Trimming Medicare costs is devilishly difficult, a frustration Congress demonstrated anew Monday when it voted to delay, for one month, deep cuts in what the program pays doctors. The so-called doc fix was necessary to avoid a 23 percent cut in physician reimbursement rates that was scheduled to take effect today.

It's just not realistic to expect doctors to absorb that kind of revenue loss. More than a few might decide it's no longer worth it to treat Medicare patients, forcing seniors to scramble in search of new doctors. Nobody wants that kind of disruption, especially members of Congress, who risk angering elderly voters at their own peril. But a permanent fix is still necessary, and that will be much more difficult.

The cuts dictated by the Balanced Budget Act of 1997 were wishful thinking. That's why every Congress has headed them off since 2003, when the formula for cuts began to bite. But controlling Medicare spending is key for any deficit reduction plan. So what's the lesson of the 1997 failure?

The only way to significantly control government health care spending is to slow the rising cost of health care generally. That won't be easy, particularly if the belief that more care is better care persists, and demagogues continue to put the "rationing" label on any change in how care is paid for or delivered.

The 1997 law attempted to limit spending for physician services without limiting the growth in the volume and complexity of those services. It did nothing to modify the fee-for-service system, which rewards doctors for doing more procedures. And it did nothing to determine which among alternative, effective procedures is the most cost effective.

That's especially important with terminally ill patients near the end of life. For some, rather than prolonging life, fewer procedures focused on improving quality of life - for instance relieving pain and ensuring a dying person can talk lucidly with loved ones - may be better care, and cost less.

The 1997 cuts were an attempt to pay less while getting more. That approach didn't work.

It just isn't enough to arbitrarily limit how much doctors are reimbursed for each procedure they perform. That's a prescription for indiscriminately squeezing doctors whether they provide necessary, cost-effective procedures or inadvisable, costly ones. Cost-control measures in the recent health reform law that simply rely on restraining reimbursement rates will bump up against the same obstacles. More promising are those that will help move toward a system that pays for the quality of care rather than the quantity of care.

Accessible, quality medical care is so critical to our well-being that the inclination is to resist any changes in the system we've come to know. When the objective of change is saving money, the antennae really start to quiver - a reasonable concern often exploited for political advantage. But there's no stress-free cure for the soaring cost of medical care. hN