Health Policy Solutions

By Phil Kalin

For those of us who have been in health care for a while, Medicare’s recent release of hospital data identifying substantial variation between prices charged and actual payments isn’t news. Nor is the fact that charges for similar services by one hospital can be vastly different from those of the one down the road. Health insiders have known for years that the amounts charged by hospitals have little or no relationship to what is actually paid. Making the data public for the first time, however, does give us an opportunity to review Medicare payments alongside amounts being paid by other health insurers to start making sense of it all.

Colorado’s All Payer Claims Database (APCD) puts Colorado ahead of most states in truly understanding and identifying health care payment variation across all insurance plans for both hospital services and those performed outside the hospital. These payments to hospitals and clinical providers are the amounts shown on Explanations of Benefits (EOB’s) that are used to calculate the copays and deductibles that consumers end up paying. Thus, the Colorado APCD will provide actionable information to consumers on what services will actually cost them.

Some have been outraged by the seemingly pointless variation in charges the Medicare data show. However, some variation in the base charges for hospital services does make sense. Facilities and providers alike need to charge differently depending on how sick and complicated their patients are, whether they have additional overhead costs because they are a teaching facility, number of patients receiving charity care, etc. The more important task, though, is to figure out where variation is not adding value and to identify opportunities to get health care spending under control.

While the Medicare data focus on the wide variation on charges and paid amounts, the more interesting question is why there is so much variation on how much is being paid for a similar service.

A new report on the Colorado APCD website shows a $44,000 difference in average payments for knee replacements being made to the highest volume facilities in Colorado. The report is based on commercial insurance and Medicaid payments, and some of the discrepancies are likely due to the health status of the patients and the fact that Medicaid may be the dominant payer at some facilities. By December, reports like this will be adjusted for patient health status, will identify facility names, and will be searchable by insurance type so that consumers can evaluate how much they might pay for a procedure or service across different facilities and provider groups. Medicare data, and small group and self-insured commercial data are slated to be included in the Colorado APCD in 2014 allowing for even more shopping comparisons.

A common patient misconception when seeing big price tags associated with health care services is “you get what you pay for.” There are no data to support that you’ll get a better result if you pay more. In fact, there is typically no correlation between cost and quality. For this reason, we’re aiming to include not only a price tag but also a quality score on the Colorado APCD consumer-focused website to enable patients to make a value-based decision.

Colorado is also ahead of the curve in that our medical community is in favor of price transparency. Colorado hospitals have long supported transparent price information. Colorado lawmakers passed a law last year to ensure that uninsured patients would have the same discounted prices at hospitals that insurance companies do. In addition, CIVHC has been working collaboratively with hospitals and physicians to identify appropriate and meaningful quality measures to accompany provider prices that will be displayed on the Colorado APCD later this year.

Medicare should be applauded for taking a step in the right direction and supporting essential health care price transparency. It often takes time and repetition for important information like this to take root, and now we’re on the road to getting enough meaningful data that we’ll be able to capture patients’ and purchasers’ attention. As Medicare indicated, the next critical step is to support data centers in each state to make the information valuable to consumers and allow providers and hospitals to compare themselves on a level playing field. Colorado has a significant head start in making sense of price variation with the APCD and our state’s efforts will only be strengthened by this additional national push for transparency.

Phil Kalin is president and CEO for the Center for Improving Value in Health Care, a nonprofit organization dedicated to improving health care by increasing quality, containing costs and enhancing the population’s health.

By Dr. Anthony Vigil

While New Mexico and other states are grappling with the question of whether to allow doctors to write prescriptions for drugs that terminally ill patients can take to commit suicide, countries such as Belgium and The Netherlands are pushing the envelope in distressing ways.

For those who claim there is no evidence of a slippery slope in abuse of physician-assisted suicide once implemented, I offer several  problems presented by the Belgium and Netherlands experiments. In these countries, it is legal for  physicians to directly euthanize patients.

For example, within the last 10 years, several patients who have opted for euthanasia have then agreed to donate their organs. This was eerily predicted by Wesley Smith in his 1993 Newsweek article, “Whispers of Strangers.”

For those who agree with doctor-assisted suicide, this is a no-brainer. Why not get the organs right away?  For those against doc-assisted suicide, this is one more opening of an ethical Pandora’s Box.

