Back in August when the teabaggers were raging and protesting at various town hall meetings around the country, the President stopped in Grand Junction, CO to have a town hall forum of his own - on health care. He picked Grand Junction for a reason - they have some of the lowest cost and highest quality of care in the country. Grand Junction is proof that lower cost ≠ fewer benefits & poorer care. Looking at the health care debate, it's clear that the White House has been pushing the Grand Junction model. The final bill will likely include several elements of the Grand Junction model - the goal being lowest cost and highest quality of care possible.
You can see Obama's speech here. (h/t to icebergslim's blog)
First, a bit of background:
NPR ran a short story about this back in August. I think it's the best summary of what Grand Junction is up to and it's under 5 minutes long. Listen here.
It seems like there are a few simple things going on in Grand Junction that aren't going on elsewhere. One of those things is communication, another is an effective use of technology, and another is a sense of community - that everyone in Grand Junction is entitled to health care even if they're uninsured.
This piece provides some of the details by looking at a case study of what the community in Grand Junction has accomplished.
The case study analyzes features of Grand Junction health care including::
Quality over quantity. Incentive contracts between physicians and the area's largest insurer help move providers away from fee-for-service, pay-for-volume reimbursement. High quality care is rewarded -- particularly if it's high quality and efficient.
A safety net that not only catches but embraces the needy. A clinic for the uninsured is located on the grounds of one of the major hospitals in the community. Eligible uninsured patients who show up in the ER get transferred over to the clinic for follow up or ongoing care, with care provided free or on a sliding scale. The clinic offers them a same-day, one-stop shopping for primary, preventive and behavioral health. If they need to see a specialist, the clinic can call on a network of volunteers. The coordinated safety net reduces the cost (and cost-shifting) of caring for the uninsured. Every patient receives quality care regardless of income or insurance status.
Transparent performance data, peer-to-peer feedback, and information sharing that encourages doctors to collaborate and communicate. Physicians learn how much each test, drug, specialist referral, and hospitalization cost the health plan. This transparency, coupled with quality measurement, raises physicians' cost-consciousness, and, along with the incentive contracts, channel physicians' competitiveness into efficiency rather than revenue maximization.
A strong primary care physician workforce that coordinates treatment. Team-based care is common, and the health IT enables disease management and care coordination among multiple physicians and facilities. Primary care doctors are encouraged (and compensated) for seeing their patients in a hospital, even if they are under the care of a specialist. That promotes good communication and smooths transitions and follow-up care from hospital back to the community.
Innovative community service organizations that play a key supporting role in filling the community's health care needs from birth to death. Make that even before birth: prenatal care is excellent and available to benefit the next generation of Grand Junction residents.
Rocky Mountain Health Plans is a non-profit managed care organization. They collaborate with the providers in Grand Junction to provide care. You can read more detail here (pdf), but here's how it works:
Rocky is one of the main vehicles of collaboration in the Grand Junction health care community. Responsible for at least part of the paycheck of nearly every physician in the area, Rocky can affect the financial incentives that help drive the quality of care across the entire community. Physicians are reimbursed based on the blended fee-for-service (FFS) payment structured for all patients regardless of insurance source. This means physicians have no incentive to cherry-pick private patients, or shun those from lower-paying public programs like Medicaid. Doctors are free to focus on the quality of care they provide to all their patients, and the bonus they can earn from doing so.
The negotiation and implementation of a new payment methodology in the Medicaid contract for this year (FY 2009-10) illustrates this value. Rocky, the IPA, and the state of Colorado used actuarially established guidelines to create incentives for physicians to attain quality metrics established by the state Medicaid program, such as emergency room (ER) utilization and hospital readmission rates. The lesson is important to the sustainability of public programs: doctors across the country refuse to see Medicaid patients, but physicians in Mesa County continue to accept patients supported by public funds.21 Such innovative models can serve as a roadmap for payment reform and accountability in all public and private insurance arrangements.
Rocky also encourages coordination through regular reviews of physician practice patterns across various quality of care dimensions (process and clinical outcomes). Rocky convenes these reviews to promote preventive care and best practices, but physicians representing each specialty conduct them. Key players share results and take action to improve errant practices. Rocky also hosts monthly reviews of hospitalized patients with physicians caring for them, and encourages primary care physicians to visit their acute care patients in the hospital—and compensates them for this time.
In other words, the insurance company works with the state and with medical providers to keep costs down by ensuring that they are providing the best quality care - care that is medically necessary. The best part of this is that the community benefits the most - but so do the providers because they can get a bonus for providing the most quality care at the lowest cost.
Because Grand Junction has had this system in place since the 1970s, the population of Grand Junction has gotten healthier over time - resulting in a decreased need for high cost care.
