Dr. David West, a member of the physicians' association, says specialists are generally paid two to four times as much per year as primary care doctors, and he thinks that's too much. In Mesa County, specialists are hired to think, not to run up the procedure count, and that means they give up income to benefit their patients, their community and the family doctors, he said.
"Thinking about patients pays nothing to physicians, but doing to patients pays well — in most of the rest of America," says West. Doctors "are paid too much for procedures — surgeries, radiology studies, chemotherapy, endoscopy and diagnostic tests — and far less for bedside and office care to patients."
"We have just one cardiology group, 10 cardiologists in it," Ladenburger says. "They're culturally conservative. They'll do cardiac caths when they decided they're needed," but only when they're needed.
The rules established by the physicians' association and by RMHP "have led to better efficiency and better quality and certainly have kept prices down," he adds.
The fact that RMHP is a nonprofit is also key, he said. "In a shareholder-driven system, that money (saved) would have gone back to the shareholders instead."
The constant peer review also is counter-intuitive for patients who want the most drastic treatment immediately.
Take back pain.
Some primary care physicians automatically refer a patient to a specialist or recommend an MRI. More expensive? Yes. Better medicine? Not usually, say advocates of the Grand Junction system.
Try some ice, lay off of it for a few days, try to lose a little weight.
If a patient needs medication — or if he or she suggests one recently seen in a TV ad — the primary care physicians first try to see if a generic can work at perhaps $5 a month rather than $60 for a brand-name medication.
Crucial to measuring quality and maximizing efficiency is a transparent look at all the data.
For that, Grand Junction has a region-wide electronic medical records system. "It allows us to see the data immediately from St. Mary's (Hospital) or anywhere else. It means there is less repetition of tests, and it's going to drive down health care costs over time," Pramenko said.
It also means doctors' peers can see what they are doing.
"At the end of the day, they can see that they may be giving 10 times as many MRIs as their peers," says Rocky Mountain Health Plans CEO ErkenBrack. "Decisions should be made by the doctor and patient, period. But those decisions ought to be reviewed. Not in terms of Patient X — because there may be a good reason that any particular patient needs some treatment out of the norm — but in terms of practice patterns."
In McAllen, many doctors turned out to be owners of the surgery centers, home health agencies, and testing facilities. Sending patients for more procedures even outside the office was lucrative.
In Grand Junction, Pramenko thinks RMHP's dominant size has been essential — a contradiction for healthcare reformers who believe more competition is the answer.
"As it is, it's hard to ignore what Rocky says," Pramenko notes. "They are a big force. Fortunately for us, they are a friendly force."
Not that there aren't plenty of debates about how much specialty care is needed.
"It sounds like we all go tripping down the yellow brick road with no disputes, and that is not the case," says ErkenBrack. "At the end of the day, it's not easy to get buy-in from anybody.
"But we're having the conversation — with the hospice, the home health people, everybody. It's really a matter of looking at things and talking to each other. Saying, ‘This is what I need to make this work.' And it's also a matter of listening, to understand that other points of view have to be considered."
Healthier populations cost less
One critic, healthcare blogger Daniel Gilden, calls the Grand Junction advantage an illusion. He says the area has lower costs primarily because it has much less serious chronic illness than residents of the flip side of the spectrum, McAllen.
Indeed, a color-coded map of U.S. obesity rates shows all of Colorado as having the fewest weight problems in the country.
"In Grand Junction, there are many fewer low-income Hispanics with combinations of diabetes and heart disease," than in the Mexican border town of McAllen, Gilden says. "Years of exposure to environmental risk factors, poor diet and limited access to preventive care lead directly to high rates of chronic disease and high health care costs. The high cost of medical care for this population is a side effect of the life-long neglect in key areas related to health maintenance in aging populations."
Darene Schroeder, a Grand Junction nurse who once worked in Texas, concurs that western Colorado residents are simply healthier. In Texas, "there was a lot of tuberculosis, including multi-drug resistant TB. There's none here."