Americans spend more than any other nation on Earth for health care, but cost and quality don't necessarily go together. The health care system is ripe for a makeover, according to keynoters at the American College of Chest Physicians Conference in the Salt Palace.

And that makeover is coming in the form of quality measures, "pay for performance" initiatives and "value-based" competition.

Currently, there's enormous variation in what a health consumer gets, said Dr. Mark Levine of the Center for Medicare and Medicaid Services. He said that some of the most expensive care is of the poorest quality. There is no logic to the current relationship between cost and quality. And patients have a 50/50 chance that they will receive evidenced-based care, he said. That's care that follows a best-practice protocol for certain conditions, such as use and timing of antibiotics with certain infections.

The CMS is a key player in careful remodeling of the health system because Medicare and Medicaid both serve large-and-growing populations that are heavy health-service consumers. "We are looking for strategies to make change," he said.

Like other speakers, Levine said change should be guided by Institute of Medicine tenets that call for safety, effectiveness, efficiency, timeliness and impartiality in how treatment that's patient-centered is provided.

Fixing the system's problems relies on transparency and a clear picture of what's actually happening. And as more pay-for-performance features are adopted, payment practices will shift to encourage good outcomes.

Right now, Levine said, if someone goes in for a gall bladder surgery and has a leg amputated instead, payors such as Medicare or insurance end up paying for the mistake, as well. But that's shifting as changes are introduced, including reduced payment for complications, such as hospital-acquired infections.

Confronted with the health system's problems, the easiest thing would be to do nothing, noted Dr. Rodger Winn of the National Quality Forum. But that's not an option, he said. However, it's clear "the devil's in the details" and high-quality measures must be developed.

Against the backdrop of a map showing costs for health services across the country, Dr. Bernard Rosof of the American Medical Association's Physician Consortium on Performance Improvement posed a perplexing question: "How can the best medical care in the world cost twice as much as the best medical care in the world?" Identical services in difference parts of the country carry wildly varied price tags. Utah, on the map, is one of the less-expensive areas.

While there are no clear national standards in either treatments or cost, Rosof strongly warned that considering cost without taking into account quality or appropriateness is misleading. Cost information shouldn't even be collected outside of that context, he said.