Charles - An integrated fixed-fee system (what you call managed care) would be interesting to explore. The system could be incentivized to keep costs down since it is paying the bills from a fixed yearly "subscription" from each patient. It would also be incentivized to keep patients out of inpatient care because that's where the costs are.

The trick will be to keep quality and safety up - you would either need competition (unlikely up here), or service/safety standards that the state or feds mandate (and we all know Alaskans like gov't-mandated things). 

The gov't employee population (or education employees) would be a good proving ground for such an arrangement, but good luck getting them to go along with a perceived reduction in "choice."

It's not an easy problem, lobbyists or not. Some of the things you propose are needed, but they're no magic bullet, and I worry that you are making them appear so.