Health Policy Solutions

By Harold Pollack

Health reform raises central ideological questions about the size and scope of government, about progressive taxation, about the individual mandate and more. It’s easy to forget that cost control will be a huge challenge, no matter how these ideological matters are resolved, indeed under any health system. Finding the right combination of humanity and restraint will be particularly hard in addressing life-threatening or life-ending illness. Economic incentives, American culture, a changing doctor-patient relationship and fundamental uncertainties at the boundaries of clinical care conspire against our efforts to provide more humane, more financially prudent care.

The necessity and the difficulty of these tasks were underscored by a beautiful New England Journal of Medicine essay, Bending the Cost Curve in Cancer Care, by Thomas Smith and Bruce Hillner. Their essay received favorable attention from health policy journalists. Yet because it didn’t push the usual partisan buttons, it didn’t receive much wider attention. That’s too bad, because Smith and Hillner raise many issues that apply beyond the realm of advanced cancer care. For instance, they offer a brave model of skilled providers identifying specific opportunities to reduce costs within their own specialties. They also present suggestions to address the burdens imposed by cancer overtreatment and undertreatment on patients and society as a whole.

Their first, deceptively simple recommendation is to target cancer testing and imaging to situations of proven benefit. Measured at the population level, the survival benefits of such imaging — routine mammography screening for asymptomatic young women or early lung cancer screening, for example — are often minimal or unproven. Such imaging is also quite costly. The annual direct costs run into the billions of dollars. Indirect costs include patient anxiety and follow-up treatments that can be expensive and intrusive. And, at the other end of the life spectrum, physicians are performing annual mammograms in patients who have quite limited life expectancy. Providers also implement follow-up scans searching for relapse, such as frequent PET-CT scans, that are not supported by guidelines or by clinical trial evidence.

In part, these problems reflect powerful incentives on providers, device manufacturers, and others which promote aggressive care. The problems go deeper, too.

Dr. Vivek Murthy, president of Doctors for America, e-mails that physicians spend less time with patients (not always for reasons of their own choosing) and are less likely to have important discussions with patients and families about priorities or tradeoffs in care. It takes less time to consent to an intervention or to prescribe a medication than it does to persuade a patient that an intervention or procedure is unwise. Murthy notes that one cumulative effective of millions of missed conversations is to reinforce the intervention mindset among patients. So, alongside efforts to alter physician incentives, medical schools and health care settings must equip physicians with the knowledge, the interpersonal skills and other supports to conduct these important conversations well.

Another problem may be even more challenging. We, the public, display a strong bias toward the most aggressive and costly care, often at the expense of other things. Theproliferation of $100 million proton beam cancer facilities, even as basic cancer prevention efforts go unfunded, exemplify the imbalance in urgency and priorities. Continued Medicare reimbursements for costly yet dubious medications such as Avastin for breast cancer raise inevitable questions of cost-effectiveness. Whatever your ideological perspective, Medicare should not and cannot provide a blank check to the supply-side of the medical economy, especially in a political and regulatory context in which private payers are under strong pressure to follow suit.

Smith and Hillner’s essay also raises sensitive issues regarding overly aggressive chemotherapy for patients who face fatal metastatic cancers. Given anxieties captured in the crystalline phrase “death panel,” I would not commence a national cost-control discussion within the frightening and divisive arena of end-of-life care. On the merits, though, Smith and Hillner cite much evidence that both patients and American society would benefit from less toxic and less aggressive care. When further chemotherapy is unlikely to be successful, they suggest that symptom-directed palliative care provides a better treatment course.

Ironically, the inclusion of palliative care elements within standard care may also prolong life. As Atul Gawande noted in the New Yorker, a randomized trial found that metastatic non-small-cell lung cancer patients assigned to early palliative care lived almost three months longer, on average, than their counterparts receiving usual care. The earlier palliative care group experienced higher quality of life, was less likely to display depressive symptoms and was more likely to be spared toxic side-effects of futile therapies. Some imperfectly understood combination of these benefits prolonged survival through provision of more cost-effective, less-punishing care.

Here again, we, the general public, must alter our own mindset to improve the quality of care. Metastatic lung cancer may be the most straightforward case. The majority of patients with this condition die within one year. Inclusion of palliative care and the turn away from further futile therapy are thus most compelling. Even here, though, many families hesitate to embrace palliative care because they regard loss of hope as the entry ticket. A definitive bleak diagnosis should not be required to receive services commonly associated with palliative care. All patients require effective pain management. All patients require open communication about prognosis and, often, advance care directives.

Such discussions aren’t easy, especially when families don’t fully trust the care team. Years ago, my father-in-law was diagnosed with advanced lung cancer. At one point, his doctors discussed the possibility of a punishing thoracic surgery. They were unenthusiastic. Yet our family wasn’t really ready to give up on the prospect of substantially life-prolonging care. Moreover, we weren’t very confident in his doctors. They had done a pretty poor job in the early stages of his care. They lacked the authority to say: “There’s nothing more we can do.”

Fortunately, one of my own physician colleagues mapped the options with me. He explained that surgery was unlikely to prolong my father-in-law’s life and the most likely outcome was that he would spend his few remaining months in recovery from a painful and failed surgery. A different path was chosen. He died soon after, at home, under dignified and humane circumstances in the care of his family and a local hospice.

We all must face these issues to control costs, and for other reasons, too. We can treat our loved ones, and ultimately ourselves, more effectively, more efficiently, and more decently than we often do.

Harold Pollack is a public health policy researcher at the University of Chicago’s School of Social Service Administration, and faculty chair of the Center for Health Administration Studies.

Reprinted with permission from Kaiser Health News. Click here to read Pollack’s piece at KHN and to see his other columns.

By Katie Kerwin McCrimmon

ALAMOSA – Spires from 14,000-foot peaks jut up like sentries as the five-seater plane banks into Colorado’s remote San Luis Valley.

Below, at Great Sand Dunes National Park and Preserve, giant waves of sand crash into the base of snowy Crestone Peak, a wayward beach lost in the mountains.

Madeleine Kane, a Denver medical oncologist and hematologist from the University of Colorado Cancer Center, holds a stethoscope and two poetry books in her lap. She peers out the  window as alpine lakes shimmer in the early morning light. Then she sees a quilt of mile-wide green crop circles from potato farms that signal her arrival in this sprawling valley and its largest town, Alamosa.

