President Barack Obama's trip Saturday to Grand Junction, Colorado is meant to highlight an efficient, high-quality health care system, one with "integrated care." That phrase has become a popular term these days as Congress and policy gurus contemplate how the national health care delivery system can be refined.
But the idea is not so new. Denver Health, just a few hundred miles east of Grand Junction, began its own evolution into an integrated care system in 1949 with the opening of Denver General Hospital. Over the years, a range of services and facilities has been brought into the network. It now serves 150,000 people, one of every four Denver residents and one of every three children.
CEO Patricia Gabow credits much of Denver Health’s efficiency and quality to the "lean" model of integrated care, which is based on Toyota's production system. Hers is one of the first health systems to adopt "lean" in an effort to streamline processes and provide better patient care. Health information technology is at the core of this approach.
Gabow has testified before Congress about the Denver Health model. She recently spoke with KHN's Andrew Villegas and detailed how this wide-reaching, inter-connected network can serve as a useful example for lawmakers and health systems to consider as they puzzle over how to expand access to quality care while keeping costs under control. Edited excerpts follow.
Q: What does integrated care mean to Denver Health?
A: It's not just a hospital -- but it has a hospital, all the community health centers that are federally qualified in Denver, all the school-based clinics and public health department, the 911 system, the call center and correctional care. All of those pieces create a variety of points of entry and a continuum of care for patients. That's the integrated model.
[The model] has been built up over 149 years of Denver’s history. Whenever a new component to a health care model occurred, it was added to Denver Health, which is very different than [what happens] in most cities. In most cities, public health is not linked to personal health. Other cities have… developed silos and nobody wants to change. We were lucky that our city never let those silos happen in the first place.
Q: What is your "lean" model of integrated care?
A: LEAN started about four years ago when we asked ourselves the question 'How do you really get it right and perfect the patient experience?' We decided that if you want to get it right, you need five rights -- the right physical environment, built for quality and safety and to support employees, patients and families; the right person in the right job; the right communication and culture; the right processes; and the right rewards. We called this our puzzle and all the pieces had to fit together. They were held together by our IT system. To date, since 2006, we have saved $27 million by eliminating waste and making all the processes better. We did that without laying off anyone or cutting any care to the uninsured.
Q: How do you balance using electronic medical records and the goal to keep such records private?
A: Obviously you have to protect the patient's privacy. But health care is a knowledge-information business. And if you don't have any information on the patient at the time you see them, you aren't giving good care. Twenty percent of all the tests ordered in America by doctors are because they don't have the data when they see a patient.
We have a single electronic record. It's across all our system -- every provider has access to all the data when they see the patient. It's… critically important for cost and safety. I think we have to protect privacy, but I personally think this has been put out of proportion. Our electronic record is much more secure than our paper records ever were. We used to drive the records around the city in the back of a truck.
Q: How will health care reform affect Denver Health?
A: I think it's too soon to know. My one concern… is that it might not be bold enough. We don't even know what's included. But I think that, basically, if the only focus is on coverage, that won't be adequate. We must address all three issues facing us concurrently: access, cost and quality. And we have to address the delivery model as well as the payment model if we're going to achieve access, cost control and quality. Right now there's been very little discussion about meaningful cost control or meaningful delivery system change. That has to happen. You see, in Massachusetts they started out with coverage. But now they're realizing they have a cost issue. So if the country is already spending twice as much as any other industrialized nation and leaving 46 million to 48 million people without insurance, if you're trying to bring those 48 million in and you don't lower your costs, there's a problem.
Q: If Congress incorporated one part of Denver Health's model into its reform plans, what should it be?
A: I do think they need to push payment models towards the development of integrated systems of care. The more we can create multiple points of access for patients that covers them across the continuum of their lives and across the continuum of their disease – that is the way we're going to get high-quality, low-cost [care].
Q: How much savings can be wrung out of things like integrated care?
A: There is a lot of money to wring out. We're a very efficient system already. … But to give you an idea: Forty-six percent of our patients can't pay us. We have a very low subsidy. (Last year it was $27.9 million to cover $318 million of uninsured care.) But we're in the black every year and we've put $320 million into information technology. We're one of the most sophisticated IT systems in the country. It shows you that this can be done.
Our charges are lower than the average metropolitan charges … Our Medicaid charges per stay are about 30 percent lower than the metropolitan peer hospitals … Medicaid is our single biggest payer, which is classic for the safety net. And we are the largest Medicaid provider for the state of Colorado.
Q: If it's so great, why aren't more hospitals integrating care?
A: They're ingrained in their ways and I think the reason that there's such a push back against health care reform is what it always comes to: money. It's a $2.2 trillion industry. Somebody's waste is somebody else's profit.