Health Policy Solutions

By Francis M. Miller

Within the next two weeks, Colorado Attorney General John Suthers will rule on the proposed sale of the HealthOne hospitals by the Colorado Health Foundation to Tennessee-based HCA. This $1.45 billion transaction would be a major transfer of nonprofit hospital assets to the private sector.

Testimony to date has centered on whether Colorado’s poor and indigent, who are enrolled in Medicaid or require charity care, will continue to be served. One option is to require HCA to continue serving these populations for at least five years. Another option is to let the Colorado Health Foundation channel proceeds from the sale into new areas outside hospital-based care. Both possibilities have pros and cons.

I assert that we are now at a unique point in the evolution of Colorado’s health care system and should look at the situation with a jaundiced eye.

When I arrived in Denver in 1971, Colorado’s hospital community was ethnic- and religious-based. To name just a few, there were Lutheran, Swedish, Jewish (Rose), Presbyterian and Catholic hospitals. Hospitals were flourishing not only as the post-war Denver population swelled, but because cost-based reimbursement paid by Medicare and Medicaid allowed hospitals to issue revenue bonds and build new facilities.

I consulted to most of these hospitals and knew their board members well. Their administrators were either from religious orders or the kind of guys who could have been interchangeable as school superintendents.

The issue of taking care of the indigent has long been with us, but between Denver Health & Hospitals, University Hospital and the religious mission of the community hospitals, the job somehow got done. It is a pastoral, romantic landscape of a bygone time.

The train derailed in the mid-1980s. By then cost-based reimbursement was fueling hyper-inflation in the health sector and the oil boom was causing Colorado’s population to grow. This was also happening nationally, and in 1986, Congress passed TEFRA, a budget reconciliation act that instituted prospective fee schedules for medical procedures.

Over the next 10 to 15 years this act ushered in the era of managed care. And, it precipitated feverish cost shifting between payors. Business reacted by forming coalitions, and alliances and hospitals responded by forming networks and hiring a new generation of CEOs.

There was great hue and cry for reform, but strong hydraulic forces within the hospital community and insurance industry negated any attempt to change the system except at the margins. Tinkering seemed to bring unintended consequences, and inflation in the sector has consistently run double or triple inflation in the economy at large.

This brings us to the pending sale of HealthOne hospitals. In their current incarnation, these hospitals only provide token alternative care such as prevention and public health. They are traditional, high-tech hospitals and, as such, are a place to go for surgery, a heart attack, chemotherapy and, yes, to die.

They have been forced to discount their services upwards of 40 percent to Medicare and Medicaid and, in turn, the insurance industry has negotiated similar discounts. As a result, the self-paying patient who lacks insurance pays 30 percent above average costs, and charity care is highly restricted.

That is the current system, and it matters little whether the hospital is nonprofit or for-profit. Hospitals simply must run like businesses and recover enough money to rebuild their buildings, acquire the latest technology and compensate their staffs. Hospitals are like fixed-cost railroads. Those that are highly occupied make money, but they all are reimbursed about the same by government and large insurers.

In the past 10 years, the in-migration to Colorado and the growth of suburban counties has resulted in near abandonment of the core hospital system in Denver. Even University Hospital and Children’s Hospital moved to Aurora, and St. Anthony moved to the Federal Center. Douglas County and the south suburban area are now home to three large new hospitals. The change in the landscape is truly profound.

In my mind these large hospitals are like the booster rocket on a NASA launch. A large, fuel-laden rocket is attached to the Space Shuttle and expends the immense energy to get it off the ground and into orbit. Once it is beyond normal gravitational pull, the booster rocket is jettisoned and the spaceship heads towards the moon. But, once there, the spaceship launches a lunar lander. This highly mobile, lightweight ship is launched to land on the surface and explore.

We need to jettison these large, cumbersome hospitals and turn them over to the private sector where they will be run like businesses. In the future, if hospitals need to be closed or staff laid off, a disciplined management team will get the job done or the market will punish them.

Right now, there is incessant hand-wringing by nonprofit board trustees who are more concerned about their social status, and this prevents hard choices. And, if capital is necessary, then the private sector managers will get investors to cough it up, not hold out a begging cup asking for donations and volunteers. Those days are over.

What remains to be seen is whether the Colorado Health Foundation can leverage the proceeds of the buyout to launch a new system that offers more prevention and alternatives. Hard-hitting programs to reduce childhood obesity and target special needs populations are direly needed. There is no shortage of opportunities to grow a new and different type of system. It’s the lunar lander equivalent.

As for charity care and public entitlement programs, I suggest little will change, either way. Continued inflation in hospital and doctor costs will put these programs under the legislative microscope.

Prior to 1965 and the enactment of Medicare, health care was a failed market dominated by insurance companies who did not innovate to find a way to care for the elderly or the poor. It took the intervention of the federal government.

We have to remember, though, when government uses the blunt force of public policy, it will, and should, demand care be provided at the marginal cost rather than higher average costs.

This is deemed a traumatic act by providers and insurers who want to be paid average costs. When hospitals respond, not by becoming more efficient, but by increasing utilization or shifting costs, then government has no choice but to respond by ratcheting down on reimbursements.

Insurance companies have only followed government’s lead during the managed care, cost-shifting era. This struggle has become existential and I do not believe it will cease until…..

Only when a new 21st-century health care system based on prevention, evidence-based care and alternatives outside the hospital-centric system is in place will the current medical model of care be eclipsed. And, that is the opportunity that all of the health care foundations in Colorado have before them.

It is a big challenge, but if not them, who? They are now the custodians of billions of dollars of capital accumulated from the old system. They alone have the opportunity to redeploy it to a new system in the 21st century. They should be jumping at the chance to do so.

Francis M. Miller is a management consultant, author and public policy analyst with a graduate degree from the CU School of Public Affairs. He was past president of the Colorado Business Coalition for Health and vice chairman of the Colorado Health Data Commission. He is the author of “Health Care 2050: The 13th Strategy.” 

By Bob Semro

Lack of health insurance is a problem for many Americans, but for thousands every year it can lead to an avoidable and premature death.

For this and other reasons, the new health care law, the Affordable Care Act, puts new reforms in place to reduce the number of uninsured Americans and improve their access to care.

Estimates on the number of deaths resulting from lack of coverage range from 18,000 to 45,000 annually. A consensus estimate is difficult to come by because studies use different methodologies and focus on different historical time frames and age groups. Inevitably, any number can become the subject of partisan debate.

The Institute of Medicine attributed 18,000 deaths in the United States to lack of insurance coverage in 2000. The Urban Institute found that 22,000 Americans died in 2006, and in the latest report, Harvard Medical School estimated 44,789 Americans died due to lack of coverage in 2009.

