As for who pays for care, Dirksen is in favor of a single-payer system.

"I'll say upfront: I don't know of any way to do it other than single payer, but that's my opinion. That's my method. That's not the outcome," he said. He wants to educate people about the difference between who pays and what the quality of the care is.

A regional or national single-payer system under one umbrella makes sense, he says. But he's aware that there are differences of opinion.

"It doesn't matter what Vic wants. What really matters is what we as a nation want. And I'm not sure. I'm not sure we have an agreement on that. I think one thing most people can agree on is that most people don't want people to go bankrupt as a result of healthcare costs. And I think most people but not everyone believes we ought to have accessible medical care."

And people are going bankrupt because of health care.

The American Journal of Medicine reports that in 2001, 62.1 percent of all bankruptcies were related to medical issues. That was up dramatically from 1981, when only 8 percent of families filed for bankruptcies in the "aftermath of a serious medical problem."

Again, Dirksen is concerned that the national discussion is being diverted from quality issues to that of who pays.

"I'm not sure everyone agrees on accessible health care," he said, questioning what that encompasses. Does it include preventive care, for example?

Dirksen, who says he sees health care as a right, says the problem now is that "we have a system that is not taking care of our citizens adequately and we have a system that is costing businesses and individuals more than it's costing in other countries."

Interestingly, Dirksen says there are systems in the United States that are working well to address quality and access issues.

So-called "closed systems," such as those offered by Group Health that offer insurance, providers and hospital services all in one package and focus on taking care of a patient by offering easy access to services, "are ahead of us."

"If you are a Group Health member, if you stay well, they benefit," Dirksen said of that system keeping costs down while also providing care.

"If you can have the access, if the care can be coordinated, if you can recruit and retain quality people in health care, that's what I want. We've been working with this free-market system for years and haven't gotten there. I look at other countries that get better scores than us," he said. Other industrialized countries with national healthcare systems fare better on patient satisfaction scores, not just the bottom-line issue of cost.

Full discussion

While he wishes Obama would seek a single-payer system like Medicare, Dirksen says Obama is taking the right tack by involving everyone in the discussion.

"The Clintons went into back rooms, and they came out with a product Congress didn't understand," Dirksen said.

Still, Dirksen is concerned that the focus has been more about "coverage for all" than it has been about reform.

And he also clearly worries about that nagging workforce issue.

In any future of health care, Dirksen says people should realize it will take more providers to fill in for retiring physicians.

"When you have a physician retire today, it takes close to two physicians to replace the one who retired because physicians are wanting more reasonable lifestyles than their predecessors have," he said.

Dirksen has seen three generations of physicians pass through the hospital doors.

The first generation of doctors couldn't understand the next generation of doctors who went home for dinner instead of heading for the hospital or homes to see patients.

Today's physicians want to have lives, too, not just see patient after patient nonstop and do paperwork that seems to be growing, even with laptops coming into use.

Leaning into change

It's not just physicians who are changing. Jefferson Healthcare also is changing.

And almost any conversation Dirksen has these days includes comments about Lean, a program that employs the so-called Toyota management method.

"The core idea is to maximize customer value while minimizing waste. Simply, Lean means creating more value for customers with less resources," according to lean.org.

"I wish we had gone to Lean when we first learned about it. We're only in Phase 1," Dirksen said.

About 40 percent of employees have gone through the Lean system in various departments, Dirksen estimates.

The system has worked so well that it's actually saved one department, the laundry service, which the hospital was at one point thinking of outsourcing.

Because of changes made in the department, many based on suggestions by employees, the hospital is now looking at replacing equipment and not laying off anyone.

Lean also was implemented in clinics, and because of changes made using the Lean model, the clinics were able to start taking new patients. Not long ago, they were turning patients away, Dirksen said.

It all gets back to delivery of care - a subject that might not be on the national radar, but one that Dirksen says he hopes will be soon.