In my last blog post, I talked about managing care within the medical neighborhood, what I consider the health care version of "it takes a village." Now, let's move beyond the neighborhood and talk more specifically about the neighbors.
"Who is my neighbor?" may sound like the title of a sermon, but to paraphrase an old political slogan, "It’s the relationship, stupid." If we retreat into our private little kingdoms like tribal warlords, we will never achieve better outcomes for our patients.
In Colorado, there is an excellent medical neighborhood in the city of Grand Junction. In last November’s Forbes magazine, Rick Ungar detailed the success that the doctors, hospital and major health insurance plan have been able to achieve. I’ll hit the high points here.
Medicare spending in Grand Junction is just $5,873 per patient, compared to the national average of $8,304. The cost of chronic disease management in this area is 1/3 the national average. Low-income patients on Medicaid are more than twice as likely to get preventive care. Low birth weight babies are a rarity.
How was all this accomplished? Did the citizens of Grand Junction form a consumer group? Did the government provide a new program?
No, the doctors, hospital executives and predominant insurance company in the region worked together. Specifically, the doctors formed an IPA (Independent Physicians Association) where good relationships amongst the doctors allowed them to take a hard look at spending. With a solid primary care base, care management was more taken care of more easily.
The insurer, Rocky Mountain Health Plan, a non-profit company, agreed to pool the money collected from private payers with the money collected from Medicaid and Medicare. This allowed the doctors to treat everyone the same, no matter who was paying the bills. Finally, the hospital was able to manage its own costs so even as the number of bed days declined, the hospital could stay financially viable.
For another example, let’s move across the country to Camden, New Jersey to look at “Hot Spotters.” Atul Gawande’s wonderful New Yorker article from January 2011 has all the details but, again, I’ll hit the highlights below.
Dr. Joseph Brenner is a family physician living in an impoverished community in New Jersey. Poring through data provided by local hospitals, he identified the sickest individuals in his neighborhood. Then, by “building relationships” with these people, managing their care and coordinating their community resources, Dr. Brenner and his colleagues have been able to reduce medical costs for these first 36 "super-users" by over $500,000 in just two years.
This is not to say we must all become like Grand Junction, Colorado or Camden, New Jersey. But, I think there may be some themes worth copying.
First, primary care physicians must have the resources necessary to manage their patient populations. This means being able to look at their data with an eye toward chronic disease management and proactive care for high risk patients.
Second, PCPs must be able to look at the care provided by their sub-specialist neighbors. This means outcome and cost data must be readily available.
Third, hospitals must take a hard look at their revenue streams and stop the medical arms race for the fanciest new suite for the care of this or that disease. Finally, insurers must provide meaningful data back to the doctors so we can see where the money is being spent and who is spending it. Risk stratification is not just a term for health insurance companies—all care givers must become comfortable looking at the data.
The stakes are high. As a country, we can’t continue to increase health care spending. The good news is that relationships with our neighbors in our medical neighborhoods can still save us.