Does the desire to donate organs play a role in the patient’s suicide decision? Do the pharmaceutical suicide agents affect the donor’s organs? Ethically, what is the difference between the doctor who prescribes the suicide drug and the surgeon who takes the vital organs of someone still alive? Couldn’t we eliminate the middle-man, skip the pharmaceutical agent and harvest the vital organs of a live patient who was bent on suicide anyway?

In Belgium, twins who were going blind decided suicide was a better choice than to struggle with blindness; they ended their lives with physician-directed euthanasia. Belgium also is considering allowing minors to consent to euthanasia.

According to the Smith article, the Royal Dutch Medical Association (KNMG) has condemned doctors who refuse to euthanize legally qualified patients due to conscientious objections. KNMG also states that “if a physician cannot or does not wish to honor a patient’s request for euthanasia or assited suicide, he must give the patient a timely and clear explanation of why, and furthermore must then refer or transfer the patient to another physician in good time.” The same paper by KNMG, states that when patients don’t qualify for legal euthanasia, a doctor may refer them to how-to suicide literature.

Proponents of physician-assisted suicide in the U.S. will object, saying “physician-assisted suicide is not the same as physician-directed euthanasia as practiced in Europe.” I reply that Europeans are not naive; they realize there is no moral difference between a physician injecting the suicidal agent themselves vs.  having the patient do it (both euthanasia and physician-assisted suicide are legal in Belgium and The Netherlands).

Similarly, there is no difference between a physician sending a patient a loaded gun in the mail or hiring a hit man, and giving explicit instructions on hundreds of painless ways to commit suicide — assuming the patient consents.  In either case, the physician is providing what ethicists call “formal cooperation” to an act.  In the case of physician-assisted suicide, the intent is the same:  death of the patient to relieve suffering. Obviously, physicians have been relieving pain and suffering for thousands of years, and we can do it legally and compassionately up to and including the point of hastening death.

So we see that the Europeans have gone beyond the slippery slope and are falling headlong into the abyss of the Culture of Death. Perhaps the United States is meant to drag them out of this spin with intelligent, clear thinking and reason — or be dragged into a tailspin of suicide.

Dr. Anthony Vigil is a general surgeon practicing in New Mexico.

By Joe Sammen

May is a notable month in Asian American history.

On May 7, 1843 — 170 years ago — Nakanohama Manjiro became the first Japanese immigrant to the United States. Twenty-six years later, Chinese laborers completed the trans-continental railroad on May 10, 1869. To mark these historic events and celebrate Asian American and Pacific Islander heritage, each May we celebrate Asian Pacific American Heritage Month. It is a time to reflect on the struggles, contributions, and rich histories of the ethnic and racial groups that make up the Asian American and Pacific Islander (AAPI) community. It is also an apt time to reflect on the unique health experiences of Colorado’s AAPI community.

Over 185,000 Asian American and Pacific Islanders call Colorado home. Arguably the most diverse of any racial and ethnic group, the AAPI community in Colorado includes descendants of and immigrants from 30 Asian and 25 Pacific Island nations. The AAPI population, both in Colorado and across the country, is growing faster than all other racial and ethnic groups. Immigration has much to do with this growth. In fact, Asian Americans recently passed Latinos as the largest group of new immigrants to the United States.

Taken as a whole, Colorado’s AAPI population is one of the healthiest and most well-off in the state. Members of this group have a higher median income, graduate high school and college at a higher rate, and are more likely to be insured compared to the average Coloradan. Perhaps most tellingly, the life expectancy of an average Asian American or Pacific Islander is 12 years longer than most Coloradans. However, looking at this group in total doesn’t capture the considerable variance in health experiences between different groups in this community. The diverse backgrounds and cultures of the AAPI community make data collection and analysis difficult, but the limited information we do have suggests that these differences are worth exploring. When looked at by country of origin and gender, it becomes clear that there are significant economic and health disparities within the Colorado Asian American and Pacific Islander population.

Nationally, some AAPI ethnic subgroups face major health challenges. While only 6.6 percent of Japanese Americans are uninsured, 19.8 percent of Vietnamese Americans and 25.5 percent of Korean Americans are uninsured.  Cervical cancer rates are particularly high for Laotian Americans, Samoan Americans, Vietnamese Americans and Cambodian Americans. Native Hawaiians are three times more likely than non-Hispanic whites to be diagnosed with heart disease and also have the highest rates of lung cancer death.

