Health Policy Solutions

By Katie Kerwin McCrimmon

U.S. Rep. Diana DeGette visited Craig Hospital on Wednesday to build momentum once again for bipartisan stem cell research legislation.

DeGette, a Denver Democrat, and her new Republican cosponsor, U.S. Rep. Charlie Dent (R-Penn.), introduced H.R. 2376 on June 24.

Twice, DeGette successfully shepherded stem cell research legislation through Congress only to have former President George W. Bush veto the measures.

DeGette is hoping to win support from new Republicans in the House, then eventually send the Stem Cell Research Advancement Act to President Obama.

“Disease doesn’t know any partisan boundaries,” DeGette said, noting that her bills have won the support of many Republicans in the past.

President Obama has already renewed U.S. government support for stem cell research through a 2009 executive order, but DeGette said legislation is vital so that researchers will be guaranteed long-term support.

“Ethical embryonic stem cell research is beginning to bear fruit,” DeGette said.

For example, she said research might soon help people like Chris Chappell, a former Craig patient, who became a quadriplegic after a mountain biking accident in the foothills west of Denver in 2000.

A former Wall Street investment banker, Chappell now works for Craig as a liaison to other former patients. He said people with spinal cord injuries are closely watching research that would give them even small improvements. Chappell was racing down hill fast when he turned to see what his buddies were doing behind him. He’ll never know for sure whether he hit a rock or a hole, but he flew 50 feet off his bike and broke his neck.

“I hit so hard that my chin broke my sternum,” he said.

Chappell knew instantly that his injuries were devastating.

“It felt like a vat of warm butter spreading over me. I felt like everything was melting away,” he said.

Through rehabilitation work at Craig, Chappell has regained some motor function in his arms. He now functions at about 90 percent in his right arm and 80 percent in his left. Immediately after the accident, his fingers were useless. Now he can shake hands, has some sensation in his fingertips and is able to use his hands.

“With legislation in Congress, we will get research that will bring nerve regeneration. We can get back function,” Chappell said.
Chappell compares stem cell research to heart and lung transplants. Not long ago, patients receiving transplants could expect a short extension of life. Now, a transplant dramatically changes a recipient’s outlook over the long term.

“The magic is in human trials,” said Chappell.

While politicians have debated the morality of stem cell research, scientists have moved forward, hoping to bring improvements to patients suffering from an array of medical problems from Alzheimer’s and multiple sclerosis to spinal cord injuries and cancer.

At Craig, neurosurgeon Scott Falci has been working with researchers for 18 years at the Karolinska Institute in Sweden and is now poised to conduct clinical trials on humans that will be among the first in the world to inject stem cells in humans. So far, the Geron Corp. in California has injected stem cells into two patients with spinal cord injuries.

Falci happened to care for a Swedish doctor years ago at Craig and the two hatched plans for a cooperative relationship. Craig doctors have extensive experience working with patients with spinal cord injuries while the Swedish Institute has state-of-the art research facilities.

Falci said the initial trials of his study are set to begin in Sweden in 2012. He is working to win FDA support for follow-up trials that could take place at Craig and various sites around the U.S. Falci said the Swedish facility already has multiple stem cell lines ready to go and Craig has the facilities to store the cells and conduct the trials.

“Without question, we will bring it here,” Falci said.

“Nobody can claim a miracle cure yet,” he said. “But if it works, all of us hope to see incremental steps. And that can be huge for patients.”

By Katie Kerwin McCrimmon

A new health insurance program for Coloradans with pre-existing conditions has enrolled just 800 people in its first year, but is costing much more than expected: more than $12 million so far.

Under the Affordable Care Act, Colorado is due to receive $90 million for its new high-risk health pool called GettingUSCovered. Actuaries predicted that 4,000 people would participate in the program between July of last year and January 2014, when the Affordable Care Act goes into full effect and insurance companies can no longer turn down people who have suffered previous illnesses.

Nationwide, high-risk health pools have also drawn far fewer people than anticipated. So far, about 30,000 people have signed up for the program across the country, well below the 200,000 to 400,000 who were expected to sign up between last year and 2014.

“Our enrollment is not as high as originally projected, but the expenditures are much higher,” said Steve ErkenBrack, president and CEO of Rocky Mountain Health Plans, the nonprofit health insurance company that has a contract to run Colorado’s high-risk pool.

“The people who are accessing this program are very sick, and it’s fulfilling a very crucial need,” ErkenBrack said.

Officials at Rocky Mountain Health Plans declined to give Solutions figures on the average cost per patient. They said the program is too new to provide accurate data and cited lag times in paying claims. In June, the average patient paid a premium of $355.  Individuals pay monthly premiums ranging from $116 to $729 depending their age, where they live and whether they smoke.

It’s unclear yet whether pent-up demand brought sicker people to the program in its first year. Those who sign up in the second year could have less costly health problems or costs could continue to exceed projections.

Because such sick people are joining GettingUSCovered, ErkenBrack said program managers may have to consider limiting enrollment, trimming benefits or hiking premiums to keep the program viable.

Steve ErkenBrack, president and CEO of Rocky Mountain Health Plans, the nonprofit Colorado health plan which has a contract to run GettingUSCovered. Limits and waiting lists may be necessary to slow spending. ErkenBrack: "Running out of money is not an option."

“We may need to adjust premiums and adjust who can come into the program,” ErkenBrack said. “We may need to freeze enrollment for a bit. That’s very premature, but the bottom line is that we have a set amount of dollars.”

In order to qualify for GettingUSCovered, patients must suffer from a pre-existing condition that would disqualify them from obtaining private health insurance. So, by definition they have medical challenges. And, they have to have lived without health insurance for at least six months.

It’s not a program for low-income people. The patients also must be able to pay 100 percent of their premiums, which mirror those that healthy people would pay if they were buying individual health insurance policies in Colorado.

ErkenBrack said some of those who have signed up have been severely ill patients suffering from cancer or in need of expensive transplants.

Health and Human Services Secretary Kathleen Sebelius came to Denver last week to highlight successful prevention programs at Denver Health. While in Colorado, she also met with ErkenBrack to discuss a variety of health issues, including GettingUSCovered. ErkenBrack said he did not ask for additional funds for Colorado’s program.

“At the end of the day, we have to maximize the $90 million and make sure it lasts for this amount of time. Running out of money is not an option,” ErkenBrack said. “We are looking at this very, very carefully and working with the feds to make sure the program works.”

Sebelius told Solutions that high-risk pools were always intended as bridge programs to provide immediate help for people who have been shut out of private health insurance. She said the requirement that people be uninsured for six months has been a barrier along with the costs and the lack of knowledge about the program.

Colorado runs its own program with federal dollars. But in many states, the federal government is running the high-risk pools and has lowered prices to try to attract more patients. Sebelius has urged other states like Colorado to consider lowering premiums. But lowering premiums would only compound Colorado’s problems with soaring expenses and could also bring costs below market rates for private insurance.

Some critics of the Affordable Care Act have argued that stagnant numbers in the high-risk pools are an early sign that health reform won’t work. Sebelius countered that even with relatively low enrollment numbers, high-risk pools are critical  to the people they are serving.

