In the quest to contain escalating health-care costs, we've tried cost controls, set payments for hospitals and physicians, used managed care and pay for performance. But U.S. health-care costs are still the highest in the world, while we sit near the bottom on key health indicators.

But health-care reform bumps into three formidable quality barriers: overuse, misuse and underuse, according to Dr. Mark R. Chassin, chairman of the Department of Health Policy at Mount Sinai School of Medicine, who in January will lead The Joint Commission, which monitors health-facility quality.

Overuse is the barrier that could make the biggest difference, but it's also the one that has received the least effort to overcome it, he said during Intermountain Healthcare's Healthy Dialogues discussion Wednesday morning in Salt Lake City. Chassin believes overuse drives up costs more than the other two, but would be the least costly to fix.

Health-reform efforts have "simple goals," including access to care for everyone, affordability and high quality, Chassin said. But discussion gets bogged down in the "everybody" part and debates on coverage as a right or a privilege "are not very helpful."

He prefers an education analogy. Just as an educated work force is good for the economy and the country, so is a healthy work force. Poor health interferes with education, productivity and social interaction, he said.

We spend a higher portion of our money, nationally, on health care, but are "among the bottom on almost all the key health indicators," he said, including infant and maternal mortality. The single area where we don't lag is life expectancy once you've reached 65. And that, he said, is likely due to universal coverage for the elderly in the form of Medicare.

More attention has been paid to underuse of services and misuse than to overuse, but it is probably the biggest problem, Chassin told about 150 corporate, government and health-care leaders. Most patient-safety efforts have focused on misuse. And public reporting of problems has quantified misuse and underuse, but not overuse.

An example of overuse is prescribing antibiotics for a cold, which won't help and could do harm, simply because patients expect something. Areas with documented overuse of resources include tranquilizers, sedatives, coronary angiography, hysterectomy, carotid endarterectomy, heart pacemakers, upper GI endoscopy, CT and MRI scans for back pain and drainage tubes for a child's ears. Overuse is expensive and harms patients by exposing them to unnecessary risks.

It's also not, as sometimes has been stated, related to geographic variation, he said.

Underuse and overuse take place in the same communities for identical services. Meanwhile, much attention is focused on medical errors, which account for a tiny percentage of the adverse outcomes to care, he said.