In Colorado, Asian American and Pacific Islander men lag far behind women in key health indicators. Approximately twice as many AAPI men are obese, smoke, have diabetes and are in fair or poor health compared to AAPI women. Nearly 30 percent of Colorado’s AAPI men do not have a medical home — a doctor’s office or clinic where they go for basic health care services — compared to only 16 percent of AAPI women.

Even though the AAPI population generally does well as a whole in key health and economic indicators, they fare poorly in important preventive health figures. Nationally, AAPIs are less likely to undergo mammograms, Pap smears, and colorectal cancer screenings than whites. And AAPI children and adults are more likely to have had no health care visit to an office or clinic in the past year when compared to their white counterparts.

Another obstacle to optimal health for Colorado’s AAPI population is limited access to culturally-appropriate care. Creating more culturally appropriate health care homes — like the Asian Pacific Development Center is working to do — will help improve access to health care, including preventive visits and services, and hopefully also improve overall health.

Given the growth in Colorado’s AAPI population, it is important that we work to increase our understanding of these disparities and any others that may exist among  Colorado’s AAPI populations. A true celebration for Asian Pacific American Heritage month would be to ensure that we are adequately providing for their unique health needs.

Access the full CCMU infographic on Colorado’s AAPI population at www.ccmu.org/AAPI.

Joe Sammen is the director of community initiatives at the Colorado Coalition for the Medically Underserved.

By Linda Gorman

Spending money makes some people feel better, especially when it is other people’s money. As a case in point, the Colorado legislature has voted to expand Medicaid eligibility.

By Francis M. Miller

The script for the Colorado Health Benefits Exchange is beginning to read like the storyline of Gilligan’s Island. It all started as a “three-hour tour.”

From the outset the debate has centered on whether Colorado should set up its own exchange or have the feds do it for us. So far, 13 states, including Colorado, have opted to set up state-run exchanges. More than half the states, 26 of them, are refusing to participate and the feds will have to run it out of Washington, D.C. This has pretty much divided along party lines with Republican-led states resisting Obamacare whenever and wherever they can.

Colorado in the past two decades has become  a metropolitian oasis and its politics have been bleached from purple to blue. Once the Republicans lost control of the state, Gov. Bill Ritter’s 208 Commission became a blueprint for a socialist field of dreams. That includes mandates, exchanges and a cooperative.

The focus of attention has been on the exchange’s budget and its logo. That seems par for the course these days, whether it is higher education or health care branding. It is the means to demonstrate a customer orientation. Starting out as a modestly funded organization, the exchange is now chasing $125 million dollars in grants. When they get awarded, they can relax and not feel forced to seek a premium tax on insurance premiums to fund their organization. Their funding, when combined with several hundred million dollars to expand Medicaid and nearly $70 million dollars to launch the health cooperative, represent the lion’s share of economic development that has taken place in Colorado since the 2008 recession. Legislators can now declare victory and go home.

I would have been more comfortable if the Obamacare debate had centered on two other issues. One is how do we bend the cost curve?  No one has been able to show  how this will get done.  I suspect we will crash through the 20 percent of GDP ceiling soon. Keep it up and eventually half the population will be caring for the other half. The only question is which half will be paying taxes.

The other question that has been ignored is — tell me again — how does the exchange create a competitive marketplace?  The current hyper-inflation in health care is not symptomatic of a competitive marketplace. It’s more a team of health provider rivals governed by insurance company oligarchs. Increasingly we treat the health market as an extractives industry.

Let me confront this issue by way of analogy. Let’s say you are unhappy with the level of competition in the auto industry. If you believe prices are too high and quality too low, to whom do you turn? Do you switch from an American manufacturer to a Japanese or Korean car? Or do you set up an exchange and have Ford Credit compete with GMAC Acceptance? None of us would pay $50,000 for a car without cheap financing, just as none of us would pay the outrageous bills for the average hospital stay without tax-favored subsidies from government or our employer. But, is the crucible of the marketplace formed by the financial intermediaries or by the competition between providers? I would argue that insurance is the source of the dead-weight loss in the health care industry.

Is competition furthered by standardizing benefits designs, regulating medical loss ratios and forcing fee schedules down the throats of providers? Or is it created by empowering the consumer?