“There are thousands of people, thanks to the high-risk pools, who are getting care now, that in many cases they wouldn’t have gotten. In many cases, it’s life and death care. It’s frankly saving money in hospital systems. Absent the high-risk pools, these folks would still be coming to the hospitals in critical condition. They (hospitals) would just be uncompensated.”

She said the pools are giving fragile patients stability until 2014 “when we can have some really comprehensive care for these individuals.”

Nursing student’s quandary

Among Coloradans who need health insurance, but can’t qualify for GettingUSCovered is Ashley Whitney, 28, a student at the University of Colorado College of Nursing. In order to be enrolled in school, she must prove that she has health insurance or buy it with her tuition.

Whitney pays $3,300 per year for the school’s insurance, but said it’s essentially worthless because it has strict caps on medications and procedures.

Nursing student Ashley Whitney needs better health insurance, but can't go without it for six months to qualify for GettingUSCovered.

At  22, Whitney was diagnosed with Crohn’s Disease, which causes abdominal pain, digestive ailments and lung problems.

She is supposed to be taking a medication called Cimzia that costs $5,000 per month, but has stopped because she can’t afford it and can’t find health insurance that will cover such expensive medication.

The medication cap on her current insurance is $5,000 annually. She can reach that in one month. There’s also cap of $4,000 per procedure. A single MRI can cost her up to $8,000.

Whitney had never heard of GettingUSCovered and can’t afford to go six months without insurance so she can qualify. First, she might get kicked out of school. Second, an illness could bankrupt her.

“If I got sick, I don’t know what I would do. It seems like every six months, something comes up,” she said. “When I get sick, I get really sick. It usually involves CT scans and hospitalizations. I’m typically in for three to seven days.”

In 2009, Whitney had to have surgery for her illness and in 2010 she went on a program called CoverColorado. It’s Colorado’s older high-risk health pool that dates back to 1990. It does not receive federal funds.

For eight months, Whitney faithfully paid $385 per month to make sure she’d have health coverage.

“It’s like paying for a second car payment. I was working overtime and I wasn’t even sick. I thought, ‘Why am I throwing all of this away?’”

When she did need medical help, she found the coverage lacking.

“Every time I went to the doctor, I had to pay out of pocket to reach my $4,000 deductible and they didn’t cover any of my medications.”

So, after eight months, she withdrew from CoverColorado and decided to purchase the school’s health insurance. While the coverage was poor, at least she could wrap it in to her tuition payments and use student loans to pay the premiums.

“It’s very upsetting. It’s one of the worst things with health care today. People are willing to pay (for insurance) but you have to jump through millions of hoops to have decent health care,” Whitney said.

She expects to graduate in December and hopes to get a job with good health benefits.

Safety-net health pools should expire in 2014

Prior to passage of the Affordable Care Act, people who couldn’t get health insurance in Colorado could turn to CoverColorado. The nonprofit program still exists, but both CoverColorado and GettingUSCovered are slated to end once Colorado’s health exchange starts operating on Jan. 1, 2014.

Half of the funding for CoverColorado comes from premiums individuals pay. The other half is split between fees that insurance companies pay and funds from Colorado’s unclaimed property trust.

By Colorado statute, individuals pay 100 to 150 percent of what healthy people in the individual market pay. As of July 1, enrollees in CoverColorado will pay about 113 percent of the market rate, said executive director, Suzanne Bragg-Gamble.

As the economy has worsened, enrollment in CoverColorado has increased by 22 percent and now hovers at nearly 14,000 people. Money from the unclaimed property fund is running out and could pose challenges to CoverColorado’s managers.

Bragg-Gamble also works with Rocky Mountain Health Plans to administer GettingUSCovered.

She says there are two big differences in the programs. One is the funding source. CoverColorado gets no federal money. And, second, people cannot join GettingUSCovered unless they have been uninsured for the previous six months.

The rates for CoverColorado are also slightly higher since they are set at 113 percent of market rate while GettingUSCovered must provide premiums at 100 percent of the market rate.

Bragg-Gamble said it’s been difficult to get the word out about GettingUSCovered and some people who have answered a survey on the website have said they did not sign up because of cost. Nonetheless, she’s pleased with the program.

“I don’t care what people projected. We’ve got 800 Coloradans who have health insurance and they’re able to get care. I’m not ashamed of that at all,” she said.

ErkenBrack of Rocky Mountain Health Plans conceded that one challenge of the GettingUSCovered is that people are allowed to sign up for the insurance, have a medical procedure and then withdraw. If GettingUSCovered ultimately has to create waiting lists, people who leave may have a long wait to get insurance again.

“You’d need to think twice before you drop out,” ErkenBrack said.

He believes the costs for this program don’t forecast how overall health reform will work. Part of the problem is that the patients may have costlier problems precisely because they were not getting regular care.

“Illnesses don’t get cheaper if you ignore them. They get more expensive,” ErkenBrack said.

“I view this program as very successful because it has found a way to cover people who really were not able to access the system,” ErkenBrack said. “This is a very narrow subset of the population of the uninsured. It would be unreliable to project out onto the entire Affordable Care Act.”

By Katie Kerwin McCrimmon

EVERGREEN – Thunder rumbles through this mountain town, loudly heralding a summer storm that puts locals in the mood for a hot lunch.

At Da Kind Soups, owners Dustin and Ariane Speck (the D & A in the restaurant’s name) serve steaming bowls of soup to customers who duck in out of the rain. Every day, there are 10 fresh soups that Dustin has created that morning, ranging from their best-selling tomato to spicy Cajun shrimp, mushroom rosemary, buffalo chili and special concoctions like a pumpkin bisque with chocolate shavings.

On this June day, a young woman, home from college for the summer, comes in with her mouth swollen and barely able to talk. The cause: dental surgery to remove her wisdom teeth. A mother brings in her young son and lets him choose big containers of soup to take home. He’s just had his tonsils removed.  An elderly couple huddles over the classic combo that they’re sharing: tomato soup with grilled cheese.

Since opening four years ago, Da Kind Soups has become Evergreen’s comfort headquarters. Their motto: “Live a kind life.”

Exactly one year ago, however, the restaurant and the Speck family suffered a nearly fatal blow when Dustin experienced the most excruciating headache of his life while at the restaurant. For a short time, Dustin and Ariane debated whether to call 911. The couple had given up their health insurance in 2007 after struggling to pay $800 a month for COBRA health benefits while pouring all their cash into the new business. When they tried to get health insurance again, Dustin was turned down since he had a history of head and neck pain. The Specks knew an ambulance ride would be costly.

Dustin Speck arrives in his kitchen at 5 a.m. to make 10 new soups each day. Stuck in the hospital for three weeks after his stroke, Speck tasted soups from his hospital bed to make sure his assistants were getting the recipes just right.

“Just call,” Dustin finally said. He had suffered from migraines in the past and knew this was far worse.

The call and immediate medical intervention probably saved his life.

A blood clot in his brain, known as an aneurism, had burst. He was just 41. Arteries in his brain that should have flowed freely instead bumped into a T-shaped blockage. Pressure created a bubble of blood on the other side of the T, which finally burst. Dustin may have been born with the condition. Or it might have developed in adulthood.

