Thursday, August 19, 2010

A "Home Grown" Rocky Mountain High

Writing for Kaiser Health News, reporter Bill Scanlon recounts the remarkable success Grand Junction, Colorado has had in improving health outcomes and saving money. He writes that Grand Junction has adopted five key reforms:

"Health Partnerships. Grand Junction's doctors, hospital and the dominant insurer, Rocky Mountain Health Plan, work together on patient care, with many of the doctors on salary rather than being paid for each procedure they do.

Primary care. The Grand Junction health system highlights disease prevention and management of chronic conditions to reduce expensive hospital visits, an emphasis that is also a key component of the new health law.

Treatment protocols. The local physicians and health plan have agreed to guidelines in terms of treating common problems, such as diabetes and lower back pain, based on best practices.

Electronic medical records. Doctors and medical facilities in the area use a region-wide electronic medical records system. It also means a physician's peers can see what he is doing and evaluate his style of care.

Medical homes. Nearly all patients here have a personal doctor who oversees primary care. Such 'medical homes' are also being advocated in the health overhaul."

This isn't the first time that Grand Junction has been featured as a poster child for a better health care system. The Los Angeles Times published a fascinating five part series on Grand Junction, also authored by Scanlon.

Can Grand Junction's approach be replicated? On this, there is less agreement, although many health policy experts believe that the key elements described above can be successfully adapted elsewhere.

Congress clearly believes so. The new health reform law, the Affordable Care Act, provides for a substantial investment of federal dollars to promote accountable care organizations (similar in concept to Grand Junction's health partnership), pilot-testing of alternatives to fee-for-service, new models to train and compensate primary care physicians, adoption of evidence-based treatment guidelines, and rapid expansion of patient-centered medical homes. The federal government also plans to spend billions of dollars to encourage clinicians to adopt electronic health records.

But as the federal government should heed another lesson from Grand Junction: let the doctors and hospitals decide. Scanlon quotes Dr. Michael Pramenko, a primary care physician and leading advocate for Grand Junction's reforms, on the importance of letting communities do their own thing:

"Pramenko says the beauty of the co-op is that the community can make its own rules. That lowers the tension in the public vs. private health-care debate, he asserts. 'If government makes the law that says doctors have to do this, they will get resistant,' he says. 'But if it's home-grown and if we make the rules together and we're all in this together, there's much more buy-in by the local physicians.'"

So my unsolicited advice to CMS Administrator Berwick is this: yes, the federal government should provide seed money for physicians and hospitals to develop their programs to improve outcomes and reduce costs, modeled on the key elements that have worked in Grand Junction. But don't impose so many strings that it strangles home grown initiatives from taking root.

Today's question: What do you think is the "take home" messages from Grand Junction?


Steve Lucas said...

A couple of points:

First: Grand Junction is a small scale model. I doubt this can be ramped up even in a single large metropolitan area. Not everything is scalable. While the concept is good, and the outcomes may be good, you may not be able to translate this care model into a large population.

Second: Standards of care. I believe in EBM, but I also see its limitations. Just a few short years ago a belief that a BMI of 20 or less would prolong life. I had to ask a doctor to move away from the door so I could leave an exam room as he was demanding I agree to receive fen-phen for my weight problem. Looking down at my belt buckle, I did not see a weight problem.

Tapping a folder he stated that numbers do not lie, and since I did not have a BMI below 20, I had a weight problem.

We have seen the same with A1c, where tight controls using multiple meds produce diminishing returns and an up tick in side effects.

Everyone has their favorite situation where a goal becomes a standard, and patients are forced to meet a standard regardless of side effects or desire. In the case of Grand Junction a patient would not be able to find a new doctor since they are all connected to the same system. Privacy and personality conflicts are issues not addressed.

Lessons should be learned, but limitations recognized. Colorado has a very health conscious population and I do not see some of these ideas working well in Mississippi or Ohio, where you have an overweight population with a high smoking rate, and no desire to change.

Steve Lucas

Arvind said...

Agree with Steve. Local policy-making is great but protocols are bad. They simply promote "one-size-fits-all" policies. The idea of "best practices" sound good in speeches; what is best for some might be poor for others. The best practice is to decide what best serves an individual patient for a particular condition. Everybody involved should understand that medicine is like designing a custom-fitted suit for each patient. You may get to choose the material, if you like, but each fitting is unique for every individual. No matter how much you try, one size does not fit all.

Jay Larson MD said...

Serendipitously, the CEO of St. Mary's Hospital in Grand Junction Colorado from 1999-2009 was our former CEO of St. Peter's Hospital in Helena in the mid 90s. After reading this blog, I contacted him to catch up. As expected, the medical culture in Grand Junction Colorado is much different than Helena.

In Helena the hospital, medical community, and major insurance companies are all separate and each have different agendas. If the medical community became efficient with lower health care costs and better health outcomes, the hospital would suffer by having less diagnostic images and procedures ordered as well as less hospital days. St. Mary's in Grand Junction Colorado suffered from decreased hospitalization days, but still was able to survive.

Even though the model of an accountable care organization including hospital, insurance, and medical providers sounds good on paper, it would require a significant amount of work and several attitudes changed to pull it off.