Estimates may vary, but it is abundantly clear that people without health insurance coverage have a significantly higher chance of dying prematurely than those who have coverage. Uninsured Americans frequently postpone or forgo doctor’s appointments and other treatments, even when they have a serious disease or condition. Uninsured adults are often unaware of health problems and are less likely to receive effective preventative services.

The number of uninsured Americans last year increased to 49.9 million, or 16.3 percent of the population, according to Income, Poverty and Health Insurance Coverage in the United States: 2010 by the Census Bureau. Some of the numbers from the report:

• 15 percent of all full-time employees, or 14.3 million Americans, are uninsured.
• 28.5 percent of all part-time employees, or 13.7 million Americans, are uninsured.
• 23.1 million whites are uninsured, 8.1 million blacks and 15.3 million Hispanics.

The situation in Colorado was highlighted last Friday in a presentation by Dr. Jonathan Gruber of the Massachusetts Institute of Technology to the directors of the Colorado Health Benefit Exchange. His analysis was based on 2008 data from the Census Bureau and the 2008-09 Colorado Household Survey sponsored by the Colorado Department of Health Care Policy and Financing.

According to Gruber’s preliminary estimates, one in five Coloradans (20.1 percent of the population, or about 850,000 people) is uninsured, which is higher than the national average of 16.3 percent. About 10.3 percent of Coloradans (440,000 people) are insured through public programs, compared to 19 percent nationally.

Other findings presented by Gruber:

• 59 percent of all uninsured Coloradans are employed full time, and 74 percent of them state that the main reason for not being covered is that employer-provided insurance is too expensive.
• 59 percent of the uninsured in Colorado have annual incomes under $21,780 for individuals or $44,700 for a family of four (200 percent of the federal poverty level, or the amount generally considered necessary for self-sufficiency).
• 63 percent of uninsured Coloradans are white, 24 percent are Hispanic and 5 percent are black.
• Almost two-thirds of uninsured Coloradans have been without coverage longer than two years.

Those numbers are of obvious concern. A key question is whether the Affordable Care Act (ACA) has or will have a positive impact in expanding the number of insured in Colorado and across the country.

The new census data show that, nationally, 500,000 more young adults have gained health insurance coverage in 2010 compared to a year earlier. This is largely due to the ACA provision that allows young adults to remain on their parents’ policy until age 26. More young adults will gain coverage as more families become aware of the provision; potentially, 46,000 young Coloradans could be eligible for coverage.

Gruber’s preliminary analysis projects that by 2016, two years after full implementation of the Affordable Care Act, 238,000 men, 185,000 women and 85,000 children in Colorado will fill the ranks of the newly insured (via Medicaid, private, or employer sponsored insurance). In addition, two years after the health insurance exchange is implemented, almost 600,000 Coloradans may obtain coverage through that system.

Even with those gains, it is estimated that more than 350,000 people in Colorado will remain uninsured. Of that number, about 136,000 will be undocumented residents, 100,000 will be Colorado residents not subject to the ACA mandate because of low income or inability to afford coverage, and another 77,000 will choose not to purchase insurance regardless of the ACA mandate to do so.

As with any forecast projected so far into the future, Gruber’s numbers are subject to uncertainty. But they do show the general trend that under the new health care reform law, many more Coloradans will be able to secure coverage in the near future. That coverage will reduce the cost of uncompensated care, allow greater access to health care and improve the quality of life for those that are newly insured. Most importantly, these new reforms will surely reduce the number of those who die prematurely because of lack of insurance.

Even with these advances, some Coloradans will remain uninsured. This underscores the point that the ACA is not an end in itself, but represents a foundation for future reform.

Bob Semro is a health policy analyst with the Bell Policy Center, a nonprofit, non-partisan think tank based in Denver.

By Risa Heywood

About 80 faculty and staff members at the University of Colorado Boulder took the first step on the Be Colorado wellness journey Tuesday with a no-cost health screening.  Along with a cholesterol and glucose blood draw, blood pressure check, a BMI (Body Mass Index) measurement and a flu shot, they were offered the chance to enter in a drawing to win one of a dozen iPad 2s.

It’s wellness with an added incentive.

The health screening is one of 17 that will take place on all of the CU campuses and at University Physicians Inc. (UPI) over the next five weeks.

In 2010, CU and UPI joined with the University of Colorado Hospital to form the University of Colorado Health and Welfare Trust to self-fund and administer their medical benefits.

As part of that change, the trust committee took the step of integrating a wellness program into the medical benefit plan offerings.  The committee wanted to provide the tools, resources and opportunity for trust members to enhance the health of plan participants and to emphasize the culture of health that exists in their workplaces.

They envisioned an evidence-based program that would add to the body of knowledge about employer-sponsored wellness programs.  The trust is in a unique position to conduct this research since it encompasses the employers, participants, researchers, hospital and physicians.

After a year of preparation and research, the Be Colorado program was launched last week.  The name is meant to reflect the perception of health that our state evokes in those who live in and outside Colorado.

We live in the leanest state in the nation, and Colorado has been cited by numerous organizations for being a great place to enjoy a healthy lifestyle.  Employee focus groups were clear, however, that they wanted a wellness program geared toward more than just physical activity and nutrition. The Be Colorado program, therefore, focuses on five dimensions of wellness:

• Be Optimistic – emotional wellness
• Be Energized – physical wellness
• Be Connected – social wellness
• Be Secure – financial wellness
• Be Inquisitive – intellectual wellness

In addition to the on-site health screenings, trust members can take a confidential online health assessment through Wellness & Prevention, a division of Johnson & Johnson.

This evidence-based tool was designed by University of Michigan researchers and uses cutting-edge technology to customize the questionnaire as the participant is completing it.  A participant’s answers to the assessment questionnaire will be coupled with the results of the health screening to provide personalized action plans around that person’s top four health risks.  Based on the risks, interests and readiness, the program will suggest steps and resources to improve personal health, including one of 15 digital coaching programs.

These online programs, available 24 hours a day, seven days a week, are like having your own personal health coach.  Participants can choose from programs that will support them in everything from moving more and eating healthier to reducing back pain.  The University of Colorado Hospital was the first to roll out this program in March and achieved a 41 percent participation rate.

Additional activities will include a holiday challenge and Colorado Weigh classes offered on each of the University of Colorado campuses.

Colorado Weigh is a research-based weight loss program developed over the last four years by the Center for Human Nutrition at the University of Colorado School of Medicine. It is based on the most up-to-date science on obesity, nutrition and physical activity.  Classes are being offered on the Anschutz Medical Campus, but employees on other campuses can enroll in the classes beginning in January.

These programs are just the start of what Be Colorado will offer.