This 8,100-square-mile valley is as big as the state of Massachusetts. Yet there is no cancer specialist here. Poverty grips one-third of the children and 20 percent of the adults here. And while affluence has often bypassed this rural area, cancer has not.

So, three days a month, Kane flies in from Denver to see a full day’s caseload, Thanks to her visits, the patients get state-of-the-art care and access to the latest clinical trials without the added stress of a long drive to a city.

Kane has to leave home before 6 a.m., but enjoys the stunning flight through puffy clouds over jagged peaks. Only once has the weather forced her to cancel a trip.  Her patients range from Mennonites who have recently settled in the Valley to descendants of the Spanish immigrants who have lived here for hundreds of years, before Colorado was a state.

“If we weren’t coming, they would have to travel or some wouldn’t get care at all. Some people will not leave this valley, particularly older people who have lived their whole lives here. They don’t want to leave,” says Kane.

A powerful support network here helps her patients fight cancer.

“They’re not rich. They are people who don’t have a lot. Yet, they have a strong cultural heritage and very strong families,” Kane says.

Doing more with less

Visiting specialists like Kane allow the San Luis Valley Regional Medical Center to do more with less. Kane is one of 15 doctors whose specialties range from oncology to neurosurgery and cardiology who travel from Denver, Pueblo and Colorado Springs to bring specialty care to this rural valley. The hospital pays the doctors and covers their travel costs. Kane flies on Colorado’s state plane, and the hospital reimburses the CU Cancer Center for the cost.

“We get access to the best-practice medicine. But we don’t have to employ folks (full time) who logistically can’t afford to practice here,” said Timothy Pellandini, practice administrator for the San Luis Valley Regional Medical Center.

Forecasting the changes now accelerating around the country, the center has for years offered what’s called an “integrated delivery system.” About seven years ago, the specialty doctors’ businesses were teetering on the verge of collapse. The Valley has always struggled to attract and retain medical professionals and could not afford to lose its specialists. So the hospital took over the private practices and now directly employs all of the specialty providers in the Valley.

Years before policy wonks identified integrated care as a promising health care delivery model, the San Luis Valley medical center was putting integrated practices into place. The concept brings preventive, chronic and emergency care under the same roof.

The resulting cost savings and better insurance reimbursements have stabilized salaries for medical practitioners, and the Valley is now able to retain more of its doctors.

“For rural medicine, we’re really well poised for the future. We’ve been in business as an independent community hospital surviving on a 2-to-4 percent operating margin,” Pellandini said. “We’re not able to offer everybody everything.”

But, the center works to offer the patients what they need most, including cancer care and a new full-service digital mammography center dedicated to a young San Luis Valley mother who died of breast cancer.

Providing specialty care is an especially striking accomplishment here given how few of the patients have private health insurance.

About 60 percent of the hospital’s patients are either on Medicaid or Medicare, with only about 20 percent having commercial health insurance. The rest are uninsured and must pay out of pocket.

“We’re running lean and smart,” Pellandini said. “We try to keep things affordable.”

Five years ago, the medical center opened an oncology and infusion center, allowing patients to receive chemotherapy close to home. Patients who need radiation treatments still must travel to Pueblo, but for many, receiving chemo treatments in the homey center is a huge relief. Many of them are Madeleine Kane’s patients.

Cutting edge care close to home

Kane steps off the plane at Alamosa’s tiny airport. The scent of freshly mown hay hangs in the air from a farmer’s field next to the runway.

A woman in scrubs is there to meet her. Brenda Gentile is the hospital cancer program’s patient navigator. She will spend her day doling out sympathy, helping patients coordinate their medical care and finding other services they need. For instance, if a patient has no health insurance, Gentile will hunt down free or discounted chemotherapy drugs. If others are struggling with bills, she’ll find a way to pay a car payment or help with rent.

“How was your flight?” Gentile asks.

Kane tells her about storms that brought inches of rain to Denver the night before, leaving the airport socked in and delaying takeoff by about 20 minutes. The pilot eventually found an opening in the clouds and now the sun is shining in Alamosa.

The women climb into a blue pickup truck. They drive into the heart of Alamosa, bumping over the railroad tracks and past the brick train station to a medical office building.

Gentile’s phone rings. A voice on the other end tells her that Kane’s first patient is ready for her.

So begins a day of back-to-back appointments. There will be no time for poetry, much less any breaks. Kane will grab lunch while writing notes on charts. One perk of the day is the view. Her office window frames Blanca, a 14,000-foot peak in the Sangre de Cristo range that forms the eastern boundary of the Valley. To the west, past miles of flat ranch and farm land, the wild San Juans tower in the distance.

“One of the things I love most here is being ringed by mountains,” Kane says.

Among the patients she sees on this July day is Joyce Maldonado, 54. She wears a black cap over a traditional bun on her head. She is one of the Mennonites who have settled here in the last 20 years. She lives on a small farm near the town of Center. Her husband, Joe Maldonado, 71 worked as a hunting guide for years on the giant Forbes Ranch, which was a wilderness playground for one of America’s richest families and now has a new owner.

Joe Maldonado is a descendant of the Spanish immigrants who settled the San Luis Valley in the 1850s under a Spanish land grant.  Joe was raised Catholic and later converted to the Mennonite religion, which espouses humble living, simple dress and minimal technology.

Joe and Joyce married later in life.  She used to be a nurse. Now, they run a business called The Pastry Barn, but Joyce has been too sick the last few months to bake her signature pies that are their top sellers.

Joyce had no health insurance when she was diagnosed with cancer. She is now on a program called the Colorado Indigent Care Program (CICP), which provides funding to clinics and hospitals so patients can receive discounted care.

“How are you feeling today?” Kane asks as she steps in to the exam room to see Joyce Maldonado.

“I’m feeling good, but sometimes I feel lightheaded and dizzy. Is that a normal chemo reaction?” she asks.

“No, it’s not. We could give you fluids,” Kane says.

Kane examines Maldonado, reviews her lab results and discusses her pain levels.

Maldonado’s battle began over the winter. She felt like she had an unending case of the flu.

“I was achy and feverish,” she said. “But we knew we could not afford to do a lot of doctoring. “

Eventually, Maldonado went to see an internist in Del Norte who checked to see if she had lupus or fibromyalgia. Tests kept coming back negative, but she didn’t feel better. The doctor finally honed in on multiple myeloma, a bone marrow cancer, and referred Maldonado to Kane. The cancer has caused a partial fracture in one of her vertebrae. So on top of the reactions to chemo, Maldonado is walking around with a broken back.

