have read the report carefully. Here are some problems. 1. There is no mention of tort reform or indemnification of participating professionals. Any reform plan that never even mentions tort reform has clearly been tainted by the trial lawyers from the start. No one will take the risk of "Best Practices" without that protection, so over testing will continue. 2. The revenue sharing part of the program is seductive but will not keep up with current yearly cost increases of Christiana Care Health Systems, whose fees and revenue code by code have increased over 800 percent in the past 20 years while code by code fee schedule to doctors has decreased by 70 percent. So to think that doctors will do more work at a higher quality in the expectation of profit sharing depends on the wishful thinking that the hospitals, the State Medicaid system and the Insurance industry will become more efficient. That is a very unlikely prospect. 3. There is no provision to encourage the least educated patients who are the most costly to use less expensive care. All of the decades-long Oregon experience says the opposite. The poor use more emergency services in this scenario. They do not use outpatient services. The data is incontrovertible. Increased access led to increased use of expensive ER services. Those habits do not change. They are culturally ingrained. 4. Delaware has significant social disease and there is no will in the state government to address the diseases like drug violence, poor education, and nutrition. Furthermore the platinum plan benefits of the unionized state employees are very costly and unsustainable with a dwindling state economy. The State Medicaid cost is now over 20 percent of the budget and the federal subsidy expires in 3 years. These are ignored completely in the report. 5. The oft repeated phrase "Stakeholders" does not include any first line practitioners. In stark contrast to the claim that the Commission was largely not politicians, it was, if you look at the list. These people are not practitioners. They are managers, sociologists, and politicians. The underlying principle throughout the document (rather like Berwicks Triple Aim) is that someone must control the doctors through employment and mandated work. The only question is who, the state, the hospital, or the insurance company will mandate that work? The rub here is that doctors actually work less hard when they are employed and care less about the outcome because the employer pays the malpractice premium. The doctors that continue to care about quality will not increase quantity, and they have the resources to retire or do other work. They will opt out. There is already a shortage, and a projected massive shortage of doctors. The Commission correctly predicts that shortage, especially of Primary Care physicians. Access to health care will be compromised. The good news is that rationed access to health care is a cost saver for the State, however harsh that reality. 6. Finally there is no discussion at all about increasing the responsibility of the patients to remain healthy or pay for their own care. Minus that, the disconnect between supply and demand will persist malignantly. The state and the sponsors of this report are to be applauded for moving forward on meaningful health care reform in Delaware. On balance, however, I think the consultants regurgitated some very stale ideas. Christopher Casscells, MD Center for Healthcare Policy