Health Policy Solutions

By Diane Carman

Dr. Joseph Kay looks people right in the eye when he talks to them and that’s part of his problem.

When the assistant professor of medicine and pediatrics arrived at the University of Colorado School of Medicine in 2004 and realized that he would have to turn away dozens of uninsured patients who needed cardiology care, he knew he had to do something.

“I couldn’t look them in the eye and tell them, ‘I can’t care for you,’” he said. “I couldn’t personally do it.”

He understood the center’s policy that limits indigent care to 10 percent of its overall caseload. “I think it’s a reasonable policy,” he said. “In no way do I think the heart center at University Hospital is failing to do its job.”

The problem isn’t just with University Hospital, he said. It’s much bigger than that. Kay believes the problem is the U.S. health care system.

The United States is “the only developed Westernized country that doesn’t offer at least minimal health care to all of our citizens,” he said. “We should be ashamed of our system and ashamed of our lack of political will to address it.”

So even though he should have been focusing his attention on publishing research articles and doing clinical work in the intensely competitive world of academic medicine, Kay went to his supervisors and requested permission to see uninsured patients voluntarily on weekends and evenings.

They said no.

“They didn’t want to open the gate” to the thousands of uninsured patients in the community who need care, he said.

The policy made perfect sense from an administrative point of view. Still, Kay knew he couldn’t turn so many patients away untreated.

So he met with Dr. Barry Martin of the Metro Community Provider Network and the two physicians hatched a plan.

Martin has a personal interest in treating patients with developmental disabilities. Kay said that a significant percentage of these patients have congenital heart conditions, so providing expanded care for them and other cardiology patients was “a win/win.”

They opened a cardiology clinic at the network’s Potomac Street Clinic using volunteer physicians and nurse practitioners to treat uninsured patients. A federal grant allowed them to buy a used echocardiography machine, and the staff triages patients so they only see those they can help. If patients need catheterization or other sophisticated procedures they can’t do in the limited clinic setting, the doctors refer them to emergency rooms or other service providers.

“We’re seeing patients a half-day a month,” said Kay, who said that means about 14 patients a month receive care. “At any one time, the waiting list is 250 patients, so there’s a real need for this.”

Satisfying as it is to be able to care for more patients, Kay, who is married and has a daughter, still struggles to keep up with the demands of his hectic schedule.

Dr. Joseph Kay with the CU Board of Regents

At a recent CU Board of Regents meeting, he was described as “the hardest working man in the division of cardiology” by Professor Lawrence Hergott, M.D., his colleague at the University of Colorado School of Medicine.

Kay was honored with the Chase Faculty Community Service Award for 2011,  which gave him personal satisfaction well beyond the $10,000 prize.

“I was told when I was working to create this clinic that I was wasting my time and that it was going to kill my academic career because I was putting so much effort into volunteer activities rather than doing research and writing manuscripts,” he said. “That’s why it was a great honor to have the Board of Regents acknowledge that this was an important thing to do.

“It’s not all about the grants we get and the number of research manuscripts we write, but about setting an example for our trainees and giving something back.”

While Kay is proud of the work done at the Metro Community Provider Network Cardiology Clinic, he’s frustrated with the lack of progress toward a more comprehensive solution to the problem of the medically underserved.

“If I wasn’t a university physician, a state employee, I would be much more heavily involved in politics,” he said. “I have very strong feelings about this issue. I don’t like working in a system that’s unfair. I think of it every hour of every day.”

Kay recalls one patient who made at least three visits to hospital emergency rooms for treatment of recurring arrhythmia, and each time she was discharged and told to follow up with a cardiologist. But she had no health insurance and could not afford care, so she never did.

She finally found her way to the volunteer clinic, where she was examined and given a prescription for a drug to treat her arrhythmia. The drug, which costs $4 a month, has kept her healthy and saved untold thousands of dollars in emergency room care.

“It is cost-effective to do this, to keep people out of the more expensive emergency rooms and to take care of them,” he said.

Kay’s training is in both pediatric and adult cardiology. He was 35 years old before he completed the two tracks in cardiology. He holds a dual appointment at the CU School of Medicine and Children’s Hospital, and is particularly interested in congenital heart conditions and the transition from pediatric care to adult care.

As a result over the years, many of his patients have had a tough time getting health care. Before the Affordable Care Act was passed, they faced rejection by health insurance plans due to the pre-existing conditions they’d had since birth. While Kay said he believes the country still has a long way to go to achieve an equitable health care system, he’s pleased to see changes that protect his patients from categorically being denied coverage.

Preventing those practices by the insurance industry “was a huge step forward,” Kay said.

“Over the years I’ve considered moving from this country, but I’m not going to,” he said. “I’d rather stay and change what’s wrong from within.

“I know my patients at the volunteer clinic are getting a second level of care. We can’t do all the procedures they need there, we can’t offer complete cardiovascular care, but we offer some things.

“I hope someday the clinic will become unnecessary,” the 42-year-old Kay said, “certainly by my retirement … hopefully before then.”

By Katie Kerwin McCrimmon

From farmers markets to a growing number of backyard beehives, golden Colorado honey is booming in popularity, the perfect accompaniment to everything from figs to its more traditional culinary partners: tea and peanut butter.