She rates her pain at about a five out of 10, an improvement over previous months.

“When I’m up working, it’s bad. I went to church for the first time in three months. After standing up and talking to everybody, I was pretty well had,” Maldonado tells Kane.

The cancer has decimated the couple’s business. Last summer, they were selling about 130 pies a week to restaurants and individual customers. Now Maldonado can barely summon the energy to make any pies.

“We have pretty well just quit the business,” she says.

The Maldonados have had to rely on church families and others for help. Brenda Gentile, the hospital’s patient navigator, has helped allay financial worries. Cancer drugs that would have cost $900 per treatment instead require a $7 co-payment. Gentile has found funds to help with some mortgage and car payments.

Church families have brought the couple food and tended flowers in the garden. First-graders from the church school came to sing during one of Maldonado’s chemo treatments. Tears well in her eyes as she thinks of that moment.

“My back was hurting and just then, they sang, ‘My Jesus has broad shoulders, His back is stronger than mine.’’’

Maldonado is about halfway through a six-month regimen of chemo. For the most part, she tolerates it well, but feels lousy every fourth treatment.

“I always hit a day when I wonder if I should press on,” she tells Kane.

She recalls one particularly tough time. She was in the pastry shop and became emotionally overwhelmed that cancer struck her.

“This darkness rolled over me. I thought, ‘How can this be?’”

Then, she said peace washed over her as she accepted a simple message from God.

“Just take one day at a time.”

Kane offers Maldonado emphatic encouragement to keep pushing through her treatments. She tells Maldonado that her lab results show she’s getting better.

“As long as we’re continuing to see improvement, we should continue to press on,” Kane says.

“The treatment is working?” Maldonado asks, almost surprised.

Kane nods.

“Isn’t that wonderful?” Joe Maldonado says.

Joyce Maldonado stands up to leave and Kane gives her a hug.

“You really have such a calming, soothing effect on us. Thank you,” Joyce Maldonado says.

“It is so wonderful to be just a half an hour away,” adds Joe Maldonado. “With the price of gas and selling pies for just $10 each, we would never be able to afford to leave (the Valley for cancer care).”

Another young cancer victim reiterates that sentiment: receiving care close to home is critical.

“When you don’t feel good, where do you want to be?” says Carolyn Salazar, 50, who has been battling a rare form of lung cancer. “You want to be home with your own belongings.”

Salazar works in a building next door to the specialty care clinic. Instead of taking a full day off of work for her check-ups, she can simply walk over to see Kane.

“The closest place would be Pueblo. That’s still a 2 to 2 ½ hour drive. This saves me money and time away from work.”

On this day, Salazar’s blood work is “boringly normal.” Kane checks her oxygen saturation levels. Salazar proudly tells her doctor that she managed to walk in the American Cancer Society’s Relay for Life event the previous weekend in Alamosa.

“When I did my walk, I thought, ‘I’ve got to be doing this more often. Even though I’m on oxygen, it has to be helping my lung capacity.’’’

Kane agrees.

“We’ll just keep on keeping on. You look great,” Kane says.

“Next month then?” Salazar asks.

Kane nods.

“You’re good to go.”

Beating the odds

The humble cancer patients in the San Luis Valley are receiving care from one of the top specialists in the region. The CU Cancer Center is Colorado’s only comprehensive cancer center as designated by the National Cancer Institute. There are just 40 of these centers in the country.

This means that when Kane flies to this rural valley, she brings with her expertise from consultations with colleagues along with the newest treatments and clinical trials.

As a young girl, Madeleine Kane thought she wanted to become a college professor. Then, she discovered medicine, a career that would allow her to teach and do research, but also to work closely with patients.

Kane picked oncology because she liked the challenge of facing a tough medical foe. Yet, she also works closely with people.

“I like taking care of the whole patient. In oncology, there are some aspects of primary care (medicine),” she said. “You’re really taking care of the whole family.”

Kane earned her medical degree from the University of Miami. She also has a PhD in biochemistry from the University of Maryland and did her specialty oncology training at Stanford and CU. She’s an expert in head and neck cancer, along with gastrointestinal and thyroid cancers. She’s also an expert at treating cancers associated with HIV. This is a personal passion. She had a brother who died of AIDS. Kane is the medical director of clinical research studies for the CU Cancer Center and is the chief of medical oncology at the Denver Veterans Administration Medical Center.

One of the greatest challenges for cancer specialists is knowing that a certain number of your patients will die, but colleagues sometimes call Kane the “optimistic oncologist.”

“I do get pretty close to many of my patients,” Kane said. “We often beat the odds. Our survival rates are better than (rates in) the region.”

While survival is a top priority, Kane is sensitive to her patients’ wishes. For instance, she treats a 74-year-old woman who is frail and doesn’t want to the leave the San Luis Valley for radiation treatments.

“She has decided not to seek this additional care. It’s a pretty grueling day for anybody (to drive out of town for radiation),” Kane said.

So Kane and the woman’s family have created a less aggressive treatment regimen.

“She seems to be holding her own.”

By day’s end, Kane has seen 18 patients, updated all of their medical records and charted a course for their future treatment. While she’s back in Denver, many patients will continue to get chemotherapy infusions at the medical center’s Oncology and Infusion Center. Primary care providers and other oncology team members can consult with Kane by phone or e-mail if questions arise before her next trip to the Valley.

By 5:30 p.m., she walks back across the tarmac, admires the view of Blanca and ducks into the small plane. Her pilot, State Patrol Trooper Will Sanders, has been checking for thunderstorms, which are once again predicted. There’s one far in the distance, south of Denver. But he thinks he can beat it home.

Kane leans back, slips off her shoes, puts her long legs up on a seat facing her and relaxes for the first time all day. She glances out the window as the plane ascends back over the sand dunes and heads east over the mountains. Soon, Kane closes her eyes and takes a short nap.

When she wakes up, she sees that Sanders has steered clear of bad weather and after an hour-long flight and a 30-minute drive from Centennial Airport, she’ll be back at her east Denver home by 7 p.m.

“They’re long days,” she says. “But there’s something a little different about the people in the Valley. They are so nice and so appreciative that we are coming to them.”

