A decade or so ago it looked like most of the focus on health care reform was going to be on insurance. While insurance reform does continue to suck most of the air out of the room, there are many things happening to actually change the way health care is delivered in this country.

Financial pressures have played a big role in creating the impetus for delivery reform. Health care has become too expensive and politicians, policy wonks, hospital CEOs and everyday people are realizing that just reforming the way people buy health insurance is not enough.

Welcome to the world of care coordination. That is the catch all description for everything from disease management to system navigation. The need for moving in this direction has been apparent for years and, it seems that the push to reform insurance has forced everyone involved with any kind of reform, to figure out ways to restructure the health care system to save money.

Among the most critical of necessary changes is the move from a fee for service payment system to some sort of bundled payment system. Under a health care system dominated by fee for service it means that when a health care professional provides services or orders tests, that all of the entities providing those services make more money when more things are done.

If a system is to truly be a health "CARE" system then doing more should not result in greater income for service providers. There should be incentives to keep people healthy and to not to try to increase everyone's income by doing more tests and procedures.

In an ancient model of Chinese medicine practiced centuries ago, a doctor would be paid on a regular basis to keep patients healthy. They would pay the doctor a weekly or monthly fee as long as they stayed healthy, but once they became sick they would no longer pay. It was recognition of the role of a healer.

We need to move to a system that focuses more on disease prevention and health maintenance. Most enlightened health insurance models are looking to pay doctors and other health care professionals a lump sum of money on a regular basis. They would receive this money no matter what happens to their patients.

In the 1970s Medicare introduced the DRG (Diagnosis Related Group) payment structure. If a Medicare patient was hospitalized for repair of a fractured hip the hospital would receive a lump sum of money based on formulas adjusted for a number of factors. If the hospital spent less than they received for that patient they could keep the money. If it cost more to care for that patient they would eat the loss. That system forced hospitals to do a better, quicker job at repair and recovery.

DRGs marked the early days of the era of bundled payments in this country. Some policymakers believe that hospitals should be given a yearly negotiated budget and then have to live within that budget. It is called global budgeting. It places the burden on the hospitals to do a good job. Some believe it is too much of a broad brush stroke for a complex issue.

There are many other variations of bundled payments. Many models describe themselves as "patient-centered". But the money has to be delivered somewhere and that is where the concept of care coordination could come into the picture, tying insurance/payment to care.

Whoever provides insurance for a person, whether a government or private entity, could establish rules requiring a primary care doctor, or some other entity such as a care coordination center, to be responsible for the health of a person in collaboration with that person.

This kind of system would require that individuals work to take responsibility for their own health and penalties could be built in to force that issue to some degree. The coordination center, whether a doctor's office or an institution, would receive a lump sum of money every month for each patient.

Each coordination center could have the ability to negotiate with the insurers based on factors related to their particular patient population and their practice history. A system such as this would bring in an era of health care in which all players have a stake in the game and everyone wins when health is the goal.

Richard Davis is a registered nurse and long-time health care advocate. He writes from Guilford and welcomes comments at rbdav@comcast.net.