While honey lovers wax rhapsodic about its sweet, complex flavors, boosters also cite the potential medical benefits of honey.

The pitch goes like this: eat raw, local honey and you’ll reduce your seasonal allergy symptoms.

Promoters are careful to warn that there are no peer-reviewed scientific studies. But, they report that many happy customers find delicious relief from their worst sneezing spells.

The theory is based on immunotherapy. Like a flu shot, you can trick your body into combating invaders that trigger an immune response. So, proponents say that if you eat local raw honey, produced near your home, you’ll get a healthy dose of local pollens and your body will naturally immunize itself against allergies.

“Almost all the evidence regarding the immunizing effects of eating honey is anecdotal — and we’ve sure met a lot of people who swear by it,” writes Brent Edelen, a sixth-generation beekeeper and owner of Grampa’s Gourmet, a honey company in Colorado’s San Luis Valley.

Edelen has been running a survey on his website and a handful of people who took part were convinced that honey helped their allergies. The majority weren’t sure, but said they loved eating honey no matter what.

Across Colorado, the Denver Post reports that a growing number of cities from Aurora to Denver and Grand Junction have been legalizing backyard beekeeping. Bee Culture Magazine estimates that there are 100,000 backyard beekeepers nationwide.

Rare allergic reactions to honey

The hobby and the honey may be divine,  but Dr. Harold Nelson, an allergist with 25 years of experience at National Jewish Health, one of the top medical facilities for allergy sufferers in the country, warns that eating honey isn’t likely to help allergies and can do some harm to rare people with severe allergies.

“The simple answer is that it’s very dangerous. Cases of anaphylaxis have been reported due to eating bee honey,” Nelson said.

For instance, a patient in Arizona suffered anaphylactic shock after eating honey that contained mesquite pollen. Other studies, including a 2001 report in the Annals of Allergy, Asthma and Immunology, found that honey caused an anaphylactic reaction in a patient.

Other reports of anaphylaxis related to honey have emerged from Turkey to Japan.

The idea of using honey to cure allergies waxes and wanes from generation to generation. Honey cures were all the rage during the 1970s and the concept of allergy prevention through honey seems to be enjoying a resurgence again now with backyard beekeeping on the rise.

The complicating factor, said Nelson, is that it’s impossible to know how much pollen is in the honey. There are anecdotal reports of benefits dating back to the Native Americans, and honey has been found buried with ancient Egyptian pharaohs.

But, when researchers have tried to prove a beneficial effect, they haven’t been successful.

“Where this has been done in formal studies, it’s been very controlled, with the administration of increasing doses of the allergens. Even then, it’s associated with enough side-effects that it’s been abandoned as a practice,” Nelson said.

“With raw honey, you have no idea how much pollen there is. It might be foolish (for a highly sensitive person to use it for allergies). It’s like chewing poison ivy. You get that as a myth too,” Nelson said.

Controlled studies show some reduction in sensitivity to ivy, but at the same time, some subjects broke out in painful rashes.

“These things aren’t absolute fiction, but they’re not to be recommended in any shape or form,” he said.

“There’s this concept that it’s natural. What could be more natural than letting the bee collect the pollen for you then eating it? It’s like all these herbal (remedies) and megavitamins. They’re all perceived as natural when in fact, most of the time, there’s very little scientific support for their efficacy.

“Most aren’t harmful. Honey is one of the exceptions. Most people can probably get away with (eating) it. But there are these scattered reports (of adverse effects),” Nelson said.

European allergy cure coming soon to U.S.

So, if honey doesn’t cure allergies, what does?

The best treatment is avoidance of allergy triggers, but that isn’t very practical for most people. Nelson said allergy shots, which have been tested for many years, are proven to work and have lasting benefits, even after patients stop receiving shots.

Among the newest treatments is a method called sublingual immunotherapy, which will be coming to the U.S. within a year or two, Nelson said. Used commonly in Europe, the sublingual method allows allergy sufferers to put extracts that target particular allergens under their tongues.

“They’re safe enough for people to administer at home. This is attractive to many people, but there are no approved extracts for use in the U.S.,” Nelson said. “I think it’s promising with definite limitations.”

Among the limitations, most people have multiple sources for their allergies. With allergy shots, patients receive a cocktail that helps them combat as many as eight or 10 allergens, ranging from ragweed to dogs and cats. With the sublingual extracts, the pills so far target just one allergy source at a time.

In Europe, targeting a single allergy source seems to work relatively well. For instance, in England, Germany and the Netherlands, grasses seem to cause the most allergies. Spain has olive trees while in Scandinavia, birch trees are dominant.

“Here, we’re messy. We plant allergic trees on our streets. We have grasses and empty lots full of weeds,” Nelson said.

Coloradohas particularly tough weed seasons that last from July to September. The culprits range from tumbleweed and Russian thistle, also known as ragweed, to sagebrush.

“We have a triple hit on the weed season,” Nelson said. “On the other hand, we have no dust mites. It’s too dry.”

The bottom line with allergies: “It’s quite complex.”

Nelson is confident that the FDA will eventually approve new oral therapies. “In the meantime, if the pills and sprays aren’t working, the shots are very effective.”

Allergy sufferers get shots weekly at first, then monthly. After three years, some people can stop the shots and will continue to receive benefits for up to 10 years.

