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Atul Gawande’s latest piece on Palliative Careis fantastic, and I hope you have read his “McAllen, Texas piece” on the cost-conundrum in medicine. While the focus was on why there were such high costs of medical care in McAllen, one of the sites of sharp contrast provided was Grand Junction, Colorado where the quality of care was high but with low overall cost to Medicare.

So what is the secret to providing high quality and low cost? An article in this week’s NEJM looks into the success of Grand Junction more closely. The secret? Primary care and palliative care.

According to the Dartmouth Atlas of Health Care Medicare spending in Grand Junction was 24% lower than the national average and 60% below high-cost Miami. In 2005, Grand Junction had less bypass surgery and coronary angiography, and only 61% as many inpatient days during the last 2 years of life.
For those who criticize the Dartmouth Atlas for failing to control for regional differences in cost and health, the authors offer 3 important rebuttals that confirm the Dartmouth data. A MedPac analysis adjusting for price and health showed Grand Junction to be the 9th lowest service use area out of 404. Second, found that Grand Junction area is actually less healthy than higher expenditure areas. Thirdly, Medicaid expenditures were significantly less than other healthier Colorado counties.

So with sicker patients and spending less money, they probably provided worse care right? Well, Grand Junction scored above the national average on a number of measurements of preventive care, diabetes, asthma, and other quality metrics. On Grand Junction’s Mesa County ranks #1 in Colorado for health quality and better than substantially healthier communities.

The NEJM paper credits 7 features of Grand Junction that lead to low costs with high quality:
1. leadership by the primary care community
2. a payment system involving risk sharing by physicians
3. equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients
4. regionalization of services into an orderly system of primary, secondary, and tertiary care
5. limits on the supply of expensive resources, including specialists, beds, and equipment
6. payment of primary care physicians for hospital visits
7. robust end-of-life care

From the palliative care perspective, low-cost end-of-life care became a prominent part of the region’s health care system. Grand Junction’s population spends 40% fewer days in the hospital during the last 6 months of life and 74% more days in hospice than the national averages, and 50% fewer deaths than average occur in the hospital.

So what can palliative care take away from this? I think an important lesson is how important it is for palliative care to partner with primary care physicians to come together and explore ways in which Grand Junction’s story could be adapted to their local realities. Could you imagine a palliative care inpatient practice (with no outpatient program) doing joint family meeting and discharge visits with the primary care doctor in attendance (and both get paid?)

What can you do locally with any of the 7 key items?

by: Paul Tatum

This Post Has 7 Comments

  1. The Community Palliative Performance Profile, compiled by DAI Palliative Care Group, graded Grand Junction as an A-plus (an exemplar community). Why did Grand Junction earn this superlative? For starters, less reliance in the final months of life upon intensive care (less than half of national average) and one of lowest percentages of deaths occurring in a hospital (20.7%). And hospice enrollment nearly 30% greater than the national average.
    From a palliative care perspective, what practices and attributes have produced such stellar results for Grand Junction, and how easily adopted by other communities are these practices?

    Producing "high-value care" , whether for an acute episode, in an ambulatory setting, or for late-life care, is a formidable challenge. We've found that exemplar communities such as Grand Junction and Lacrosse Wisconsin share these attributes:

    • Multiple Points of Patient Access to Palliative Care
    • Multiple Sources of Reimbursement and Mechanisms to Enable Internal Pricing and Transfers
    • Presence of a "Community Chief Palliative Care Officer"
    • Protocols/Tools That Span Settings of Care (such as POLST)
    • Relentless Collection of Data and Focus on Accumulating and Disseminating Knowledge of Best Practices.

    Surely, it is easier for communities to adopt these practices where primary care is highly valued. But any community, given strong HPM leadership, can make progress toward "exemplar" status.

  2. Tom's article also hints at the importance of the family physician. A Family Physician's training is much more focused on community health and caring for family units, rather than hospital focused training that we see with many internal medicine programs. I wonder how much you think this played a role???

  3. @Eric – I think the family doctor plays a huge role in this outcome. It doesn't take an in-depth analysis of economics to figure out this piece of the picture either. Let us consider for a moment the conversation regarding treatment choices at the EOL. Will there be any difference in the conversation you have with your family doctor versus a specialist you have known for 15 minutes? Is that specialist going to spend the time to ellicit your goals and values? For the most part, only a palcare doc and family doc will do this. The combination of good longitudinal primary care and a well integrated palcare service, adds up to an almost failsafe mechanism for insuring that treatment interventions will match patient and family goals. How much do you think it plays a role? Tons!

  4. Thanks for this article. I have also heard that GJ has periodic meetings with leaders from competing health plans to discuss implementing programs (such as transitions of care interventions) where collaboration between plans and providers is necessary.

    Also, apparently they have been having meetings like this since the 70s. This kind of non-competitive approach to health care is goes completely against the views that competition will save health care. Nonetheless, the conservative community of grand junction should take pride in this "socialized" medicine.

  5. I love the attributes of successful PC programs that Tim shares. I'm going to use them with local leadership.
    The primary care doc in me (and I really view Geriatrics as a primary care discipline) agrees with Eric. We are making a mistake training doctors almost exclusively in the hospital. In return we get hospitalists and specialists instead of a primary care workforce.
    But for Palliative Medicine, I think we should be bringing up the 7 points any time conversation about "Medical Home" is raised. Excellent PC is essential to meet the goals of the Patient Centered Medical Home.

  6. In my Florida community, primary care MD's are allowed "6 minute visits" with patients and really don't get to know them. The old family physician rarely exists anymore!
    I see Hospitalists (who I had I hope for but am utterly disappointed in. Won't call back, uninterested, don't connect with their patients, etc…). I hope this isn't everywhere–but this is what I see here.
    Working at a large academic hospital makes for disjointed care and communication. This sounds like the answer–but how do we get anyone to listen??

  7. Thank You for posting this encouraging article about a community that is doing something right. Hopefully, their example will stimulate other communities to put a higher value on holistic end of life care that focuses on quality.

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