To many of you, I am arguing distinctions without differences. Most people believe that insurance companies are high profit organizations and that we can squeeze their lemon to lower costs. Forget that it is the intensity of care, excessive administrative overhead and myriad other reasons that explain high health care costs. Why do you think the 12 leading socialized democracies in Europe expend half the money we spend and get superior outcomes? Wouldn’t you think a competitive market-based system would spend even less, not more? In an ideal world we would spend half what they spend, not twice as much.

In the end, the exchange can justify its existence by serving other purposes. The CBMS has been so broken and dysfunctional that the exchange can play a major role in getting people enrolled in Medicaid. It will also shepherd the 800,000 uninsured in Colorado. Even if they manage to enroll 150,000 of them, the subsidies will be a steroidal injection into Colorado’s economy.

So, all in all, the exchange promises to contribute more to economic development than any other agency the state could conceive. The combined effects of Medicaid dollars and subsidies when doubled by the economic multiplier effect will have more of an effect than highway dollars or promoting snowboarding. Whether it was conscious forethought or accidental isn’t worth debating. The cascading, trickle-down effects are sure to ripple through the economy affecting us all. Well, maybe not us all.

What still must be answered is whether Coloradoans want to base their economic future on federal transfer payments. Or do we seek to encourage wealth creating export industries? Clearly the natural resource extractions economy is the past and the window of opportunity is closing. The in-migration of the past 20 years has changed Colorado politics permanently. The eastern Front Range is now more of a city-state. You have to drive 100 miles in any direction (Cheyenne, Limon, Pueblo, Grand Junction) to reach the great outback that stretches for 1,000 miles before you encounter another urban area of consequence. Without wealth-creating exports, Colorado will be an island economy exchanging dollars internally.

I would argue that the in-flow of federal transfer payments is unsustainable in the very long run given deficits and unfunded liabilities. Eventually the rhetoric of our debate will have to change.

Until then, party on Wayne.
Francis M. Miller is the past president of the Colorado Business Coalition for Health and the vice chairman of the Colorado Health Data Commission. He founded the first consumer cooperative for health care called the Alliance and is the current president of Health Smart Co-op.

By Francis M. Miller

In declaring American independence, our founders sought to eliminate two perverse forms of tyranny that had ruled private lives for centuries.  The monarchy and the church had become corrupt and were oppressive.

My great-great-grandfather immigrated from Poland. Peasants there were not even allowed to pick up dead tree limbs for firewood. As Walter McDougall, the historian, wrote in “Freedom Just Around the Corner,” these medieval systems were never reformed.  They were replaced when the peasants dropped their hoes, walked out of the fields and boarded ships to America.

The 18th century mindset of our founding fathers did not envision predatory global corporations or the massive apparatus of government that rules our lives today.  If we go back to 1776, the lands west of the Mississippi River were hunter-gatherer and the colonial economies were agrarian.  Adam Smith was just writing his “Wealth of Nations” and the steam engine had just been invented.  There was really no concept of a market economy. Health care was carried out by blood-letting and leeches.  Our country had neither an income tax or a federal reserve.  And, whether you disagree with all or part of what’s happened recently, we can all pretty much agree that if our founding fathers were alive today, they would share our anxiety about the future.

Take health care, where I work. It took 200 years for health care to become 4 percent of our economy.  Since the 1970s, our so-called “competitive” health care system has hyper-inflated to where it is now 18 percent of GDP, twice that of the socialized democracies of Europe.

Sadly, it produces inferior results.  Every new law passed speaks to affordability, but during implementation, it always seems that a cascade of unintended consequences conspires and results in higher insurance premiums.  High health care costs have made it all but impossible to provide health care for our population without mandates and subsidies from either government or employers.  A vicious cycle has been set up and we seemingly cannot escape.

The most recent law, the Affordable Care Act of 2010 promises to reshape the health care landscape on a scale not witnessed since Medicare’s passage in 1965.  Everyone will be required to purchase insurance.  Medicaid will be enlarged, and much of the regulation of insurance will be transferred to federal oversight. On the surface it all sounds good until you meet the devil in the details.

Consider the health exchanges that are being instituted at a cost of billions.  The idea was to create an Internet-based bazaar where insurance could be compared and purchased.  The application form that the exchanges recently published is 21 pages long. (It is 61 pages long if you get one with instructions.)  This will require prospective applicants to go through a forced-march enrollment process.

