Robert Pear of the New York Times does a good job foreshadowing one of the major controversies in health care reform: establishment of a public Medicare-like plan to compete with private insurers in covering the uninsured. He suggests it will be a major topic at today's confirmation hearing for former Sen. Tom Daschle, slated to be the new Health and Human Services chief.

Best quote in the story comes from Pete Stark, the California Democrat who has been a thorn in the side of insurers and providers from his perch on the Ways and Means committee for over two decades. Commenting on a Medicare Payments Advisory Commission report that suggested Medicare pays physicians 19 percent less than private plans, thus forcing those private plans to pick up the tab, Stark said:

Medicare is paying the right amounts. To suggest that a heart surgeon has to make $600,000 or $700,000 a year, as opposed to only $400,000 under Medicare fees, does not get much sympathy from me.

Coincidentally, the New England Journal of Medicine this morning has a perspective article on physician payment issues by Harvard medical school professors Pamela Hartzband and Jerome Groopman (yes the New Yorker and book writer). They wind around the many ways that fee-for-service medicine -- which they define as applying a dollar value to every element of a physician's time, the relative value units -- undermines quality in health care.

They offer an interesting discussion of how money-driven behavior undermines collegiality and consultation, which are the hallmarks of successful medical practices. Yet their discussion about possible solutions is sadly limited.

One answer may lie in an experimental new paradigm in primary care termed the "patient-centered medical home." The term itself suggests an emphasis on the social exchange that exists in a family rather than the market exchange of a business. The medical home is envisioned as a "compassionate partnership" of primary care providers and patients, with coordinated care for patients' ongoing problems and increased attention to preventive measures. The insurer would pay a set fee for each patient cared for in the medical home to cover what is now nonreimbursed time. Substantial cost savings are expected to result from coordination of care.

Why not use their discussion as an opening wedge into the elephant in the room of the medical home discussion: the best medical practices in the U.S. -- the Mayo Clinic, Kaiser Permanente, Group Health in Seattle -- utilize salaried physicians who don't get paid piecework-style and therefore do not have financial incentives that detract from care coordination or lead physicians to prescribe unnecessary or low-quality care. Patients in these systems don't need a "medical home" physician because they already are home when they walk in the door.

Of course, most physicians in these group practices earn less than comparable colleagues in individual or small group private practices. If readers can point me to statistics on this point, I will gladly publish them.