If you want to change the way people behave you need to change the incentives they face - nobody ever grew rice by reading Mao to the peasants.

If you want to change institutions you need to change the way people who actually have power behave - all of the accounting controls in the world will not change the commands coming from the CEO.

In our health care system right now doctors have the power and doctors face incentives that reward over treatment and punish the unmeasurable aspects of practice that actually improve health.

We pay doctors and hospitals for services, office visits, treatments administered, diagnosis related hospital stays and so on. If consultation and good advice are not accompanied by billable services we pay nothing. While we pay for services what we really want is care and support that will help us to maintain good health.

Is it a surprise that we get what we pay for and not what we want?

But, if we decide to pay for health, we will be hard pressed to find someone who is able to sell us that product. Most of us do not have an integrated medical provider in our area. There is the Mayo Clinic, Group Health in the Pacific Northwest and Kaiser Permanente in California and a few other states. Mostly we have to find a personal physician who can advise us and help us to navigate the maze of medical care and assemble a basket of medical services.

Which works pretty well if services are simple and no hospital stay is required. For most healthy people we could enable individuals to designate one particular doctor as their "health home" as in the Wyden-Bennet Healthy Americans Act and give that physician some annual payment for these services.

Once we get sick all bets are off. Our doctor may refer us to specialists and hospitals but does she control them? Do they work together or is the left hand unaware of what the right hand is doing? If the medicines prescribed by the cardiologist interact with the medicines prescribed by the neurologist leading to an emergency room visit whose reputation is damaged? Who pays for the mistake? Is it realistic to punish the primary care physician who referred the patient in the first place?

We cannot really pay for health care unless we can find some integrated provider groups that have the skills and size to provide health care in most cases.

If we want to cure our addiction to expensive services that may or may not produce health we need to change the way that we pay for medical care. Unfortunately, if we want to pay for health care rather than medical services, we will need to change the way doctors and hospitals are organized to deliver services. Some call these Accountable Care Organizations - Wonks Anonymous prefers to think of them as Doctors Cooperatives.