My review has concluded that buying insurance through the exchange will be far more complicated than filing income taxes.  Not only that, the process calls for constant monitoring of your income by the IRS to continue qualifying for subsidies and eligibility.

Once the form is filled out, it must be passed up the line for approval by  three federal agencies. You can bet this will take another two to three weeks to be approved under the best of circumstances.  You and I both know that if one ‘t’ is not crossed or an ‘i’ is not dotted, you will have to go through it all again.

In a world where we can buy a car using an iPhone, this process defies all common sense.  Tell me again.  Why can’t I just go buy insurance where I see fit and file for a credit on my tax forms.  Why submit everyone to the “tyranny-of-the-process” about to be imposed by the exchange?

There is a serious question whether all of this is going to work.  We all know what happened when Colorado implemented it’s $300 million dollar CBMS benefits management system:  it has been in a state of failure for years.  Now, the apparatchiks are going to layer the exchange on top of that house of cards.

The legislature has not yet talked about how to fund the exchange, but you can bet they will need to layer another 3 to 5 percent onto insurance premiums to fund it all.

I think I am a typical man on the street. I am a free-market capitalist when it comes to iPhones and a socialist when it comes to fire and police protection or water and sewer.  There are private goods and public services and we need different ways to deliver and finance each of them.

The recent election validated that the public wants access to health care as an entitlement.  Perhaps we should take a lesson from the Europeans. Margaret Thatcher steadfastly increased funding for the British Health Service, all the while privatizing vast tracts of their socialized economy.  It is time for us to stop,  rethink what we are about to do, and be prepared to pivot.

The problem in all of this, of course, is that there are huge insurance companies and hundreds of thousands of people employed to implement the federal government’s 20,000 pages of new rules. Like the church and the monarchy, these players will resist any changes not in their self-interest. Health care is bigger than education and national defense combined. This is not chump change.  We, mere peasants, now that the middle class has been devastated, simply cannot drop our hoes and board a ship to America.  Health care is our Alamo.

I am sanguine that the right thing will happen.  I do, however, have faith in Herbert Stein’s famous dictum that stated, “If something cannot go on forever, it will stop,” In saying this he meant that if a trend  cannot go on forever, there is no  need for action or a program to make it stop, much less to make it stop immediately; it will somehow stop of its own accord.

Francis M. Miller is the past president of the Colorado Business Coalition for Health and the vice chairman of the Colorado Health Data Commission. He founded the first consumer cooperative for health care called the Alliance and is the current president of Health Smart Co-op.

By Dr. Shelley Dworet

Back in the 1960s when I first thought about becoming a pediatrician, I was in my mid-teens.  I asked my own pediatrician, a woman who had known me since birth, if I could shadow her for a day. What an experience to watch her see patients at Brigham Women and Children’s Hospital in Boston, then follow her back to her elegant office in Brookline.

Behind the closed doors of her private space, her desk was piled with charts and letters, and journals stacked on the floor and chairs.  All at once, I didn’t feel so guilty about the state in which I left my bedroom that morning.

To her patients and their families, Dr. Allers was a warm, soft-spoken woman who inspired confidence.  She took time to talk to me and offer support to my single Mom rearing three kids in the shadow of her incorrectly diagnosed mental illness.

No hospital owned Dr. Allers or told her how much time she could spend with her patients, now called consumers by insurance companies.  No one dictated how she should code her visit to “improve her numbers.”  When my mother did not pay her bill on time, the phone did not ring on a nightly basis with calls from collection agencies.

The overall sense was one of caring and pursuit of a highly trained calling.

What happened to this beloved profession?  It has become a profit-driven financial institution owned by the medical equivalent of the big Wall Street banks.  These “owners” are insurance companies and corporate hospital entities all about profits. We have pharmaceutical giants spending a fortune marketing their overpriced drugs, while new drug research is funded through grants from the NIH, paid by the taxpayer. Medicine has been hijacked and held hostage by corporate control and greed.

How do we save this noble profession?

We, the people, must insist that health care be publicly financed and universal. It must be available to everyone equally, like public education, and police and fire protection.  The majority of people polled say YES to publicly-funded, universal health care.

How do we do it?  We have a voice and a movement.  It is Health Care for All Colorado.  Join this grassroots organization and create the tidal wave of support for publicly-funded health care for all.

We can do this.   Go to www.healthcareforallcolorado.org and sign up now.

