Especially from a Minnesota perspective, it's been one of the most frustrating disconnects in the national health care reform debate. President Obama and other key policymakers consistently lavish praise on quality medical providers like Minnesota's Mayo Clinic, Wisconsin's Marshfield Clinic and Ohio's well-known Cleveland Clinic. Yet there's been a disappointing lack of leadership from the president and senior congressional lawmakers when it comes to proposing specific changes to reward these medical centers instead of punishing them.

At the heart of the problem: The fact that Medicare's antiquated fee-for-service reimbursement system pays for quantity vs. quality, encouraging a culture of inefficient profit among providers in some areas of the country. Why does the popular federally run senior health care insurance program spend about twice as much on average each year for enrollees in Miami as it does on many Minnesota patients?

It's known as the geographic disparities issue, and it's a controversial Gordian knot of a problem whose solution matters not just to medical providers and their employees, but to health care consumers as well. While Minnesota's congressional delegation has done admirable work pushing for improvements, tackling the payment/disparities issue in a meaningful way will require high-profile advocacy by Obama and key lawmakers like Sen. Max Baucus, D-Montana, and Sen. Charles Grassley, R-Iowa. That's a critical element to watch for as the second act of the 2009 health care reform debate gets underway.

Tonight, Obama is expected to detail his vision for health care reform in a nationally televised address to Congress. Next week, Baucus and Grassley's powerful Senate Finance Committee is expected to conclude negotiations on its much-anticipated health care bill. Overhauling Medicare's reimbursement system and eliminating unfair and costly payment practices must be at the foundation of any proposed reforms.

Medicare's costs, already about $440 billion a year, are on an unsustainable trajectory. Measures to reward innovative providers -- such as Park Nicollet, which keeps heart-failure patients healthier and out of the hospital -- are critical for improving care, eliminating waste and protecting taxpayers from having to pay more to support the program. Reforming Medicare's payment system would also push private insurers to reward value vs. volume.

Minnesota and the Midwest have more at stake than other regions. Providers here are some of the region's biggest employers, and implementing across-the-board Medicare cuts -- one proposed "reform" -- would unfairly affect regional providers with less waste to trim. Another proposal, creating a public program based on Medicare's low payment rates, would threaten Midwest providers' bottom lines. Many already lose money taking care of Medicare patients, passing some of the costs onto the privately insured. More patients paying at Medicare rates would only exacerbate the problem.

Health care reform is a complex undertaking, and payment overhaul and geographic disparities are two of the most complicated components. Recognizing this, some medical providers have called for a pilot project to ease the way forward. It would revamp payment for a limited number of Medicare's most common or expensive procedures. Lessons learned could then be extended to other medical conditions. It's a sensible first step -- one that the president and leading lawmakers should embrace in the days and weeks ahead.