The Be Colorado website not only will provide access to members-only activities but also will be a resource for employees to find wellness-related activities in their workplace or in their community.  Over time, Be Colorado will make the healthy thing the easy thing to do.

If the annual increase in health insurance rates slows or drops as a result of us all being healthier, that will be an added bonus.  But it all starts with taking the first step on the Be Colorado wellness journey.

Risa Heywood is health promotion program manager in the Office of the President at the University of Colorado.

Opinions communicated in Solutions represent the view of individual authors, and may not reflect the position of the University of Colorado Denver or the University of Colorado system.

By Danny Katz

There was good news and bad news in a recent study by the Robert Wood Johnson Foundation on the state of obesity in our country.  If you are a glass-half-full person, you would have been pleased that Colorado continues to be the thinnest state in the country. If you are a glass-half-empty person you would be disappointed that a No. 1 ranking means ONLY one in five Coloradans are obese.

In fact, despite being number one, Colorado is actually fatter than the fattest state 15 years ago, Mississippi.  This means that despite being number one, over the last 15 years, Colorado has experienced a rapidly rising rate of people who are overweight and obese and a rising rate of type-2 diabetes, heart disease and the other health problems that come with it.

The causes of our rising obesity rates are multifaceted, and so are the solutions.

One of the easiest steps America can take to fight this epidemic is to stop subsidizing junk food, which has helped push the cost of junk food down and the cost of healthy food up. This results in too many of our cups being either half full or half empty of things like corn syrup.

Here’s how it works. Since 1995, Congress has spent over 245 billion in tax dollars on agricultural subsidies primarily to grow just a handful of crops, over one-third of which go to growing just corn and soybeans. Very little of that corn and soy is grown for people to eat. Most of it is used to make ethanol, livestock feed, and food additives like corn syrup and partially hydrogenated vegetable oil.

Let’s be clear. These dollars are not going to struggling family farmers, the original intent of these subsidies. Over 70percent of all subsidies go to just 4 percent of all farmers – typically the largest agribusiness operations in the country.

Giant food companies figured out a long time ago that they could use these subsidized, cheap food additives to flood the market with huge portions of incredibly sweet, fatty foods – all on the taxpayer dime.

Thanks in large part to these subsidies, the price of soda in real dollars dropped more than 20 percent between 1985 and 2000. Meanwhile, the price of fresh fruits and vegetables (which are not subsidized) rose by over 40 percent.

According to one study, a 2000-calorie-a-day diet of just junk food can cost just $3.56 per day. At that price, it’s easy to understand how we got in this mess.

We all want to live long, healthy lives. And the obesity epidemic is a complex problem that won’t be solved by cutting subsidies alone. But as long as our food supply is skewed toward the production of cheap junk food, which is saturating our markets, we’re fighting an uphill battle.

With the Super Committee in Congress charged with reducing our deficit by over $1 trillion, this is an excellent opportunity for Democrats and Republicans to come together around common ground and end this wasteful spending for the health of all Coloradans.

Danny Katz is director of the Colorado Public Interest Research Group (CoPIRG), a statewide consumer group.

<div><strong> Opinions communicated in Solutions represent the view of individual authors, and may not reflect the position of the University of Colorado Denver or the University of Colorado system.</strong></div>

By Diane Carman

For employees at Van Gilder Insurance Corp., it may feel like tough love, with fruit replacing the more typical bowls of candy often found in office meeting rooms and the not-so-subtle pressure to quit smoking and get fit.

That’s OK with Steve Purkapile.

The vice president of Van Gilder in Denver has seen the benefits to the bottom line — in his company’s health care costs, his coworkers’ fitness levels and on the bathroom scale.

Wellness programs aren’t just fringe benefits at the company, which sells a broad range of insurance products. They’re part of a corporate policy designed to increase profitability by controlling health care costs at the source. Healthier employees cost less. For Purkapile, it’s that simple.

“The fact is 70 to 80 percent of illnesses are preventable,” he said. “People can argue all they want. Empirical data show … that lifestyle choices are the No. 1 driver of health care costs. At least 50 percent of the cost of health care is related to lifestyle choices, not environmental factors or genetics.”

Van Gilder is just one of many companies around the country that are experimenting with different strategies to reduce health care costs and improve employee health and fitness.

“The way health care is delivered now largely through employers, they have to be involved,” said James O. Hill, executive director of the Anschutz Health and Wellness Center.

“A lot of aspects of workplace wellness programs are showing potential,” Hill said. “They’re doing one thing or another well. We don’t know exactly what works, so we need companies to keep trying.”

Major lifestyle change

Steve Purkapile doesn’t just talk wellness.

“I’m one of those people who, when I hit 45, I weighed over 220 pounds,” he said. “I decided that I had to do things differently. I realized I can’t consume alcohol at this level. I can’t eat this food.”

Steve Purkapile before he got fit

He embarked on a “major lifestyle change,” working out five days a week, changing his diet and building strenuous activity into his life.

“Now I weigh 180 pounds and my numbers all are in the normal range,” he said of such health markers as blood pressure, heart rate and serum cholesterol. He climbs 14ers on weekends and runs marathons.

Dozens of his coworkers have caught the fitness bug, especially since the company began implementing new health care plans and wellness initiatives six years ago.

It didn’t happen all at once, he said. “One of our earliest ventures was to make fruit available around the office.” Then in 2007, “we became much more intentional.”

The company changed its health care offerings and began encouraging employees to move to high-deductible health plans with health savings accounts. Leaders at the company wanted to help employees better understand the connection between the lifestyle choices they make and the cost of health care. With the high out-of-pocket costs of the high-deductible plans, they figured it would get everyone’s attention. They made it clear this was the direction the company was taking, and offered programs designed to help employees minimize their health care costs.

Van Gilder held a health fair with medical tests and health screenings to help workers identify their risk factors, and challenged them to improve their diets, lose weight and stop smoking.

“We did it lightly at first,” Purkapile said. “We got 40 to 50 percent participation.”

In 2008, “we really began to intentionally and specifically create strong contribution differentials,” he said. Those who participated in the wellness programs received significant company contributions to their health savings accounts.

Employee participation rate extraordinary

Last year the company transitioned all employees to the high-deductible health care plans, and now 90 percent of employees participate in the wellness activities, earning points that qualify them for company contributions to HSAs and other incentives.

The company provides an on-site fitness center, locker rooms, exercise classes and a masseuse. There’s a company hiking club and the walking team takes regular mid-day jaunts around lower downtown.

Steve Purkapile

Purkapile said that while Van Gilder’s wellness program isn’t cheap, it more than pays for itself. “Our health care costs per employee per month have remained flat for four years.”

For every dollar the company spends on wellness, he said it saves three in health care costs. Purkapile estimates the annual cost of the wellness program runs between $375 and $400 per employee.

