By Julie Appleby, USA TODAY

OXFORD, England — Insurers blame rising drug costs. Drug companies blame HMOs and hospitals. Doctors blame lawyers. And, it seems, everyone blames consumers.

The problem? Health care costs are continuing their rapid rise — averaging 13% this year and expected to be more than that next year.

"Everyone is a villain," says Drew Altman of the Kaiser Family Foundation, a research group. "Everyone is blaming everyone else because they're trying to shift the cross hairs onto someone else."

Patients and employers should not expect relief from rising costs anytime soon. The blame game is heating up because no one really has an answer on how to slow the increases.

"We should get used to the idea of double-digit health insurance increases for the next 10 years," says Uwe Reinhardt, an economist at Princeton. "I see no relief coming."

The first volley in the blame game came this spring, when an organization backed by health insurers released reports critical of the drug industry. Spending on prescription drugs, the studies said, grew more than 17% in a year — an increase of $22.5 billion — with much of the increase blamed on a relatively small number of expensive, often not very innovative drugs.

Not so fast, said the drug industry.

New medicines can save money by keeping people healthier, the drug industry said. Health insurers, it said, should be encouraging the use of more drugs. And the drugmakers issued this kicker: HMOs spend more money on administrative costs — such things as paperwork and CEO salaries — than on drugs.

And pity the poor consumers. Nearly all of the health care industry's players blame them for rising health care costs. Patients, they say, naturally want the best and latest treatments — but they also want others to pay for it.

There isn't one correct answer to the question, "Who's to blame?" Some say that's not even the right thing to ask.

"The real question is, "Is more spending bad? Or is more spending good?" asks Carmela Coyle, senior vice president for policy at the American Hospital Association. "Too often we look at health care simply as a cost. It can be an investment."

No matter what, expect to see more pressure on patients to use less health care — or less expensive health care. In the early 1990s, that restrictive role fell to HMOs, whose rules and conduct prompted a public backlash. This time, employers will require workers to pay more toward their health insurance in the hope that workers will end up as better consumers.

Blaming the consumer

Health insurance premiums rose an average of 11% last year and are expected to rise about 13% this year. Next year could be even worse, driven by rising hospital spending, an aging population, increasing drug costs, a labor shortage, pressure for profits and a host of other factors.

"The people to blame in the end, the ones ultimately responsible, are consumers," says senior economist Christopher Thornberg of UCLA's Anderson Forecast, a national survey of businesses. "People don't adequately take into account the true costs of the services they're consuming."

That's a refrain that's selling well among those looking for ways to slow rising health care costs.

Already, employers are asking workers to pay more. The Anderson survey of 460 companies around the nation found that more than 70% expect to make changes to their health benefits next year, including reducing the level of benefits and increasing the amount employees pay toward premiums and deductibles.

At Puget Sound Energy, a gas and electric utility in a Seattle suburb, medical costs have risen an average of 19% in the past year, says Dorothy Graham, vice president of human resources.

"There's really only a couple of options," Graham says. "You can absorb the increase, reduce the benefits or reduce the number of employees, none of which are popular."

Her company is working to educate employees about health care costs — and help them make wise choices. Employers in her area are also banding together to see if they can negotiate lower prices with insurers. Even so, workers will likely pay more toward their health benefits next year.

"No matter how you explain it, when you get your paycheck and it's less, it's hard to swallow," says Graham.

The self-employed and those who buy their own insurance are being hit the hardest. Their premium increases are often far above what large employers are seeing. Some brokers have also noted an increasing reluctance by insurers to offer individual policies: More applicants are turned down for coverage, sometimes for seemingly minor health problems.

Laurel Kaufer, 40, a self-employed mediator in Woodland Hills, Calif., says she's had four premium increases in the past 11 months for a policy that covers herself and her two children. She now pays $300 a month, plus a $1,500 deductible and 40% of doctor bills.

She resents comments from the industry that consumers are driving rising health care costs.

"That's absurd," says Kaufer. "Consumers who are using the industry exactly as it was intended can't be held responsible for driving up the costs because they're doing so. I have insurance so I can go to the doctor when I need to."

No relief from rising costs

Everything tried in the past decades — from wage and price controls under President Nixon to managed care — has ultimately failed to stem rising costs.