Recovering from the rupture required a three-week stay at St. Anthony Central in Denver. But survival was a gift. The family later learned that strokes like the one Dustin suffered kill as many as 75 percent of their victims.

Dustin, Ariane and their two boys, Harrison, now 11 and Taggart, now 9, celebrated the Fourth  of July last year by watching fireworks from the roof garden at the hospital. While Dustin, who only recently had started writing down his recipes, worried about keeping his assistant chefs supplied with the formulas for the more than 450 soups he makes, Ariane fretted over the bills. All told, the hospital bill came to $350,000 and was as thick as the Evergreen phone book.

Word that the “soup man” was sick spread quickly in this small community and donations started pouring in. Dustin and Ariane had made spreading kindness their mission. Now Evergreen was returning the favor. Dustin’s stroke coincided with Tag’s eighth birthday. To be sure that Tag didn’t feel forgotten, a friend put together an impromptu party and helped Ariane’s parentstake care of the boys.

Another friend had a home near the hospital and arranged for Ariane to stay there. Cards flowed in, some on cute soup can designs. One customer wrote: “You are too important to this community for anything to happen to you.”

“Everybody just chipped in,” said Judi Justus, Ariane’s mom. “We felt the love. We felt the kindness.”

Employees at Da Kind Soups took over the cooking and kept the restaurant open. From his hospital bed, Dustin insisted on tasting samples to make sure the employees were getting the recipes just right.

Ariane Speck leans over the counter to chat with children while her husband, Dustin serves up soup. After Dustin's stroke, Ariane worried that medical bills would destroy their popular business. Health insurance for Dustin has allowed the family to focus on his healing and preserve their income along with jobs for Da Kind Soup's eight employees.

Dustin and Ariane’s restaurant had survived its beginnings during a terrible recession. They had earned kudos from 5280’s editors as the Denver area’s top soup joint. While facing massive medical bills, Ariane’s greatest fear — on top of worrying about Dustin’s survival — was that the family would lose both their business and their home. She worried that the restaurant would collapse, that their only source of income would be gone and eight loyal employees — four full-time, four part-time — would be out of work.

“Our community and staff rallied around us in a circle of support and kept our restaurant open while we were away from it for the first time in three years,” Ariane said.

By late summer, Dustin and Ariane were receiving help negotiating their hospital bill to make it more affordable, and serendipity brought them hope that they could someday get health coverage and fight their way out of debt.

A customer happened to mention that he was working on health care reform. He knew that under the Affordable Care Act there was a new program that allowed people with pre-existing medical conditions, like a stroke, to get health insurance. By November, Dustin was enrolled in Colorado’s new high-risk pool. It’s called GettingUSCovered.

The family pays the same rate for individual health insurance that a healthy adult in their area would pay.  For Dustin, that means a bill of $371.28 per month. That price will go down next month because Dustin quit smoking two weeks before his stroke and once you’ve been smoke-free for a year, you pay less.

There are deductibles and co-pays as well. But the Specks are willing to pay their share — amounting to thousands a year — because they are so grateful for the peace of mind the insurance brings them.

“It’s absolutely amazing,” said Ariane. “There was so much anxiety in addition to worrying about Dustin’s health. Now we can concentrate on him getting better. We know we’re going to be OK.

“(Without health insurance) we wouldn’t have been able to keep our business open because of all the financial stress and strain. Not only would we not have our business, but our employees would have lost their jobs and we could have lost our house.”

Not surprisingly, Dustin has needed follow-up medical care.

Six months after the stroke, an angiogram found that he needed a stent to divert the blood, and doctors thought they would have to do another surgery to shrink the aneurism, which was growing again. In March, his doctor went in to do another brain surgery and found that the aneurism had shrunk to nothing on its own, an outcome the doctor had only seen in two other patients.

Dustin and Ariane Speck remodeled a 7-Eleven to create a warm atmosphere for their soup restaurant which has become Evergreen's comfort headquarters. A collection of ladles hangs on an exposed brick wall.

With the additional surgeries, Dustin and Ariane quickly met their $2,500 annual deductible. There are other expenses. They must pay 20 percent of the first $6,000 in annual medical expenses. After that, the plan covers 100 percent.

“It has changed everything. Paying $6,000 is a lot of money. But it’s a lot more manageable than paying $60,000 or $600,000,” Ariane said.

She now regularly spreads the word about Colorado’s high-risk insurance pool and shared her thoughts about health coverage at a recent gathering at Evergreen’s fire station.

Remarkably, Dustin has no lingering deficits as a result of his harrowing medical ordeal. It took time for the blood to drain from his brain and for the pain to recede. Many stroke victims have trouble speaking or lose motor skills on one side of their body. Dustin carefully abided by doctor’s orders, limiting his hours to just 10 a week when he first went back to work and getting help lifting the giant  50-pound, 35-gallon soup pots.

He now can work full time again. Each morning, he arrives at the restaurant at about 5  to begin crafting that day’s soups by hand and always from scratch. The couple remodeled an old 7 Eleven. From the outside, the familiar box shape gives away its roots. Inside, a soothing curvy counter, exposed brick walls, giant windows with a view of surrounding pine forests and homey touches like a cookbook and ladle collection give the place a warm atmosphere.

Several generations of a family walk in. Dustin is manning the soup counter.

“Who wants a taste?” he says, proudly describing each soup.

The customers sip tiny cups of soup and smile as they ponder their choices. Ariane is working the cash register. She leans low to get eye-level with the kids and talks to them about how summer is going.

Then, she tells their mothers to look at a framed baby picture she has leaning against the register.

“This is my baby,” she says. “It’s his birthday today. He’s turning 9.”

A big smile on her face, she doesn’t mention that it’s also the same day that her husband collapsed one year ago. Ariane worried about the anniversary. She feared that something might happen again. But the day passed uneventfully. Rain fell lightly through the afternoon, bringing the customers in. The next morning, a new day found Dustin back in the kitchen, making 10 new soups.

Surviving has given the Specks a new perspective on the value of life, their family, their community and a safety net support system that has given them health coverage and kept their business alive.

Said Ariane: “People who are at high risk are the people who need it the most. It should just be something we don’t have to think about.”

By Marguerite Salazar

The Colorado community will celebrate the one-year anniversary of the establishment of the GettingUSCovered health plan on July 1. GettingUSCovered is a Colorado-specific program under the Affordable Care Act of 2010 that provides comprehensive health insurance for eligible uninsured Coloradans with a pre-existing condition who have gone without coverage for six months.

This new health plan is designed to act as a temporary bridge to 2014 when Americans will have access to affordable health insurance choices through a competitive marketplace called an exchange. Also, in 2014, thanks to the new consumer protections in the Affordable Care Act, insurance companies will not be able to deny coverage to adults based on a pre-existing condition.

GettingUSCovered has already proven to be successful in the Colorado community by making access to health insurance easier than ever before. Today, GettingUSCovered has increased access to care for 830 previously uninsured Coloradans, making this new health plan a welcome option to receive the much-needed care of Colorado residents.

