I am a patient. Yes, and a physician; a brother, father, husband, grandfather, uncle, friend, neighbor, taxpayer and concerned citizen. What healthcare reform means to you means the same to me, or more. Maybe because as a physician I focus on it a little more than the average person, I have an additional responsibility to share my perspectives? Maybe a little knowledge is a dangerous thing, as the saying goes.

I am surrounded by very bright people every day: doctors, businesspeople, administrators. All have good hearts; all want to do the right thing for patients, but all can’t be correct.

The struggle today is how do we provide healthcare to all in a value-focused manner? It is easy to agree that quality must be the primary driver. Physicians and healthcare institutions are accountable for this and oversight is written into the regulations. Got it; check.

What I wanted to opine on, need to opine on, is the third leg of the stool, which, if missing, will lead to failure. Yes, you guessed it—that would be me and you—the patient.

When my father came to this country from Mussolini’s Italy, he was fascinated that Americans were free to choose, even if they chose poorly. Not so in Italy of his time; if you were unfortunate enough to choose poorly in Italy of the 1930, you generally never got another chance—fini! He would famously joke that “In American you have the right to be stupid, and most people exercise that right!”

I agree, and so do you—admit it. What you did as a teenager you would never do when you were a young parent or later as a grandparent; see where I am going?

I rounded this weekend and easily 50% of the patients we saw made choices, poor ones, that impacted their lives as well as the healthcare system. Most were not focused on healthcare change (if you know what I mean). They had, let’s say, shorter-term goals.

So where am I going? My conflict is that as a physician I want us all to make the right choices. Yes, education, information access will help. But as a patient I want choice, the freedom to choose, even if I am incorrect. Why? Because that is the essence of this country, why my father came here.

The “quick fix” is getting the doctors and health institutions on board; that’s the easy part. Changing patient behavior will take generations. But we are told that change has to happen more quickly; political solution? Legislate behavior? It is starting. Legislation as to the size of sugared drinks recently floated as an idea in New York is surely the tip of the iceberg; there are many hungry bureaucrats that are sure they know what is best for you, for us. Is “free” healthcare the way to change patient behavior, to make us accountable for our own actions? History has clearly shown us the answer is a resounding no.

What will be done if we, patients, do not adhere to the regulations? There are already proposed fines if you choose to not be insured; it wouldn’t be a stretch to extend that penalty to behaviors deemed to be unhealthy.

So here we are. What do I believe? I believe that integrated care is the right thing to do—hospitals and doctors will work out the details. But when it comes to us, the patient, I am concerned. Only personal responsibility and accountability can save us from ourselves. This cannot be legislated; it is what we should have learned as children. Let commercial insurance products be priced based on patient risk, just like home, car and life insurance. Let’s get back to “insurance” protection against catastrophic care needs, not for Band-Aids and everyday needs.

Does your auto insurance pay for oil changes? Medicare could, to some extent, mimic this and yes, incrementally increase participation age commensurate to life expectance indexed to when the legislation was effected. Safety-net programs, State Children’s Health Insurance Program and Medicaid need to be seriously cleaned up and funded for those individuals who may not change behavior no matter what payment system is in place. And we need to be accountable in a society that rarely holds anyone accountable anymore.

Robert Provenzano is a nephrologist and Vice President of Medical Affairs, DaVita Inc. He blogs at the ACO Blog.