“The shots have a major impact on the immune system that persists for a long time.”

By Maren Stewart

Colorado is officially the leanest state in the nation, with a 19.8 percent adult obesity rate, according to the F as in Fat: How Obesity Threatens America’s Future report released in July based on data collected from 2008 to 2010 by the Robert Wood Johnson Foundation and the Trust for America’s Health.

While some Coloradans may consider the ranking a victory for the state, many local health organizations are urging residents to consider all the facts before celebrating. For example, despite its top ranking, Colorado’s obesity rate has nearly doubled in the last 15 years, and today one in five Coloradans are obese and more than half of our population (56.2 percent) is either overweight or obese. Even though Colorado’s current obesity rate may sound positive when compared to Mississippi’s 34.4 percent obesity rate (the worst in the nation), consider that a 19.8 percent obesity rate would have garnered Colorado the title as the most obese state in the nation in 1995 – just over a decade ago.

The Colorado Department of Public Health and Environment (CDPHE) also points to the health disparities among the different regions of Colorado and among minority populations. Colorado African-American and Latino populations have obesity rates of 27.9 percent and 24.8 percent, respectively, as compared to Caucasians at 18.3 percent. In addition to the minority obesity rates, children are also at risk. In Colorado, 1 in 4 children are overweight or obese. Without a drastic change, overweight children are going to grow up to be overweight adults.

Generally speaking, the highest rates of obesity in Colorado are in the southeast region of the state, followed with the northeast. In addition to geographic isolation, both regions have corresponding high rates of poverty and unemployment. These factors illustrate the complexity of  addressing obesity and the necessity of working in partnerships across the state.

“Take a walk around your office, neighborhood, or grocery store.  More than half of the adults you see are either overweight or obese,” says Chris Lindley, Director of CDPHE’s Prevention Services Division.  Lindley adds that “we intend to reverse this epidemic threatening our health and welfare by working with advocacy groups, other government agencies, school districts, and citizens across Colorado.”

Many Colorado organizations, including CDPHE, the Colorado Health Foundation, Kaiser Permanente, and LiveWell Colorado and others are partnering to inspire sustainable individual behavior change and improve Coloradans’ access to healthy foods and opportunities for physical activity – two vital strategies to prevent and reduce obesity.

LiveWell Colorado launched a culture change marketing campaign in May, and Coloradans have calculated more than 180,000 “gut checks” at livewellcolorado.org. This online tool helps people identify if they are healthy at their current weight and offers simple ways to learn to make better choices. As more Coloradans become aware that obesity is not someone else’s problem, they are adopting healthier habits and will eventually engage in policy efforts to make environments more conducive to those healthy habits.

Through a collaborative process with many partners, LiveWell Colorado has also developed a series of Policy Blueprints to guide statewide efforts in the areas of Food Access, Worksite Wellness and the Built Environment. These blueprints help to inform efforts and have resulted in legislative successes, such as the creation of Colorado’s first-ever Food Systems Advisory Council focused on improving access to healthy food within Colorado. The Healthy Eating and Active Living (HEAL) Policy Group, comprised of multi-sector partners and stakeholders, recently led the successful passage of a bill which ensures Colorado elementary students get 30 minutes of physical activity each day.

Being dubbed the leanest state in the nation when adult obesity rates did not decline in any state last year, and in fact increased in 16 states, is a dubious honor. However, it is obvious that momentum is already underway to improve Colorado’s health and establish a successful obesity prevention model for other states to emulate.

Maren Stewart, JD,  is president and CEO of LiveWell Colorado, a nonprofit focused on preventing and reducing obesity in Colorado by promoting healthy eating and active living. Find out more atLiveWellColorado.org.

By Bob Semro

 Medicare Advantage is alive and … doing very well. Opponents of the Affordable Care Act raised fears among senior citizens by saying that the new law would gut the popular program, but the latest information tells a far different story.

 Medicare Advantage gives seniors the option of enrolling in private insurance instead of the traditional government-run Medicare program. As of August 2010, 11.8 million Americans were enrolled in Medicare Advantage plans, representing about 25 percent of all Medicare beneficiaries. The program offers additional benefits and therefore is more costly for the government, and that is why the ACA targeted the program for cuts.

 Concern about cost was based on trends for the program. According to the Medicare Payment Advisory Commission, the government was projected to pay Medicare Advantage plans 14 percent more per beneficiary than those enrolled in traditional Medicare. Between 2004 and 2008, these additional payments to Medicare Advantage plans totaled nearly $44 billion and averaged more than $1,100 for each MA beneficiary. According to the Centers for Medicare and Medicaid Services, these higher payments helped to drive up premiums for beneficiaries in the traditional Medicare program by an additional $86 per year.

 As a result, the Affordable Care Act included several provisions to reduce federal spending:

•    Reduce additional payments to MA plans over three years beginning in 2011.

•    Require MA plans to meet an 85 percent medical-loss ratio by 2014.

Combined, these provisions were expected to reduce federal Medicare spending by at least $136 billion over 10 years. The American Association of Health Plans (the national political advocacy and trade association for health insurers) predicted these provisions would “result in seniors facing higher premiums; a reduction in additional benefits; fewer health care choices; and higher out-of-pocket costs.”