Early last fall, I was lucky enough to speak with a man from Colorado who enrolled in this new insurance program.  Working in the service industry, he was not provided health insurance through his employer.  When he tried to purchase it on his own, he was denied because he needed two hip replacements.  Working as a bartender, he was on his feet for several hours a day, and without the surgery, he would have been forced to quit his job, and file for disability.  Today I can happily report that both surgeries were successful, and this man continues to be a working, contributing member of our community.

We underestimate the importance of access to care, and how critical it is to help people lead healthy and productive lives.  This new plan in Colorado, GettingUSCovered, offers a broad range of health benefits, including primary and specialty care, mental health coverage, nationally recommended preventive care services, and prescription drugs. These benefits apply to those with a pre-existing condition without the imposition of a higher premium. Eligibility is not based on income allowing denied individuals access to one of the largest networks of physicians in the state. This network includes more than 2,500 primary care physicians, 9,000 specialists and 99 hospitals statewide.

Also, this program encourages individuals to take advantage of the age and gender specific screenings offered as preventative services, which are covered 100 percent after a physician’s office co-pay. Some of the covered preventative care services include:

• Adult routine examinations
• Immunizations
• Smoking cessation programs and patches
• Pelvic exams
• Pap smears
• Mammograms
• Colonoscopies
• Prostate exams
• Flu shots

People struggling with pre-existing health conditions need affordable and accessible medications to help manage individual illness. The GettingUSCovered pharmacy benefit plan encompasses a statewide network including King Soopers, Safeway, and Walgreens allowing individuals to choose a pharmacy based on convenience while providing a comprehensive benefit to cover medications.

GettingUSCovered is funded by enrollee premiums and federal funding, and the rates do not change because of individual health conditions. An enrollee would not be subject to pay more than the rate a person without any health conditions would pay. Rates are based on age, county of residence and smoking status. Premiums range from $115 to $601 a month for non-smokers. A tool for determining individual rates is available at the website listed in the tab Check Rates.

In order to be eligible for the GettingUSCovered Plan, a Colorado resident must be a U.S Citizen (or have a lawful presence in the U.S), have been uninsured for the past six months (excluding individual receiving COBRA benefits) and have a pre-existing condition.

An applicant must submit all requested information by the 15^th of every month to be considered for the first of the following month. However, if the 15^th falls on a weekend or a federal holiday, then the application is due to the office the Friday prior to the 15^th.  Applicants are also required to submit a voided personal check (no business or temporary checks accepted) along with the application. It takes approximately two weeks to process an application. Individuals will be notified regarding their application status.

We are lucky that Colorado has such a robust program in place, and we look to this as just one of the many successful new opportunities available through the passage of the new federal health care law, the Affordable Care Act.

Marguerite Salazar is the regional director of the U.S. Department of Health and Human Services.

For more information, including eligibility, plan benefits and rates, as well as information on how to apply, please visit www.gettinguscovered.org. Or call 303-749-1109 (Denver metro) or toll-free: 877- 397-1109 (8am- 5pm M-F).

Rep. Jim Riesberg, D-Greeley, will resign his House seat on Thursday to become Colorado’s new insurance commissioner starting Friday, Gov. John Hickenlooper announced on Monday.

“Jim has deep experience as a legislator and public servant. He also has a distinguished career in the insurance, human resources and private sectors,” Hickenlooper said in a prepared statement. “He shares our commitment to an ethic of outstanding customer service and we are pleased to have him as the new commissioner.

Riesberg will replace John J. Postolowski, who was appointed as interim insurance commissioner on December 1. Postolowski joined the Division of Insurance in 1998, and was eventually promoted to his current deputy position in 2004.

“We also want to extend our thanks to the interim director of the Colorado Division of Insurance, John Postolowski for his service. We are delighted that he will return to his deputy role and continue to work with us,” Hickenlooper said.

Riesberg was first elected in 2004 to represent House District 50 (Greeley, Garden City and Evans) in the Colorado General Assembly. He is the ranking member of the Health and Environment Committee and a member of the Appropriations Committee.

“It’s truly an honor to be selected by Gov. Hickenlooper to oversee the Division of Insurance for the state and to be recognized for my decades of experience in this field.  There’s important work to be done, including implementing the Health Benefit Exchange. This position will require striking a balance between the needs of the insurance industry with the needs of consumers, and I’m confident this can be accomplished. I look forward to working with consumers, the insurance industry, the Department of Regulatory Affairs, the Governor’s Office, and my colleagues in the legislature in this new capacity,” Riesberg said.

Riesberg is a Colorado native who has lived in Greeley for 30 years. He worked for 24 years at various insurance and human resource companies, including Allstate Insurance Co. and Hearth Company Real Estate and Insurance. He also spent 16 years in leadership roles with nonprofit organizations specializing in aging, hunger and housing issues. He also taught junior high school for five years.

Riesberg has earned many honors, including the “Defender of the Patient” award from the Colorado Medical Society and Weld County Medical Society, the “Outstanding Achievement” award from the Colorado Alzheimer’s Association, and the “Legislator of the Year” award from Colorado Bioscience Association.

Riesberg earned a bachelor’s degree in history and a master’s degree in gerontology, both from the University of Northern Colorado. He completed the Graduate Realtor’s Institute and holds numerous certificates and awards for courses in insurance, real estate, sales training and personal development.

By David B. Kopel

Within a few weeks, the federal courts of appeal may begin handing down their decisions in the constitutional challenges to President Obama’s “Patient Protection and Affordable Care Act.” (PPACA). By now, almost everyone agrees that one or more of these cases is headed to the U.S. Supreme Court.

When the PPACA was moving through Congress, there was a lot of bluster from proponents of the law, who insisted that there were absolutely no potential constitutional problems. Most famously, House Speaker Nancy Pelosi scoffed “Are you serious?” to a journalist’s question about the law’s constitutionality.

As it turns out, there are a lot of serious questions. Rather than being solidly grounded in established constitutional law doctrine, the PPACA pushes into several gray areas. That doesn’t mean that the appellate courts and then the Supreme Court will rule against the PPACA, but it does mean that to uphold the PPACA, courts will have to break new doctrinal ground.

Although there have been many suits filed over the PPACA, let’s focus on the cases that have advanced to the appellate courts, and that appear to have the best chance of eventually being granted a writ of certiorari by the Supreme Court. (A writ of certiorari is an order by the U.S. Supreme Court, or the Colorado Supreme Court, telling a lower court to send to the supreme court a certified, complete record of the case, so that the supreme court can decide the case. The U.S. and Colorado Supreme Courts both have almost complete freedom to choose which cases they will hear, and the writ of certiorari is the formal mechanism by which they exercise that choice.)

Thomas More Law Center v. Obama. Oral argument has already taken place before a three-judge panel of the Sixth Circuit Court of Appeals. (There are 12 federal circuit courts of appeal, each of which covers a particular region of the U.S. Here in Colorado, we are in the 10th Circuit; the Sixth Circuit covers Michigan, Ohio, Kentucky, and Tennessee.) The plaintiffs are appealing from the federal district court (trial court) decision upholding the PPACA.

Cases that are appealed to a federal circuit court are heard by a three-judge panel, which is randomly selected from 10 or more federal appellate judges in that circuit. Making predictions about case results based on oral argument is risky, but based on the oral argument, observers think that there is some possibility that the three-judge Sixth Circuit panel might rule against the PPACA.

