The places that spend far more on medical care and get worse results — south Texas, south Florida, New York City and its suburbs — don’t have those advantages. They tend to have more diverse populations and a more diverse set of medical needs. None of these places is ever likely to reduce its costs, or raise its life expectancy, to Utah’s levels.

But once you acknowledge all this, you are still left with some fairly striking facts. There is nothing inherently Mormon about waiting until the 39th week to deliver a baby. Nor is there something unique to Utah that allows doctors there to analyze their results and systematically try to improve them. There is no reason, really, that a hospital anywhere else cannot do the same. Maybe more hospitals will begin to do so on their own, pushed by the same internal forces that remade medicine a century ago. But maybe not. The economic incentives in health care are still pointing in the other direction. As long as doctors and hospitals are paid for each extra test and treatment, they will err on the side of more care and not always better care. No doctor or no single hospital can change that. It requires action by the government.

One big remaining uncertainty about health reform — assuming some version of it passes — is how much it will do on this front. Earlier this year, James and doctors from Dartmouth, the Mayo Clinic and the Geisinger Health System in Pennsylvania traveled to Washington to talk about health reform with a small group of Obama administration officials. It was part of a continuing effort by the evidence-based crowd to influence reform in Congress. At one point during the meeting, the doctors began to talk about a potential pilot program that would make it easier for hospitals to improve care and hold down costs. Ezekiel Emanuel, an oncologist and budget-office official (and brother of Rahm, the White House chief of staff) who has spent much of the past year trying to get such programs included in the bill, asked how much this one would cost to set up. The doctors estimated $250 million over five years. The White House officials laughed. It was a much smaller sum than they usually discussed.

Several pilot programs with similar aims have made it into some of the health-reform bills considered by Congress. One is a bundling program, in which Medicare would pay hospitals a set fee for certain operations or chronic illnesses, rather than paying piecemeal for every aspect of the treatment. Hospitals would then have an incentive to avoid complications and readmissions, because they would no longer be automatically reimbursed for them. The hospitals that did the best job of keeping their patients healthy would end up helping their bottom lines. The details are still being fleshed out, but Medicare or private hospital groups would most likely monitor outcomes to make sure the incentives didn’t lead hospitals to skimp on care or turn away the sickest patients.

These pilot programs have been largely overlooked in the public discussion of health reform, because they start small. At first, they would be voluntary. Places like Intermountain would presumably sign up for them, and high-cost hospitals would not. But the Obama administration is hoping to make the pilot programs national — and mandatory — if they are successful. In that case, the program would suddenly not be so small. It would begin to attack medicine’s most upside-down incentives.

Other such ideas also have a chance to be a part of health reform. One is the so-called Cadillac tax on the most expensive health-insurance plans. It would put pressure on insurers to hold down costs, which would increase their incentive to steer patients to hospitals like Intermountain. Another idea would aim to make the market for health care more like the market for new cars. Pushed by Senator Ron Wyden, the Oregon Democrat, the proposal would encourage employers to let their workers choose from a much wider range of insurance plans, which would allow people to shop around for those that provided good, cost-effective care.

James and his allies have no illusion that any of these ideas is a silver bullet. But given the scale of Medicare’s long-term budget shortfall, the only sensible strategy is to try anything that seems promising. At the top of that list is moving medicine away from the fee-for-service system and toward something like a fee-for-health system. As dispiriting as the health care debate has been at times, Congress still has a chance to pass a bill that would begin to make life easier on the hospitals trying to do the right thing and, eventually, nudge many more hospitals into that category. That would be no small thing.