“I give them credit for doing this,” said Hill.

The big problem with most workplace wellness programs is that participation remains low. Often, only the employees who already are committed to fitness take advantage of them. “It’s hard to move the needle,” Hill said.

The Van Gilder program “uses both the carrot and the stick,” he said, providing financial incentives for participation and the likelihood that non-participants will bear higher health costs. Ninety percent participation is extraordinary.

The key question in this and most other wellness programs is whether participants can sustain their weight loss and fitness levels over the long term.

“I hope they’re collecting outcome data,” Hill said.

At this point the Anschutz Health and Wellness Center does not maintain records of the performance of these various employer programs. “I wish there were some way to do that,” Hill said. “It would be great if we could capture both successes and failures and learn from them.”

Everyone pays high cost of care for unfit

The Denver Business Journal recently highlighted several companies – including Van Gilder — for their wellness programs. Among them were Oakwood Homes, IMA Inc., United Healthcare and the University of Colorado Hospital.

Kenneth Thorpe, a professor at Emory University, did a study published this month in the journal Health Affairs and found that over a 10-year period, $7 billion or more in Medicare spending could be saved by getting overweight, pre-diabetic people to participate meaningfully in wellness programs that emphasize good nutrition, weight loss and exercise.

The data are clear, Purkapile said. “The impact of a smoker on a company is 10 ½ more unproductive days a year than nonsmokers, and being an obese person is now worse than being a smoker in terms of the additional medical costs.”

It’s one reason he is not a fan of universal, national health care.

“Who’s going to make the guy who’s 400 pounds, smokes and never walks pay five times what I pay for health care because it costs that much more? There’s no incentive to do the right thing in the system,” he said.

That’s why Purkapile believes it’s up to employers to create incentives for workers to make better lifestyle choices.

“Sure, it’s a free country. Civil liberty is great,” he said, “but we have to have to be accountable.”

By Katie Kerwin McCrimmon

Colorado Attorney General John Suthers plans to rule within about two weeks on the Colorado Health Foundation’s proposed $1.45 billion sale of its share of HealthOne hospitals to Tennessee-based HCA.

At hearings this week, Suthers and Deputy Attorney General Geoff Blue heard conflicting testimony about how best to protect community interests and ensure health care for the poor in Colorado where HealthOne now runs seven large hospitals, 13 surgery centers and 50 medical imaging and specialty centers. HealthOne is currently co-owned by the nonprofit Health Foundation and for-profit HCA. HCA operates 164 hospitals and has 180,000 employees across the country.

Supporters of the deal flooded a standing –room-only hearing Monday night at Rose Medical Center, one of the HealthOne hospitals. Many of those who spoke represented other large Colorado foundations  or organizations that have received funding from the Colorado Health Foundation.. They praised the foundation’s work, which centers on three strategies to make Colorado the healthiest state in the nation: promoting wellness and fighting obesity, increasing access to care, and promoting innovations that improve the quality of health care.

Several speakers testified that it’s wise for the foundation to diversify its assets and sell the hospitals for a good price now while also eliminating an inherent conflict of interest. The foundation’s goals increasingly center on keeping people out of hospitals. Shedding their financial interest in the hospital chain would allow foundation executives to pursue that mission without concerns about fluctuating hospital profits or hospital consolidation that may be coming under national health reform.

Attorney General John Suthers plans to rule within about two weeks about whether the Colorado Health Foundation can proceed with its planned $1.45 billion sale of several Denver-area hospitals to part-owner HCA. Suthers has jurisdiction over nonprofits and heard testimony about potential impacts of the sale.

“They will be 100 percent in the health business and not in the hospital business,” said Lisa Brown, CEO of the Northwest Colorado Visiting Nurse Association, which provides health services to nearly 30,000 people from newborns to seniors in Routt Moffat and Jackson counties.

Brown’s agency has received extensive support from the health foundation and she said she drove all the way from Steamboat Springs to testify because the health foundation’s work is so critical to rural communities. She said her association is struggling with an aging, underemployed population and needs powerful, stable partners like the health foundation.

Other proponents of the sale said it’s financially imprudent to have such a large investment in one business sector: hospitals.

Robert Kauffman, an attorney at Brownstein Hyatt Farber Schreck who served on the HealthOne board from 2002 to 2010, said the board carefully considered two questions before accepting HCA’s offer. First, was it wise to keep over half of its assets in one company, and second, would the leaders of HCA and HealthOne live up to commitments to educate future doctors and provide care to all people in the community?

“The answer to both questions was very clear,” Kaufmann said. “Under no scenario should the foundation keep all of its assets in one company.”

Furthermore, he said that HCA and HealthOne’s commitment to charity care is unparalleled across the country and unwavering.

But some opponents pointed out that the Health Foundation has enjoyed stunning returns from the hospitals over the years, while others urged Suthers to require increased charity care since Colorado’s Medicaid population is expected to grow dramatically in coming years.

Dede de Percin is executive director of the Colorado Consumer Health Initiative, a consumer group that represents about 50 groups across the state. She said the group is not opposing the deal, but wants to ensure that commitments to charity care and coverage for Medicaid patients will increase over time.

An independent analyst whom Suthers hired found that the $1.45 billion purchase price was fair, but some critics wanted to see the financial statements on which the price was based. Others said it’s unwise to sell.

“I understand why HCA is interested,” said Dr. Richard Parker, a Denver surgeon, but he warned that once the for-profit company takes over, hospitals could close. That’s what happened with Mercy, a former hospital in east Denver that shut its doors only three years after a for-profit entity purchased it.

“When is enough enough? When is big enough enough?…If this (sale) goes forward, we can’t go back,” Parker said. “I have great respect for HCA. No question about their commitments. But, having watched this joint venture succeed, why are we so quick to run away from it?”

The architects of the proposed $1.45 billion hospital sale: (from left to right) HCA president of operations Sam Hazen, Anne Warhover, president and CEO of the Colorado Health Foundation, Gary Drews, CFO and vice president for finance of the health foundation and Troy Eid, the health foundation's attorney.

Other opponents pointed out that the foundation has enjoyed a remarkable infusion of cash from hospital profits. Today, the foundation reports that its assets total more than $1 billion.

“If this entity in 1995 had taken its $17 million and invested (those profits in the stock market) it would have only (generated) $50 million,” said Jay Horowitz, a Denver attorney who spoke on his own behalf and is not involved in the transaction. “Non-diversification has paid off more than 20-fold.”

Horowitz said that all of the speakers who praised the work of the foundation were missing the key issue. In additional to their excellent work today, he believes that the people of Colorado expect the mission to include the original intent. When the foundation was created through the partial sale of nonprofit hospitals back in 1995, the people of Colorado expected an ongoing commitment to protect community interests.