Oh, and Dr. Allers?  When I was 18, she left Boston, headed for Arizona, and helped create the Pediatrics Department at the new University of Arizona School of Medicine. Never underestimate the power of each person, and then the next, and then the next…

Dr. Shelley Dworet is president of  Health Care for All Colorado, a group advocating for a public universal health care system in Colorado.

By Denali Johnson

Colorado has one of the fastest growing aging populations in the U.S. Currently, one in nine Coloradans is a senior citizen. By the year 2030, that will increase to about one in five. While Colorado historically has had one of the smallest percentages of seniors, our annual growth rate is now 3 percent above the national average.

The increasing number and percent of older adults in Colorado presents new opportunities and challenges to communities across the state. With the baby boomer generation aging, a larger number of active older adults will be available to contribute to the community as volunteers, board members, community leaders, employees and caregivers. However, an increasing number of frail older adults will need services to meet significant health care, housing, transportation and other needs. Certain areas of Colorado will feel this growth more than others. In San Miguel, Garfield, Eagle, Grand, Summit, Douglas and Elbert counties, the change in the 65+ population from 2010 to 2030 is expected to increase by more than 250 percent. Only in Lincoln County is the percent change expected to be less than 10.

Colorado’s seniors are generally healthier than seniors in other states, but they still have significant needs. Following national trends, Colorado’s older adults are living longer and healthier lives. In fact, there are currently about 650 Coloradans 100 years old or older. Coloradans have the highest rate of physical activity compared to older adults in other states, and we’re near the top for older adults reporting good physical and mental health. However, our seniors are significantly more likely to be diagnosed with diabetes, high blood pressure and/or high cholesterol than younger Coloradans. Nationally, 80 percent of seniors have at least one chronic condition to contend with and that means increased health care needs in order to stay active.

Mental health challenges are also of particular importance for our seniors. While the great majority of Colorado’s seniors reported zero days of poor mental health in the past month, we cannot ignore the need to keep them socially engaged. In 2006, the Center for Disease Control did a nationwide study on mental health and aging, and the results showed that older Coloradans feel less socially-supported than middle-aged Coloradans. While less than 5 percent of 50 to 64 year old Coloradans reported not getting the social and emotional support they needed, nearly 8 percent of 65+ year-olds felt that way.

Another important aspect of seniors’ health is dental health, and there again Colorado ranks well overall. However, 18 percent of Colorado’s seniors have lost all their natural teeth. Having missing teeth can cause problems speaking and eating and can influence a person’s choices in food quality and quantity. While Americans paid out-of-pocket for approximately 50 percent of all dental care expenses in 2000, people age 65 and older paid more than 75 percent of their dental expenses. For low-income seniors, taking care of their oral health may be so cost-prohibitive that it results in decreased quality of life.

While Colorado is making an effort to keep older Coloradans at home and independent as long as possible, we know that the majority of Americans will need long term care. Long term care varies; it can be informal care from a spouse or family member, in-home care from a paid provider, a residential care facility or a nursing home. The new generation of seniors is demographically different than previous generations, which makes it difficult to predict what kind of long term care we will need more of and what its financial impact to the system will be.

Baby boomers are generally wealthier, meaning they may be able to afford private care and relieve some pressure on the public assistance system; however, they also have smaller families, and that could mean less informal care is available to them. Help from adult children currently reduces nursing home use by 60 percent among disabled adults over 70, but if family help declines, it will mean an increase in seniors’ reliance on other forms of care.

While it is unclear how the system costs will eventually play out, we do know that long term care services are expensive for seniors and families. According to the U.S. Department of Health and Human Services, the average annual cost of a single room in a nursing home in Colorado is over $80,000; for an assisted living facility, it is nearly $37,000.

Furthermore, a recent study found that nationally, seniors with Medicare coverage still paid nearly $40,000 out-of-pocket in the last five years of their life. These are big numbers, and we need to be thinking critically about how we can provide affordable care to our older Coloradans in need.

Just like with other health care challenges we face in Colorado, we will need creative solutions to address the issues facing our older adults. We should continue to encourage active and healthy lifestyles, and look for ways to keep our aging boomers at home and independent. The “silver tsunami” will bring a variety of new opportunities and challenges and it’s time to act to ensure that we are prepared and can appropriately care for a generation that has done so much for Colorado.