 So far, pretty much the opposite has happened.

•    Medicare Advantage beneficiaries can expect to see their monthly premiums drop by an average of 4 percent without any changes to their benefits.

•    Enrollment in plans is expected to grow by about 10 percent next year.

And what about quality?

The ACA had provisions aimed at improving quality based on a five-star rating system. The new law provides bonus payments of up to 5 percent per beneficiary payment to those companies that can achieve a four-star rating. In addition, five-star plans would be allowed to enroll members year-round, instead of being limited to an annual open-enrollment period. Both are strong incentives for plans to improve ratings. (Recently, the Department of Health and Human Services implemented a three-year program that goes beyond the ACA by providing a 3 percent bonus payment to plans that attain a three-star rating. This means that 62 percent of Medicare Advantage plans could qualify for bonus payments. Even though health plans would not receive those payments until 2013, they can use the marketing advantage of this rating throughout 2012.)

 The star rating system has introduced an element of competition among insurance firms. “Everyone is taking this seriously,” said Sarah Baker of Health Dialog, a Boston-based insurance analytics firm that is advising plans on how to improve their ratings. Higher ratings offer a “huge competitive advantage,” she added.

 Dr. Rhonda Medows, the chief medical officer overseeing quality for the UnitedHealth Group, stated the company has set a goal for having all of its members in four-star or better plans by 2014.

So, to date, Medicare Advantage premiums have gone down, benefits have stayed the same for most plans, enrollment has gone up and the law seems to have provided an incentive for insurers to improve the quality of their plans. Not exactly the dire results that some opponents predicted.

 Much of the opposition to the ACA is based on fears and predictions that don’t hold up to scrutiny. In the end, only time will tell how successful the law will be. Some provisions may not work as well as hoped and will need modification. What we can be sure of is that efforts to defund, dismantle and repeal the law will leave us with a status quo system that is broken and financially unsustainable.

Early on, proponents urged patience and told skeptics to give the reforms a chance. In the case of Medicare Advantage, that advice was sound, and the results speak for themselves.

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

By Katie Kerwin McCrimmon

The deadly listeria contamination at Colorado’s Jensen Farms may have begun with imperfect cantaloupes that were hauled to a nearby cattle ranch.

The dump truck carrying those misshapen cantaloupes was parked right next to the open-air processing plant. The truck may have inadvertently brought listeria from cow manure back to the farm and spread the disease to prized Colorado cantaloupes, which were then shipped across the country.

Federal officials released their findings today from an investigation of the listeria outbreak. While a team of health detectives from various state and federal agencies is certain that the outbreak began at Jensen Farms, they cannot pinpoint how the listeria first arrived at the facility or exactly how it spread.

Investigators said the processing plant did not have an adequate system for chilling cantaloupe from the field and that the packing facility was not easy to clean. Water pooling on the ground also became a perfect area for listeria to thrive, grow and spread.

Officials had never previously inspected the farm, but said it’s not typical of cantaloupe processing facilities.

“I would say they were fairly unique,” Sherri McGarry, senior advisor for the U.S. Food and Drug Administration’s Coordinated Outbreak Response and Evaluation (CORE) team, said during a Wednesday press conference.

The investigation remains open and new cases of the illness continue to be reported. Officials from Jensen Farms have vowed not to distribute more cantaloupe next summer before state and federal official can certify that their operation is safe.

But anger among Colorado cantaloupe growers in Rocky Ford, nearly 100 miles away, has been boiling over as farmers fear that the reputation of their sweet melons has been marred permanently.

So far, 25 people have died from the listeria outbreak. One pregnant woman has miscarried and 123 cases of listeria have been reported. Cases are continuing to surface, but new reports are beginning to decrease.

“This is the deadliest food borne outbreak in the U.S. in more than 25 years,” said Dr. Barbara Mahon, deputy chief at the Centers for Disease Control and Prevention. “It’s too soon to declare the outbreak over. We will monitor for two more weeks.”

The outbreak marks the first time that whole cantaloupes have been implicated in spreading listeria.

“This is huge. It’s awful. Our hearts go out to the families of these patients and the folks that passed away,” said John Salazar, Colorado Commissioner of Agriculture. “We are working as a department to make sure we can minimize any possibility of infection in the future.”

Alicia Cronquist

Colorado health officials said the first sign of the listeria outbreak emerged on Aug. 29 when two cases of listeria were reported on the same day. That is “highly unusual,” said Alicia Cronquist, an epidemiologist with the Colorado Department of Public Health and Environment.

tate and county health officials began conducting standardized interviews with the victims. Colorado health officials contacted the FDA on Sept. 6 and within three days were confident that cantaloupe was the source.

A cantaloupe from one victim’s refrigerator and two stores where others had purchased suspected cantaloupe tested positive for listeria.

McGarry of the FDA’s rapid response team said investigators were able to use the equivalent of DNA fingerprinting to link the illnesses to Jensen Farms.

“Multiple samples tested positive,” McGarry said. “These results indicated that the cantaloupe contained a poisonous substance. The firm was packing cantaloupes under unsanitary conditions.”

Investigators decided to conducted a full-scale environmental assessment on Sept. 23 and 24 to try to find the root cause of the outbreak.

