Over the years, he's developed some definite ideas about what makes a health-care system work — and what reform ought to look like.

The industry faces huge challenges in terms of reform, he says. "All of us demand health care. We demand the best. And we demand it right away." While reform is needed, he adds, "I think the challenge is how to use the health-care system differently to balance the costs and the services we get."

Polls show that most people want health-care reform, he says. But ask if anyone's willing to pay $100 more a year to get it and the answer is no, someone else should pay that.

He believes the best reform would include a basic benefit plan and both incentives and penalties, depending on how one uses the system. It would break health-care services into several categories, providing coverage of preventive care and "ongoing logical stuff," including for the acute and necessary. Coverage would be different for services that are beneficial but not critical. And the entire cost of "lifestyle and convenience" care would be borne by the individual, he says.

"People are looking for the bad guys" in health-care cost and reform. "In reality, we're the bad guys, every one of us." Still, Utahns are lucky because they live in what he calls the "sweet spot" of health care: the highest quality and lowest cost in the country.

Intermountain has reduced variation, spending considerable time and resources finding the best practices and making them standard across cases. Practicing evidence-based medicine, with proven outcomes, makes both financial and medical sense, he says. So there are protocols and the result is health care he calls safer and more effective.

Nelson's quick to point out that he is not the idea guy. "My role is an enabler." Once the "brilliant thinkers" have come up with something, he makes it happen and "maybe sets priorities, too." He spends most of his time in meetings.

The lowest point in his tenure, he says, came when the Legislature considered removing Intermountain's tax-exempt status and formed a task force to examine health-care delivery in Utah, amid allegations that Intermountain was a monopoly. That also turned out to be one of the high points, he adds, after an independent consultant concluded that Utah was lucky to have Intermountain.

"It turned out wonderfully. The consultants' report said we are clearly a benefit to the community."

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E-mail: lois@desnews.com