“And here we are now and we have this big outside force. They’re not Coloradans. They’re not living and working here. They don’t have a long tradition here. The Colorado Health Foundation should be continuing what it set out to do,” Horowitz said.

Leading that point of view was former board member, Dick Anderson, who helped negotiate the original deal with HCA’s predecessor back in 1995. Anderson and nine former board members urged the attorney general not to approve the deal. They said that the foundation has served as a moral compass, preventing mass layoffs and hospital closures, and ensuring the long-term viability of expensive residency programs that train future doctors.

Anne Warhover, president and CEO of the health foundation, sought to reassure Suthers and Blue that the transaction is indeed in the public interest.

“This is the right decision at the right time,” Warhover said. “It’s clear that our state’s health needs have changed. Today acute care is only one piece in a complete health system. Today we know more about preventive measures.”

Dr. James Dreisbach (left) and Dick Anderson, two former board members, both oppose the hospital sale. They were on the board and helped negotiate the original sale of half ownership to Columbia, which became HCA. Anderson and Dreisbach say that the nonprofit health foundation has been a "moral compass" protecting local interests and halting staff layoffs or hospital closures.

Warhover said studies show that only 10 percent of health outcomes are determined by health care. Environmental factors, income, behavior and genetic makeup have far greater impacts on health outcomes, she said. That means that the foundation wants to spend more resources promoting wellness so people need less health care.

She said covenants in the proposed sale would ensure that the HealthOne hospitals will continue to care for Medicare and Medicaid patients and will provide the same levels of indigent care for at least five years.

“This transaction is good news for the people of Colorado,” Warhover said.

Ed Kahn, an attorney who specializes on health issues for the Colorado Center on Law and Policy, testified that after analyzing the proposed sale, the center  supported the deal, but he encouraged Suthers and Blue to modify it. Click here to see Kahn’s full analysis in Solutions. Opinion: Five ways the HealthOne hospital deal should be adjusted to protect the public.

Kahn believes it’s wise for the foundation to divest itself of the hospital interests, but he said there’s no reason that HCA should be able to require a non-compete clause and the health foundation should be able to fund endeavors in the future that might bring about dramatic reductions in hospital costs.

Kahn said HCA should be required to contribute at least $10 million per year plus additional funds adjusted for inflation to support the graduate residency programs, and he said that HCA should promise that it won’t close any of the HealthOne hospitals for at least 10 years.

Furthermore, he called on Suthers to require that the community board overseeing the HealthOne businesses  have a majority of members who represent consumers. The current structure would mandate 50/50 representation with HCA choosing the chair.

Finally, Kahn urged the attorney general to make available all the financial materials that his consultants used to determine that the $1.45 billion sale price is fair. That way, members of the public could evaluate the price on their own if they wished.

“Ten years of financial statements from HealthONE should be made public so that any individual who wishes to investigate the fairness of the purchase price can do so,” Kahn said.

The attorney general is also accepting comments via e-mail at hospitaltransfer@state.co.us

By Ed Kahn

With fine tuning, the proposed sale of the Colorado Health Foundation’s interest in the HealthONE system should be approved by the Colorado Attorney General.

The transaction, which converts a stock type interest in a hospital joint venture to cash, involves a payment of $1.45 billion, which, when added to the foundation’s current portfolio, will make the Colorado Health Foundation the third largest health foundation in the country. It will free resources from restrictions and possible conflicts of interest so the foundation can promote its vision of making Colorado the healthiest state in the nation.

In the meantime, public hearings on the transaction Attorney General John Suthers has scheduled for Monday and Tuesday are an opportunity to make sure the deal is structured to benefit the public interest. The deal should enhance the ability of the Colorado Health Foundation to carry out its mission once ties to a for-profit hospital system are severed. And it should protect people who rely on the care they receive at hospitals in the HealthONE system, the largest hospital system in the Denver area.

Coloradans might reasonably ask why the attorney general is involved at all in the deal, and why would the Colorado Center on Law and Policy and other health care advocates weight in. Generally, the sale of a hospital or any other business is a private matter. The plan to sell the Colorado Health Foundation’s interest in the HealthONE hospital system is different because the health foundation benefits from tax-exempt status. That special treatment, which is not granted to for-profit companies, creates a public interest in protecting assets accumulated for charitable purposes.

Colorado statutory law doesn’t directly address the dynamics at work in the HealthONE transaction, but Suthers made the right call by deciding to review the transaction under his common-law authority. Here are some ways the deal could be adjusted to ensure protection of the public interest:

1. The deal should not preclude the Colorado Health Foundation from competing with the HealthONE system. It’s unlikely the health foundation would open a new hospital to compete with a HealthONE institution. Still, the non-compete clause contained in the deal submitted to Suthers could unreasonably constrain the health foundation from other, more modest activities that could be construed as competition, such as funding a health clinic that experiments with new service-delivery methods.
2. HealthONE has agreed to continue its community-benefit functions, including providing charity care for people who can’t afford a hospital bill, at the same level they’re provided now. That provision should be changed to ensure the value of the community benefit is adjusted each year to account for inflation in the price of medical goods and services. Without an adjustment for medical inflation, the value of HealthONE’s community benefit activities would diminish greatly over time.
3. The deal should prohibit the closure of any of the nine HealthONE hospitals that are part of the transaction for at least 10 years. That would protect people who now rely on those hospitals for their care.
4. A board is designated to assure that the community benefit obligations of the HealthONE system are met for 10 years. That board should be required to be composed of six foundation-appointed members, with HealthONE selecting two. The chair should come from the community. This replaces the current proposal for equal membership and HealthONE selection of the chair, which unfairly gives HealthONE a veto over effective action by the board to fulfill its responsibilities if HealthONE objects.
5. The foundation should be required to report to the attorney general for three years whether investment advisors for the sales proceeds are free of connections to any foundation officer, board member or staff member of the Colorado Health Foundation. A reporting requirement would help assure the public of no conflict of interest of the investment advisor.

The fine tuning of the proposed sale of the foundation’s interest in HealthONE will help to ensure that the public interest is well served by the transaction.

Denver resident Ed Kahn is special counsel for the Colorado Center on Law and Policy, a nonprofit, nonpartisan research and advocacy organization seeking justice and economic security for all Coloradans.

By Katie Kerwin McCrimmon

WESTMINSTER — Exam room No. 1 at Westminster Medical Clinic is a striking departure from the classic, sterile rooms in a typical doctor’s office.

The walls are pale lavender.  Soft light from a lamp washes over a plush couch and easy chair.

Candles and a CD player sit on a bookshelf next to wellness and self-help books along with the bible of the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders.