Student bloggers and live video streaming via the Internet will expand the reach of the sold-out Colorado Health Symposium, which runs Wednesday through Friday at the Keystone Conference Center.

The agenda includes debates and discussions on health policy at both the national and regional levels. Live streaming of the forums will be broadcast via Ustream.

Symposium University is designed to extend the content from the seminar into the classroom. Seven student bloggers will provide information throughout the three-day event.

Comments are encouraged via Facebook and Twitter.

By Katie Kerwin McCrimmon

ALAMOSA – The grandmother sports chic short gray hair, her post-chemo look. She tells her doctor that she finally feels well enough to tend her vegetable garden this summer – a sure sign that her cancer is abating.

Dr. Madeleine Kane, a visiting medical oncologist and hematologist from the University of Colorado Cancer Center in Denver, confirms at this July follow-up appointment that the outlook is excellent.

“Your tumor markers are all normal,” Kane tells Carla Shawcroft, 65, a mother of four and grandmother of eight, who lives in Manassa, about 30 miles south of this clinic at the San Luis Valley Regional Medical Center.

“You’re doing very well,” Kane says, smiling. “We’ll see you this time in two months.”

After the checkup, Shawcroft can barely believe her cancer is gone.

“It’s such a great relief,” she says, tears overwhelming her. “She’s really been very nice to me, very caring, someone I can depend on.”

Being able to depend upon your doctor sounds simple. But, until Shawcroft found Dr. Kane at a hospital clinic minutes from her home, she repeatedly experienced poor medical care that could have cost her her life.

The saga began in 2009.

Shawcroft felt a lump in her breast and went to see a physician’s assistant who told her she was fine and that the lump was just tissue.

Shawcroft had been having regular mammograms for years. She had one in 2007 and now knows from her records that the radiologist had spotted an area of concern. She had another in 2009, but the same radiologist said that nothing had changed since 2007. By then, Shawcroft felt the large lump and her intuition told her that something was wrong. But medical providers kept dismissing her concerns.

“I kept thinking, ‘Why am I worrying?’”

The lump continued to grow and her breast would ache, waking her in the middle of the night. Shawcroft waited about six months, then went to see a different physician’s assistant. Finally, a mammogram, an ultrasound and a needle biopsy confirmed that the lump was cancerous.

“They said it was pretty aggressive. The tumor was big enough that if I had delayed another six months or a year, it would not have been good,” Shawcroft says.

Once she knew she had cancer, the problems with the medical system continued. Shawcroft tried to forge ahead with treatment and saw a surgeon in Pueblo, who asked her what she wanted:  a lumpectomy or a mastectomy.

“I don’t know what I want,” Shawcroft recalled, thinking mostly that she didn’t want cancer at all.

She made a blind choice to have the lump removed last May only to be told a few days later that the surgeon had not been able to excise all the cancer.

She says the doctor told her that if they took the entire breast, she wouldn’t need radiation.

Shawcroft agreed to the mastectomy.

“Afterwards the surgeon told me I was cancer free,” she said. “I thought, ‘Glory, hallelujah! This is over.’”

Then tests came back showing that her cancer was “triple-negative,” which is a more aggressive type of cancer.  She would need chemo.

Shawcroft had no idea the hospital close to her home had a cancer clinic or offered chemotherapy.

“I didn’t even know it existed. I had no way to know that I could see Dr. Kane.”

So, she decided to get chemo in Pueblo, where one of her daughters lives.

Once again, she received care that made her doubt the system. A technician at Rocky Mountain Cancer Center was supposed to be with her as she received her first infusion of a strong drug called Taxotere. But instead, Shawcroft found herself alone, apparently experiencing an allergic reaction to the medication.

“I started feeling strange and the nurses were all gone. It was almost like I couldn’t breathe.”

Finally, she was able to wave to another patient who got her help.

“It was scary. The whole thing is scary,” Shawcroft said.

“I came on home. I drove 2 ½ hours from Pueblo. I felt terrible and called over there (to the Pueblo cancer center) and asked for help. They just said ‘see your family physician.’’’

Shawcroft returned to her physician’s assistant and finally learned about Dr. Kane. She never went back to the Pueblo cancer center. Kane started overseeing her care and arranged for her to get chemo treatments in Alamosa.

“It was a total night-and-day difference. I didn’t know that I could do chemo in the Valley,” she said. “Now I feel like I’m in very good hands.”

After each treatment, Shawcroft could return to her house. She was wiped out, but she could sit in her own living room and recover. She had always been the cook in the house, but family members made sure she had meals.

Last year, Shawcroft’s husband had to plant the garden for her. This year, she felt well enough to do it herself.

“I love to be outside. Working with the soil is therapeutic. You can get out there and weed. You can actually see the garden grow,” Shawcroft said.

It’s been dry this summer, but her tomatoes, potatoes, corn and cauliflower are all thriving. So is Shawcroft.

“I’ve learned short hair is good. And you should explore your options.”

By Katie Kerwin McCrimmon

Gov. John Hickenlooper officiated at the Beaver Creek wedding of a TriZetto executive on May 28 weeks before naming controversial TriZetto appointee Eric Grossman to Colorado’s new health exchange board.

The governor’s spokesman, Eric Brown, said Hickenlooper performed the wedding on behalf of the bride, Kasia Iwaniczko, who is a longtime friend. The wedding took place at the Ritz-Carlton Bachelor Gulch. Through Brown, the governor said he had not met the groom, David MacLeod, or known where he worked until the couple came to Hickenlooper’s office for a 15-minute meeting in May to discuss plans for the ceremony.

Brown said that Hickenlooper’s decision to appoint Grossman to the health board had nothing to do with the wedding ceremony and that the governor has no personal relationship with the groom or any other TriZetto executive.

Iwaniczko MacLeod met Hickenlooper about 10 years ago through CultureHaus, an arts education program that he helped create with the Denver Art Museum.

Iwaniczko MacLeod has worked as a philanthropist for numerous nonprofits and as a lobbyist. She now owns a consulting firm. She’s also a Hickenlooper campaign contributor. Records show she gave Hickenlooper $500 for his gubernatorial bid. MacLeod is vice president of research and development and technology architecture at TriZetto. He is also the company’s chief technology officer. MacLeod donated $100 to Hickenlooper’s campaign last year. Grossman, the health exchange appointee, is a colleague of MacLeod’s. Grossman is vice president of strategy and government affairs for TriZetto.