Access the full CCMU infographic on Colorado’s refugees at www.ccmu.org/seniors

Denali Johnson is project associate at the Colorado Coalition for the Medically Underserved.

By Michele Lueck

In college basketball, being No. 1 means winning the Final Four. In cinema, it means taking home an Oscar. But when it comes to Colorado’s health, being No. 1 could improve hundreds of thousands of lives and greatly benefit the local economy and business environment.

Though Colorado already is No. 1 in certain measures (we have the leanest and most-active adult population of any state), the 2012 Colorado Health Report Card shows there’s plenty of room for improvements.

For example, we’re No. 31 among other states in prenatal care and No. 38 in children’s preventative dental care. And though our adult population is the leanest relative to other states, our obesity rate for adults and children has risen dramatically in recent years

For the most part, Colorado is pretty average when it comes to health, but these statistics reveal a level of mediocrity that belies our national reputation as a healthy, vibrant and innovative state.

In fact, Colorado’s grades haven’t changed much since the Colorado Health Foundation partnered with the Colorado Health Institute to produce the first Colorado Health Report Card seven years ago. While that’s frustrating in many respects, it also begs the question: “What if we were No. 1?”

For the first time ever, the 2012 Colorado Report Card looks at exactly what it would mean if Colorado were No. 1 in key health indicators.

For example: If Colorado were ranked No. 1 instead of No. 36 on the percentage of children without health insurance, an additional 78,593 children would have coverage.

Among the other possibilities if Colorado were No. 1:

• 2,100 more babies would be born at a healthy weight
• 123,400 more children would have access to a medical home
• 24,900 fewer children would be obese
• 32,600 fewer high school students would smoke cigarettes
• 92,600 fewer adults would report mental health difficulties
• 376,800 fewer adults would binge drink
• 16,200 more older adults would have all of their recommended immunizations

It’s worth noting that most of these numbers reflect “modifiable health risk factors” – in other words, actions we can take to improve our health. A recent article in Health Affairs magazine noted that 22 percent of what we spend on health care can be mitigated or modified — such as lifestyle, behavior, the things we eat and how much we exercise.

Frankly, given our state’s resources and collective brain power, being No. 1 in these indicators isn’t much of a stretch.

Being No. 1 would not only make a difference to hundreds of thousands of Colorado lives, it’s a goal that would boost business and the economy.

Tom Clark, CEO of the Metro Denver Economic Development Corp., once told me that health is a major factor that companies consider when they look to relocate or expand to Colorado. He said ranking in the “top three” of key health measures greatly improves the “win rate” of landing prospective employers.

For businesses that are already operating in the state, the supplement to the 2012 Colorado Health Report Card “Keeping Colorado Competitive: Roadmap to a Healthier, More Productive Workforce,”  shows how certain health indicators affect Colorado’s economic health and competitiveness in terms of dollars saved.

For instance, Colorado employers and employees could save an estimated $121 million annually in health care costs if the state had the lowest rate of depression. Likewise, employers and employees could save an estimated $229 annually in health costs if obesity rates returned to 1996 levels.

The supplement also highlights nonprofits that are working to make a difference in improving Colorado’s health. They include The Youth Foundation in Eagle County, which uses an evidence-based program to increase the level of physical activity among at-risk K-8 children. We also highlight Mental Health First Aid Colorado, which focuses on increasing literacy and awareness about mental illness, reducing social stigma and supporting the community with tools for coping with mental illness.

A vast majority of us aren’t destined to win the Final Four or an Academy Award, but striving for the goal of being No. 1 in these key measures of health is worth doing and within reach. And it can be achieved through the individual and team efforts of Coloradans if work together.

Michele Lueck is president and CEO of Colorado Health Institute.

By Edie Sonn

Measuring outcomes in meaningful and consistent ways; giving providers incentives to improve; holding them accountable for their results. Comparing providers against their peers as well as against their own historical trend. Rewarding low-performers who improve, without penalizing high-performers that don’t have as far to go. Making sense of a bewildering tangle of expectations and requirements.

That’s the landscape of health care accountability, right?

Yes, and it’s also the landscape of school accountability. Every single balancing act described above that lies at the heart of every discussion we have about paying for value in health care echoes the challenges of measuring school performance. What can we learn from the struggle to make Colorado’s schools more accountable that can inform our efforts to measure and reward quality in health care?