Even the hospital in Grand Junction works to remain cost effective:
Over the years, St. Mary’s expanded to meet—but not exceed—the needs of the residents of its region. The goal is to provide an appropriate amount of medical resources—not to expand to the maximum size that the economic resources of the community could support. Unlike hospitals that fight for ever-larger Certificate of Need licenses under the assumption that "a built bed is a filled bed," St. Mary’s is loath to grow for the sake of growth. Keeping the number of beds appropriate to the needs of the community prevents the unhealthy incentive to boost volume, thereby keeping health care costs down.25
Instead of focusing on profits, they're focusing on serving their community - and there's the Marillac Clinic, a community clinic that's located on the campus of St. Mary's - these two providers work hand in hand to provide quality care to the uninsured.
Reading this piece (see PDF linked above) demonstrates that when every participant in the health care system works together with some incentives, quality care at a low cost is achieveable - and the result is a healthier community and lower costs for health care in the long term.
Atul Gawande has been a popular guy to reference throughout the health care debate. I listened to an NPR story about his effort to get surgeons to use a checklist during surgery. Here's a link. The one thing that I kept thinking about as I listened to him talk was - "wow, I bet quality of care will improve and save these hospitals money and it will all happen because of a checklist!" This part in particular really struck me as surprising:
"We caught basic mistakes and some of that stupid stuff," Gawande reports. But the study returned some surprising results: "We also found that good teamwork required certain things that we missed very frequently."
Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.
"Making sure everybody knew each other's name produced what they called an activation phenomenon," Gawande explains. "The person, having gotten a chance to voice their name, let speak in the room — were much more likely to speak up later if they saw a problem."
I'll spare everyone the details, but I had surgery in November - and to hear this on NPR the other morning, my heart leapt into my throat at the thought that the people in the operating room may not have all known one another's names and that this could have lead to a serious problem if something had gone wrong - and my surgery was fairly routine, not likely to be a serious problem, but what about the 40 other people who had surgery that morning?
The fact is, something as simple as a mistake in surgery can end up costing everyone in the entire health care system. Getting more care when more care isn't necessarily medically necessary, doesn't mean the quality of care is better. My mom has a tendency to demand tests and antibiotics and equipment that may not be necessary - this kind of activity drives up costs for everyone (and no matter how many times I tell her she doesn't need antibiotics for the common cold, she just won't believe me - or the dozen doctors she's asked). How many people are out there that are doing what my mom does? How many mistakes end up costing everyone more money? And in the meantime, everyone pays the high cost for the uninsured. Communication seems to be the theme here.
John Hopkins, CEO of Rocky Mountain Health Plans, says communication is what makes care so affordable here. Doctors meet regularly with the HMO to talk about a variety of topics, including quality of care, pharmaceuticals, healthcare infrastructure and overall costs.
As a result, the HMO was ahead of the curve when it started using generic prescription drugs to keep costs down. The area also uses an electronic network to share patient information and is mindful of unnecessary tests and extended hospital visits.
"More care doesn’t necessarily result in better care," says Hopkins.
Link.
Looking at the Kaiser Family Foundation's side by side comparison of the House and Senate bills, and reading about the Grand Junction model, I'm seeing a lot of opportunity here for communities to follow the Grand Junction model. I've written previously about the various cost controls and innovation ideas in the Senate bill (link), one of which is the "Waivers for State Innovation" - an entire state could take the Grand Junction model and make it work. Now, it would probably work better on smaller levels, but we have several small states, or low population states where I can see this working very well.
The House bill seems to focus quite a bit on quality of care reporting and requirements. Medicare has a program, the Physician Quality Reporting Initiative (PQRI) that gives incentives to providers who report on the care they're providing for certain diagnoses. Medicare is able to collect this information and get an idea of what the standard is in the medical community - from there they will be able to identify providers who are far below or far above the standard and try to learn why that might be - and if those providers are unnecessarily providing a service that might not be necessary. This is basically what they're doing in Grand Junction when providers meet to compare notes - as discussed in the NPR clip above.
The health care reform bill isn't just the excise tax, or the exchange, or that stupid (mf) Nelson amendment, or the change to Medical Loss Ratio, or a ban on pre-existing conditions, or state innovations, or quality of care, or any of the other 1000 individual changes. It's the total package - it's all of those things. And there are definitely some BAD elements in there at the moment. I don't have a desire to see this devolve into yet another "excise tax" argument. There's enough negative out there. I'm wondering how many other "Grand Junction's" are out there? How many other surgeons have ideas as simple as a "checklist" that could end up cutting costs and improving quality of care? How many millions of people will end up benefiting from the exchange and the community health centers that will come out of this bill?
Somewhere in my ramblings above, I mentioned 3 things that Grand Junction seems to have working for it that we haven't had elsewhere on a big scale: communication, an effective use of technology, and a sense of community - that everyone in Grand Junction is entitled to health care even if they're uninsured. This health care bill we're going to pass is going to be far from perfect, but if it helps us nationalize those 3 things, I think we stand a chance at being on our way to higher quality and lower cost health care for all Americans.