Yet, this oasis is a place within the walls of a busy primary care practice where doctors can lead a patient, giving them what’s called a “warm handoff.” That means the patient goes straight from a traditional doctor into the hands of a behavioral health counselor.  No stigma. No need for a referral or a trip to a different location. The doctor hopes that patients will get help right away with mental health issues that could be affecting their physical health profoundly.

The room is also a symbol of hope that a badly broken system finally can be fixed.

Dr. Scott Hammond, 58, is a family practitioner at Westminster Medical Clinic. He has been trying for nearly two of his three decades in primary care to blend behavioral health care with his medical practice. He and his colleagues even provided a free office to counselors. But, three times, these attempts failed.

Physician's assistant, Sarah Goff, and health coach Beth Neuhalfen compare notes on a patient at Westminster Medical Clinic. Goff is amazed to hear that the patient has already cut his soda intake and working out several days a week.

Now Hammond and his co-workers at Westminster Medical Clinic have been identified as “innovators” who are receiving $150,000 and extensive technical support from a new program called Advancing Care Together (ACT). They will spend the next three years trying to prove that the disparate worlds of physical and mental health can finally be integrated and that patient health will improve dramatically while costs level off or go down.

“Fifty percent of my patients have (mental health) problems. I can’t treat them without having comprehensive care,” Hammond said. “We’ve failed in the past. We co-located a mental health person right in our office. This time, we will get it right.”

An impatient optimist

You could call Hammond an impatient optimist. Getting integrated medical and mental health care right is nothing short of critical. Experts often say that the U.S. health system is broken. Slip on Hammond’s white coat for a moment and you’ll understand just how broken it is.

He had one patient who tried to commit suicide. She was released from the hospital and given a long list of mental health counselors for follow-up care.

After 119 attempts, she gave up. The calls were unanswered or unreturned. Some providers no longer were in practice. Other therapists refused to take new patients or couldn’t provide an appointment for weeks. So, the woman called her most trusted health adviser, Dr. Hammond.

He worked the phones.

“We got her in to see someone within 48 hours. I called six people and twisted arms. That’s the mental health system: barrier after barrier,” Hammond said. “It’s a sham, a complete sham. There’s no effectiveness to the system at all and patients are suffering terribly.

“That’s why I brought a therapist into our office. How desperate must you be to pay to bring them in? We have a connection to our patients. We have a different standard of personal responsibility,” Hammond said. “Our strength is our weakness. We will do whatever we can to take care of our patients even if it is at our sacrifice personally, professionally or financially.”

Sometimes the circumstances are less dire than suicide, but just as deadly over the long run.

Dr. Scott Hammond carries a laptop with a photo of an old-fashioned doctor's bag. Hammond has aggressively adopted the newest innovations in primary care. He's hoping that a behavioral health counselor and health coach will help him provide better, less expensive care to patients.

Hammond had a patient in his 40s who was smart and successful in his job. Yet, his diabetes was completely out of control and would not adhere to either medical or lifestyle recommendations.

“I worked with him and worked with him and couldn’t find the button to push. It was incredibly frustrating for me not to be able to figure this out. He would voice agreement with me, but he wouldn’t adhere to a treatment plan,” Hammond said.

“I offered to send him to a therapist suspecting a psychological barrier. He said he would go, but he didn’t.”

After five years of frustration, Hammond ultimately made a choice he didn’t like. He decided he was not helping the man and suggested he see one of his partners instead.

“I hardly ever discharge patients, but I wasn’t helping him,” he said. “It’s not pleasurable for a physician to be a failure when you know that you could help someone.”

Hammond believes that control issues, not diabetes, were at the root of the man’s health issues. He wonders if that patient’s glucose levels would have improved quickly had he had access to free or inexpensive therapy right in the office.

“He needed to be in control. By denying his disease, he was in control,” Hammond said. “Clearly psychological issues were interfering with his care. We in primary care don’t have the time or, at times, the skills to deal with the difficult problems that sometimes interfere with success.

“How do you get the patient to be activated in taking care of problems? That’s not the primary role of the primary care physician anymore,” Hammond said. “Yes, I’m trained in engaging patients…but it really requires a team.”

Health investment: coaches and counselors inspire change

Enter the health coach and the behavioral health counselor, two experts who earn far less than a doctor, but who may be more skilled in coping with mental health challenges or helping people change their behavior.

Desiree Sanchez is the behavioral health counselor who just started last week as Westminster began its ACT experiment. She’s a licensed clinical social worker and is already seeing patients who’ve gotten a warm handoff from their doctor. A health screening might indicate depression, anxiety or another mental health challenge. Or a lab result might show a disease that’s out of control. In cases like these, Sanchez can give the patient quick coping tools or set up several appointments.

“I bring them into a comfy area. You feel safe, more like you’re at home,” Sanchez said. “The feeling that you’re not in an exam room helps people let their guard down.”

Another expert on Westminster’s team is Beth Neuhalfen. She’s the integrated health coach and is also Westminster’s medical home manager. The practice is one of 16 family and internal medicine practices along Colorado’s Front Range that are leading efforts to implement the newest innovations in primary care. The concept of a medical home is like primary care on steroids. A team of providers uses data and unconventional methods like group appointments and focus groups to put patients at the center of their care. The idea is that giving patients intensive primary care keeps them healthier and prevents exorbitantly expensive hospital visits.

Desiree Sanchez, the new behavioral health counselor at Westminster Medical Clinic, says goodbye to patient, Ariadne Williams. The family practice is experimenting with providing a counselor that any patient can see.

Integrating mental and physical health care fits right in with the medical home model.

Neuhalfen’s job as health coach is to partner with patients and inspire them to think of ways they can maximize their health.

“It’s about clarifying their mission, purpose and goals to help them achieve that outcome, giving them tools and inspiration to avoid a chronic disease or not letting a chronic disease take over their health,” Neuhalfen says.

She holds sessions with patients and discusses nutrition, exercise and ways they can change their behavior to have positive relationships. Providers refer patients to the health coach when they are difficult to treat or aren’t getting better. The most stubborn chronic problems in nearly every doctor’s office today relate to chronic conditions like diabetes, obesity and cardiovascular health.

Passing through the hallway at Westminster Medical Clinic on Tuesday, Neuhalfen compared notes with physician assistant, Sarah Goff. Neuhalfen was celebrating a patient’s victories after just two visits.

“He’s cut his Mountain Dew from two liters a day to one-half liter per day and is now going to the gym three or four times a week. He hadn’t stepped foot in a gym for six years,” Neuhalfen said.

Three failures, now hope

Fifteen years ago, when Dr. Hammond made his first attempt at mental health integration, two psychologists set up shop at Westmed.

“We were so frustrated with the inability to access care for our patients that we offered them free room and board. The need was so great that we chose to do that,” Hammond said.

That first arrangement failed due to a contract dispute.