Grossman was not invited to the wedding, Iwaniczko MacLeod said. He did not make a campaign donation to Hickenlooper. Other health exchange appointees whom Hickenloooper appointed donated to his campaign including Elizabeth Soberg, chief executive of United HealthCare of Colorado, who donated  $525 and Richard Betts, a Telluride businessman, who gave the governor $350. Arnold Salazar, executive director of Colorado Health Partnerships, LLC, a consortium of mental health providers in rural Colorado, donated $895 to Hickenlooper’s campaign. He was appointed to the health exchange board by House Minority Leader Sal Pace, D-Pueblo. Steve ErkenBrack, president and CEO of Rocky Mountain Health Plans, gave $1,000 to Hickenlooper’s gubernatorial opponent, Scott McInnis and was appointed to the exchange board by House Speaker Frank McNulty, R-Highlands Ranch.

The governor’s spokesman said he understands that there is “turmoil” over Grossman’s appointment and that conspiracy theorists might want to make a connection between the wedding and the appointment.

“But they’re missing the mark on this one,” Brown said.

The governor continues to support Grossman despite calls by consumer groups that Grossman should resign.

“We have no reason not to (have faith in him) right now,” Brown said.

The governor and his health advisers believe in having “different voices” on the health board, Brown said.

“The board has only had one meeting,” he said. “They’re going to move forward and work through all these issues.”

Consumer groups believe that Grossman is a “health industry insider” and question whether he will be willing to vote against clients if necessary.  Grossman was supposed to be one of five “non-industry” appointees on the nine-member board. (Four other board appointees work for health insurance companies.)

TriZetto is a health information technology company whose primary clients are health insurance companies. The Greenwood Village-based firm has 2,000 employees and on its website says it touches “half the U.S. population through its contracts with health insurance companies.”

Solutions first reported on July 6 that Grossman penned an article for clients last fall called  “There’s Gold in Exchanges. Here’s How to Stake Your Claim.”

In that article, Grossman wrote that it was “good” that health exchanges would generate more business for insurance companies, “bad” that they would force more competition and “ugly” that government regulations would drive down profits.

Grossman told Solutions he regrets using those words, but that he has no intention of resigning and supports the health exchange. He said he wants to perform his civic duty by evaluating potential IT programs that the state might use.

Eric Grossman, left, a TriZetto executive, at the first health exchange board meeting. On the right is Colorado Insurance Commissioner Jim Riesberg. Consumer advocates have called on Grossman to resign from the board.

Grossman said he carefully followed legislation related to Colorado’s new health exchange. He said his company decided not to bid for business related to the exchange.

“Government business has never been a key aspect for TriZetto,” he said.

Grossman said that TriZetto’s leadership team “reached out to the governor.” Grossman said he had met the governor at a couple different conferences.

Eric Brown said the governor does not remember having met Grossman previously and that the governor did not attend the wedding reception. After the ceremony, he posed for photos with the family, then left to rejoin his wife and son for the Memorial Day celebrations.

Iwaniczko MacLeod is upset that her private wedding has become a topic of public discussion. A two-time breast cancer survivor, she lost her father to cancer weeks before the wedding. She said Hickenlooper has been supportive of cancer causes and her other philanthropic interests for years and kindly agreed to perform the wedding ceremony.

“It was a special and touching ceremony. John paid great homage to my father,”  she said. “John did us a favor by coming to the wedding, then he took a few pictures and didn’t attend the reception.

“There was no canoodling. There was no interaction. This was a personal relationship that I have with John. That’s it.”

She says Grossman’s appointment had nothing to do with her husband or their wedding.

“I don’t understand. How would one would have to do with the other. I can’t help where my husband works.”

Editor’s Note: In the interest of full disclosure, then Mayor Hickenlooper also officiated at the wedding of Mark Eddy and Solutions Editor Diane Carman in 2004.

By Bob Semro

The Health Care Affordability Act of 2009 is one of Colorado’s most effective reforms, but the program it fostered could be in jeopardy because budget-cutters in Washington are targeting the federal funding that makes the act work.

As talks continue on deficit reduction and increasing the debt ceiling, a number of proposals are zeroing in on the federal matching funds that cover hospital provider fees and help support Medicaid funding. Colorado is not alone among states that could lose funds.

The Health Care Affordability Act, with the agreement and support of state legislators and the Colorado Hospital Association, assessed a provider fee on 83 Colorado hospitals. That money is matched by federal funds, which help reimburse hospitals for uncompensated care and over time allow Colorado to expand Medicaid coverage for many uninsured citizens.

By the end of last year, almost 32,000 uninsured adults and children in Colorado had been enrolled in the public Medicaid program. When fully implemented in 2012, the program could provide coverage to as many as 100,000 previously uninsured Coloradans.

In addition to covering more people, the act provides significant assistance to Colorado hospitals that treat Medicaid patients and the uninsured. Before the act, hospitals were paid approximately 56 cents for every dollar of care provided to a Medicaid patient. Under the act, those payments increased to just over 70 cents. Nearly one-third of hospitals that had losses in 2009 were able to generate operating income in 2010, and operating losses for 13 hospitals in 2010 would have been nearly 40 percent greater if not for revenue from the hospital provider fee, according to the Colorado Hospital Association.

All of these benefits are paid for without a single dollar from Colorado’s General Fund. In addition, the act reduces the cost of uncompensated care that otherwise is passed on, or shifted, to those who have health insurance.

Although Colorado is one of a very few states that use provider fees to expand Medicaid eligibility, almost all of the states (47) use the fees to help finance their Medicaid programs. In fact, states have relied more heavily on provider fees as other sources of funding dried up during the economic downturn.

Due to this widespread use of the provider fees for Medicaid – and the resulting growth in federal expenditures – these fees have become the target of several national deficit-reduction proposals.

The Simpson-Bowles commission (officially the National Commission on Fiscal Responsibility and Reform) proposed reducing the fees that states can impose upon Medicaid providers, which would reduce the amount of federal matching funds. The commission estimated the provision would cut federal expenditures by $6 billion in 2015 and $49 billion by 2020.

The president’s proposed budget for fiscal year 2012 embraces the Simpson-Bowles provision and modifies federal regulations to limit the amount of provider fee revenue that states may use to fund their share of Medicaid costs. These modifications would take effect beginning in 2015 and would reduce federal Medicaid spending by $18.4 billion between 2012 and 2021. The president’s deficit reduction proposal, released in April and entitled the Framework for Shared Prosperity and Shared Fiscal Responsibility, would also limit the states’ use of provider fees.

