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(www.nejm.org) to mainstream media(www.newyorker.com), and from public policy think tanks(www.newamerica.net) to President Obama(www.whitehouse.gov) and other health care reform advocates.
Family physician Michael Pramenko, M.D., evaluates a patient in his Grand Junction office. According to Medicare data, the Colorado town had the sixth-lowest health care costs out of more than 300 U.S. cities evaluated in 2005 while ranking 31st in quality of care.
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(www.rmhp.org), known locally as "Rocky," and Mesa County Physicians Independent Practice Association, or MCPIPA(www.mcpipa.org). Both are nonprofit organizations, as are both local hospitals, two mental health centers, a hospice and a handful of other vital health care entities.
The Colorado AFP(www.coloradoafp.org) is helping its members take the first steps toward earning patient-centered medical home, or PCMH, recognition from the National Committee for Quality Assurance, or NCQA, by offering an all-day session April 14 in conjunction with its Annual Scientific Conference(www.coloradoafp.org) in Colorado Springs. That session, which covers the requirements for NCQA recognition, marks the beginning of a 10-week program, said Angel Perez, B.S.N., the Colorado AFP's PCMH resource adviser.
Practices follow up by participating in three one-hour webinars during a seven-week period. The practices also participate in conference calls with PCMH trainers a week after each webinar and peer-to-peer conference calls with participating practices two weeks after each webinar.
In addition, practices have the option of receiving weekly in-office coaching at no cost through HealthTeamWorks, a Lakewood, Colo.-based nonprofit organization that helps practices transform their procedures and culture.
The Colorado AFP and HealthTeamWorks are part of a collaborative -- the Systems of Care/Patient Centered Medical Home initiative -- that received a two-year grant from the Colorado Health Foundation in 2009. The collaborative is seeking an extension that would make additional training possible, said Perez.
The April 14 session kicks off the second PCMH training program funded by the grant. The first started with 20 practices, and 18 completed the program. Perez said the Colorado AFP likely will take 20 practices again this time. As of March 24, 10 practices had registered.
Perez said practices that complete the 10-week program should be prepared to submit an application for PCMH recognition to NCQA within six months.
"The transformation process takes about two years," she said. "We want to make sure they have tools and resources to start that transformation."
"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(www.htop.org), 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.
- Physicians are paid similar rates for both commercially insured and publicly insured patients, improving access to care.
- Incentive contracts reward physicians for quality performance.
- Individually identified performance data from each physician is shared with all physicians in the system for peer review, largely eliminating overutilization of services.
- Primary care physicians are paid to see their patients in the hospital, even if those patients are under the care of a subspecialist, resulting in improved follow-up care and reduced readmission rates.
"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."
Obesity affects one-fifth of U.S. children ages 6-11 years, according to the CDC(www.cdc.gov). The Colorado AFP and several partner organizations are planning a pilot program (www.coloradoafp.org)that will address this growing public health problem.
"There are not a lot of systems in place or tools for primary care physicians to treat childhood obesity," said Cara Coxe, the Colorado AFP's wellness programs manager. "Some physicians shy away from dealing with childhood obesity because it's an overwhelming issue. We're offering tools to diagnose and treat it."
Eighteen primary care practices, including 13 family medicine practices, will participate in the pilot, which begins with a training session on April 9. Coxe said practices then will recruit patients and their families for the Fit Family Challenge: Addressing Childhood Obesity in Colorado. Implementation of the pilot in practices is scheduled for the fall.
The project will evaluate the use of a clinical guide designed to help physicians diagnose and treat obesity in children ages 6-12 years. A later phase of the pilot will seek to link efforts of physicians, schools and community organizations.
In addition to developing a specific office intervention for addressing childhood obesity and developing protocols for diagnosis and treatment, the pilot aims to:
- develop a pediatric patient registry;
- increase body mass index assessment of pediatric patients;
- train physicians and staff members in motivational interviewing and behavior change techniques;
- develop a proven process to educate and motivate families and children to make healthier food, activity, and sleep choices;
- mobilize physicians to be proactive in their patients' and community's health education;
- create community-based interventions and access to obesity prevention and intervention opportunities through a myriad of community settings, as well as at home and in school; and
- create a replicable, scalable model based on research.
The pilot, which is being funded by the Colorado Health Foundation, also will provide patients and families with resources based on the "5210" approach, which stresses that children should eat at least five servings of fruits and vegetables each day, watch no more than two hours of television, get at least one hour of physical activity and drink zero sweetened beverages.
Coxe said the department of family medicine in the University of Colorado School of Medicine, Aurora, will evaluate what works and what doesn't and will disseminate that information to physicians statewide and, possibly, nationally after completing the nearly three-year study.
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:
- leadership by the primary care community;
- a payment system that involves risk-sharing by physicians;
- equalization of physician payment for the care of Medicare, Medicaid and privately insured patients;
- regionalization of services into an orderly system of primary, secondary and tertiary care;
- limits on the supply of expensive resources;
- payment of primary care physicians for hospital visits; and
- robust end-of-life care.
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.
FP Michael Pramenko, M.D., is one of more than 1,500 users of the Quality Health Network in western Colorado and eastern Utah. The online repository of patient data is a collaboration of the local physicians' association and Rocky Mountain Health Plans.
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.
Chapter executive: Raquel Alexander, M.A., C.A.E.
Number of chapter members: 1,899
Date chapter was chartered: 1948
Location of chapter headquarters: Aurora, Colo.
2011 annual meeting date/location: April 14-17/Cheyenne Mountain Resort, Colorado Springs
"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(www.stmarygj.com) 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."
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