An op-ed piece, No Country for Old Men, filed today on The Health Care Blog by health industry consultant and futurist, Jeff Goldsmith, provides a brilliant review and excellent analysis of our past sins and possible future under health reform. Perhaps most telling is the frightening scenario he paints of doctors, especially primary care physicians, leaving the profession.

In a recent HealthBlog post that was also picked up by ABC News I provided some of my own thoughts on why "affordable" and "health insurance" shouldn't be used in the same sentence. It's really all about cost. Unless we figure out a way to substantially reduce the cost of just about everything related to healthcare (which like food is something that every one of us must consume) we are doomed to failure. But where to cut?

A lot of folks immediately point to greedy doctors. Yes, there areimage some of those, but if medical practice was so lucrative why a predicted shortage of physicians? A new MGMA survey of physician incomes ranged from a low of around $150,000 for primary care to $650,000 for neurosurgery. I don't know about you, but I want the doctor drilling into my head to be well paid. $650K doesn't seem like all that much for someone who trained for more than a dozen years and sacrificed all of his or her 20's and early 30's learning a trade. Likewise, $150K seems inadequate for people making life and death decisions after a minimum of 8 years of very expensive, post graduate education. Heck, they don’t even come close to qualifying as “needlessly wealthy” which has been defined by some people as those earning more than $250K per year.

I do know one thing. These days even the "needlessly wealthy" are having trouble saving for retirement, paying for college, and funding their future healthcare needs. To the idea of a public healthcare plan that would let me retire before I become eligible for Medicare and also be affordable, I’d say “sign me up”! The problem is, the math just doesn't figure without passing along much of the burden to someone else. And I just don't know who that someone else is going to be.

Our present health system doesn’t “scale” for lots of reasons; access and cost among them. Technology can help. If a unit of health service can be delivered by telephone, e-mail, web visit, home test, home monitoring, retail medical clinic, or visiting nurse as a less costly or more efficient alternative to traditional office or hospital services, we should encourage it. Organizations like Group Health, Kaiser, UPMC, Geisinger, and Mayo are already paving the way. The health industry is ripe for disruptive innovation. What’s needed are the appropriately aligned incentives that will move us in that direction.