All of these proposals would limit the notable achievements, not to mention the future, of the Colorado Health Care Affordability Act. It is unlikely that Colorado could replace that lost federal funding. That would threaten Medicaid eligibility expansions, improved reimbursement rates to Medicaid providers and reduced cost-shifting of uncompensated care.

It is unclear when any of these proposals, if adopted, would take effect. In the worst-case scenario, immediate implementation could impact Coloradans who have recently become eligible for Medicaid or would become eligible in 2012. Hospitals that treat Medicaid and uninsured patients could see lower reimbursement rates.

More than likely, these proposals would not take effect until after 2014, when the majority of the national Affordable Care Act’s reforms and provisions are implemented.

If that happens it could have a significant financial impact beginning in 2017. Between 2014 and 2016, all of the Medicaid expansions created by the national Affordable Care Act will be paid for with federal funds. Beginning in 2017, Colorado will begin to pay a share of those costs, but the provider fee would pay about $236 million between 2017 and 2020. If the provider fee were reduced or eliminated, Colorado’s General Fund would have to cover a greater share of those costs.

The situation is further compounded by another deficit-reduction concept offered by the Obama administration – the “blended rate proposal.” This proposal would replace all of the matching rates used by the federal government to reimburse state Medicaid and CHP+ costs with a single state-specific “blended rate.” Since the blended rate would be set below the reimbursement rate under current law, the federal government would save money.

All of these proposals would marginally reduce federal deficits without creating additional taxes. But they would do so at the expense of the most vulnerable in Colorado, and they would once again pass the cost of treating uninsured Coloradans on to hospitals and the insured. In the end, they would simply hand the problem over to the states to solve.

Colorado Sens. Mark Udall and Michael Bennet have stated that the recommendations of the Simpson-Bowles Commission represent a starting point for any deficit-reduction negotiations. In March, Sen. Bennet, along with Republican Sen. Mike Johanns of Nebraska, organized a bipartisan group of 64 senators that sent a letter to President Obama urging action on a comprehensive deficit-reduction plan that builds upon the work of the that commission.

While neither senator has explicitly stated support for a provider fee adjustment, we would hope that they remember the comment made by Sen. Udall after the passage of the Colorado Health Care Affordability Act: “I am proud to see Colorado lead the charge to increase access to health care for our most vulnerable citizens.”

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

By Katie Kerwin McCrimmon

A former board president and negotiator of the original hospital sale that created the Colorado Health Foundation is warning that the foundation could lose control of $1.45 billion in profits from its current proposed sale of seven hospitals and should cancel the deal.

Dick Anderson, who was chairman of the joint venture board that ran the hospitals from 1995 to 2000, filed comments with Colorado’s attorney general on Thursday.

He believes that the original intent of the deal was to protect community assets, not to serve as an investment engine for the Colorado Health Foundation.

Anderson said at least six former board members join him in opposing the sale, which would affect seven Denver-area hospitals including Presbyterian/St. Luke’s, Rose, Swedish and Sky Ridge medical centers.

He is prepared to testify against the deal if Colorado’s attorney general holds hearings.

Mike Saccone, a spokesman for Attorney General John Suthers and Deputy Attorney General Geoffrey Blue, who specializes in hospital transactions, said attorneys are reviewing the proposals to determine if they will step in. They said they have no specific timetable for how long their analysis will take.

Anderson believes that local financial interests could suffer, expensive residency programs that train future doctors could close after five years and for-profit hospital owners could essentially mortgage Colorado hospitals, using them as collateral to build new out-of-state hospitals.

“The (joint venture) currently does not have to respond to the whims of ‘Wall Street’ that have no particular interest in our community interests or values in this rapidly changing health care delivery environment. Is the community interest best served by having these critical decisions controlled in Denver by members of the community or in Nashville, Wall Street or wherever the (joint venture) hospitals may eventually reside?” Anderson wrote in his comments.

Charles Reyman

He believes that the foundation board has shifted its mission and should return to its primary job of protecting community interests. During his tenure as board chair from 1995 to 2000, he said the board considered and rejected at least two offers to sell. He believes the current board is being seduced by a “pot of gold.”

Anderson said he’s not even sure that board members understood that if the hospital disclosure law applies to this sale, the attorney general will require them to surrender the funds to a new nonprofit entity.

“They may lose the dollars,” he said.

“We’re talking about an investment in the joint venture that will provide the community control over the hospitals and a significant return (on investment) in perpetuity,” Anderson said. “Why give that up for a one-time payout?”

Charles Reyman, vice president of communications for the foundation, said that on the contrary, the proposed sale stabilizes the foundation over the long term.

“This is not a transaction about a volume of money. This is a transaction about longevity. So, what the switch of assets will provide for us is a capability to sustain our current level of grantmaking in perpetuity for generations to come,” he said.

Currently, he said the foundation does not have “the luxury of a long term future. We were tied to the uncertain performance of the brick and mortar asset.”

Anderson  believes the board should withdraw from the proposed deal with its partner, HCA-HealthOne. HCA, which stands for Hospital Corporation of America, is a Tennessee-based company now owned by Wall Street investors.

“The best result would be for the Colorado Health Foundation to reconsider their action,” Anderson told Solutions. “If there are concerns, they can hopefully withdraw.”

Reyman, said the board has no intention of canceling the deal.

He acknowledged that Anderson is correct that the $1.45 billion in profits would have to go to a new nonprofit entity if Colorado’s Attorney General determines that the sale falls under Colorado’s Hospital Conversion Act.

But Reyman said the foundation’s legal team and even one of the original authors of the conversion act believe that the sale will not fall under the law. Click here to read an opinion from Ed Kahn, special counsel to the Colorado Center on Law & Policy and one of the authors of the conversion act. Click here to read the Colorado Health Foundation’s “White Paper,” which spells out its point of view and to which Anderson refers in his comments.

(Disclosure: Both Solutions and CCLP receive financial support from the Colorado Health Foundation.)

At the core of the dispute — and critical to the AG’s decision — is whether the joint venture between the foundation and HCA shares control of the hospitals in a 50-50 split or whether HCA owns 60 percent of the assets, as the foundation lawyers contend. Reyman conceded that some tax filings portray the relationship as a 50-50 split. And indeed, the board governance is split 50-50. But he said what’s critical is ownership.