“The team visited and surveyed cantaloupe growing facilities, cold storage, food safety, post harvest and agricultural production,” McGarry said.

Experts found that the water used at the farm was safe. All of the samples from the field also tested negative for listeria.

That left the packing facility as the most likely culprit for contamination.

Either cantaloupe were contaminated with listeria in the field, then were improperly cooled and the bacteria grew and spread. Or, the dump truck became contaminated and brought listeria to the facility.

“This was an open-air facility where the produce was packed. Defective cantaloupe would be put into a dump truck that hauled it to a cattle ranch,” said Jim Gorny, a senior advisor for produce safety for the FDA. “Cattle are definitely a reservoir of listeria. They could have transported listeria back. The truck was parked right next to where the food was handled.”

Gorny said listeria was fairly widespread throughout the processing facility, however, and it could have also come in from the field with the cantaloupe.

“Once it was established, it spread,” he said.

Both federal and state officials emphasized the need for prevention and said the newly passed federal food safety act will improve monitoring and prevention.

“It’s very important for farms to employ good agricultural practices. Equipment should be designed so it can easily be cleaned and sanitized,” McGarry said. “Recognizing points of contamination and putting controls in place will prevent outbreaks like this.”

Added Margaret Hamburg, commissioner of food and drugs: “The tragic deaths and illnesses have again demonstrated the need to continually address food safety issues. If we’re to have a food safety system that prevents illness, we must all practice prevention.”

By Katie Kerwin McCrimmon

Unshackled from managing hospitals, the head of the third-largest health foundation in the country envisions an entirely different health landscape in Colorado’s future.

Some hospitals might close because they have too few patients. Child obesity will once again be rare. And primary care could feel more like a fitness center or a neighborhood gathering spot that also happens to have health coaching along with integrated dental, medical and mental health care.

“I feel lighter,” Anne Warhover, president and CEO of the Colorado Health Foundation, said this week after the monumental sale of hospitals, whose hefty profits had funded the foundation’s philanthropy.  “I know the hospitals are doing great. The timing is right. This was meant to be.”

Anne Warhover

Last week, after Colorado Attorney General John Suthers mandated some additional consumer protections and signed off on the $1.45 billion sale, the Colorado Health Foundation closed its deal with Tennessee-based HCA, selling its share of HealthONE hospitals, which include Denver area stalwarts, Rose, Sky Ridge, Swedish and Presbyterian/St. Lukes medical centers.

With assets totaling $2.3 billion, the Health Foundation now is among the 25 largest foundations in the country. The Robert Wood Johnson Foundation, worth $8 billion, is the largest health foundation in the country, followed by the California Endowment, which has assets of $3.5 billion, then the Colorado Health Foundation.

Robert Wood Johnson’s mission covers the entire country, while the California Endowment focuses on the 35 million people of California.

The foundation’s mission remains making Colorado the healthiest state in the nation. With a population of 5 million, Colorado now boasts one of the biggest players in health philanthropy.

“We’re really lucky that we have this kind of resource for the health of Colorado. We’re the biggest (health foundation in the country) on a per capital basis. We have more to invest in health,” she said.

Now that the negotiations and hearings have ended, Warhover reflected on the past and the future.

She said there were times in the past when she felt the weight of the inherent conflict of interest that came with simultaneously promoting health while also owning hospitals that derived profits from the sick.

“It was a burden,” Warhover said. “Every day, we felt that conflict. You couldn’t help it. It wasn’t that we were compromising our own income stream. We wanted to be a good partner for HealthONE and for their mission. But, it wasn’t our mission.

“Sometimes that was confusing,” Warhover said. “It was getting harder and harder to do.”

Warhover said she didn’t realize how heavy the burden had become until the sale was finalized. Then, she felt an unexpected lightness and saw new possibilities.

Warhover is convinced that health comes primarily from aspects of life that have nothing to do with our health care system. For instance, genes and lifestyle play a much bigger role than doctors and hospitals do in determining healthy outcomes.

“When you’re sick you need good health care,” Warhover said.

But creating a community of people who are well and who have access to healthy foods and easy fitness opportunities may have a much greater impact.

Warhover dreams of generating cultural change.  Two of the foundation’s primary focus areas are obesity prevention and integration of primary care.

“In my dreams, I think that the culture of eating healthy foods will change, that like smoking, the environmental pressures on people to change their eating habits will be prevalent.

“In five to 10 years, I really do think that the predominant culture will be healthy eating and physical activity. It will not be fast food and hot dog-eating contests.”

Warhover is particularly concerned about Colorado’s escalating child obesity rate.

“What I want to see is our childhood obesity rate declining. If our babies are born today and this culture of health starts to take hold by the time they’re 10 years old, they’re going to be on a healthier path.

“I’m concerned about obesity, but also all the chronic diseases it leads to,” she said.

With respect to primary care, Warhover envisions entirely new systems.

“My dream is that you go to your neighborhood or community health clinic and you don’t even know or care whether you’re seeing a medical doctor or another provider. All you know is that that person cares about your mental health, your dental health and your physical health and can (refer) you to others within that clinic.”

Warhover believes that investing in quality health care will actually bring costs down.

“Usually, you think it’s the opposite. But in this case, quality will bring savings,” she predicted.

As this new era dawns, Warhover wants Colorado to lead a health revolution.

