Consistently disproportionate annual spending increases like health care’s own peculiar kind of crack: we know it can’t keep going on like this, but almost nobody wants to give up on getting more. Facing up to reality requires not just admitting there’s a problem, but also understanding its roots.

The good news, according to Don Berwick and Andrew Hackbarth, is that we just have to cut wasteful spending. The bad news: cutting it requires dramatically improved system integrity and behavior change. Their analysis shows the two largest of six waste categories have nothing to do with quality or quantity of care. “Administrative complexity” and “fraud and abuse” lead the parade with upwards of $661 billion of the high-end $1.3 trillion in estimated 2011 waste. They are followed closely by $226 billion worth of “overtreatment,” changes many would likely accede to given the appropriate education and understanding of what medicine can and can’t do.

Berwick and Hackbarth conclude that “[r]educing waste is by far the largest, most humane and smartest opportunity for evolving an affordable health care system.” The $1.3 trillion question is, can everyone involved – patients, providers, hospitals, insurers – shift paradigms and hold each other accountable to get it done?