“It was a business model failure,” Hammond said.

The next time, the doctors charged a psychologist from West Metro Mental Health $5 per day for a room. He didn’t seem to engage with patients and soon left.

The third provider came in for another sweetheart deal on rent, but chose to reduce her practice to Saturdays only.

Hammond decided that even though he had resolved the barrier related to location, patients still wouldn’t or couldn’t pay for care.

“There were two obvious barriers: financial and logistical.”

Under ACT, the team at Westminster is using $36,000 per year from their grant to cover the expenses of the part-time therapist.

The new model requires no copay from the patients.

The ACT funds are paying for the behavioral health counselor’s time. She will be there three days a week. Instead of charging under a fee-for-service model, where the medical provider charges per visit, Westminster is contracting with a mental health provider called Community Reach to keep its patients well. Community Reach will get $36,000 per year. The therapist will see all the patients who need help. Under this model, providers want to do everything to get a patient well quickly. There is no incentive to continue seeing a patient if they no longer need care.

Neuhalfen’s health coaching visits can be reimbursed through health insurance plans. Once the initial three years of ACT have passed and there is no longer grant money to fund the behavioral health counselor, practice managers are banking on health coach reimbursements to fund the mental health care at Westminster.

Hammond and Neuhalfen are hoping for tangible results.

“If you have a problem right now, it’s seamless. Let’s go right now,” Hammond said.

If a patient doesn’t get better after six visits, the mental health counselor and doctor can still refer the patient for longer-term therapy.

“We took a moral stance to do this because it’s the type of care we want to give,” Hammond said. “Previously, giving away the room wasn’t sustainable. It isn’t something you could spread.”

Hammond said some patients respond quickly and easily to his treatment. For instance, one patient was an ex-military man. He compared his doctor to his general, took the orders and immediately lost 30 pounds. Others don’t comply with treatment plans and may resist seeing a health coach.

“They tell me, ‘I’m going to try harder. Give me one more chance,’” he said. “They apologize and they’re humiliated, but they’re unable to make behavioral changes.”

Usually a single session overcomes that reluctance.  One man initially didn’t want to see the coach. He brought his wife and both loved the visit so much that the wife was soon scheduling her own health coaching session.

“It’s a different relationship. I know that patients will tell me things knowing they won’t do them. They want to please me. It’s pervasive. With the coach, it’s more peer to peer,” Hammond said. “My patients are honest with me, but they don’t want me to think poorly of them. It’s like getting sent to the principal’s office. People come to the health coach prepared to talk about real issues.”

About 10 years ago, Hammond had become so frustrated with the seemingly intractable problems in medicine that he nearly quit. Learning cutting-edge medical home practices reinvigorated him. And one of his daughters convinced him that one doctor does indeed have the power to change the system. Together they started a nonprofit called the Colorado Center for Primary Care Innovation.

Now, Hammond is hoping that the ACT program will give him more reason to stick with his calling as a healer.

“Family physicians handle 53 percent of mental health care in this country. I’m extremely excited. This is my back-to-the-future dream.”

By Katie Kerwin McCrimmon

COLORADO SPRINGS – National leaders will be watching an ambitious experiment beginning at 11 sites across Colorado that aims to revolutionize and integrate long-separated primary care and mental health.

As the economy continues to falter while health costs climb, Colorado alone could save an estimated $3 billion a year by giving integrated behavioral and medical care to people with complex illnesses, according to Steve Melek, a Denver actuary from Milliman, an international actuarial and consulting firm.

The new program is called Advancing Care Together (ACT). It is bringing integrated care to adults and children in test sites from Cortez to Lamar and Fort Collins to Colorado Springs. Melek presented data at an ACT launch conference in Colorado Springs this month and will be assisting with the evaluation of the Colorado effort over the next three years.

Melek showed that Colorado patients with chronic medical conditions like diabetes — who also have untreated mental health challenges such as depression —  cost insurance companies, employers or taxpayers an extra $625 per person per year. Depression may cause the patients to skip medication or allow their symptoms to worsen, which in turn can trigger costly hospital visits. Multiply those extra costs over millions of people who are already covered through commercial health insurance or government programs like Medicare and there are huge untapped opportunities to save.

“Roll that up and at a minimum, over one year, you’re spending $3 billion and maybe as much as $8 billion,” Melek said. “Depression is a big deal to employers.”

When health coaches or care managers use data to find and help these patients, care costs drop dramatically, sometimes by as much as 50 to 100 percent per patient, Melek said.

The numbers are not just theoretical. Melek presented data about a large health plan outside Colorado that hired Milliman to analyze what would happen if it gave patients behavioral health care. Melek studied two large pools of Medicare patients. Some got behavioral health and Melek’s firm compared them to “twins” who didn’t. The twins were other Medicare patients who were the same age with the same health challenges and even the same interests such as gardening, fly-fishing or watching NASCAR.

The program cost nearly $16 million in one year and provided mental health care to 13,000 patients.  Some got telephone counseling. Others got longer-term therapy that extended three to four months.

The results were startling. The company saved $40 million, generating a return on  investment of $2.50 for every dollar spent.

Dr. Kelly Lowther (lower left) a family practice doctor at Miramont Family Medicine in Fort Collins, maps out her company's plan to use kiosks to help screen patients and help them receive mental health care. Assisting her is Dr. Bijal Balasubramanian, an epidemiologist and assistant professor at the University of Texas School of Public Health.

By the end of the year trial, the naysayers were demanding that more patients be included in the program.

“In 2012, they will more than double the program,” Melek said.

“People are looking for solutions to bend the cost curve,” he said. “There’s a lot of opportunity from these comorbid patients (people with two or more simultaneous health problems), complex for sure, but there’s a lot of opportunity.”

Along with the financial incentives, there’s also a powerful moral and medical imperative to bring immediate improvements now.

“There are simply tens of millions of people in the United States at this very moment who are not getting the health care they need to have longer and better lives,” said Larry Green, director of ACT, a national expert on integration and a faculty member at the University of Colorado’s Department of Family Medicine.

ACT organizers and the group’s high-powered steering committee, which includes national mental health experts and honorary member and former First Lady Rosalynn Carter, hope to find the “secret formula” for integration through results at the demonstration sites. Then they want to create a playbook that can then be duplicated around the country.

“What we’re doing (now) doesn’t work very well and it’s unsustainable,” Green said. “Our health system can’t be fixed without addressing the emotional and behavioral health of our patients.”

Green said Colorado has been a “hotspot for innovation” when it comes to blending primary health care with behavioral health. Even so, he said the current systems don’t work for most people.

“We’re in a mess. Our business models suck. We’ve got a lot of cultural problems. This is a big problem. The conditions are adverse. We can’t see our way all the way to the end,” he said.