“I want companies to locate here because employees are going to be more productive because they’re healthier. I want us to grow our own healthier kids.

“I think Colorado could be a model of this new health culture.”

Editor’s note: Solutions receives funding from the Colorado Health Foundation.

By Katie Kerwin McCrimmon

Opponents of the Colorado Health Foundation’s $1.45 billion sale of HealthONE hospitals to its partner, Tennessee-based HCA, believe Colorado will suffer in the long run.

But a legal analyst from the Colorado Center for Law and Policy thinks Attorney General John Suthers went further than expected to protect consumer interests.

Suthers approved the sale last week and found that the sale price was fair. He attached modifications that included:

• A guarantee that none of the seven large hospitals will close in the next five years
• The board of community trustees will continue for an additional five years beyond the 10 years proposed in the original agreement
• Indigent care will continue for an additional five years beyond the 10 years proposed in the original agreement.
• The $12 million initially earmarked for the community benefit programs will increase with inflation.

Less than 24 hours after Suthers issued his opinion, HCA and the Colorado Health Foundation closed their deal.

Despite Suthers’ modifications, opponents led by Dick Anderson, a former board chair who helped negotiate the original hospital merger in 1995, believe Colorado will suffer without local stewardship of vital hospitals.

Attorney General John Suthers

“We’re very disappointed and don’t agree with the attorney aeneral’s rulings,” Anderson said. “Only time will tell what the impact on the community will be. Clearly, in my opinion and the opinions of others, it will have an adverse effect on the community.”

Among the risks to the Denver area community that concern Anderson the most are the potential loss of services and residency programs along with long term reductions in care for the poor.

Costs of health care likely will rise or services will be cut so that HCA can obtain a return on its hefty investment.

“It’s only fair that they receive a return on their investment. After all, their primary responsibility is to the stockholders,” Anderson said.

He also believes graduate medical education programs will be at risk. Anderson said documents released through the sale show that HCA already has a process in place to end those programs once the sale allows the company to shed the expensive training programs for doctors.

“I think it’s a signal of what’s to come,” he said.

Protecting indigent care and community programs for 15 years may sound like a long time but is actually a blink of the eye in the long-term history of health care in Colorado, Anderson said.

“Whether it’s five or 10 or 15 years, the community has lost control of some very important assets,” Anderson said.

He also worries that HCA could mortgage Colorado hospitals to buy or build out-of-state hospitals.

Dick Anderson

“It’s still not clear to me what the benefits are to the community,” Anderson said. “The fact is that when the old HealthONE board gave the joint venture interest to the foundation, the intention was to keep control of these hospitals. If the foundation doesn’t want to do anything but give grants, then they can give the interest back to HealthONE, but retain community control.

“Only time will tell. It’s a shame that so many prominent Denver companies have found it necessary to sell out and not be based in our community.”

Ed Kahn, a lawyer who specializes in health policy for the nonprofit Colorado Center for Law and Policy, is much more optimistic about the sale.

“We’re pleased with what the AG did in terms of recognizing concerns we had raised,” Kahn said. “In a couple of respects, he went further than we recommended in protecting the public.

“I think he improved the deal for the public of Colorado and to the benefit of the foundation as well. He’s making sure the hospitals stay open.”

Kahn believes some hospital consolidation is inevitable. Across the country, he said inner-city hospitals have been closing. He compares changes in hospitals to the contractions in the 1980s and ’90s among health insurance providers. There used to be about 15 players nationally. Now there are fewer than half a dozen.

“Even if there were no Affordable Care Act, there is consolidation happening in health care, not just in hospitals, but also among physicians, specialty groups, labs, drug dispensaries, pharmacies and mail order suppliers,” Kahn said.

Because of this trend, the law and policy center asked Suthers to prevent closures.

“In some communities there have been instances where hospitals have been purchased. The population changes or management is just bad and they want to get out of the hospital business,” Kahn said.

He said many of the closures have come in low-income urban areas. Those areas are  different from HealthONE’s Denver-area hospitals.

“Even though these hospitals are not in the inner city, it’s possible that HCA could decide that (one of the hospitals) is less profitable and could close it if they thought it would help the bottom line,” Kahn said. “It seemed to us that these founders did make a commitment to have hospitals for folks in these communities.”

Kahn thinks it will be beneficial in the long run for the foundation to diversify its assets, and he said he always was concerned about the conflicts of interest in both owning hospitals and promoting health.

“What if some economist or physician comes to the foundation and says, ‘We have come up with a great idea to improve health care for patients and reduce hospital usage. We want to try this in Denver. Up until now, the foundation might have stepped back because No. 1, they would be potentially angering the joint venture and No. 2, they might have been adversely affecting their own flow of income,” Kahn said.

“What the transaction does is free them from those concerns and should an opportunity arise, they don’t have to go to HealthONE and say, ‘Bless this please.’”

For that reason, Kahn had asked Suthers to strike a non-compete clause from the deal. Suthers instead ruled that if any disputes surface over the non-compete agreement, the parties will have to come to him for mediation instead of suing each other.

Kahn said that’s a good solution.

From his personal point of view, and not representing the policy center, Kahn hopes that hospital profits will decline in the long run. If that’s the case, the foundation will have been wise to sell now.

