Big health-care promises are playing a big role in the presidential primaries, as usual. But talk, as the saying goes, is cheap, and health care, as we all know, is not.

As in past campaigns, the focus this year has been on expanding insurance coverage, with little discussion about how to pay for it and even less about how to reduce costs by improving the safety and quality of health care. These are paramount concerns in any meaningful health-care reform.

Polls suggest Americans want in health care what they want in fast food: convenience, efficiency, affordability and super-sized portions. They're not getting what they order.

A recent RAND Corp. study suggested that U.S. patients get only half of the care that has been proven effective for their conditions. Although U.S. health care is the world's most costly, it ranks last or next to last among Western nations when it comes to quality, access, equity, efficiency and outcomes, according to a 2007 Commonwealth Fund report. In other words, it is relatively expensive, unfair, wasteful and unsafe.

Nearly a decade since reports from the Institute of Medicine and the Centers for Disease Control and Prevention found that 180,000 U.S. patients die annually of health-care-acquired infections or medical errors, too little has been done to fix the system. There's been shockingly little political debate about these fatalities even though they equal in magnitude a weekly reprise of 9/11.

No one is immune -- not me, not you, not our families. Not the late Boston Globe reporter Betsy Lehman nor Hollywood star Dennis Quaid's infant twins -- three of the more high-profile victims of medication errors.

Credible estimates suggest 40 percent of our health-care spending is wasted. Treatment for complications from errors and avoidable infections accounts for some of the lost dollars. Other spending is simply useless, from duplicative or unnecessary tests and treatments, to the wasted time and motion of daily work in chaotic delivery systems. Misspent energy wears down health-care workers, draining them of the will and time to perfect patient care.

But what if every dollar spent bought care of proven value, delivered efficiently? We know it's possible.

With support from the Pittsburgh Regional Health Initiative, physicians in our region have proven time and again that much higher standards of quality and efficiency can be met. In small demonstrations, they've shown infections can not only be reduced, but eliminated; that people living with diabetes need not be blind nor have amputations; that lab tests can be conducted without misinterpretation or mishandling, saving lives and money by reducing the number of costly procedures delivered unnecessarily, or worse, too late. They've even shown that outpatient clinics can reduce waiting times and run smoothly with same-day or next-day scheduling. Imagine -- an appointment the day you call the doctor!

From these and other projects, the PRHI has identified five hallmarks of excellence:

• Well-organized care systems;

• Ambitious targets for eliminating errors, waste and obstacles to the best care;

• Team commitment to 100 percent compliance with proven clinical and safety practices;

• Frequent redesign of work procedures to quickly solve problems that arise;

• Support from leaders at every level to demand continuous improvement.

Too often, however, initiatives to improve health-care safety, quality and efficiency are like isolated, hothouse experiments. The results might be published, only to gather dust on a shelf. In other industries, such innovations would quickly spread and safety improvements would not be optional. Consumers would demand with their dollars higher quality at lower cost.

Why we demand less when we shop for health care than for a toaster is the riddle, though one plausible explanation is that as health-care consumers we have too little basis for comparison.

Americans are born shoppers. Arm them with enough information about price and quality and most seek out the best buy on a car, a computer or a TV.

As it celebrates its 10th anniversary, the PRHI hopes to help empower southwestern Pennsylvania consumers to demand similar value in health care. The U.S. Department of Health and Human Services is promoting "value-based" care by forming a network of Chartered Value Exchanges that will report on quality and cost differences among physician groups in 14 regions across the country. The PRHI recently was selected as one of the exchanges, all of which will receive data from Medicare to help consumers shop more wisely for what is arguably the most important service they buy.

Health insurers must start shopping, too. The things health plans reward, the questions they ask and the information they give corporate purchasers matter a lot. They must build an incentive system that encourages quality so that first-rate health-care providers make more money, not less, for delivering value.

Of course, providers also will be able to use the Medicare data to target improvements on their own.

We should not assume that health-care reform can come almost solely at the national level or that there is little we can do regionally to cut costs by eliminating waste, error and inefficiency.

We are hearing lots of ideas from the presidential aspirants this year. Maybe their promises will withstand the vagaries of the political process. Maybe they won't.

But whatever their future, let's do our part locally. Let's ask the right questions, choose providers carefully, reward quality-driven practices and participate in managing our own health care.

We can't promise that we'll get it all. But we can get better care at lower cost.