Health Policy Solutions

By Katie Kerwin McCrimmon

The pseudo therapist is the ultimate manly man: part Ron Burgundy, part Dr. Phil, and part Burt Reynolds.

Meet Dr. Rich Mahogany, the hilarious, irreverent online doc who uses dark humor to combat the deadly serious topic of male depression and suicide. Dr. M, as his creators affectionately call him, teaches breathing exercises complete with the F-word so you can deal with your SOB boss and that “105-year-old lady doing 7 in the fast lane.” His idea of yoga is the seventh-inning stretch.  He cleans his desk with a leaf blower, counts a long spell on the toilet as meditation and graduated from Porksausage University. So of course, his therapeutic recipe for guacamole includes bacon.

Welcome to Man Therapy (www.mantherapy.org), the Colorado creation that is going global.

Launched in July by an unlikely trio — Colorado’s Office of Suicide Prevention at the Colorado Department of Public Health and Environment; the Denver advertising firm, Cactus Communications; and the Carson J. Spencer Foundation, a Colorado suicide prevention nonprofit — Man Therapy is heading Down Under.

Beyond Blue, Australia’s leading organization that fights depression, is adapting Man Therapy and plans to launch a national public education campaign this summer. At first, Australian mental health experts were leery of using the word therapy in the name of their site because of the stigma men attach to the concept.

Dr. Mahogany does a trust fall with himself to demonstrate group therapy. Denver stage actor, John Arp, plays the irreverent fake doc. (Photo courtesy of www.mantherapy.org.)

But Joe Conrad, founder and CEO of Cactus, helped convince them that smashing that stigma was central to their concept.

“We’re not apologizing. We’re presenting it in a new light.”

As the Man Therapy creators explained in a PowerPoint presentation to a national conference of suicide experts:

“Men think therapy is for women and sissies. So they don’t seek the help that they need, when they need it. Let’s show them that therapy and honest talk can be masculine by providing them the therapist they need. A therapist who is a no-nonsense man’s man.  A therapist who will tell it like it is. A therapist like Dr. Rich Mahogany.

“He’s part doctor, part football coach, part drinking buddy and 100 percent action hero.”

Before signing on, Beyond Blue did a study with Australian men and found they loved Dr. M’s wacky attitude. So they decided to stick with the name Man Therapy and are creating a fake Aussie colleague dubbed Dr. Byron Ironwood who supposedly studied in Vienna once upon a time with Mahogany.

The Aussie un-therapist therapist will dole out advice mirroring the U.S. website. Mental health experts in Canada and the United Kingdom also are planning to join the movement and likely will use Dr. Mahogany for their campaigns, said Jarrod Hindman, director of Colorado’s Office of Suicide Prevention.

Along with winning a raft of health and advertising awards, Conrad said he’s been humbled by the impact Man Therapy started having right out of the chutes.

On July 8, the day the site launched, the New York Times ran a story about Man Therapy.  The site received more than 5,000 hits. That night, a message to Dr. Mahogany landed in Conrad’s inbox. It was from a 28-year-old combat veteran in Baton Rouge, La., who had been struggling with depression.

Apparently the man’s therapist had seen the site and told him to check it out.

“He took time to write about what an incredible experience it was for him. He said he got a lot out of it and had already emailed the link to combat vets in his support group,” Conrad recalled.

“He has a young family and said the site already helped him think differently and want to continue in therapy. We didn’t create the site for vets or people outside of Colorado,” Conrad said.

But, Man Therapy is clearly resonating with veterans, cops and other guy’s guys around the U.S. and the world.

“We’ve seen it continue to pick up speed,” Conrad said.

For instance, he just shipped a box of materials to a supervisor with the Boston Police Department. And he received an email from the head of the Connecticut National Guard.

“They were finding the campaign really helpful. They had just lost three guys to suicide in the last six months,” Conrad said.

So far, Conrad says Man Therapy has generated over 225,000 unique visitors with an average of about 572 per day. Men, therapists or women concerned about men in their lives poke around on average for several minutes, an eternity in the online world. More than 50,000 visitors have taken the “18-point head inspection,” which generates advice and recommendations. Ninety percent of those who took the self-assessment reported that they were likely or very likely to use the advice.

The campaign also features billboards, bus shelter ads, drink coasters to distribute in bars and, of course, award-winning videos intended to go viral.

Funding for the $400,000 project came from the Anschutz Family Foundation. Now those funds are gone and the partners are applying for new grants and keeping the project alive through pro-bono work, professional kudos and word of mouth.

“I’ve never been closer to a campaign. It’s our baby,” Conrad said.

Some mental health professionals were skeptical at first because they thought the campaign was too edgy.

But that was precisely the point of it. Conrad and his team tried to come at the campaign from an entirely new vantage point.