Virginia v. Sebelius. Brought by the Attorney General of Virginia, and based in part on the conflict between the PPACA’s individual mandate and a Virginia statute, which protects people from being forced to buy health insurance. The trial court ruled against the individual mandate. The Fourth Circuit (covering Maryland to South Carolina, but not D.C.) tends to be very friendly to government power at all levels, and the oral argument indicated that the circuit judges were inclined to uphold the PPACA.

In an interesting twist after oral argument, the Fourth Circuit asked for additional briefing, which suggests that the court may not reach the merits of the PPACA.

The main argument in favor of the individual mandate is that it is an exercise of the power that the Constitution grants Congress “To regulate Commerce…among the several States.”

As a backup theory, the U.S. Department of Justice has argued that the penalty for not buying the type of insurance required by the individual mandate is an exercise of Congress’s enumerated power “To lay and collect Taxes.” This argument has been a loser in all the district courts, rejected even by district court judges who upheld the mandate under the interstate commerce power.

The Fourth Circuit, however, appears more sympathetic. The Tax Anti-Injunction Act is a federal statute, enacted in 1867, which essentially says that most challenges to the legality of a federal tax cannot be considered by a court until the tax is actually due. Because the mandate does not go into effect until 2014, a legal challenge to the mandate in 2011 might be premature. (Assuming that the penalty for not obeying the mandate really is a tax,  even though the PPACA itself calls the penalty a “penalty” and not a tax; an earlier version of the bill had characterized the penalty as a “tax,” but this was changed in the version that was enacted by Congress.)

The Fourth Circuit’s request for additional briefing on the Tax Anti-Injunction Act indicates that the Circuit may throw the case out as premature.

In the Fourth Circuit, Virginia v. Sebelius has been consolidated with Liberty University v. Geithner. Liberty University, founded by the late Jerry Falwell, lost this case in the district court.

Florida v. Department of Health and Human Services. Florida and 25 other states, including Colorado (led by Colorado Attorney General John Suthers), as well as the National Federation of Independent Businesses, won the case in the district court. Oral argument before the 11th Circuit (Florida, Georgia, Alabama) indicates that this case is the most likely one to produce an appellate decision against the PPACA.

Besides the individual mandate issue, the Florida case also challenges the PPACA’s requirement that states must either dramatically expand their Medicaid programs, or face a complete cut-off of all federal funds, even for current levels of Medicaid.

The 1987 Supreme Court case South Dakota v. Dole upheld a federal law that cut federal highway grants by 10 percent for states that did not raise their drinking age to 21. Chief Justice Rehnquist’s opinion for the Court said that conditional federal grants to states were permissible, but warned that some grants might be so coercive as to violate the 10th Amendment and principles of federalism.

Since 1987, no court has found any conditional federal grant to be invalid under South Dakota v. Dole, but no case until now has involved such vast sums of money, or funding which has become such a major part of state budgets.

To the surprise of many, the 11th Circuit judge’s questions during oral argument indicated that they were taking the South Dakota problem very seriously.

Finally, there is Seven-Sky v. Holder, in the federal Circuit Court of Appeals for the District of Columbia. Oral argument will not take place until September. The cases raises not only the standard issue (whether Congress can impose the individual mandate via its interstate commerce power or its tax power), but also a First Amendment question.

All the Seven-Sky plaintiffs are individuals who, for one reason or another, have religious objections to using the standard services of western medicine. The PPACA contains no exemption for such people. The PPACA has an exemption for some persons in certain “Health Sharing Ministries,” and also has a narrow clause for conscientious objectors; the Amish are exempt, but Christian Scientists are not, nor are members of any religion which was created after 1950.

The Seven-Sky lawyers are from the American Center for Law and Justice, a public interest law firm with a long record of success in religious liberty cases, including in the Supreme Court. They argue that the mandate violates the First Amendment’s guarantee of free exercise of religion, as protected by a federal statute called the Religious Freedom Restoration Act (RFRA). That 1993 law provides that the federal “Government shall not substantially burden a person’s exercise of religion even if the burden results from a rule of general applicability.”

Under RFRA, the federal government may substantially burden religious freedom only in “furtherance of a compelling government interest,” and even then, only when the burden is the least restrictive means of furthering that compelling interest. The Seven-Sky plaintiffs argue that the PPACA’s refusal to exempt genuine conscientious objectors who do not fit into PPACA’s narrow exemption categories violates RFRA.

What next? When you lose a case before a three-judge Circuit Court of Appeals panel, you have the option of petitioning for a rehearing “en banc.” An en banc rehearing of the case takes place before all or most of the appellate judges for the Circuit. (E.g.,  in the 11th Circuit, all 11 circuit judges would hear an en banc case.)

Because there are so many judges involved, it can take a long time for an en banc hearing to be scheduled.

The grant of en banc rehearing is purely discretionary, and requires a vote of the majority of the judges in the circuit. (E.g., 6 of the 11 judges of the 11th Circuit.)

Instead of requesting an en banc rehearing, a losing party may simply petition the Supreme Court for a writ of certiorari.

Of course a party can request an en banc, and if the en banc request is denied, the party can then attempt to go the Supreme Court. If the Circuit does grant an en banc rehearing, whoever loses that hearing can then ask the Supreme Court to take the case.

In the PPACA litigation, the Obama administration has been doing everything possible to slow the cases down. The longer the delay, the greater the window of opportunity for President Obama to appoint another Supreme Court Justice. So if the PPACA loses in any Circuit Court, the administration will almost certainly petition for en banc rehearing.

Conversely, the various plaintiffs would, if they lost in a Circuit Court, almost certainly skip the en banc, and would immediately file a petition for a writ of certiorari to the Supreme Court.

Thus, although losses in the Circuit Courts of Appeals would be terrible for PPACA supporters in terms of public opinion, losses would give the Obama administration the tactical freedom to use en banc rehearings to keep the cases away from the Supreme Court for up to one additional year.

However, the winning plaintiffs could have one important additional tool to keep the cases moving forward. If they win on some but not all of the issues they raise, they could, as the losing party on some issues, try to go directly to the Supreme Court. The Supreme Court, if it decided to hear a particular case, would then have the option of considering all the issues, regardless of who won or lost in the lower courts.

So the most likely outcome is that at least one of the cases discussed above will be ready for the Supreme Court to consider sometime during its next term, which begins in October 2011, and will end in June 2012.

David Kopel is research director for the  Independence Institute and adjunct professor of advanced constitutional law at the University of  Denver Sturm College of Law.

By Bob Semro

The future of national health care reform under the Affordable Care Act may hinge on a single provision in the new law. The individual mandate, or the “minimum essential coverage provision,” requires most uninsured Americans to purchase health coverage or pay a tax penalty. The big question is whether the individual mandate is constitutional.

Twenty-six state attorneys general (25 Republicans, including Colorado’s John Suthers, and one Democrat) have joined the state of Florida in challenging the mandate. That case, State of Florida vs. U.S. Department of Health and Human Services, represents the most significant test of the mandate. Oral arguments were heard June 11 in the 11th Circuit Court of Appeals in Atlanta.

