LaCrosse health plan is potential model to build from

http://www.jsonline.com/business/59087997.html

This is exactly the type of health care model we should be utilizing to undertake true reform.

Efficient, quality, and integrated care. I apologize for the length of this entry. I think this is very informative, however, so I'd hate to edit it too much.

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Here are excerpts:

La Crosse - The United States would spend less money on health care if more health systems were like Gundersen Lutheran.

This community in western Wisconsin has the fourth-lowest health care costs in the country based on Medicare spending.

Only Honolulu and two North Dakota cities, Fargo and Minot, rank lower. At the same time, the quality of care is as good as or better than most parts of the country.

Gundersen Lutheran, a health care system that employs 6,600 people, including 453 physicians, is one reason. The other is its crosstown competitor, Franciscan Skemp Healthcare, part of the famed Mayo Health System.

Both are among the health systems being cited as proof that the United States can slow the rise in health care spending without hurting quality.

"There are models available, and we happen to be one of them," said Jeff Thompson, a physician and chief executive of Gundersen Lutheran.

Medicare spent 30% less on average for each beneficiary in the La Crosse area than the national average in 2006, the most recent year for which data is available, according to the Dartmouth Atlas of Health Care.

It spent 64.5% less than in Miami and 61% less than in McAllen, Texas, the two most costly areas. And it spent 23% less than in the Milwaukee area.

The huge regional variations in Medicare spending - documented by more than 30 years of research at Dartmouth College - occur after adjusting for age, sex and race.

They also exist among areas with similar poverty rates. And they exist within the same geographic areas, varying from one hospital to another.

The variations show that some parts of the country - and some health systems - simply make better use of health care dollars.

The doctors and hospitals in places such as La Crosse, Eugene, Ore., and Grand Junction, Colo., do a better job of eliminating duplicative and unnecessary care, preventing illness or detecting it earlier, avoiding unneeded or preventable hospitalizations, increasing productivity and reducing administrative costs.

They also challenge the contention that slowing the rise in health care spending will mean denying patients needed care. And they refute the widely held belief that more care is better care, and that expensive care is even better.

The evidence is indisputable that high-cost communities do not have better health outcomes, said Tom Oliver, a professor at the University of Wisconsin School of Medicine and Public Health.

"We are spending billions of dollars that is wasted in our health care system," Oliver said.
Quality care

No simple explanation exists why Gundersen Lutheran or the Mayo Health System can provide quality care at a fraction of the cost of their counterparts in Miami or McAllen. But both are integrated health care systems that employ doctors, and research suggests that integrated systems and large physician practices closely aligned with a hospital often produce better care at a lower cost.


Gundersen Lutheran and other integrated systems also often operate their own health insurance plans. That, too, could contribute to their lower costs by giving them an additional incentive to provide efficient care.

The Gundersen Lutheran health plan accounts for about 28% of the revenue at its hospital and its clinics. But when a patient is insured by the plan, the cost of his or her care isn't passed on to an insurance company. Gundersen Lutheran instead incurs the costs.

Being integrated gives Gundersen Lutheran a huge advantage in coordinating care, getting information on best practices to physicians and creating a culture of shared values, said Thompson, its chief executive.

Doctors run the health system, and they are expected to become involved in its operations and to work to control costs, he said.

The health system's orthopedic surgeons, for example, reduced costs by $900,000 a year just by getting together and agreeing to use medical devices from one supplier.

Standardizing care also is easier in an integrated system. The doctors at Gundersen Lutheran have developed specific guidelines and order sets for specific diseases and procedures.

When Gundersen Lutheran installed an information technology system in its hospital, it had more than 300 order sets, said Brian Mulrennan, an internist. It was told by Epic Systems Corp., the Madison-area company that designed the system, that some hospitals had none.

This means that doctors who specialize in diseases of the ear, nose and throat, for example, have developed standard orders for the post-operative care for children who have had tubes placed in their ears for chronic infections.

The standard orders lessen the variation in cost and outcomes.

At the same time, nurses no longer have to follow slightly different orders from each physician, thereby reducing the chance of error.

All this is harder to do when doctors work for dozens of small practices. First, the doctors have to be willing to take the time to develop and agree on the guidelines or standard orders.

And the hospital may be wary of antagonizing doctors who bring it patients and revenue.

There's a saying in health care that a hospital's first customer is the doctor. That's less of a problem in an integrated system that employs them.

Practice guidelines and standard order sets also can help control discretionary care, such as office visits, referrals to specialists and the use of imaging tests. It is one reason for the huge variation in health care costs.


Culture also plays a part. The doctors at Gundersen Lutheran repeatedly refer to the value placed on cooperation and on a focus on the patient. And the health system works to recruit doctors who understand those values.


Gunderson doctors are well paid and make excellent livings. They just aren't the highest paid.

When recruiting, if a doctor notes that he or she could make more money in a Chicago suburb, Thompson will say, "Then you should go."

The low costs incurred by Medicare in La Crosse also stem partly from a communitywide initiative, begun in the 1980s, to encourage people to have advance directives - legal documents that state patients' decisions about end-of-life care should they become incapacitated.

"It's now so part of the process of care that, when we don't know a patient's wishes, it's upsetting to people," said Bud Hammes, a clinical ethicist and director of medical humanities at the Gundersen Lutheran Medical Foundation.

The program, which has drawn international attention, enables doctors to know when patients don't want heroic measures taken to prolong their lives.

In the last six months of life, Medicare spends 29%, or about $8,000, less on patients treated at Gundersen Lutheran than the national average. And it spends roughly $10,000 less than at Aurora St. Luke's Medical Center and Froedtert Hospital, the two hospitals in the Milwaukee area with the highest costs.
No quick cures

National data on the wide variation in costs is available to researchers only for Medicare patients. But studies suggest that how doctors and hospitals provide care for Medicare beneficiaries indicates how they treat patients covered by commercial health plans.

Gundersen Lutheran gives credence to that research. The health system says that its rate increases for commercial plans for the past three years were below the rate of inflation.

That's almost unheard of in health care.

The challenge is how to make the U.S. health care system look more like Gundersen Lutheran and other integrated systems.

That won't be easy to do.

Integrated systems, including large physician practices closely affiliated with hospitals, such as Dean Health System in Madison and the Marshfield Clinic, are common in Wisconsin. But they aren't the norm in the U.S. health care system.

As recently as 2005, roughly half of all office visits were made to practices with one or two physicians, according to the National Ambulatory Medical Care Survey.

Yet the Dartmouth research suggests that high-cost markets are characterized by a much higher percentage of physicians in solo or two-person practices. That kind of fragmentation is characteristic of the U.S. health care system.

It also will be one of the challenges in slowing the growth in health care spending.