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The most visible and controversial parts of Obamacare the insurance exchanges, Medicaid expansion, requirements that individuals obtain coverage are just pieces of the law and, in the long run, may not even be the most important pieces.

The way the nation pays for health care and the kind of health care the nation will pay for are undergoing a revolution, dictated by financial pressures, common sense and changes required by Obamacare (officially known as the Affordable Care Act).

If you change the payment system, the delivery system will follow, said Rich Umbdenstock, president of the American Hospital Association, who was in Albuquerque recently to address the New Mexico Hospital Association.

AHA board Chairman and Presbyterian Healthcare Services CEO Jim Hinton, who also addressed the NMHA, said there is a volume payment model of health care and a value payment model. Hospitals today, he said, are caught in the gap between the two approaches, still dealing with the one while trying to figure out how to implement the other.

The payment system that has dominated American health care for generations is a volume model. You pay doctors, hospitals and other providers of care for everything that they do. It doesnt take a doctorate in economics to grasp that if you pay a system for anything that it does, the system has an incentive to do as much as possible.

And it does. Hinton provides one of my favorite statistics: Almost half of all tests ordered by the system are either unnecessary or of dubious clinical value.

The value payment model, as you might guess, is designed to reward providers for doing smart things, delivering high-quality care at lower cost, and keeping patients healthier.

You may have heard the term alignment of interests in the context of health care. Insurance companies are finding that employers, who still help pay for most of the health insurance covering working-age people and their families, cant keep paying double-digit increases in premiums. Employees are finding it hard to afford their share of the coverage. But if the payment system keeps giving providers incentives to do more, regardless of the value, the providers interests do not align with those of workers, employers and insurers.

The challenge is to get everyone beating the value drum while still providing adequate and fair compensation to the people who deliver the care, because it is in no ones interest to drive health care providers out of business.

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Health care challenge: Value vs. volume