The three hours of arguments covered many technical issues and addressed other topics, but the main focus was on the mandate provision. The basic arguments were fairly straightforward.

Opposing arguments

Opponents contend that if citizens make the decision not to buy health insurance and assume financial responsibility for their own health care, then they should have that right.

Thus, the question, as stated by Paul Clement, the attorney representing the states, is whether Congress has the authority (under its power to regulate commerce) to compel an individual to engage in commerce in order to better regulate it. According to the attorney general of South Carolina, “For the federal government to be telling people that they must buy health insurance, or they must buy anything at all, is not one of the powers that is given to the federal government by the Constitution.”

The mandate’s opponents argue that the Commerce Clause of the Constitution, from which this power would arise, applies only to “economic activity.” Failure to buy insurance is the opposite — “inactivity.” It is therefore unconstitutional to compel Americans to engage in a form of economic activity that they would not otherwise choose to be a part of. Clement said that in the more than 200 years that Congress has exercised its commerce powers, no similar law has ever been imposed and no legal precedent or past court case supports such an action.

Supporters of the individual mandate contend that everyone will ultimately engage in this form of commerce, since everyone will eventually have to use and pay for health care. However, Clement argued “they are not engaged in commerce if they are sitting in their living rooms,” and even if they may need health care at some point in future, right now they do not.

Clement suggested that it would be constitutional to require the purchase of health insurance at the time of medical treatment — basically, after the individual has chosen to engage in commerce. He also said that Congress took the easiest path by imposing an individual mandate rather than a more constitutionally viable approach, such as passing a tax and then providing a credit to individuals who purchase health insurance.

Finally, the attorneys for the states argued that if the individual mandate and its broad definition of commercial regulation were upheld, it would represent an unconstitutional expansion of federal power and authority that could extend beyond health care. According to Judge Roger Vinson of the Federal District Court of Northern Florida, in the ruling that led to last week’s hearing, “If Congress can penalize a passive individual for failing to engage in commerce, the enumeration of powers in the Constitution would have been in vain, for it would be difficult to perceive any limitation on federal power.”

Supporting arguments

Neal Katyal, the acting solicitor general of the United States, said that the purpose of the mandate is neither to force Americans to buy a private product nor expand congressional authority. “It’s about how and when health care will be paid for,” he said. The individual mandate is commercial and economic in nature, it substantially affects interstate commerce, and as such, is entirely within the powers granted to Congress by the Constitution. If the provision were determined to be unconstitutional, it would seriously undercut the ability of Congress to regulate this major sphere of national commerce.

It is true that health care and health insurance represent a significant portion of the national economy. A study from the Department of Health and Human Services in 2010 indicated that in the previous year, health care spending was estimated to be 17.6 percent of the gross domestic product (GDP). That is equal to $2.5 trillion, or about $8,047 per person. The same study, done prior to the passage of the Affordable Care Act, projected that those costs would almost double by 2019, to $4.7 trillion. In 2009, private health insurance spending was projected to be about $854 billion and covered medical supplies, drugs and equipment that are shipped between states.

Katyal insisted that the issue of inactivity was irrelevant to the constitutionality of the mandate because health care is unique when compared to all other commercial markets. At some point in time, virtually every American will use health care, unlike any other commercial market or activity. No American can or will remain inactive permanently. Secondly, because hospitals cannot turn away patients based upon inability to pay, the cost of uncompensated care is passed on to individuals and employers who have health insurance. No other commercial sphere functions in the same way.

He said the argument boils down to “the failure to pay and not the failure to buy” and noted that $43 billion in uncompensated care is passed on or shifted to other Americans each year. This represents an increase in premium costs of more than $1,000 annually for each American family. Rather than an effort to make individuals buy a private insurance product, the mandate is about ensuring that the cost of their care will not be disproportionately shifted on to others.

Through the powers granted by the Commerce Clause, Congress chose the individual mandate because it is based upon the existing private insurance system and is the most effective way of regulating this commercial sector. A radical restructuring of the system, state-based alternatives, incentives or tax options would not address the problem as efficiently or effectively.

Finally, responding to the argument of expanding federal control and authority, Katyal argued that the individual mandate represents a unique solution for a unique market. It is not universally applicable to other forms of federal regulation and oversight. In addition, other provisions of the Constitution and legal precedent will prevent the wholesale expansion of federal authority. For this approach to be used again, the problem must be economic, it must substantially affect commerce, it must solve a national and not local problem, there must be direct causation and it cannot contravene other provisions of the Constitution.

The debate between these positions will likely continue throughout this year and the next. While the legal arguments will be based in case law and precedents, the core of each position will likely remain the same.

Bob Semro is a policy analyst at the Bell Policy Center, a nonprofit, non-partisan policy research center based in Denver.

By Diane Carman

Effective July 1, Colorado will join 17 other states in dropping coverage for routine circumcisions under Medicaid. The move was part of a series of budget cuts approved by lawmakers during the recent legislative session.

The decision will save the state’s general fund an estimated $186,500 annually, but it also will nudge Colorado closer toward a debate that has been growing in intensity across the country. In Massachusetts, a bill banning routine circumcision was introduced in the state legislature last year. Bans also have been proposed in Santa Monica, Calif., and San Francisco, where voters will decide in November whether to make the procedure a crime.

Gillian Longley

Gillian Longley, a registered nurse in Louisville, looks at the change in Medicaid policy as a critical moment for public education surrounding the issue. A member of the National Organization of Circumcision Information Resource Centers (NOCIRC), Longley said that until recently, new parents were remarkably ill-informed of the pros and cons of circumcision.

“Doctors were not giving them the information they needed to make a decision,” she said. “The usual ethical requirements for informed consent were overlooked. Circumcision was a cultural habit that was accepted as normal.”

Circumcision is the most common medical procedure performed on children in the United States, but is far less common around the world. According to data from the World Health Organization, 75 percent of men in the U.S. have been circumcised compared to 30 percent in Canada and 6 percent in the United Kingdom.

As states have dropped coverage for the procedure under Medicaid, circumcision rates have dropped. Researchers from UCLA studied 16 states where circumcision is not covered and found that the rate dropped 24 percent below rates in states where Medicaid covers the cost. The researchers said if Medicaid covered circumcision in all 50 states, the rate for newborns being circumcised would increase to 62.6 percent. If all states dropped the coverage, the rate would decline to 38.5 percent.

No medical justification

Colorado lawmakers had to cut hundreds of millions from state spending to balance the budget this year. Halting Medicaid coverage for circumcision is increasingly common across the country and is a relatively easy choice because there is no medical justification for the procedure.

“The medical reasons are not convincing either way,” said Dr. Susan Pharo, director of Medicaid and External Pediatric

Dr. Susan Pharo

Care for Kaiser Permanente.

Research has found a “tiny” benefit in terms of circumcision reducing the frequency of urinary tract infections in the first year of life, Pharo said, “but the numbers are so low it’s not significant.”

Some research has found a slight decrease in the transmission of HIV and sexually transmitted diseases among circumcised men in sub-Saharan Africa, “but that’s not really applicable here,” Pharo said, “and the evidence is not strong either way.”