“Most people who go to the ER don’t have a choice. It’s pretty bad when you have a heart attack. Paying a 20 to 30 percent markup on that (as well) seems excessive,” he said.

“If we eventually get to a system where the markup is 5 or 7 percent, that to me is a social good. The same is true of physicians and specialists. Once you figure out the base rate, why should they be in the top 1 percent of wage earners compared to the average person. There’s a better way to finance health care.”

By Sherry Walker

Pink ribbons, pink shirts, pink phones, even pink dog collars. It’s a sea of pink. In the middle of Breast Cancer Awareness Month, it’s a pretty safe bet that literally no one is unaware of breast cancer, the No. 2 killer of women. But knowing there’s some big scary disease out there doesn’t mean women (or men) have all the knowledge we need about breast cancer or its detection.

Six months ago, I became one of the more than 200,000 women to be diagnosed each year with breast cancer. What has surprised me most is how few of us know there’s more to self-exams than feeling for lumps or that some cancers aren’t visible through technology.

I found my cancer on a bad hair day. As I was dressing for work, I stopped in front of the mirror to see what was up with my hair. As I raised my arms over my head, I saw a dimple on the bottom of one breast. “Holy cow,” I thought. “This is new and it’s not normal.”

I made a same-day appointment with my primary care provider who sent me straight for a mammogram and an ultrasound. She also suggested I see a surgeon. Neither the high-magnification mammogram nor the ultrasound showed anything.

I considered canceling the appointment with the surgeon, but my normal paranoia told me to keep it. The surgeon took one look and said, “It’s a tumor. Nothing else makes a dimple like that.” Although he knew it was there, he had a hard time finding it in a clinical exam because this type of cancer, invasive lobular carcinoma, doesn’t form a hard lump. It merely thickens the tissue. I could barely feel it even when the surgeon showed me where it was.

I started querying friends and colleagues – “Do you know there are breast cancers that aren’t always detectable in self-exams, mammograms or ultrasounds?” The answer was always no. “Do you know that a dimple can be a sign of breast cancer?” Mostly no. “Do you ever stand in front of your mirror naked with your arms over your head and look for changes in your breasts?” Again, no. Of the three dozen or so women I’ve asked so far, only one knew that this should be part of their self-exams.

So, from the Susan G. Komen website, here are the signs:

• Lump, hard knot or thickening inside the breast or underarm area
• Swelling, warmth, redness or darkening of the breast
• Change in the size or shape of the breast
• Dimpling or puckering of the skin
• Itchy, scaly sore or rash on the nipple
• Pulling in of the nipple or other parts of the breast
• Nipple discharge that starts suddenly
• New pain in one spot that doesn’t go away

If standing in front of your mirror naked strikes fear in your heart, it’s still better than the alternative. Combine this with your regular self-exam, plus mammograms if you’re over 40, and see your doctor right away if you have any of these symptoms. Chances are even if the diagnosis is cancer, you’ll end up like me — stage one, no radiation, no chemo. A great prognosis because of a bad hair day.

 Sherry Walker is director of communications for the Colorado Health Institute.

By Katie Kerwin McCrimmon

More than 5,200 people are on a waiting list to receive primary care through Denver Health, and across Colorado at least 20,000 more low-income patients are waiting to receive care.

In Denver, the waiting list at the city’s safety net health system began in 2008 when the economy started its freefall.

At its peak, Denver Health had 7,200 patients on its waiting list. About 80 percent of those waiting for care in Denver have no health insurance while the rest have either Medicaid, Medicare or private health insurance.

“The reality is that there are more patients in the entire state who are uninsured and need access to care from safety net providers than there is capacity in the safety net provider system,” said Dr. Paul Melinkovich, a pediatrician and director of Community Health Services for Denver Health. “We can’t handle all the people who want to get in.”

While it’s difficult to track exactly what is happening to people who can’t get care through Denver Health, Melinkovich and others are certain that some patients stuck on waiting lists are getting sicker and winding up in hospitals.

“They’re delaying care and sometimes they’re getting care in much more expensive places like hospital ERs,” Melinkovich said.

He said the acuity or severity of illness is increasing, which pushes costs up. People who show up in Denver Health’s urgent care center or in the ER don’t have basic health complaints.

“It’s not a sore throat and a headache. Instead it may be diabetes that’s been out of control for months. Or, ‘I lost my insurance and can’t fill my blood pressure medication.’ It’s uncontrolled hypertension. It may be chronic pain…from a tumor that’s bleeding,” Melinkovich said.

In Denver, the cause of the problem is relatively straightforward, but difficult to resolve: lack of money. Denver Health and community health systems across the country anticipated hiring additional medical providers in 2011 to begin ramping up for 2014 when hundreds of thousands of newly insured patients are expected to flood health systems across the nation under the Affordable Care Act.

Money ‘disappearing before our eyes’

But, funding for additional teams of providers got ensnared in the much bigger budget battles in Washington. The Washington Post and Kaiser Health News reported this month on the national impact of promised funds that never arrived.

Denver Health was one of a record 810 health centers who anticipated receiving $250 million to serve 2 million additional people across the country. But the Post reported that instead of awarding the promised $250 million, the Obama Administration handed out just $29 million as part of the deal to trim the deficit.