In 2004-05, the Colorado Accountability Project convened public and private sector education leaders and policymakers to try to make sense of the confusing array of systems for measuring and reporting on public school performance in our state. Some of the challenges they faced will sound familiar:

• Differing measurement and reporting programs from the state and federal government for schools and districts. At best, each provided an incomplete picture; at worst, they provided conflicting information.
• Reporting tools (School Accountability Reports or report cards) that provided only a point-in-time picture of how a school did on the state standardized tests compared to others. These report cards didn’t account for how individual students’ academic performance changed over time, nor did they account for the socioeconomic profile of a school’s population.
• No system for rewarding consistently high performing schools or for actively helping low performers to improve.

The Accountability Project said at the time, “How do we measure and report in ways that are useful to parents, educators and policymakers?” And: “Parents can’t make good decisions, and schools can’t improve, with conflicting and incomplete information.”

Does all this sound familiar? Replace “parents” with “patients” and “educators” with “providers”; re-frame socioeconomic profiles of school populations to risk profiles of patient populations; change school report cards to provider profiles; and you’ve neatly summarized the challenges of accountability in the health care arena.

It’s taken many years for some of the solutions proposed by the Accountability Project in 2004 to get implemented. And Colorado’s educators haven’t solved all the problems outlined above. Yet we can learn some useful lessons from what they’ve achieved and apply it to our own needs:

• Colorado’s school accountability system now combines what used to be three different measurement systems and philosophies into one reporting framework. No longer do we see schools that meet federal goals for adequate yearly progress but are on “accreditation probation” from their district, while simultaneously showing higher-than-average performance on their School Accountability Reports.
  • Sound familiar? Can we see a show of hands of physicians who receive “A” ratings from one health plan and “C” or worse from another? The key here (and yes, we and other have been beating this drum for a long time) is agreed-upon, consistent measures. A plan can use those measures to support whatever payment system it wishes – just as long as providers are tracking and reporting on the same things to each plan.
• Colorado’s schools are now measured according to a growth model that tracks cohorts of students over time, rather than just a yearly snapshot. Crucially, this model measures across different domains: achievement and growth. It breaks down the percent of students catching up, keeping up and moving up, based on median percentages. So, low-performing schools that are nevertheless demonstrating improvement receive recognition – as do high-performing schools that maintain their performance. However, low- and mid-performers that don’t improve are required to make changes.
  • As we move to outcomes-based payment systems and new shared savings models in health care, this is a vitally important principle to bear in mind. We want to incent improvement while recognizing that high-performing organizations have less room for upward movement. Thus, we need to ensure these new payment models reward those that “keep up” as well as those that are “moving up.”
• Schools that don’t meet expectations for achievement and/or growth must conduct root cause analysis to diagnose the reasons for their under-performance, and develop/implement improvement strategies. Districts are required to support these turnaround plans.
  • Perhaps no one understands root cause analysis better than clinicians. But do our payment models facilitate its use, and give clinicians the tools and resources necessary to address those causes and change their behavior? When we’re measuring primary care physicians on how they manage their diabetic patients’ Ha1C levels, are we giving them the care coordination payments that allow them to purchase and use registries, and hire the nurse educators to coach them on diet? Do we have the health information exchange platform that enables them to track those patients’ potentially avoidable trips to the ER?
• Schools report achievement and growth for their population as a whole as well as for specified sub-groups (e.g., English language learners, population on free and reduced-price meals, etc.). Evaluations of schools take those factors into account.
  • Can you say risk-adjustment? Think about an Accountable Care Organization that covers a swath of metropolitan Denver encompassing both high- and low-income neighborhoods, and whose clinicians treat both commercially-insured and Medicaid patients. Should those clinicians’ strategies for hitting performance targets vary depending on the population? Should the targets? Should the payments? When every patient deserves the best care, regardless of income, how do we account for socioeconomic differences? Those aren’t questions to answer off-the-cuff; they demand data and discussion.

I doubt that anyone would say that Colorado’s public K-12 education system is the best in the country; certainly I am not arguing that it is. Yet our educators and policymakers have put in place a vital mechanism for getting us there: a consistent, meaningful and predictable way of measuring outcomes and progress.

Maybe it’s time for our health care leaders to go back to school.

Edie Sonn is vice president of strategic initiatives at the Center for Improving Value in Health Care or CIVHC. Contact her atesonn@civhc.org.