“We were trying to create something for men. That’s what drove us, no predetermined idea of what would work,” he said.

Added Hindman: “We’ve created a venue for men to dip their toes in the water for mental health support and treatment. It’s a place where men can safely and anonymously learn some things, try some tips or tools. And if you need professional help, you’ve got to man up and get it.”

The need for help in Colorado and around the country is more urgent than ever. And targeting men in their middle years has proved prescient.

The U.S. Centers for Disease Control and Prevention released a report earlier this month showing that suicides among middle-aged people rose dramatically from 1999 to 2010 both in the U.S. and in Colorado.

The suicide rate among people ages 35 to 64 increased across the U.S. by 28 percent during that period. Colorado consistently has had one of the highest suicide rates in the country and during that period saw an increase in the rate of suicides among people ages 35 to 64 from 25 to 41 percent.

Initially Man Therapy targeted men ages 25 to 54, but they are now expanding to reach men up to 64 years old.

Man Therapy’s veneer is humor. Check out the yoga video to see Dr. M’s 1970s Rocky-era shiny “yoga shorts.”

“Competitive Therapy” the way a man would do it. (Photo courtesy of www.mantherapy.org.)

Try taking the self-assessment and you’ll see questions like this: “Did you know koalas sleep 18 hours a day? Lazy little bastards. Tell me about your sleep habits.”

There’s a section of the site called Gentlemental Health 101. Dr. M does a trust fall with himself in the Group Therapy section. There’s “One-on-None,” DIY therapy. And of course, there’s a section on “Competitive Therapy” where you’ll get to see Dr. M naked and learn about “exercise, camaraderie, sweating, winning and/or hoisting championship trophies.”

Beneath the spoofs, however, there’s real advice, an omnipresent red phone with links to suicide help lines and ways to connect with other men or real therapists.

“We want depression to be a health issue. It’s been separated out as a mental health issue. Obviously one’s brain is part of one’s body. We should screen for it, just like they check your heart…just like asking about smoking or the number of drinks you have,” Hindman said.

The serious intent of the campaign is to reach men before they’re in crisis.

“There’s a huge void,” said Conrad. “Guys really bottle up their feelings. Unlike women, they don’t have networks of support. They tend to swallow their emotions. We tapped into something that’s universal.

“The strategy was not to wait for someone to hit a crisis, to catch things before they become a crisis. It’s much more of an early-intervention, prevention campaign,” Conrad said.

“We still have only scratched the surface with the potential impact.”

By Debra Judy

The Colorado Consumer Health Initiative is celebrating the end of the Colorado legislature because the takeaway is “Colorado health care consumers win big this session!”

For all of us, getting the care we need, when we need it isn’t too much to ask. So we were delighted that Colorado’s legislators and Gov. John Hickenlooper really took this idea to heart this year as they helped move toward barrier-free access to quality and affordable health care for all Coloradans. 

Sponsored by Rep. Beth McCann and Sen. Irene Aguilar, the bill to modernize stop-loss health insurance is an important step toward stabilizing and protecting the small group insurance market.  This bill raises the attachment point for businesses purchasing stop-loss insurance and will ensure that small businesses are not inappropriately self-insuring, thereby protecting the small group market from employers who jump into the market only when they have unhealthy employees. In addition, the Division of Insurance will collect data about stop-loss policies in Colorado so that we can better understand the impacts on the market.

One of the biggest health care issues the Colorado General Assembly faced this year was the creation of the New Medicaid program. On election night, Speaker of the House Mark Ferrandino said he hoped Colorado would honor Obamacare’s provision to expand Medicaid eligibility to individuals making about $15,000 a year or $30,000 a year for a family of four. After Gov. Hickenlooper announced his support for the expansion in January, the bill passed at the end of April. Adult dental care was also added to Colorado’s Medicaid program. Thanks to these bills, thousands of Coloradans will have better access to the health care they need.

Colorado took another huge step forward in implementing Obamacare with the passage of the Health Insurance Alignment Federal Law. While Colorado is one of the leader states in implementing health care reform, many of Obamacare’s consumer protections were not in Colorado law. With the passage of this bill, in 2014, Colorado will ban discrimination based on pre-existing conditions and allow young adults to stay on their parents’ plans up to age 26, among many other popular benefits.

Moreover, Colorado is well on its way to establishing its new health care marketplace, Connect for Health Colorado. The General Assembly passed a funding bill to ensure Connect for Health Colorado is financially sustainable in 2015 and beyond. Open enrollment begins Oct. 1, when thousands of Coloradans will be able to easily compare health plans – and use tax credits to help afford their insurance premiums. Now it’s time to get Coloradans enrolled in Connect for Health Colorado!

