The New York Times this morning carries the second story in three days cataloguing difficulties in reforming the U.S. health care system. Today's story reports on an experimental Medicare program that involved private firms running call centers staffed by nurses to encourage elderly patients with chronic disease to stick to their treatment regimens. Unless there is a dramatic change over the next few months, the programs will end up costing Medicare as much as they save, with the possibility that they will even cost more than they save.

What's the companies' solution? Like most private firms involved in managing health care, their solution is to cherry pick the patient population they'd like to serve. According to George B. Bennett, the chief executive of Health Dialog:

He wants Medicare to give the companies more flexibility to manage patients in ways they say have already been proven to work among the employees they cover in commercial plans. Such measures, he said, include giving the insurer a bigger role in selecting the patients, with an eye toward identifying the ones most likely to be helped.

Other experts quoted in the story suggested these call centers are inadequate to the task. They recommend adopting the "medical home" strategy, where primary care physicians are reimbursed directly so they can hire staff to follow-up with their patients and coordinate their care.

It also would help alleviate the primary care shortage, which was chronicled in Saturday's Times in a story that looked at Massachusetts and its experiment with universal coverage (that is still far from universal). Hundreds of thousands of newly insured persons are scrambling to find primary care physicians, with many having difficulty. Others report long waits to get their first visit to receive treatments for chronic conditions that have gone unaddressed due to lack of insurance.

One statement in that story struck me as quite off the mark. "Whether there is a national shortage of primary care providers is a matter of considerable debate," the story claimed. "Some researchers contend the United States has too many doctors, driving overutilization of the system."

That mischaracterizes the critique. The U.S. doesn't have too many doctors, it has too many specialists -- about 70 percent of the total. In Europe, the ratio is almost exactly reversed -- 70 percent primary care and 30 percent specialists.

Physician payment policy is at the heart of this mismatch. In the U.S., insurers, whether Medicare or the private sector, pays for each individual service provided. Physician pay scales, set by a committee of the American Medical Association, give the highest rewards to specialties like intervention cardiology, radiology and surgeons, and the lowest rewards to primary care docs. Put the two together and you get a powerful economic incentive for young doctors to enter specialty practice and eschew primary care.

A medical home plan that gave primary care docs extra pay for coordinating individual care for patients with chronic diseases (which account for about 70 percent of all health care costs) would begin to redress that imbalance. But, like companies running call centers, it probably wouldn't generate major savings for the system, at least not in the short run.

To squeeze out short-run savings to cover the uninsured, government programs need to develop a strategy to eliminate some of the wasteful use of drugs, procedures and tests that now permeate the system. There's a growing consensus to set up a comparative effectiveness agency in the U.S. to combat that waste. But even this long overdue reform can run off the tracks if it isn't done the right way, an issue I'll address later this week.