Want to fix the economy? Fix the health care system.

It's like answering a question with an equally difficult question, but Dr. Brent James, Intermountain Healthcare's chief quality officer, may have answers. James has made several trips to Washington, D.C., in the last few months to testify before different congressional committees about their system and why Intermountain is working.

The good news for Utahns is that health care in the state isn't as bad as throughout the nation. People have access to care, and doctors and hospitals are working to become more efficient, said Kimball Anderson, chief operating officer of MountainStar's Utah County network.

The bad news is Utahns still spend a large chunk of money on health care right along with the rest of the United States. And the coming answers may raise a lot more questions.

"When Barack Obama says that the key to the economy is health care, he is fundamentally correct," James said.

The real health care issue

Just how much additional time can good health care buy a person? On average, only a few years, according to a British study, James said.

"It turns out that at best, health care delivery accounts for 5 to 10 percent of how long and well you live," he said.

The rest is about 40 percent behavior, namely the use of tobacco, alcohol and other recreational drugs, obesity, sexually transmitted diseases, unwed teen pregnancy and violent or risky behaviors; 30 percent genetics; and 20 percent public health, including the level of sanitization and immunization as well as clean air and water.

Changing people's behavior actually will be more effective in improving health than focusing on health care, James said. Raising educational levels in a community will almost always result in better community health because people are more likely to practice healthy behaviors, not because people will spend more money on health care.

Today, in the United States, a lack of insurance coverage is not the biggest problem, he said. More than half of the uninsured people can afford health insurance or qualify for Medicaid. They simply have not signed up.

"Merely expanding insurance by itself does not necessarily mean that people will sign up for it," James said.

What needs to happen is for health care reformers to identify the right issues, including the roles of total health, high touch care (or the role of trust and advisement in health care), and rescue care. Rescue care in the United States is top notch, so the focus for rescue care could be more preventive, such as seat belt campaigns, he said. Total health care programs also need to focus on prevention and engaging in healthy behaviors. The problem is, diet, exercise and seat belts are less sexy than massive insurance reform and emergency care.

Insurance reform

"I think that in order for reform to work, we have to figure out a way to get universal access," Anderson said. "Everybody needs to have coverage."

Both James and Anderson agreed that health care products and services need to reach a wider group of people for the reforms to have any success. This, the insurance debate, is the political umbrella under which health care reform is falling.

Requiring coverage, and offering a government-sponsored plan, does relieve some of the pressure people feel about health insurance and get them using the plans and getting more health care. Anderson said changes in the industry are necessary, because businesses can no longer afford to offer health care.

However, both also said that insurance itself isn't really the problem.

"I don't know that the insurance situation is not working," Anderson said. "The biggest problem is that, as economic times have made it tougher for us because there's an increased number of uninsured people, that's a problem, but I don't know that's a fault of the insurance companies."

Part of the high insurance costs also relates to the disconnect between patients and the bills. Anderson said most Americans will accept the tests suggested by the doctor because they don't know how much an MRI or an X-ray costs. If they paid the bills, people might be more cautious in the tests they'd have, he said.

Simply having the money to pay insurance premiums also isn't always the problem, James said. He said the government's focus on making insurance available to all Americans is more ideological than practical.

"Just because we increase the proportion of people who have insurance, don't think it's going to have a big effect on total health," he said. "It won't."

Anderson said any system would need to be a compromise between government and private insurers, with both sides giving. He admitted he didn't know exactly what that compromise would look like, but that it needed to happen to appropriately offer insurance.

"I don't think the government can do it all, and it's proven the private sector can't do it all," he said.

President Barack Obama agreed in a forum held Wednesday at the White House.

"What we see is great examples of outstanding care, businesses that are working with their employees on prevention, but it's not spreading through the system. And unfortunately government, whether you like it or not, is already going to be involved," Obama said, according to the White House's Web site. "And so the key is for us to try to figure out how do we take that involvement not to completely replace what we have, but to build on what works and stop doing what doesn't work."

