After many failed attempts to control health-care costs, Tony Miller says, it's time to rethink health care by putting more emphasis on health and less on care.

"We need a paradigm shift," said Mr. Miller, chief executive officer of Carol, a Minneapolis-based health-care consulting company, in a presentation yesterday to the Pittsburgh Business Group on Health.

He said it starts by seeing ourselves as consumers of health care, in control of what our dollars purchase, and not patients who passively accept what is offered by a hospital or an employer's health plan.

But it also involves transforming a reimbursement system that rewards those who do the most procedures -- with even greater rewards for the most complicated procedures -- while offering little support for prevention efforts.

"We do not spend enough on the health consumption system. And we spend way too much on the illness burden treatment system," Mr. Miller said.

He cited two examples: When Duke University developed a laparoscopic procedure for heart surgery, using small incisions that allowed patients to go home in three days, its revenue suffered. That's because reimbursements are much higher with the traditional approach of cracking the patient's sternum to get at the heart, which can entail a seven- to 14-week recovery period, Mr. Miller said. "Which would you rather have?"

And the spine clinic at Virginia Mason Medical Center in Seattle took a similar revenue hit after it found that an approach of "watchful waiting," perhaps including some physical therapy, could be as effective as launching into a regime of MRIs and surgery.

Although watchful waiting avoided thousands of dollars in care, "they got to recapture none of that value," Mr. Miller said.

An open-marketplace approach might steer a diabetic into a program in which, instead of talking to a nurse on the phone after developing a serious complication, he or she might have a nutrition expert tag along on a grocery trip to help control the condition through diet.

As it is now, payment is based on a formula of "the sicker someone is, the more you get paid," said Mr. Miller.

Changing that will carry consequences for those profiting under the current system, he acknowledged. "Yes, it does mean some hospitals will fail. And, yes, it does mean some people won't have their jobs because they weren't doing their jobs that effectively in the first place."

But changing the system could take a while, he acknowledged, even with a new administration that was elected to office on that campaign promise.

"There is no catalytic event that's going to do it," he said. "Change only happens at the margins."