“The 50-50 (percent split) represents the governance component of the joint venture. The 60-40 (percent split) represents the ownership component and the ownership component is at the heart of transaction,” Reyman said. “It’s about ownership, not governance.”

Dick Anderson

Reyman says that the proposed sale does not signify a change in mission.

“What this transaction represents is a shift of assets from brick and mortar (hospitals) to a financial asset. What that allows the foundation to do is diversify its portfolio. Any money manager will tell you that 40 percent of your interests should not be contained in any one asset. That’s not wise stewardship moving forward.”

He said that investment concerns are “one component of the deliberations, but it’s a pretty small one.”

Anderson believes that the current board failed to consult the architects of the original deal to understand their intent.

Reyman said that board members consulted with past leaders and thoroughly explored the intent of past deals.

Anderson said he learned of the proposed sale just before Health Foundation leaders announced it on June 15.  He was not entirely surprised.

“It’s a huge amount of money and a pot of gold is always attractive to some,” he said.

Anderson said he immediately registered concerns and that executives from the Colorado Health Foundation offered to meet with him. He says he told them that the time to have met would have been months earlier as they pondered the sale.

Anderson fears that the six residency programs operated by the hospitals will be in jeopardy.

“I know from my prior experience that HCA has always been concerned about the cost of the (residency) programs,” Anderson said.

Reyman said that the programs will actually be in better shape under the new arrangement, which requires HCA or future hospital owners to retain and fund the programs for five years.

Anderson said they could be closed on the first day of the sixth year.

“Five years goes by pretty quickly,” Anderson said. “Who will decide at the end of five years (what should happen). Should the community in Denver decide or should it be controlled in Nashville?”

Reyman said the foundation will not allow the programs to wither away. He pledged that the foundation will bear 100 percent of the cost if HCA pulls the plug.

“If the transaction goes through, those programs would actually be in a strengthened position from where they are today,” Reyman said. “Where things stand today, those programs could end at any time. If the transaction goes through, one of the covenants mandates that they are in place, fully funded and fully functioning, for the next five years.

“The foundation is 100 percent committed to those programs,” Reyman said.

The health foundation picks up the tab for about $2 million per year in deficits for the educational costs of the programs. The hospitals also share in about $2 million per year in deficits for clinical costs. There are three residency programs at Presbyterian/St. Lukes, one at Rose, one at Swedish and one at the Medical Center of Aurora.

Anderson said local control is paramount to the current deal and while a community board will still exist, he worries that it won’t have the muscle he had to exert at times.

For instance, he cites occasions when competing hospitals tried to interfere with one another and the board had to step in. He recalls one occasion when the for-profit hospital company, AMI, tried to stop construction of an expansion at Presbyterian/St. Luke’s.

“I was able to turn that around in 24 hours because we had local authority,” he said.

On another occasion, the board received word that Columbia wanted to lay off 800 nurses and fought the layoffs. Anderson said he told them they didn’t have the authority to proceed without the approval of the joint venture board.

“The nurses were not laid off. If Wall Street says you’ve got too many hospitals and you have to close Rose or Swedish, should that be of community concern? I believe so,” Anderson said.

Reyman said the foundation has “every confidence” that local interests will continue to be served.

“Through our 15-plus-year relationship with the HealthOne hospitals, they have established a commitment to community benefit, to providing for indigent and Medicaid (patients) and high quality,” he said. “That commitment is going to continue not only because it’s in their culture, but because it’s mandated in the covenants that are part of the transaction.”

The history of the past transactions is complex and includes numerous name changes.

In 1995, the for-profit company Columbia (which has since become HCA) entered into a joint venture with the nonprofit HealthONE hospital system.  HCA was a private venture, but in the last 90 days has gone public and is now owned by Wall Street investors.

The 1995 merger of hospitals turned HCA-HealthONE the largest health provider in the Denver area.

In 2006, HealthOne changed its name to the Colorado Health Foundation. If the sale goes through, the foundation would become Colorado’s largest by far. Currently, the foundation describes itself as having $1 billion in assets. In 2009, it invested $94 million in improving health and health care in Colorado.

By Myung Oak Kim

Concierge service. Jacuzzi tubs. Bacon-wrapped scallops or New York strip steak prepared by professionally-trained chefs and brought to your room.

These amenities can be found at most new hospitals in Colorado and across the country. Gone are the days of sterile, white hallways, fluorescent lights and cloth curtains separating patients in the same room. The newest hospitals offer bountiful natural light, warm-colored walls and floors, soothing art and private patient rooms with large windows and relaxation videos.

Sky Ridge Medical Center in Lone Tree features fireplaces on every floor. Children’s Hospital Colorado in Aurora offers video games in patient rooms. The cafeteria at the new $435 million St. Anthony Hospital in Lakewood includes a soda machine that can make 100 different types of drinks.

“It’s a far cry from the old days,” said St. Anthony spokeswoman Bev Lilly. The new hospital includes stone archways, heated sidewalks, flat-screen televisions and a grand piano donated by volunteers. It was designed with the latest technology and features to be more energy efficient and to provide the maximum comfort for patients, she said.

The transformation in hospital design reflects several larger trends in American health care. First, federal privacy regulations and the need to stem the spread of infections have driven the move to providing individual patient rooms. Second, new studies show that soothing design, art and natural light – creating what is known as “healing environments” — improves patient outcomes.

Third, hospitals need to compete for the most profitable segment of the health care market: patients with commercial insurance and disposable income to pay for extra amenities. These patients are more likely today to shop around for the latest and greatest in technology and comfort before choosing a facility, especially for non-emergency and outpatient procedures.

Steven Summer

Steven Summer, president and CEO of the Colorado Hospital Association, said there are many reasons why hospitals build attractive new facilities.

“There are clinical reasons to do these things. There are patient-safety reasons to do these things. There’s also the need to respond to the needs of their customers,” Summer said. “The kind of patients that hospitals want to attract are those that have the choice of where to go. They have commercial insurance as opposed to Medicare or Medicaid. Hospitals will go out of business if they are just serving government patients.”

Profits soaring

Hospitals also can afford to add these features. Hospitals in the Denver Metro area nearly doubled their profit between 2008 and 2009, bringing in more than $740 million in pre-tax net income, the highest revenues in years, according to independent analyst Allen Baumgarten. Baumgarten believes the trend toward increased profits continued in 2010.

