No matter what happens in the national debate over health-care reform, our local medical folks plan to make health care better in our community.

Accordingly, area physicians are working with administrators and community board members from FirstHealth Moore Regional Hospital in a serious effort to improve medical care delivery and control its cost locally.

The Integrated Delivery System (IDS) that results from this effort will significantly affect the health of our community for years to come. Yet there is little awareness of these discussions outside the people involved.

Those participants are trying to understand how they can make medical care in our area more patient-centered, high-quality, cost-effective and team-oriented, with improved access for all of our neighbors. Achieving these outcomes will require improved clinical management of the patients, the hospital and physician practice.

Integration will require all elements of the care system to work together, focused only on the patient's needs. Unfortunately, driven by our current payment system and practice environment, there are at times institutional considerations embedded in and influencing clinical decision-making.

An Integrated Delivery System will require significant changes in how care is delivered. The cultural changes for all involved will be difficult. You can imagine how complicated these discussions are when you begin to discuss sharing revenue and dividing up the money in different ways.

Moving from individual units of care to focused preventive team care will require the development of new systems of care delivery. Improving the health of our community requires different approaches from individual medical crisis intervention.

This is an exciting and sometimes frightening prospect that will require a lot of learning on everyone's part. Individual patient/physician relationships must remain central to medical care. Physician leadership training will be an important, must-accomplish task for an integrated delivery system. Several physicians will be required to devote some of their clinical time to system leadership.

It is a particularly difficult time for these discussions when most physicians are doing well financially in their current practice modes. The threatened contraction of Medicare and Medicaid reimbursements, especially for hospitals, will make future financial management of the hospital more difficult. Our hospital, unlike many others in America, remains solvent because of good financial management.

The current state budget has a 3.4 percent decrease in Medicaid reimbursement for physicians. This will be very difficult for physician practices with a large Medicaid patient load. It will also result in increased pressure on the hospital's emergency room, where currently Medicaid does not pay what it costs to care for these patients.

No one knows what changes in federal Medicare payments will result from the national discussions currently under way on health-care reform. Almost no one believes reimbursements will keep up with the current rate of medical inflation that for years has run well ahead of general inflation. We must lower the cost by changing the way medicine is practiced in America. Simply reducing the rate of reimbursement for current practices is not sustainable.

One of the significant problems inherent in these discussions is the lack of reliable data on just what evidence-based medicine is when applied to an individual patient with that patient's unique set of incompletely understood genetic and environmental influences. That is to say, the art of medicine doesn't fit easily into protocol-driven care, sometimes referred to as "cookbook medicine." However, there is good evidence that some established clinical practices are greatly improved by having physicians follow well-researched protocols.

The reason for this column is to tell the community about the inspired work on their behalf by a group of dedicated physicians, hospital administrators and citizens that has been going on now for over a year.

The IDS steering committee is currently being ably led by Dr. John Ellis, a retired orthopedic surgeon. It is not clear what the results of these discussions will be for our community. Already they have resulted in an improved level of trust among the parties involved. That is a good thing for our community.

H. David Bruton, M.D., is a retired pediatrician who served as secretary of health and human services under the administration of Gov. James B. Hunt Jr. He is a founder of the Moore Free Care Clinic.