The risks of the procedure include relatively rare incidence of complications such as bleeding and infection and, more commonly, “poor cosmetic effect,” said Dr. Sarah Pilarowski, pediatrician at Cherry Creek Pediatrics.

“We do have a lot of baby boys going in later for revisions,” she said.

The No. 1 risk is pain. “We try to minimize it,” Pilarowski said, but penile nerve blocks don’t always work and numbing creams “are not 100 percent.”

Since 1999, the American Academy of Pediatrics has not recommended routine circumcision. A task force convened on the issue concluded that the “potential medical benefits … are not sufficient to recommend” it.

Cultural factors still important

The AAP defers the decision to parents, saying that it is “legitimate” to consider “cultural, religious and ethnic traditions, in addition to the medical factors, when making this decision.”

Acceptance of the procedure varies widely across different religious and ethnic populations. It is a culturally important tradition in the Jewish and Muslim communities, but is rare in Europe, most Asian countries and in Hispanic culture. In states with large Hispanic populations, circumcision rates are markedly lower than the national average.

“When asked by a family whether a circumcision should be done, most pediatricians  say unless there is some special reason in the family, they don’t recommend it as a general policy,” said Dr. Donald Schiff, professor emeritus of pediatrics at the University of Colorado School of Medicine.

For some families, however, the procedure is a cherished tradition.

Scott Levin, director of the Mountain States Region Anti-Defamation League, said that circumcision is “among the most sacred of obligations that Jews have” and proposed bans are an extreme affront.

“This is really about the free exercise of religion, something that is guaranteed to everyone in the United States under

Scott Levin

the First Amendment,” Levin said.

An effort to place a circumcision ban on the ballot in Santa Monica resulted in charges of anti-Semitism from Jewish groups. The author of the measure, Matthew Hess, refers to circumcision as “male genital mutilation” and ridicules the procedure in his online comic “Foreskin Man.”

The ADL issued a statement criticizing Hess’ tactics.

“This is an advocacy campaign taken to a new low,” it said in a written statement. “This is a sensitive, serious issue where good people can disagree and which the Jewish community feels is an assault on its values and traditions going back thousands of years and centered in the Hebrew Bible.  …  ‘Foreskin Man,’ with its grotesque anti-Semitic imagery and themes, reaches a new low and is disrespectful and deeply offensive.”

Hess, who is founder and president of MGMbill.org, said the ADL is “just trying to redirect the argument.

“Any time you challenge a tradition that is thousands of years old and this entrenched, you’re going to stir up fierce opposition,” he said. “Rather than address the human rights abuse of forced circumcision, they have attacked me. It’s pretty standard tactics.”

Ban written for Colorado

Hess said a bill outlawing circumcision in Colorado has been written and is awaiting a legislative sponsor. The measure would amend the existing law outlawing female genital mutilation, extending the same protections to males.

Longley said Colorado’s NOCIRC activists are not associated with Hess.

“One benefit we see in putting these measures on the ballot is that it results in a lot of public discourse about circumcision,” said Longley. “Our culture is ignorant and blind on this issue.”

In arguing against routine circumcision, Longley compared it to laws outlawing female genital mutilation. “Boys need equal protection,” she said. “We consider this a human rights issue.”

She cites the value of the foreskin in its role in male sexual function and female satisfaction. “We’ve lost the knowledge and the value of normalcy in our culture,” she said.

Schiff said evidence on the role of foreskin in sexual function is scarce and “very anecdotal. There’s nothing objective about that kind of research.”

Hess insists that male and female circumcision are exactly the same.

“You can argue about which one is more damaging or traumatizing, but the bottom line is both practices remove healthy functioning sexual tissue from an unconsenting minor.”

While he has no formal polling to cite, Hess said he believes the movement to ban circumcision is growing across the country. “Requests for interviews come in daily,” and he said traffic to his website and relevant Facebook and YouTube sites has increased dramatically.

Dr. Pharo said she has seen no evidence of a decline in support for circumcision in Colorado in her three decades as a pediatrician. “I don’t think as a society our culture has really changed very much.”

Dr. Sarah Pilarowski

That’s not surprising to Dr. Pilarowski. Outside of religious traditions, she said, the overriding factor influencing parents’ decisions about circumcision is whether the father was circumcised.

“Men want their little boys to look like them. They say, ‘I don’t know how to care for it. I don’t know how to counsel them,’” she said. “There’s a comfort level in the father and son being alike.”

If it was up to the mothers, the pediatricians said, far fewer newborn boys would be circumcised because the moms would rather not subject their new babies to unnecessary pain and risk.

Real savings questioned

Some pediatricians and family practice physicians are concerned that the Medicaid cut will result in pressure on doctors to perform circumcisions on baby boys later when the procedure is more complicated and costly. Parents who feel strongly that their sons should be circumcised could try to urge physicians to claim that it is a medical necessity at six months in order to have the procedure qualify for Medicaid reimbursement.

If even 30 or 40 such cases occurred in a year, the savings to the state would likely be obliterated.

Another concern is that with every cut in Medicaid reimbursements, more physicians reduce the number of Medicaid patients they will accept into their practices.

Pilarowski speculates that the changes in Medicaid policies will spark changes in private insurance coverage.

“Everyone is looking to cut costs,” she said. “It’s very possible other insurance companies will follow suit.”

That would be considered a victory for the anti-circumcision activists.

“This is a normal body part,” said Longley. “We are doing our sons a favor to support them to stay whole.”

Sasha Dillavou contributed to this report.

By Michael Pramenko, M.D.

Earlier this year, more than 100 physicians attended the Colorado Medical Society (CMS) Physician Summit on Payment Reform in Denver. Ninety-eight percent of them left the summit wanting to hear more and willing to stay involved with the discussion.

The importance of payment reform cannot be overstated. Here’s why.

For years now, physicians have been talking about how the practice of medicine is changing. We’ve been talking about our “new realities,” including decreasing reimbursement relative to inflation and the difficulty of maintaining a practice. At the same time, a wide range of public and private stakeholders, have recognized that the current health system is financially unsustainable and have been talking exploring ways to improve care that is also more cost effective. The main value-driving elements to this proposition are improved access and care coordination. New payment systems must be developed and operationalized with physician input in a manner that incentivizes us to practice medicine using new models that provide high quality, cost effective patient care. The dots have to get connected if the new models of care are going to be successful.

How can physicians modify our practices and invest in technology when the current fee-for-service payment system incentivizes the status quo? The tools that are fundamental to powering these value-driven elements are health information technology and payment reform. Many physicians are simply caught between a rock and a hard place during this time of transition. They are working hard to ramp up technologically, which, as we all know, is much more complicated than simply installing new equipment and hitting the “on” button. The specific problem for many of our colleagues is the inability to proceed with needed technological and logistical practice changes due to a lack of financial capital and payment systems that link back to the desired outcomes of more cost-effective, improved care. Make no mistake, doctors are being asked to change while the current payment structure for physicians relentlessly directs them down the same old path.

