As the federal health-care overhaul debate rages on, research examining the cost of quality health care - particularly geographic disparities in the cost of delivering care - has garnered national attention. But it's an issue doctors in Northern Colorado like John L. Bender have been grappling with for years.

Bender understands better than anyone the special cost and access challenges of providing care in rural areas. Earlier this year, his Fort Collins-based Miramont Family Medicine came to the rescue when Cheyenne Regional Medical Center closed its Wellington Medical Clinic, eliminating the area's only family practice doctor. Miramont's Wellington practice opened two days later.

Then Bender partnered with Janice Weixelman, M.D., who had opened the only medical clinic in tiny Red Feather Lakes in 2003, and added it to his practice in June. Miramont - with four physicians and three practices - now serves about 10,000 patients.

"We're very optimistic about the future," Bender said. "We know there's a lot of consternation and concern, but Miramont remains pleasantly optimistic that we'll be able to maintain Wellington and Red Feather Lakes indefinitely."

The patient-centered medical home model that has enabled Bender to bring care to these underserved areas is a method of insurance reimbursement that pays doctors not just for quantity of work, but the quality of outcome. Because Miramont had applied for and received the highest levels of national certification, the practice was able to negotiate contracts with five major insurers that pay for outcomes.

In exchange for the reimbursement changes, Miramont created a more patient-centered, team approach. The practice now offers same-day scheduling for patients needing multiple services and e-mail access to physicians. A nurse educator does diabetes prevention and management. A health coach provides asthma training. And the office has a wide array of in-house ancillary services for lab work, X-rays, pharmacy, and the like.

In another cost-saving move, Miramont recently scanned and shredded 2,800 patient records, turning them into electronic files that allow for more efficient data management. If a patient from Wellington is admitted at Poudre Valley Hospital in the middle of the night, their records can be transmitted there instantly.

"It used to be a two hour drive just to get a record," Bender said. "It also improves patient safety because every time we write a prescription, the software does a cross-check for allergies. We also communicate data in what's known as a patient registry that tells us where we need to improve processing patients, and we change our systems accordingly. None of that would have been possible with paper charts."



Providers rare in rural areas

Still, the transition has not come without hiccups. Bender has been trying to recruit a geriatrician for over a year with no success. Just last month, Weixelman - who used to run both the Red Feather Lakes and Wellington clinics - got called up for Air National Guard duty.

"I have not been able to get a physician to cover all of the hours she was working," Bender said. He's made do with nurse practitioners and physician assistants. "I did have one physician who drove up from Boulder for a couple of shifts at Red Feather Lakes. It was 200 miles roundtrip for him to do that."

Bender says compensation is key to the area's provider shortage. He suspects part of the reason that health care costs nearly $2,000 per capita less in Fort Collins than the national average is because physicians get paid less where there aren't as many providers to join together to negotiate reimbursement rates with insurers. He believes that's been a factor in the eight bankruptcies that have shuttered practices in Northern Colorado in recent years.

"Sometimes the cheapest care doesn't always mean the most access," Bender said. "Someone with Medicare, if they move here it can be difficult to find a physician. A number of people in Fort Collins travel to Loveland to see doctors because they cannot find physicians in Fort Collins."

Toward the goal of improving access, Poudre Valley Health System and North Colorado Medical Center have for years been developing telehealth programs to serve patients in rural areas through interactive video and digital radiology.

But whether or not such programs actually translate into cost savings is a question that's yet to be answered.

In 1995, PVHS received a federal grant through the High Plains Rural Health Network to establish a telehealth program. After the initial, $1.5 million three-year grant, the hospital received other, smaller grants and the federal government started reimbursing doctors for some telehealth services.

And while the change in reimbursements helped, PVHS' telehealth coordinator Steven Mecklenburg still says the benefits of telehealth have been in increased access, not cost savings. "This is the problem with telemedicine," Mecklenberg explained. "What did it do for cost? All it did was add a bunch of cost, quite frankly. There's no federal reimbursement for equipment, or for telecommunication links, so all we did was move a FedEx (record) transfer, which cost $10 for overnight from Sterling to Fort Collins, and replaced it with a multimillion-dollar telemedicine transfer."

The biggest savings is to patients when - for example - a trip to Children's Hospital in Denver can be prevented because a pediatric cardiologist reads a telemedice-transmitted echocardiogram and determines there's nothing wrong. "So what are we saving?" Mecklenburg asks. "An ambulance or helicopter ride, possibly the extra echo that's down there, and the travel cost to the patient, but we look at those as being soft costs."



Increased access for patients

That's not to say PVHS doesn't see value in telehealth. To the contrary, the hospital is proud to have increased access for patients in rural areas, providing over 1,513 clinical consultations and 2,200 hours of educational programming since the program's inception.

Mecklenberg simply argues that there's still a lot to be worked out in terms of reimbursements, as well as legal/liability issues, in order for telemedicine to be made affordable for providers. What he finds particularly exciting is the recent announcement by insurance company United Healthcare of a large telehealth pilot program.

"They made some big comments about lowering costs," Mecklenberg said. "I don't know where the cost lowering is going to be. There's no federal money. This is all on their own, so you can tell that this is a pretty powerful statement that this is valuable."

Will Shanley, a spokesperson for United Healthcare, said Colorado's Connected Care is one of six pilot telehealth programs in the country. It's set to launch in the first quarter of 2010 with four pilot hospitals across the state: Buena Vista Family Practice; High Plains Community Health Center in Lamar; St. Vincent General Hospital in Leadville; and a fourth that has yet to be announced. The program is expected to provide for 3,500 specialist visits per year.

"We're going to set up the connective care technology and then have patients in those locations work with their primary care doctors to conference in specialists from other parts of the state," Shanley said. "We haven't identified what specialties this will target, but it will enable patients to meet with their primary care physician and conference in a medical specialist who could be hundreds of miles away in Denver or other locations."

Shanley said the cost savings are difficult to quantify, but they will come by way of preventative care.

"Often for some of these health conditions, they require ongoing care and for people who are elderly or ill, geographic distances can make that a challenge," he said. "By providing this technology and working with Centura (health clinics), making sure patients are getting their regular checkups with specialists, it basically keep them out of emergency rooms and leads to healthier, better outcomes for these folks."

He said patients don't have to be a United healthcare member to participate. They just need an insurance plan that covers telehealth visits. "We're definitely seeing more and more plans cover these services," he said.