In the long and often contentious debate leading up to thepassage of the Patient Protection and Affordable Care Act, thespotlight fell on Grand Junction, Colo.—a bustling town of 58,000people nestled on the Centennial State's Western Slope. While thecity is a gateway to the Rockies and a hub of mountain living, itturns out that Grand Junction and Mesa County also feature one ofthe most affordable health care systems and some of the highestquality care in the United States.

Not surprisingly, politicians, politicos andmedia types descended on the Grand Junction area as the PPACAdebate raged. President Barack Obama delivered a speech in GrandJunction in 2009, when trying to gain support for hisnot-so-popular health overhaul law. Shortly after, the city foundits way into the pages of The Los Angeles Times, The New Yorker andthe New England Journal of Medicine as well as the nightly news andPBS.

It's easy to see why the system stands out. Doctors across thecommunity work very closely with one another and the plan provider,Rocky Mountain Health Plans. The system has been very keen to adoptnew methods of delivering care or improving the delivery ofservice. And administrators and medical professionals have beenable to find ways to work through their disagreements anddifferences for more than 30 years.

Starting out

The system's roots trace back to 1973, whenPresident Richard Nixon signed into law the Health MaintenanceOrganization Act, which provided government support in the form ofloans and grants to build or expand HMOs. A small group of GrandJunction physicians decided to start their own HMO and signed upJohn Harrison, who had recently obtained a master's degree inhealth administration from the University of Colorado HealthSciences Center, to be plan administrator. Harrison took care ofthe business side while the doctors set up the network. Harrisonsays it was possible because the doctors had existing relationshipsand a mentality typical for people in the West at that time.

“To keep the government off their back, they wanted to show thatphysicians could be responsible,” Harrison says.

“The physicians did it themselves. For the most part, these guysknew each other professionally and socially and they all lived inMesa County. It was the biggest industry on the Western Slope—themedical industry. There were an awful lot of informal negotiationsbecause they all knew each other and they all wanted to prove theycould do it on their own.”

Doctors in Grand Junction and Mesa County essentially built amanaged care system where the plan provider they created—now knownas Rocky Mountain Health Plans—coordinated and collaborated onhealth care with a newly created Mesa County Physicians IndependentPractice Association. Over the years, the partnership has developedseveral distinct methods to increase quality and decrease cost.

Working together

A key facet of the model is called the “withhold.” RockyMountain Health Plans withholds 20 percent from every doctor's billit receives and places the money into a pool. Since doctors agreeto take less to treat patients with private insurance, there's lessreluctance to treat patients on Medicare and Medicaid.

That means doctors in Mesa County and Grand Junction treatplenty of patients on government healthcare programs without havingto make up for lost revenue from private insurers.

“Having that kind of global risk across lines of business allowsfor more financial capability to see Medicaid members, as opposedto models where Medicaid is a sole payer and it's not always beenfinancially possible to have a lot of Medicaid members,” says Dr.Greg Reicks, president of the Rocky Mountain Physicians IndependentPractice Association.

But the withhold also serves another function. At the end of theyear, Rocky Mountain Health Plans divvies up the pool anddistributes it to doctors in the form of a bonus. How much of abonus doctors receive depends on how efficiently they deliver care.For example, if one doctor orders 10 times the amount of MRIs thannormal for the area, that doctor will receive less of the year-endbonus.

That efficiency of care is measured by the MCPIPA through a peerreview process. The association also shares data with its memberson community norms, generic prescriptions and best practices fortests, treatments and procedures. Unlike some other peer reviewboards, the Grand Junction model allows doctors to confer withfellow physicians in their own community.

“The medical directors will conduct an office record review, sothe physician will have another physician come in and go over howhe practices medicine,” says Steve ErkenBrack, president and CEO ofRocky Mountain Health Plans. “If the practice raises certainissues—good or bad—that will be brought to the medical practicereview committee. It's a best-practices sort of review.”

The association, which currently hasapproximately 300 members, also oversees several committees thathelp oversee care. 

According to the association's website, the Medical PracticeReview Committee is “responsible for the review and evaluation ofthe quality of medical or other health care services and theutilization of medical or other health care services in conjunctionwith any health plan for which the IPA has agreed to provide theservices of physicians and other health care professionals.” ThePhysician Incentive and Engagement Committee has a responsibility“to design, facilitate and monitor programs relating to payments tomembers under the terms of incentive plans.” The QualityValue and Outcomes Committee, among other things, develops“clinical quality and utilization review programs and monitor theoutcomes of such programs, set overall utilization review andmanagement priorities, design clinical care guidelines and provideongoing oversight, review and modification of such guidelines and,as appropriate, generate general financial and analytical reportsregarding utilization of medical service, based on historical claimdata, for the purpose of measuring historical claims data, for thepurpose of measuring results of, or necessity for, utilizationprograms or guidelines.”

Another way the system helps manage healthcare is throughprimary care physicians, who essentially serve as the gateway tothe system. The use of primary care physicians is so extensive thatpeople in Grand Junction and Mesa County outpace the nationalaverage for utilizing primary care physicians.

“Primary care is critical. We use a lot of nursing coordination,and more than 10 percent of our employees are nurses at Rocky tokeep a patient-focused approach to care,” ErkenBrack says. “We'vehad a program for many years—we will have a nurse call the patientjust to make sure they understood their discharge instructions. Wediscovered a lot of patients that didn't realize they had dischargeinstructions, so as a result, we have fewer re-admits. We've done alot of things like that in the community.”

Health care professionals in Mesa County alsouse an electronic system for medical records. The system allowsdoctors easy access to a patient's medical history, which in turnmakes it easier for them provide efficient care. “We decidedseveral years ago that we wanted to get into health informationexchange,” Reicks says.

Reicks says Mesa County's medical records system has a dataexchange and a data repository. The exchange allows labs, hospitalsand doctor's offices to share medical records as a patient movesthrough the system, say from a general practitioner to a testingfacility to a specialist. The repository serves as an archive of apatient's medical history that doctors can access without having torely on a patient's memory. The repository, Reicks says, helpseliminate redundant tests or procedures.

In terms of the area's hospitals, Rocky Mountain Health Plansnegotiates fees while the physician's association provides itsmembers with data about hospital charges. And the administratorsand doctors in Grand Junction and Mesa County were at the forefrontof offering pre-natal care, palliative care and end-of-lifecare.

Weathering storms

Over the years, it hasn't exactly been easy. Some physicians,even in Grand Junction, say the system rations health care oradvocates costs savings over a patient's interests.

“I tell people it's been very hard, and it's not always beencollegial,” Reicks says. “We've had multiple points in the IPAwhere it's come to disillusion. We have some specialists who don'tlike the model and don't participate.”

But Reicks says the primary element those involved focus on isthat there's the potential to make everyone's life easier,including the physician and the consumer.

“Lots of folks come away from this thinking it'd be great tolive in Grand Junction and we all hold hands,” ErkenBrack says.“The reality is we fight about it. But it's OK to fight about it;it's good to fight about it, because we're trying to resolve ourdifferences. The problem with health care is when you withdraw intoyour silo.”