Across Colorado, as demand for care at community health centers is increasing, hopes for new funding are dimming.

A family exam at the Pueblo Community Health Center. Children and pregnant women are never placed on waiting lists in Pueblo or at Denver Health. But demand for care has meant that some adults must wait to get primary care.

“There was $11 billion earmarked for community health centers and it’s disappearing right before our eyes,” said Polly Anderson, policy director for the Colorado Community Health Network, a coalition of 15 community health systems with 131 sites across the state who provided care for a total of nearly 459,000 people last year.

The federal funds were supposed to start flowing in 2011 and help community health centers build capacity over five years.

“This is a real factor in the waiting lists. We all anticipated that by now, we’d have more grants and we’d be expanding existing sites and building new ones. The need is increasing, but the funding on the federal side is really flat,” Anderson said.

At the same time, state funding for community health centers has declined by $38 million over the past three years.  The cuts have come in three areas: loss of funding to care for the uninsured, cuts in Medicaid reimbursements and the loss of grant dollars for prevention programs like prostate cancer screening.

Overall,  Anderson attributes waiting lists across the state to the lousy economy.

“As people lose their jobs and health insurance, they need somewhere else to seek care that’s affordable. Waiting lists are a real reflection of the economy,” she said.

Children don’t wait

National health leaders, including U.S. Health and Human Services Secretary Kathleen Sebelius, have visited Denver to tout the successes at Denver Health. The system has won numerous awards, and health gurus cite Denver Health as a model system for providing high quality care for relatively low costs. But, even this highly-touted public health system can’t serve all the people who need care.

Altogether Denver Health served 117,000 patients in 2010 and anticipates serving 120,000 this year, an estimated quarter of Denver’s population. Anyone needing care immediately will be seen either in the urgent care clinic or in the ER. Adults who are trying to get in to Denver Health’s eight family health centers for primary care sometimes have to wait four to six months before they can join the system.

In Pueblo, the wait can be even longer and the challenge of enticing primary care providers to a more rural area can make it even harder to reduce waiting lists. Pueblo’s safety net health provider, the Pueblo Community Health Center, served about 23,000 patients last year. But in 2008, the center had a waiting list of 2,600 people. In order to reduce that waiting list, the center embarked on an expansion campaign and raised money to triple the size of its main clinic. Thanks to the new building and successful recruiting of four physician assistants and two doctors over the past two years, Pueblo has cut its waiting list to just over 1,000 people.

“Our single limiting factor is recruiting providers,” said Janet Fieldman, chief foundation officer for the Pueblo Community Health Center. “A lot of medical students are going into specialty care because they know it pays better and they’re coming out with major loans. It’s really frustrating and it’s hard to find family physicians.

“Typically it takes us about a year to recruit one provider,” Fieldman said.

Pueblo’s economy has remained relatively flat. Fieldman said Pueblo never experienced a great surge in its economy, so there wasn’t as much to lose. But 10 percent cuts in the Colorado budget over the past two years for community health centers have meant that Pueblo has had to try to serve more patients with fewer dollars.

When the waiting list was at its worst, patients in Pueblo had to wait as long as two years for care. Now, patients wait about a year.

“The reason we have a waiting list in the first place is we need to make sure our current patients receive the same care and access that they have now. The only way we can keep that service level and quality high is to have a waiting list,” Fieldman said.

There are exceptions to the waiting list. Children and pregnant women never wait. Providers also try to ensure that if parents of young children are uninsured, they can get in to the system relatively quickly as well.

“You want the whole family to have coverage and access to care,” Fieldman said.

People who are discharged from the hospital also get instant access because managers want to be sure that those people don’t wind up right back in the hospital.

There is grumbling about the waiting list.

“Some people think having exceptions makes it unfair,” Fieldman said.

The Pueblo system has tried to contact every person on the waiting list. It’s difficult to find some of them since people who are uninsured tend to be transitory or can change phone numbers frequently.

Once in, patients more invested in care

Surveys of new patients have shown an unexpected side effect of the waiting list.

“When people have been waiting a year or more and get access (to care), they are the most dedicated patients. They’re very compliant with treatment plans. They’re very grateful and they keep their appointments. They’re invested in their health.”

Because so many people are waiting for care, the Pueblo center will discharge patients if they repeatedly fail to show up for appointments or are disruptive, rude or violent.

In Denver, Melinkovich thinks the solutions to reducing waiting lists are multi-pronged.

“We either need to get the uninsured health insurance so they come with a method to reimburse us for providing care for them and we can add more staff for patients who have Medicaid. Or we need some sort of base funding to take care of the uninsured. It’s probably a combination of the two.”

In Denver, recruiting physicians and other providers is much easier than it is in rural parts of the state.

Said Melinkovich: If the funds were available to pay providers, “we could find people to hire. In Denver, we are certainly better off than most of the state.”

Sasha Dillavou contributed to this report.

Title: Health IT forum
Location: Terrace Room, 1380 Lawrence St.
Link out: Click here
Description: Aneesh Chopra, U.S. Chief Technology Officer, will be among the experts on health information technology discussing its challenges and opportunities. The event is sponsored by the School of Public Affairs, the CU Law School and Silicon Flatirons
Start Time: 11:30
Date: 2011/11/09
End Time: 15:30