Recently, The Tribune has featured several articles discussing economic methods to finance medical reform. Some favor public insurance (something like Medicare) and others private insurance. This debate is not fundamental to health care reform. We could make do with either one or both.

What is most important is the removal of the inefficiencies in the delivery of health care and the elimination of the profit motive that promotes unnecessary care. The goal should be "what is best for the patient" is best for the health care system. This means efficient, effective care is the best care. A cooordinated, team effort produces the best results at the lowest prices -- a win-win situation.

Atul Gawande reports ( New Yorker , June 1) that there is a tremendous variation in how health care is delivered. McAllen, Texas, is the most costly because it provides more "across-the-board overuse of medicine" than any other locality in the country.

Mayo Clinic in Rochester, Minn., with its high technology and high-quality care is toward the bottom at a cost at $6,688 per Medicare patient per year (2006). McAllen is $8,000 more than Rochester.

Why this difference? Inefficiency. The overuse of medical procedures on the one hand and private ownership of medical facilities on the other inflate the utilization of medical services. Salt Lake is near the bottom in Medicare costs and in the same league as Rochester.

In McAllen, the

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entrepreneurial spirit has devolved into so-called "profit centers" such as proprietary medical laboratories, imaging centers and hospitals that are partly owned by physicians who make a profit from referrals to them. The overusage of nursing home care from aggressive marketing is another factor in high costs.

The myth that the best care is the most care too often contaminates medical practice. Since all procedures carry some risk (there are 100,000 deaths related to surgery in this country every year), unnecessary procedures result in unnecessary risk. These adverse events are avoidable.

Each physician establishes his/her style of patient care based not only upon the science of medicine as he or she understands it, but also the values of the medical community in which he or she practices. If the local medical community is cost-conscious and oriented to efficiency like the Mayo Clinic, lower costs and lower risk are promoted.

The cardinal rule that "the patient's welfare always comes first" becomes the value that promotes good care.

Defensive medicine causes expensive medicine. I found in my radiology practice that a head CAT scan was too frequently ordered on head injury patients especially when lawsuit-conscious physicians were on duty. Just a head bump is not an indication for a head scan.

One need only watch television sports or the evening news to see the cause of defensive medicine. Trial lawyers and medical-legal reform aside, unnecessary medical care promotes lawsuits.

Some group practices in Utah are in many respects similar to the Mayo Clinic. As a patient at the University Medical Center and Intermountain Health Care systems, I was treated in one instance for a stroke due to atrial fibrillation and in another a diseased aortic valve. Quality care and good fortune probably extended my life 10 years -- I am 75 now. Sadly, Regence Blue Cross canceled my supplemental insurance to Medicare when I missed a premium payment. With universal health coverage the cancellation would not have occurred.

The threatened deal-breaking debate over payment methods is wrongheaded. The first priority should be to cut costs by eliminating unneeded care. This means elimination of the fat and inefficiency in the system. Rationing should not be part of reform.

Richard H. Keller is a Salt Lake City physician.