These great accomplishments are just a few of the health care related bills that passed this year, thanks to our legislative allies and the thousands of health care advocates across the state. Colorado is moving full steam ahead in implementing Obamacare to help thousands Coloradans gain health care coverage. This session has shown that our voices matter when it comes to decisions about health care – cheers to a great 2013 session.

Debra Judy is the policy director at the Colorado Consumer Health Initiative.

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 Katie Kerwin McCrimmon

Despite outrage from some lawmakers who called review of Colorado’s health exchange a “mockery,” a bid for an additional $125 million in federal dollars is likely to move forward by next week.

“I would anticipate that we will sign off on this,” said Sen. Irene Aguilar, D-Denver. This (federal) money exists. If we don’t take it, we’re going to have citizens picking up the costs for their premiums. Our goal is to have the most successful exchange in the country and this is part of that.”

Aguilar anticipated “sticker shock” over such high costs, but as chair for the legislature’s exchange review committee, she and vice-chair, Rep. Beth McCann, D-Denver, can authorize the grant request.

The 10-member oversight committee did not take a vote and has no plans to do so before the legislative session ends Wednesday.

Members of Colorado’s health exchange board plan to meet again to finalize the grant application before exchange managers must submit it next week.

Republican members of the committee scolded exchange managers for dramatically boosting the estimated costs to run the online health insurance market, which is supposed to make it easier for uninsured people to find and buy private health insurance.

“I am stunned, shocked and horrified at this proposal at this time,” Sen. Ellen Roberts, R-Durango, said early Tuesday when exchange managers came to the legislature to ask for approval for a new federal grant request. The new $125 million grant request is far larger than two previous federal implementation grants of $18 million and $43 million respectively. In earlier cost estimates, exchange managers have predicted that the exchange would cost $22 to $26 million a year to run.

Roberts said she had only seen the drafts seeking $125 million more in federal cash for the first time on Tuesday morning and could not possibly live up to her obligation to properly oversee Colorado’s health exchange. She called the review process a “mockery.”

In part because some states are refusing to build their own health exchanges, there is more federal money available to states like Colorado that are building exchanges. And the U.S. Department of Health and Human Services is now allowing states to request “implementation” funds for costs that stretch well into 2016. Colorado’s health exchange is supposed to open for business on October 1 of this year for plans that will cover people starting on Jan. 1 of 2014. Previously exchange managers planned to ask for funds to build the exchange and run it during 2014.

Lawmakers on Tuesday scolded sxchange board members and managers. Testifying were Rob Ruiz-Moss, an exchange board member who works for Anthem Blue Cross and Blue Shield, exchange CEO and executive director, Patty Fontneau and board president, Gretchen Hammer, who is also executive director for the Colorado Coalition for the Medically Underserved.

Now, with looser federal rules, they are asking for additional funds. For instance, managers are considering using $3 million in federal funds to buy a building in Colorado Springs that will house the exchange’s call center. Previously, managers planned to rent the space and cover those costs as an ongoing expense.

Among other major costs included in the $125 million application:

• $52 million for technology costs
• $10 million for customer service center infrastructure
• $13 million for customer service staffing
• $8 million for “back office” staff to handle manual processing that IT programs can’t yet do
• $10.5 million for a customer assistance network
• $15 million for marketing and outreach campaigns and consultants

Sen. Kevin Lundberg, R-Berthoud, joined Roberts in his frustration with the exchange managers saying that he was “disgusted” and “flabbergasted.”

Just last week in a health committee meeting, Lundberg said he asked about costs for the exchange and recalls managers telling him they’d be $48 million in 2013 then $22 to $26 million thereafter.

“This adds an extra $60 million over the next three years,” Lundberg said. “Last week I’m told one number. Somehow it’s magically changed.”

Exchange CEO and executive director Patty Fontneau told lawmakers that Colorado is applying for federal grants to save Colorado taxpayers money.

“Our main and primary goal is ‘how do we do this while keeping costs to individuals in Colorado as low as possible?’”

She said Colorado is right in line with other states including Washington that requested a similar grant for $127 million and Maryland that applied for one for $123 million.

Sen. Jessie Ulibarri, D-Commerce City, defended the $125 million request.

“If we don’t receive (the grant) these funds will go to another state,” Ulibarri said. “We as Colorado taxpayers are paying into this fund.”

He said Colorado should reduce health costs for its citizens by applying for the funds.

On Monday, during an exchange board meeting, a similar schism erupted between board members. Dr. Mike Fallon, who owns urgent care clinics, said the exchange should be run like a lean business operation.

“What I’m a little bit aghast at is that we are now an entity closing in on $200 million to sell insurance,” Fallon said. “I don’t think we need $125 million.”

“We are supposed to be a market savvy business operation, not a government entity. Just because other people are doing it (asking for additional federal dollars) doesn’t mean we should.”