Green and the ACT backers are convinced that within three years, the Colorado innovators who are each receiving $150,000 along with extensive coaching, technical assistance and evaluation will show dramatic improvements and offer key lessons for policymakers across the country. The Colorado Health Foundation is funding the four-year, $3.9 million ACT program.

“The people are waiting. We need to catch up and help them,” Green said. “This has been an intractable problem for decades.”

ACT aims to produce practical solutions now. Green said study after study has shown that integration of mental and physical care helps patients.

“As long as this care stays silent and separate and fragmented, the solutions will elude us,” he said.

The innovative aspect of ACT is turning knowledge into practice. Hence the acronym’s active tone: act.

“We aim to change practice across the country,” Green said. “It’s a reality-based approach to learning, not an idealized approach.

“We’re not interested in finding ways to do things that require being propped up by extra resources. We want to know how this can be done in real life for single mothers with three kids and two jobs.”

Dr. Patrice Whistler, a pediatrician with Primary Care Partners in Grand Junction, works with her partners to refine their plans for integrated physical and behavioral care.

Green said doctors and therapists have known for decades that people need integrated behavioral and medical care. The true innovators are on the ground.

“We have experts who have already figured a lot of this stuff out,” Green said. “The true game-changers are already out there in Colorado communities. They want to be better and could use a little help.”

A history of hiding the mentally ill

Dr. Mary Jane England is one of the top mental health experts in the country and is serving as chair of the ACT steering committee. England chaired a watershed 2005 report for the National Academies’ Institute of Medicine on improving care for people with mental health and substance abuse problems.

“We found that if you want to have quality in health care, you’re going to have to integrate mental health and substance use treatment,” England said. “On the other side, if people with mental illness don’t get good health care, they die two decades earlier.”

How did our country go so wrong in segregating mental health care from physical health care?

England says it’s because cultures dating back thousands of years had no good treatment for the mentally ill so they tried to hide them.

“The behaviors were difficult to manage, so they locked people up,” she said.

Attempts to hide the mentally ill continued well into the 20^th century.

But then, scientific advancement produced a better understanding of mental illness along with drugs that could help tame symptoms. England calls the 1990s “the decade of the brain.”

“We understand the brain better now. We learned that brain cells regenerate. So, (mental illness) looks much more medical,” she said. “We found treatments that worked. Wow. You can do something about depression. You can do something about bi-polar disorder. Even schizophrenia. It’s difficult. But we have treatments.”

Today, primary care doctors can successfully treat many mental health problems. Access to care has in turn, reduced the stigma about mental illness.

“That’s what has made such a big difference,” England said. “The brain is part of the whole physical being. People are accepting that more. It’s the behaviors that frighten people.”

England is a visiting professor of health policy and management at the Boston University School of Public health. She earned her medical degree there in 1964 and became a child psychiatrist and is a former president of both the American Medical Women’s Association and the American Psychiatric Association.

England has worked extensively with Rosalynn Carter who is especially concerned with helping children and adolescents who are coping with behavioral health challenges. She said Carter is intrigued with ACT because she’s eager to see integration spread.

“We have the financial data. We know it’s right. Now, can we show that we can change clinical practice?” England said.

Another ACT steering committee member and advocate for change is former Colorado First Lady Jeannie Ritter. She became a vocal advocate for the treatment of mental illness during her husband’s term in office.

“This is a stigma buster,” Ritter said of ACT.

Giving people the ability to seek mental health care right where they get primary care is key.

But fusing the two worlds will be difficult. Many experts at the launch conference said that primary care providers spend too little time with patients while behavioral health experts spend too much. The doctors may need to slow down while the counselors need to speed up.

England said that mental health experts are quite accustomed to putting the patient first. When a patient is mentally ill, you simply can’t treat them without getting their buy-in, she said. Traditional doctors are just now learning to put patients at the center of the care and to ask them what they want.

She said it’s vital that everyone understand that the overall system is broken. We can’t look just at individual practitioners or clients and expect to generate system-wide results, England said.

“Change is tough. Some patients don’t ship easily from one system to the next,” England said. “But, I’m more hopeful today that ever before. I’m excited that there’s a movement toward wellness. People understand prevention and intervention. We have to talk about exercise and smoking cessation.”

England said national experts in the behavioral health community and in family medicine will be closely watching Colorado’s results.

“We can no longer just treat the medical problems.”

The 11 innovations sites for ACT are:

Axis Health System, Durango

Practice: Cortez Clinic

Project:  Using a Personal Health Profile to Facilitate Integrated Care

Principal Investigator:  Pamela Wise-Romero, PhD

Bender Medical Group, Inc., Fort Collins

Practice:  Miramont Family Medicine

Project:  AIMS:  Automation of Mental Health Services

Principal Investigator:  John Bender, MD

Denver Health and Hospital, Denver

Practice:  Lowry Family Health Center

Project:  Meeting Patient Preferences for Behavioral Health Screening and Treatment

Principal Investigator:  Rob Keeley, MD

Jefferson Center for Mental Health, Wheat Ridge

Practices:  Independence Outpatient Services, West Colfax Outpatient Services, Cedar Adult Intensive Services

Project:  Healthcare Homes without Walls

Principal Investigator:  Donald Bechtold, MD

Kaiser Permanente Colorado, Denver

Practice:  TBN

Project:  Practical Approaches to Integrating Mental and Physical Healthcare

Principal Investigator:  Arne Beck, PhD

MidValley Family Practice, PC, Basalt

Practice: MidValley Family Practice, PC

Project:  Optimizing Healthy Lifestyle Management

Principal Investigator:  Glenn Kotz, MD

Plan de Salud del Valle, Inc.

Practice:  Salud Family Health Center, Brighton

Project:  Integrated Primary Care Workforce Development in the Medical Home

Principal Investigator:  Andrea Auxier, PhD

Primary Care Partners, PC, Grand Junction

Practices:  Western Colorado Pediatric Associates, Family Physicians of Colorado, Behavioral Health and Wellness

Project:  Expanding the Patient Centered Medical Home

Principal Investigator:  Patrice Whistler, MD

Southeast Mental Health Services , La Junta

Practice:  High Plains Community Health Center

Project:  Lamar REACT:  Rural Excellence in Advancing Care Together

Principal Investigator:  Jay Brooke, LCSW

University of Colorado Colorado Springs/CU Aging Center, Colorado Springs

Practice:  Peak Vista Community Health Centers

Project:  Cognitive and Psychological Screening to Enhance Integrated Care for Seniors

Principal Investigator:  Michael Kenny, PsyD

Westminster Medical Clinic, Westminster

Practice: Westminster Medical Clinic

Project:  Behavioral Health-A Shared Service Model

Principal Investigator:  Scott Hammond, MD