People can argue long and hard about the particulars of the Affordable Care Act — the results of such a debate at the highest echelon, the U.S. Supreme Court, are due this month — but there is broad agreement about one problem the law seeks to remedy.

The American health care system is driven at least partly by the fee-for-service model that dominates in the industry. It adds fuel to the rise in costs by incentivizing practitioners to order procedures and tests, all generating fees but some of them not necessary.

The countervailing force behind much of the health care reform effort is movement toward a system of payment based on the outcome — improved wellness — and not the input — tests and procedures. Health care is one of the few industries in which the buyers, who typically see themselves as patients rather than consumers, have such a weak voice.

The release last week of a national patient-safety survey grading hospitals is part of a welcome course correction, in Hawaii and elsewhere. More than half of the hospitals here were rated average or worse in the report issued by the nonprofit Leapfrog Group, underscoring how much room for improvement there is.

Some hospital executives have criticized the data as being out of date, and even some of the survey proponents acknowledge the limitations. Dr. Ashish Jha of the Harvard School of Public Health was among the national advisers to Leapfrog on its methodology; the grading system will improve over time as data collecting and reporting practices are refined.

Even so, Leapfrog’s mission statement describes its intent "to trigger giant leaps forward in the safety, quality and affordability of health care," and on balance it’s preferable to have such watchdog groups get qualitative information out there.

Another recent national study, a poll titled "Sick in America," was issued in May. The research team again involved the Harvard school, in partnership with the Robert Wood Johnson Foundation and NPR. Rather than grading individual institutions, the researchers surveyed about 1,500 adults nationwide, a third of whom had required a lot of medical care or had been hospitalized in the past year.

Of those surveyed, 57 percent were critical of the quality of their care; 35 percent described the shortcomings as "very serious," 22 percent as "somewhat serious."

Regardless of the fate of the federal health care reform law, Hawaii advocates have taken a reasonable, proactive stance aligned with some of its initiatives aimed at reducing waste and delivering care more effectively.

Beth Giesting had been chief executive officer of the Hawaii Primary Care Association until becoming the state’s health care transformation coordinator a year ago. Providers have been working to enable electronic medical record keeping in their practices to share information on a patient, Giesting said, reducing the likelihood of unnecessary or duplicate tests.

Kaiser Permanente Hawaii and Straub Clinic & Hospital were the two in the islands that earned an "A" in Leapfrog’s study. Some of their practices should be viewed as instructive. Kaiser has long used a delivery system akin to the "patient-centered medical home" model advanced in reform initiatives. And in October 2010, Straub’s parent organization, Hawaii Pacific Health, reached agreement with the Hawaii Medical Service Association to develop a payment system linked to patient outcomes and quality measures.

Leapfrog describes its purpose as "supporting informed health care decisions by those who use and pay for health care." The patient’s part is to sit up and take notice of the quality of care they receive, and become more discerning consumers.