Payment reform

The current system does not pay doctors to heal patients, James said. It pays doctors to run tests and treat symptoms, which isn't always the same. There's a prevailing idea in health care that more tests, procedures and possible treatments is better.

"There's very strong evidence that a lot of that 'do more,' well, it generates huge income for certain individuals and companies, but it probably has very little benefit for the patients involved," he said.

So hospitals order more tests, insurance pays out more, and premiums go up. Doctors can skip tests or find other ways to diagnose more efficiently, and hospitals in Utah do that, he said. However, the hospitals then lose operating revenue for being more efficient, and rarely do patients see the kickback from that, he said. Usually, the insurance company is the party that comes out ahead.

"When we do these things we get screwed over financially really bad," James said.

This leads to waste, to the tune of more than $1 trillion annually. It also leads to less effective care. He cited a doctor at LDS Hospital in Salt Lake City who, in the 1980s, figured out a way to use antibiotics more effectively and reduce the percentage of infection in the hospital from almost 2 percent to 0.4 percent. That saved patients time in the hospital and additional complications. It cost the hospital about $35,000 per patient who didn't get treated for infections.

They want these results, James said. Every health care provider wants fewer infections, fewer accidents, less time spent in hospitals. In the current system, though, being innovative in health care just doesn't pay.

"What if you changed the payment system so that when we improve the care and save money, what if we got some of the income we generated back?" he said.

That way, instead of the insurance company making a ton of money on doctors' ingenuity, the health care providers would get some of it and patients would get some of it. SelectHealth, Intermountain's insurance option, pays rebates when money is saved, James said. More companies need to do that so everyone has financial incentives to practice healthy behaviors and appropriately use health care.

Anderson said they are always looking for ways to eliminate costs from the system, much of which is done through communication between doctors and the hospitals. He said he didn't completely agree with James's assessment that greater efficiency led to reduced revenues.

"Efficiency to me is a synonym of quality, and we're all after the best quality," he said.

Health care costs in the state of Utah already are among the lowest in the nation, and much of that he attributed to health care providers seeking out those inefficiencies and working to correct them, a practice that needs to continue.

What's going to happen

"It's just that they don't have a clue in this world about how to make it work," James said of the politicians, adding that wasn't unique to the United States. "You can't travel the world and find anybody who has figured this thing out."

Anderson is not in favor of a single-payer system. He doesn't think the United States will have a socialized system like European countries and Canada anytime soon, but he worries that a public plan will include rates similar to that of Medicare and Medicaid, which are lower than what private insurance companies pay.

"That might be problematic," he admitted. "But whatever the government chooses to do, we're all going to have to adapt."

He also discussed the pitfalls of a system like Canada's, which would not offer open-heart surgery or other major procedures to an 80-year-old patient or to a 24-week-old baby, for example, so that somebody else who is deemed more healthy or fit, based solely on age, could get that care.

"The system hinges on the rationing of health care," Anderson said, adding he doesn't want to decide who gets life-saving care and who doesn't. "I'm not sure the government should be in that position."

Obama's plan at this point is to set up a public option that collects premiums and reimburses doctors fairly, but because it is administered by the government, administrative costs are lower. This will provide good competition for private insurers and provide Americans with another choice.

"Now, you'll always hear folks say that the free market can do it better; government can't run anything," he said in Wednesday's forum. "And what I say is, well, if that's the case, nobody is going to choose the public option. So the private insurers, who I think are very confident that they're providing a good service and a good product to their customers, should feel confident that they can compete with just one other option."

James's idea of health care reform is to reward doctors and health care providers for coming up with efficient and effective ways to successfully treat patients. Doctors will have the incentives to be more creative in improving their systems, health care providers will encourage preventive techniques and greater all-around health, insurance companies will anticipate paying less and should charge lower premiums, and average Americans should see fewer dollars going to pay for health care.

"That's not the system we have today," James said. "I think that would do more than any other single thing to get it right. Here in Utah, we're going to do it anyway. The mistake is to believe that real health care reform will come out of Washington."

• Heidi Toth can be reached at htoth@heraldextra.com.