Physicians recognize the need for integrated care. Physicians realize the need for bending the cost curve and improving the quality of health care in Colorado. Many physicians have come to recognize that the current payment system is failing physicians and patients by failing to incentivize what is needed for us to provide high quality care for our patients in the rapidly evolving new health care environment. New payment models can play a critical role in transitioning our respective practices to achieve our goals. In other words, we can’t get where we want to be by building on the current payment model unless the Congress, the legislature and business decide to seriously upgrade reimbursement. We can’t get there from here.

So what are our options in payment reform? Renowned payment reform expert Harold Miller has said that the current payment system has created an environment where existing stakeholders think that each can only gain at the other’s expense, whereas he believes that there are win-win opportunities for everyone if they could work together to find them. If we are committed to seize win-win opportunities to ensure that payment and delivery system reforms evolve in the right way, then we need physicians at the table shaping the conversation.

This win-win concept provides the perfect framework for our future conversations within the house of medicine and with other critical stakeholders.

On your behalf, CMS is seeking solutions to these barriers that impede our progress. A project of this size and scope will require collaboration, cooperation and leadership. It will require all of us working together to find the win-win payment reform scenarios. It will require us to think in a new way and that new way of thinking will apply to other stakeholders as well. Health plans, health systems, employers and consumers are all critical to this discussion.

These, and other important questions, are being debated at CMS. Indeed, to reach the lofty goals of health reform we will need stronger lines of communication within the house of medicine and new relationships and new collaboration with other stakeholders, such as hospitals, payers, business and consumers. Is that possible? Is that a realistic expectation? Whether or not it is realistic or possible, we cannot sit on the sidelines. The conversation is underway for the good of the patient, the economy, other stakeholders and our profession.

Despite the difficult task at hand, CMS is developing a path to move forward on payment reform by reaching out to our members, creating cross-specialty discussions that are collegial and safe, and building new bridges, new partnerships and new projects. This means greater collaboration at a level previously deemed impossible. If a state exists that can do this, I believe that it is Colorado. CMS is open for business and ready to meet with any and all stakeholders to find the win-win scenarios that benefit all and increase the quality of health care in Colorado. Let me know what you are thinking by contacting me at president@cms.org.

Michael J. Pramenko, MD is a family physician in Grand Junction and president of the Colorado Medical Society.  He is one of 15 members of the federal CO-OP Advisory Board, appointed by the U.S. Comptroller General to advise the Secretary of Health and Human Services and the U.S. Congress on the creation of qualified nonprofit health plans as part of the Patient Protection and Affordable Care Act enacted in 2010.

By Myung Oak Kim

Most doctors in Colorado and across the United States still use a pen and paper to keep medical records. But those days are numbered. The health care industry is (finally) stepping firmly into the digital age.

Spurred by new incentives and regulations from the federal government, thousands of medical providers are making the costly and arduous transition to electronic medical files, digital information sharing and computerized analysis of patient data to improve care and reduce costs.

“We’re finally joining the rest of the world,” said Michael Pramenko, president of the Colorado Medical Society, the

Dr. Michael Pramenko

state’s largest organization of physicians. “Doctors are very slow to this. If you look at other business entities, they did this 10 years ago.”

Tough for small practices

“The challenges cannot be overstated, especially for smaller practices. There’s no way for some doctors to do this, unless they get a second mortgage on their home,” he said. At the same time, given how the health care industry in changing, “you really have to have electronic records to get where we need to go.”

While precise statistics are not available, at least one-quarter of Colorado medical providers are currently using some form of electronic records. Some use electronic medical records, which can only be shared within the practice. Others are using electronic health records, which have the added feature of interoperability — the ability to share information outside of the practice. Some medical groups in Colorado, such as Kaiser Permanente and the Quality Health Network on the West Slope, have been using electronic records for many years. But most of the transitions from paper to computer files, especially among independent primary care providers and specialty groups, have taken place in the last few years.

“Up until very recently, it was the Wild West of health technology. Nobody knew how to apply it appropriately and people were spending a lot of money to do it,” said Phyllis Albritton, executive director of the Colorado Regional Health Information Organization (CORHIO).

Phyllis Albritton

CORHIO facilitates the implementation of health information exchanges – systems that allow multiple provider groups to share medical records. They are on track to establish exchanges in every Colorado community by 2015. Its sister organization, the Colorado Regional Extension Center (CO-REC), assists medical providers with implementing electronic health records.

Federal incentives spark change

Major federal legislation, including the American Recovery and Reinvestment Act, the HITECH Act and the Affordable Care Act, have provided incentives, guidelines and regulations about electronic records that have spurred many medical providers to make the jump. They include financial reimbursement from Medicare (up to $44,000 per physician) and Medicaid (up to $65,000 per physician) for HIT implementation. Now, doctors have a price point to look at when deciding how much to spend on a new health information technology system, along with details about what the systems need to do.

Albritton said the new federal laws have helped make the implementation of HIT less like the Wild West. There are also more doctors who have experience with the technology and can say how it affects their work and patient care.

Pramenko has used electronic records for the last 10 of his 13 years in practice. He and the 30-plus physicians at his Grand Junction practice implemented electronic medical records in the 1990s and converted to a more advanced system about five years ago, he said. Their upfront costs exceeded $1 million.

He said digital records help reduce unnecessary tests and procedures and quicken data capture and analysis. The doctors order fewer tests now because they can see in the files that patients have already had those tests done.

They gained staff efficiency by not needing to file and locate paper charts. But they also hired three full-time IT specialists. Are they saving money? “It’s a wash,” Pramenko said. However, the electronic records help the practice provide better care and better communication among staff, he said.

The 13 doctors at the Mountain Family Health Centers on the West Slope have been using electronic medical records for about four years, said executive director David Adamson. They plan to install an interface to join the Quality Health Network, a regional health information exchange, which will allow them to share information with other providers in the region.

Systems improve care

Adamson said his health centers have been able to analyze patient data for chronic diseases, such as diabetes, using a new data warehouse that was implemented with a grant from the Colorado Health Foundation. This has helped improve care. But the true benefits of electronic records won’t be seen until the health center is connected to the surrounding medical community, he said.

Adamson said the greatest challenge during the transition was making doctors and other providers feel comfortable with using a computer in the exam room. Today, some doctors in his group love the electronic records and others dislike it.

Miramont Family Medicine in Larimer County, which serves 15,000 patients in four offices, implemented electronic records in 2004 and changed to a more sophisticated system in 2006. Each week, the staff analyzes patient data from its electronic health record system to determine ways to improve care and outcomes for patients. They won a national award last year for successful use of HIT.

Scott Kenyon, chief executive officer at Miramont, said the costs are steep, but patient care has improved. They order fewer tests, are more efficient with patient visits. And patients save time and have access to certain records through an online portal.

Electronic records essential for future

Kenyon and the medical and HIT officials interviewed for this article said that electronic records will be an integral part of the future of health care. The ability to gather, analyze and send data from patient files will become increasingly necessary as the health care industry moves away from a fee-for-service system and toward approaches such as accountable care organizations, they said.

“We’re getting to the point where we’re going to start getting paid in health care reform based on how we manage our population’s health and that will eventually trickle down to the physicians,” Kenyon said.

“If you look at any other industry, like the financial industry, they use technology in a successful way to reduce cost and efficiencies and improve the quality of what they do,” Albritton said. “That’s where we’re going in health care.”