There is an ongoing argument between the people who say we have too few doctors and the people who say we just don’t have the right kind of doctors (it’s quality not quality). More evidence that more is not better, better is better, and better is Family Medicine was put forth once again in the New England Journal of Medicine recently. Thomas Bodenheimer and David West went back to the town that Atul Gawande wrote about in his classic New Yorker article about run away health care costs. Not McAllen Texas (the town with the highest cost) but Grand Junction Colorado (the town with the lowest cost) to see why this town succeeded where others failed. They went there because

The usual explanation is that this town of 50,000 benefits from a cooperative spirit among health plans, hospitals, and physicians, who work together to serve the population. But even if this explanation were accurate, cooperation could not be transferred to other geographic areas — nor could the small-town nature of the Grand Junction community with its relatively homogeneous racial makeup. So what aspects of the Grand Junction success story might be replicable in other communities?

What they found was

that seven interrelated features of the health care system that may explain the relatively low health care costs could be adopted elsewhere. These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care.

It wasn’t just any type of “primary care” physician, it was Family Physicians. These physicians created a culture of accountable care before it was popular. The fixes were not high-tech (in fact, several such as pay equity are exceedingly low tech) but they have created a culture of exceptional care.

A lesson for America? Perhaps. In the understated words of the authors

These features could be replicated in other markets — though generally not without political battles.

Accountable Care Organizations, anyone?

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