Atul Gawande's latest piece on Palliative Care is fantastic, and I hope you have read his "McAllen, Texas piece" on the cost-conundrum in medicine. While the focus was on why there were such high costs of medical care in McAllen, one of the sites of sharp contrast provided was Grand Junction, Colorado where the quality of care was high but with low overall cost to Medicare. So what is the secret to providing high quality and low cost? An article in this week’s NEJM looks into the success of Grand Junction more closely. The secret? Primary care and palliative care. According to the Dartmouth Atlas of Health Care Medicare spending in Grand Junction was 24% lower than the national average and 60% below high-cost Miami. In 2005, Grand Junction had less bypass surgery and coronary angiography, and only 61% as many inpatient days during the last 2 years of life. For those who criticize the Dartmouth Atlas for failing to control for regional differences in cost and