Grand Junction: Radiology and the IDN
A recent New Yorker article¹ shone a harsh light on the city of McAllen, Texas, where Medicare data suggest that health care costs are nearly twice as high as the national average. Garnering less attention was the example that the author (surgeon Atul Gawande, MD, MPH) gave of a community where health care delivery functions efficiently and effectively—Grand Junction, Colorado. Grand Junction has some of the highest Medicare quality scores in the country, yet costs per enrollee remain low—30% below the national average, in fact.
Bob Ladenburger
McAllen’s inflated health care costs are blamed on overutilization of medicine, particularly high-cost services like imaging. Gawande notes that according to data from 2005 and 2006, patients in McAllen received “more of everything,” including 20% more abdominal ultrasounds, 30% more bone-density studies, 60% more stress tests with echocardiography, 200% more nerve-conduction studies, and 550% more urine-flow studies than the national average. Bob Ladenburger, president and CEO of St Mary’s Hospital and Regional Medical Center, the larger of two Grand Junction hospitals, offers insight on how Grand Junction maintains high-quality care without overutilizing imaging. Ladenburger explains that the delivery of health care in his community is governed, in large part, by the relationship between the local independent practice association and the local health plan. Rocky Mountain Health Plans (RMHP), a nonprofit HMO, was founded by physicians in the 1970s; a few years later, the Mesa County Physicians Independent Practice Association (MCPIPA) was formed. All of Ladenburger's 10 hospital radiologists are members of MCPIPA. Members benefit from the collective bargaining power of the organization; in turn, they are subjected to a rather unique payment plan that gives physicians incentives to act with quality and cost-effectiveness as their watchwords. “The compensation system incentivizes providers to look at what makes sense from a quality and cost perspective and to have the conversation about how to make the best choices,” Ladenburger says. “That has resulted in a medical community that works well together. We share a collaborative spirit.” St Mary's 10 radiologists staff both the hospital and its joint-venture OIC, Pavilion Imaging, located across the street from the hospital. The radiologists are members of Western Colorado Radiologic Associates, which formed the joint venture with the hospital. “We’re better off working together to serve community needs than duplicating outpatient imaging resources,” Ladenburger says. “That works very well in helping us, as a hospital, stay together with the radiologists in a collaborative model.” Quality and Cost Efficiency MCPIPA members are subject to an RMHP payment plan under which a percentage, usually 10%, of the professional component of all payments is withheld from each paycheck. The withheld monies are placed in a sort of savings account until the end of the year; at that time, if the health plan's finances are in the black, a portion of the saved money is returned to MCPIPA physicians in the form of a bonus payment—provided they have met or exceeded quality benchmarks. Kevin Fitzgerald, MD, chief medical officer of RMHP, says, “The physicians themselves build the metrics, with input from the health plan. This is a very dynamic system with regard to what the physicians want to keep an eye on, so the metrics change every couple of years." Each week, hospital radiology staff and leaders meet to discuss issues that include improving communication, equipment downtime, new initiatives such as reducing time elapsed before CT scanning for acute stroke patients, and quality metrics. Bill Voss, director of laboratory and imaging services for St Mary's, maintains a spreadsheet called the QA Dashboard charting benchmarks currently being tracked for each modality (see table). Indicators are drawn from multiple sources, including the ACR® and Mammography Quality Standards Act benchmarks and Joint Commission National Patient Safety Goals. Radiology efficiency is augmented by the use of a PACS that is shared between the hospital and Pavilion Imaging; the system is further enhanced with integrated communications software that enables radiologists to send messages directly to one another and that hastens the delivery of critical results. Both hospital and imaging center also use a local regional health information organization called Quality Health Network to check for prior exams and special indications. Though primary care physicians bear the majority of responsibility for ordering appropriate imaging exams, the hospital’s radiology department plays a role through its radiology patient coordinator, a clinically knowledgeable technologist who serves as a liaison between clinicians and the radiology department. The coordinator aids in scheduling and, when necessary, helps physicians determine the most appropriate test. By providing radiologists and referrers alike with incentives to keep system costs down while maintaining high-quality care, MCPIPA and RMHP manage to curb utilization without using preauthorization for MRI or CT. "When you look at larger utilization statistics, days of hospital care are low here," Ladenburger says. "The number of back surgeries per thousand is low. The number of cardiac catheterizations is low. Our costs are similar to other organizations’ costs, but care is conservative, and that gives the community value. We try to maintain transparency, openness, and involvement, and that drives the efficiency of health care here more than anything.” Cat Vasko is editor of Medical Imaging Review.