HealthONE is the largest and most profitable health system in the region. In 2003, HealthONE opened Sky Ridge Medical Center, a new hospital on 57 acres of unused land off of I-25 and C-470. The first hospital built in Douglas County, Sky Ridge has grown quickly, adding 80 patient beds, expanding the intensive care unit twice and adding wings for cardiac and spine and joint outpatient procedures since it opened less than eight years ago.

Sky Ridge features sage-colored walls, skylights and rocking chairs. The hospital provides a wide array of amenities and services, including pet visits, afternoon tea for new mothers and “amenity suites” – larger patient rooms with Jacuzzi tubs and other features for patients who are willing to pay more during their stay. Linda Watson, spokeswoman for Sky Ridge, said patients expect more today from a hospital environment, she said.

“I don’t think fancy is what we’re going for,” Watson said. “What we are going for is comfortable and healing.”

Sky Ridge benefits from not being close to competition. The Denver market is a different story, especially in pediatric care. After Children’s Hospital (now called Children’s Hospital Colorado) moved to the Anschutz Campus in Aurora in 2007, HealthONE opened a new Rocky Mountain Hospital for Children in 2010 at the Presbyterian St. Luke’s campus. Both new, modern facilities, the two hospitals are battling for patients and physicians.

Amenities’ costs insignificant

 The transformation of hospitals into hotel-like environments is happening at a time when health care costs are increasing each year. Baumgarten said the costs of building new facilities and providing amenities eventually get shifted to the consumer through higher insurance premiums or provider charges.

Summer denies that amenities drive up costs for consumers. He said the largest cost in health care is for staffing. Hospitals devote most of their money to salaries, technology, new equipment and pharmaceuticals. Installing and maintaining fireplaces in a hospital is insignificant compared to the total cost of the facility, he said. And some amenities, such as the new grand piano at St. Anthony’s in Lakewood, are donated. The notion that amenities “for amenities sake” are driving up health care costs is a “fallacy,” he said.

DiAnn Sherk, director of interior design at Boulder Associates, which designs health care facilities across the country,

DiAnn Sherk

agrees.

Sherk said hospital administrators focus on building facilities that make patients feel relaxed, help them recover and accommodate family members. She said hospitals are using more elements of design that have been used in hotels, but the amenities are a minor cost compared to the technology and staffing.

“I don’t see extravagance,” Sherk said. “I think our clients are very budget-conscious. They are very considerate about cost and the rising cost of healthcare. They don’t want to go overboard by any means.”

By Anne Warhover

There’s been a lot of talk – both fiery rhetoric and thoughtful discourse – on the national stage about “fixing” health care since Congress and President Obama took a crack at overhauling the entire system last year. Fast-forwarding to mid-2011, health care reform is moving along, but many key provisions still face legislative, judicial and budgetary scrutiny — not to mention an onslaught of partisan bickering and negative ads from both sides of the political aisle.

Whether the pillars of the Affordable Care Act and the health care debate succeed in expanding access, improving quality and reducing costs, one fact is indisputable: meaningful systematic change in health care won’t occur without fully engaging business and community leaders in the conversation.

For businesses, the stakes in health care are high – literally. Businesses already shoulder most of the nation’s health care expenses through their employees’ health insurance premiums – which continue to rise year after year. According to Colorado’s insurance commissioner, the average insurance premium rose by 22 percent between 2007 and 2009, with only a slight decrease in 2010. Meanwhile, the Centers for Medicare and Medicaid Services estimate health expenditures ballooned to 17.6 percent of GDP in 2009. By contrast, military expenditures accounted for 4.7 percent of GDP that same year.

Communities also factor heavily in the health care equation. Clearly, the environments where we live and work play a major role in our health and well-being. That said, communities that have easy access to parks and recreation, and safe pathways that allow people to ride their bikes or walk will fare better health-wise than those that don’t. The actual health of Coloradans living in those communities also influences the economy. A recent statistic from the Centers for Disease Control and Prevention shows the health consequences related to obesity cost Coloradans an estimated $874 million a year.

Keeping those jaw-dropping numbers in mind, it’s absolutely apparent that Colorado won’t improve health care without tapping into the concerns and creative thinking of business and the community.

Fortunately, businesses and communities throughout the state are already thinking about innovative and collaborative solutions in health and health care that will ultimately save and improve lives. A few examples:

• The Center for Improving Value in Health Care – The nonprofit CIVHC is partnering with the business community, providers and health plans to develop new solutions to contain costs, improve quality and build a stronger, more efficient health care system. CIVHC provides an open forum for direct dialogue and development of innovative ideas with health care facilities and the doctors, nurses and staff who work there.
• Westerly Creek Park and Garden Project – With support from business, community and nonprofit organizations, this project will transform a vacant lot into a soccer field, playground and expanded community garden. Once completed, the low-income, east Denver neighborhood will have safe, quality recreational space along with a source of fresh fruits and vegetables. The Westerly Creek project is one of dozens of similar projects throughout Colorado that aim to make communities more conducive to good health.
• Bipartisan legislative efforts – Business and community leaders were instrumental in backing a number of health-related bills during the 2011 General Assembly, including a bill that established a Colorado health benefit exchange to provide health insurance options for individuals and small businesses who may qualify for financial assistance to pay for premiums.

Because the role of business and communities in improving health and health care is critical, the Colorado Health Foundation called upon business and community leaders to share their insights at the 2011 Colorado Health Symposium, one of the top health policy conferences in the country. This year’s event, which takes place July 27-29 at Keystone Resort & Conference Center, focuses on emerging solutions and daunting challenges in health care.

For the first day, we’ve assembled a strong group of health care providers to discuss how reform is affecting delivery of services. Day Two of the symposium will highlight how large and small communities across the country are re-imagining themselves in the context of health. Finally, Day Three will explore how health issues and health care reform are affecting businesses. Though this year’s event is sold out, observers can keep up with the dialogue online and through social media at www.coloradohealth.org.

To forge meaningful solutions to today’s significant health care challenges, everybody needs to think outside of the health care box. That’s why the Colorado Health Foundation encourages collaborative thinking at the symposium and elsewhere. By harnessing the collective wisdom of health care, business and the community in one gathering, the symposium provides a catalyst for ideas that could potentially change the shape of health care.

Anne Warhover is president and CEO of the Colorado Health Foundation.

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