Nov-Dec 2009 Table of Contents

OPINION

Creating a High-Quality, Low-Cost Health Care System: Lessons From Grand Junction, Colorado

Good things happen when physicians collaborate and have a health plan that supports their efforts.

Fam Pract Manag. 2009 Nov-Dec;16(6):7-8.

Since 1993, Family Practice Management has chronicled the progress of the Grand Junction, Colo., medical community, where physicians organized as an independent practice association in 1971 and spearheaded the creation of a local, non-profit health maintenance organization in 1972. This combination of an inclusive independent practice association (85 percent of local physicians belong) and a health plan that shares data with these physicians and listens to them has produced remarkable results in hospital and emergency room utilization, measurable quality and access to care.

The Dartmouth Atlas of Health Care study first revealed that Grand Junction's overall medical cost data was nearly the lowest in the nation,1 and more recently the local health community was prominently discussed in a New Yorker article2 that compared it with one of the more costly medical service areas in the nation. Subsequently, an accurate summary of Grand Junction's health care system was published by The New America Foundation,3 and the attention prompted President Obama to deliver a health care speech in Grand Junction in August.

Lessons learned

Here are some lessons from Grand Junction that might prove useful for other medical communities and health care policymakers:

  1. A non-profit health plan can clearly out-perform for-profit health plans in terms of cost of care.

  2. Providers who collaborate with one another can clearly out-perform those who compete with one another.

  3. High cost is not necessary to achieve high quality.

  4. Physician attitude is a more effective driver of behavior than financial incentives.

  5. Access to care is not a problem when Medicaid and Medicare payment is adequate.

  6. Physicians provided with financial data can make very good decisions about cost and value of services.

  7. Cost awareness carries over to all physician behavior, not just the lines of business or health plans where there is major financial risk or opportunity for financial gain.

  8. Ambulatory care peer review by physicians, coupled with the sharing of cost data of individual physicians, is an effective tool for cost containment.

These are not theoretical conclusions. The health care system in Grand Junction has served the community well for 37 years and continues to thrive.

We are frequently approached by physicians who want to know whether our system might work in their area. In discussing their options, we have found that certain issues impede efforts to develop a collaborative medical community.

  1. Few non-profit health plans are available with which a physician group can collaborate. Most for-profit plans are unable or unwilling to work with physicians and share meaningful and believable financial data.

  2. The Office of the Inspector General (OIG) and the Federal Trade Commission (FTC) are huge obstacles to any physician group attempting to be inclusive and collaborative. The current aggressive approach of the OIG needs to be modified. The FTC serves as the bulldog of for-profit health plans.

  3. The demoralizing effect on physicians of years in the for-profit, competitive health care environment has made collaboration exceedingly difficult. However, physicians are resilient, and most are altruistic.

  4. Most segments of the health care industry, including some physicians, are not solidly behind reduced spending (read: profit), given our current payment systems.

Grand Junction physicians are eager to see whether their adventures and misadventures can somehow be used to help the nation evolve toward a better health care system.

FURTHER READING

Grand Junction physicians have authored a number of articles for FPM over the years that reveal some of the strategies that underlie their community's success.

“New Drugs: How to Decide Which Ones to Prescribe.” Mohler PJ. June 2006:33–35. http://www.aafp.org/fpm/20060600/33newd.html

“Improving Chronic Illness Care: Lessons Learned in a Private Practice.” Mohler PJ, Mohler NB. November/December 2005:50–56. http://www.aafp.org/fpm/20051100/50impr.html

“1-800-Chronic Disease Management.” Shenkel R. November/December 2005:17. http://www.aafp.org/fpm/20051100/171800.html

“Weighing the Risks and Benefits of Clinical Interventions.” Mohler P. January 2004:53–56. http://www.aafp.org/fpm/20040100/53weig.html

“Creating a Successful After-Hours Clinic.” Quackenbush J, Shenkel R, Schatzel V. January 2004:39–42. http://www.aafp.org/fpm/20040100/39crea.html

“What Every Physician Should Know About Generic Drugs.” Mohler P, Nolan S. March 2002:45–46. http://www.aafp.org/fpm/20020300/45what.html

“Dancing With the Federal Trade Commission.” Shenkel R. July/August 1998:17. http://www.aafp.org/fpm/980700fm/edit.html

“Building Rapport With Consultants: A Matter of Economics.” Shenkel R. May 1996:36–40. http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pre-1998/199605consult.html%20

“Rural IPA Formation: Nothing Like What the City Slickers Do.” Shenkel R. October 1994:10–14. http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pre-1998/199410ruralipa.html

“Medicaid Miracle in Mesa County.” Shenkel R. February 1994:45–48. http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pre-1998/199402medicaid.html

“Rural Managed Care: A 20-Year Road to Success.” Shenkel R. October 1993:79–84. http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pre-1998/199310managed.html

About the Authors

Dr. Shenkel is a family physician who has practiced in Grand Junction since 1973. He served on the FPM Board of Editors for nearly 10 years. Dr. Reicks is a family physician in Grand Junction and the current president of the Mesa County Physicians Independent Practice Association. Author disclosure: nothing to disclose.

Send comments to fpmedit@aafp.org.

1. Fisher ES, Bynum J, Skinner J. A Dartmouth Atlas Project Brief Report: The Policy Implications of Variations in Medicare Spending Growth. Hanover, NH: Dartmouth Institute for Health Policy and Clinical Practice; 2009. http://www.dartmouthatlas.org. Accessed Sept. 22, 2009.

2. Gawande A. The cost conundrum. The New Yorker. June 1, 2009.http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawa-nde. Accessed Sept. 22, 2009.

3. Nichols LM, Weinberg M, Barnes J. Grand Junction, Colorado: A Health Community That Works. Washington, DC: New America Foundation; August 2009. http://www.newamerica.net/publications/policy/grand_junction_colorado. Accessed Sept. 22, 2009.

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