Community-focused Colorado Health Care System Touted as National Model

During the past few years, a highly integrated, community-focused health care system unique to Grand Junction, Colo., has been held up as a model to the rest of the country by sources ranging from medical journals to mainstream media, and from public policy think tanks to President Obama and other health care reform advocates.

According to Grand Junction family physician David West, M.D., who wrote about his hometown last year in the New England Journal of Medicine, or NEJM, such regionally run, regionally financed health care systems represent the sole pathway to achieving the twin goals of providing high-quality health care and holding down costs.

"We will never solve health problems comprehensively until we somehow escape profit centers and the current reimbursement system," he said.

With those goals in mind, a group of primary care physicians and subspecialists in Grand Junction got together nearly 40 years ago and started the independent benefits provider Rocky Mountain Health Plans, known locally as "Rocky," and Mesa County Physicians Independent Practice Association, or MCPIPA. Both are nonprofit organizations, as are both local hospitals, two mental health centers, a hospice and a handful of other vital health care entities.

"I can't stress enough the importance of a health plan that's community-oriented," said Grand Junction family physician Michael Pramenko, M.D. "I don't think this would have happened in Grand Junction without Rocky. Physicians made their own health plan and made it a nonprofit."

Specifically created to accept Medicare and Medicaid patients, as well as those who are privately insured, Rocky and MCPIPA work together to keep costs low. The organizations withhold 15 percent of physician fees in a risk pool. If health care costs are kept low, physicians receive the withheld funds at year's end.

The two organizations also are part of a consortium that subsidizes a health program for pregnant women and their infants, providing them access to insurance. The program actually lowers health care costs for the community by improving outcomes and reducing the need for intensive care services for newborns, Pramenko said.

And at the other end of the life spectrum, primary care physicians in the area encourage patients to have advance directives, thus decreasing costs by allowing patients to avoid unwanted procedures at the end of life.

The upshot of these and other cost-containment measures is that when Medicare ranked more than 300 cities for quality of health care in 2005, Grand Junction ranked 31st. At the same time, the town had the sixth-lowest costs.

Rocky, which is the largest private payer in the region, has several other distinctive features.

"It's another set of eyes looking in on a patient, and it's someone who knows that patient better than anyone at the hospital because of the long-term relationship you have as a primary care provider," said Pramenko, who added that the arrangement saves money, shortens hospital lengths-of-stay and improves outcomes.

Pramenko also noted that subspecialists in Mesa County don't balk at having primary care physicians checking in on patients.

"When a patient sees their primary care doctor," he said, "their experience is improved and they feel better taken care of. Most specialists appreciate the primary care physician's involvement."

Grand Junction -- a town of about 50,000 people -- has just two hospitals, and Pramenko acknowledged that making rounds might not be possible in a larger community.

"In a bigger city, my patients could be at three or four hospitals," he said. "Logistically, it would take all day, and you'd be better off with a hospitalist. It's easier in a small town. I wouldn't be doing this in a big city."

In their NEJM article, West and his co-author -- Thomas Bodenheimer, M.D., M.PH., co-director of the Center for Excellence in Primary Care at the University of California-San Francisco -- pointed out seven features of the city's health care system that could be replicated elsewhere:

West, who is vice president of medical affairs for Hospice and Palliative Care of Western Colorado, told AAFP News Now that effective hospice care might be one of the least difficult measures to duplicate in another setting.

Conversely, he added, the most difficult is changing the payment system.

Although Grand Junction's successful system has been around for decades, it hasn't been duplicated. Pramenko said the Health Maintenance Organization Act of 1973 led to the creation of new health plans, but, in time, many were sold to for-profit insurance companies or larger nonprofit insurers.

"That didn't happen with Rocky," he said. "It stayed focused on the community."

Pramenko hopes more nonprofit insurers will result from a provision of the Patient Protection and Affordable Care Act that calls for $6 billion in loans to start nonprofit, consumer-oriented, privately run, local insurance plans.

"The only reason it hasn't happened before is people haven't had the start-up money to cover the risk," said Pramenko, who is a member of an advisory board that is writing guidelines for HHS regarding the application process for such loans. "If you want to start your own health plan, the best opportunity in a lifetime is in Section 1322 (of the Affordable Care Act)."

Another obstacle to creating a Grand Junction-type system is the scrutiny the county's physicians had to withstand from the Federal Trade Commission, or FTC, in the 1990s. Eighty-five percent of Mesa County physicians belong to MCPIPA, and that caused antitrust concerns for federal regulators. Although the matter eventually was settled by a consent order and the organization was permitted to continue almost all of its operations, the prospect of violating antitrust regulations raises a significant barrier to collaborative health planning among community-focused organizations.

New regulations regarding accountable care organizations are expected by the end of summer. Pramenko said those regulations could be another force to help build better health care systems.

"You need to have collaborative effort," he said, "but people are wary of collaborating based on historical rulings of the FTC and the Department of Justice. It's going to be important to see that there are safe harbor provisions in the regulations, like if you stay community-oriented or share risk."

The collaborative spirit in Grand Junction is easy to see. After Rocky won a $21 million judgment against the state's Medicaid department in 2002 because of underpayments made to the plan during the 1990s, physicians were due $2.5 million in interest. Instead of divvying up that money, Rocky and MCPIPA agreed to invest in the Quality Health Network, a shared repository of patient data.

"Everybody agreed to do something with the money to continue the progress we've made," Pramenko said.

In addition to Grand Junction's health care model, Pramenko said the outdoor lifestyle of western Colorado -- complete with skiing, hiking and great scenery -- boosts physician retention. West said there are about 75 family physicians in Mesa County, including more than 50 who are graduates of the family medicine residency program at St. Mary's Hospital in Grand Junction.

Perhaps most importantly, as Grand Junction continues to garner attention for its health care system, medical students are beginning to take notice. Michelle Jimerson, M.D., a second-year family medicine resident at St. Mary's, told AAFP News Now about her experiences during the interviewing process for prospective residents in which she, like her peers in the residency, is involved.

"I received questions from several applicants during interviews about the 'Grand Junction model,'" said Jimerson. "For those interested in health care reform or public health, I think this model is a draw to the area. As new physicians, we are going to face a very different landscape of health care when we enter practice than even existed when we entered residency. Learning about these possibilities in a place with a progressive model like Grand Junction is a great way to help with this transition."