This is no news to THCB readers, but let me remind you. Chronic care is hard work. Disease management programs are only partially effective because — even if you get it right — it goes against the incentives of doctors and hospitals (to do more, more expensive procedures now) and health insurers (to get sick people off their rolls ASAP). In a long look at diabetes care, the NY Times comes up with the conclusion that In the Treatment of Diabetes, Success Often Does Not Pay.

It‘s a long article but well worth a skim for those of you wondering what’s wrong with our health care system. How can we fix it? With FFS medicine, such as Medicare and copied by most insurers, you just can’t. The only hope is an extension of Kaiser-like pre-payment, or a chronic care system mandated from the top. Pay-for-performance has some potential, but it will require structural change, particularly in terms of the types of doctors and health professionals we train and the resources we allocate to preventative rather than sick care. And of course a system that excludes the poor and the sick by making it impossible for them to get insurance is never going to get close to doing that.

And just to depress you further, one health plan that has a better record than most in promoting DM programs, Pacificare, has just canceled a demonstration project in heart failure for Medicare FFS beneficiaries because it somehow couldn’t get people involved—even thought it will mean sending money back to the Federal government!