What's Working

The 'You' Factor
Pilot Plan Guides Users to Higher-Value Health Care

  What's Working - Winter 2012 - The 'You' Factor

Russ Johnson
Chief executive officer
San Luis Valley Regional Medical Center

By Rebecca Jones
Photography by Barry Staver

Russ Johnson and his colleagues at the San Luis Valley Regional Medical Center don't just provide health services. They use those services themselves.

Who better, then, to pilot an innovative program aimed at redesigning the center's medical benefits in a way that encourages employees and their dependents to use more services that produce more bang for the health care buck and use fewer of those that don't?

"This is one way we can continue to do our part," says Johnson, chief executive officer for the Alamosa-based medical center, which provides benefits to 690 employees. "The jury is out right now. We're completely aware there will be some apprehension and skepticism. We want to be open about what we're trying to do. Our employees know and respect that."

On Jan. 1, the medical center rolled out the Colorado Innovative Design Benefit pilot, a project that derives from the concept that not all health care services are created equal.

Under the pilot program, procedures from a high-value list will be offered free to insured medical center employees and their dependents to encourage their participation. Policyholders won't be denied procedures from a lower-value list, but they will be asked to share more of the cost. In addition, they will be given some straightforward information about the procedures to help them decide whether the extra cost is desirable.

"There's clear evidence that we overutilize some services and we underuse some others," says Dave Downs, MD, medical director for Engaged Public, a public policy strategy firm in Denver that is using a federal grant to explore the best ways of cultivating savvier health care users.

For the pilot program, Engaged Public assembled a group of high-profile physicians, insurance leaders and consumer advocates and developed a list of high-value services that most agreed would provide a good return on investment: preventive care, chronic disease management, prenatal care and dental care. Ultimately, such health care services should lower costs because they ward off expensive hospitalizations and complications.

The panel also developed a list of services where value is less clear, including back surgery for back pain, coronary artery stents and bypass surgery, and hip and knee replacements.

"These are things that may be right in some situations, but not right in others," Downs says.

People will be able to use "decision aids" – DVDs and pamphlets – that provide data about short- and long-term outcomes for various procedures. The choice will be theirs to make. Now there's a charge for using the aids, but Downs hopes to make them free eventually.

"We like this model. It still maintains a lot of choice in benefits, but we're hoping it will lower the cost," he says.

Johnson sees this pilot, which will run for two years, as a first step in dismantling what he sees as a "culture of entitlement" around health care.

"Many people feel that as long as they've paid their premium, they should get anything they want anytime they want it. We need to change that so there's more of a sense of personal responsibility," Johnson says.

He is well aware that some of the procedures the plan will discourage are offered by the medical center's professionals, who stand to lose income if fewer patients opt to have them.

"This definitely has implications for providers," Johnson says. "Engagement of providers is absolutely essential. If they're not supportive, this is doomed. They've got to be even-handed, even if that's not always serving their own ends."