Some observers say those failures were because the nation never really went all the way with any one idea. Others say the numbers show the intractability of the problem: Health care costs will always go up, they argue, because of advances in medical treatments and an aging population.

"We've had no meaningful and sustained way to control health care costs," says Altman. And now, "There's no big new idea for controlling costs, so the result is a free-for-all. Working people will pay more, benefits will be cut back, and we're likely to see an increase in the ranks of the uninsured."

While there is unlikely to be a sweeping change in the health system, such as national health insurance, a number of smaller approaches to slowing health care costs are being tried.

Among the ideas: charging patients more if they use higher-priced hospitals, cutting administrative costs through better use of computer technology, getting patients with chronic diseases into special management programs, and doing away with one-size-fits-all health insurance payments in favor of paying insurers more to cover sicker employees. (Related story: Policymakers propose baby steps to curb costs)

Will health care costs eventually moderate? Experts are divided.

"I actually believe costs can go down, although most of my colleagues think I'm crazy," says Regina Herzlinger, a professor of business at Harvard who has written several books on the health care system.

To control costs, Herzlinger says, consumers need to participate more in health care spending decisions, something they can't do unless the system changes.

She says a combination of getting employees to spend more of their own money toward health care — and paying insurers more to cover the sick — could create a true market in health care and lower spending. But skeptics disagree, saying there isn't enough data for patients to truly shop around. And should they?

"When we get really sick, we're not facing choices about 'Is the treatment worth it?' It's hard for us to know whether any particular treatment will be worth it in many cases. We rely on doctors and to some extent health plans for those decisions," says Richard Kronick, professor of family and preventive medicine at the University of California at San Diego.

Some experts, including Herzlinger, say insurers don't have any incentive to offer special health care programs to the sick because they don't want to attract those patients. "Many insurers get paid the same (by the employer) whether the patient is a healthy person or a person with diabetes," says Herzlinger. "The average annual cost of treating a diabetic is $11,000, and for a healthy person it's virtually nothing."

"Risk-adjusting" for individual employees — paying more for the sick and less for the healthy — would encourage insurers to provide specialized care for those with diabetes or heart conditions — and thereby improve health and reduce hospitalizations, she says.

Others aren't so sure that would really reduce costs. They add that such an effort to base payments on who is sick and who is not could easily violate patient privacy.

Consumer advocates fear that information about who costs employers the most could also be used to discriminate in hiring or promotions.

Consumer-driven care

Nor are some skeptics convinced that a new type of health insurance policy — dubbed consumer-driven care — will work to control costs, either.

Such plans are being offered by an increasing number of employers, including Medtronic, Novartis and Humana. Generally, the employer gives each worker a set amount of money toward health care — say $1,500 a year — along with a high-deductible health plan, say one with annual deductibles of $2,000 or more. As long as the patient keeps expenses below $1,500, the plan doesn't cost her any additional money.

After that, the employee picks up the difference toward the deductible. After the deductible is met, the employer or insurer picks up the rest of the tab for the year. Any money left over is often rolled over to help cover the next year's health costs. Employers say they expect such plans will help control costs by lowering monthly premiums, shifting more costs to workers and getting employees to make better choices on how they spend their health dollars.

"Consumer-driven health plans will reduce the rate of increase of health care costs 2% to 4% over time. It won't eliminate costs," say Don Broecker, director of employee benefits at Charter Communications, a broadband company in St. Louis. Charter began offering such a plan this year, among several other options, after revamping its benefits plan in response to three years of rising costs.

But many also admit that it's too early to tell how much savings may occur from consumer-driven plans. Some critics say the amount of money that each worker has control over isn't enough to create a true market — or put a dent in health care spending.

For some services, patients may have the time to shop around for a lab test or an elective procedure, such as laser eye surgery, to try to find the lowest price. But for most, Kronick argues, they can't.

"If I have diabetes or coronary artery disease or some problem walking, I can't go to a physician and say, 'How much will it cost to get better?' The best I can find out, maybe, is how much the physician will charge for a visit, so I might be able to compare charges with different physicians," he says. "But the main thing is how many visits? How many tests? What kinds of tests? For all those tests, I can't effectively shop ahead of time."