On the opposite side, Arnold Salazar, executive director of Colorado Health Partnerships, LLC, said Colorado should be applying for as generous a grant as possible.

“We are implementing an exchange that we know nothing about. It’s never been done,” Salazar said.

He added that it’s impossible to accurately estimate how much it’s really going to cost and that it will be difficult to go back to the federal government and “backfill” with new grant requests later.

Telluride businessman and board member Richard Betts seconded Salazar’s opinion.

“The No. 1 reason businesses fail is a lack of proper capitalization,” Betts said. “We need to make sure we ask for enough money. We made certain promises of accomplishments in the first 18 months.”

Several board members wanted additional funds for navigator programs. In previous board meetings, exchange managers estimated that they would need at least $20 million to successfully help people sign up for health insurance. People who have never before had insurance could need at least 90 minutes in a face-to-face session with someone who could help them through the complicated process.

The federal grant request so far includes a specific request of about $10 million for an assistance network. But Fontneau has said other sources of cash could bring the funding for navigators to about $14 to $16 million.

Fontneau told both the board members on Monday and lawmakers on Tuesday that she and her colleagues are building “a sophisticated web-based marketplace.”

She said the grant application includes funds for a “creative and celebratory” public outreach campaign and that the exchange supports options for small businesses and the opportunity to connect the public and private sectors, although she emphasized that there will be only minimal “interoperability” between public systems like Medicaid and the health exchange.

As for the increased cost estimates and the much larger than expected $125 million grant request, Fontneau said that exchange managers had a new understanding of federal rules.

“We had understood that when they said we had to be self-sustaining by December 31, 2014, that meant no federal funds could be used after that,” she said. “When we pulled the grant request up, it says that the grant can be used for three years.”

By Katie Kerwin McCrimmon

I’m blaming Francis Underwood.

The soulless snake responsible for all evil in the nation’s Capitol on the Netflix hit, “House of Cards,” turned me into a couch potato this winter.

Oh, and those Crawley sisters on Downton Abbey also messed up my metabolism. I was late to that party, so my daughter and I binged on three seasons of love, war and class intrigue, galloping from the sinking of the Titanic through World War I to the Roaring Twenties in a matter of weeks.

I’m a health writer so I try to monitor my wellness in part by wearing a pedometer. As my TV watching spiked, my steps plunged.

No surprise there. It turns out that that more than 10,000 people now being tracked on the National Weight Control Registry who have successfully lost at least 30 pounds and kept it off for a year or more can’t be couch potatoes and move a lot more than average Americans.

Of those who have succeeded in losing weight and keeping it off:

• 62 percent watch fewer than 10 hours of TV per week
• 98 percent modified their food intake in some way to lose weight
• 94 percent increased their physical activity, most frequently by walking
• 78 percent eat breakfast every day
• 75 percent weigh themselves at least once a week
• 90 percent exercise, on average, about one hour a day

This week, I’ve been getting a crash course on the obesity epidemic during a conference sponsored by the National Press Foundation at the University of Colorado’s gleaming new Anschutz Health and Wellness Center.

I’ll be sharing a series of stories from all that I’ve learned in the coming months. So, stay tuned for research that may depress us all. The numbers are bleak. Solutions seem to be elusive. And long-term success is rare. Our bodies seem to be hard-wired to pack on the pounds unless we move a lot more than we do now.

Forget the Caveman diet. Rather than focusing on eating Paleo, we may need to start moving like some prehistoric creatures are chasing us.

For now, here are some tidbits gleaned from experts and fellow journalists to whet your appetite:

• “Our chairs are killing us.” That’s the bottom line message from Dr. James Levine, a professor of medicine at the Mayo Clinic and inventor of the famous “fidget pants” that track movement. Levine is convinced that non-exercise movement — all the energy we expend living our daily lives — could save us if we move more. I watched Levine refuse to sit during a panel on obesity solutions. Perhaps we all need to take a cue from him and start working at stand-up treadmill desks. Levine also consults with schools. And guess what? Kids who move more score better on tests. Rather than focusing on P.E., maybe it’s time to re-engineer schools so kids can move all day.
• We think of obesity as a problem of the uneducated poor. Indeed, minority groups have the highest rates of obesity, “but we’re seeing increases in every group. This is a problem that affects the rich and the poor,” said James O. Hill, executive director of the Health and Wellness Center.
• If you think obesity is an easy problem to solve, check out anti-obesity activist, Morgan Downey’s list of 83 potential causes that have popped up in scientific research. They range from air conditioning and suburbanization to early antibiotic use and maternal employment. Go figure.
• If you’re biased against surgical solutions to obesity, step for a moment into the shoes of journalist Michael S. Miller, editor in chief and a columnist for the Toledo Free Press.  Miller started at 380 pounds and has lost more than 160 pounds since September. He shared his story with us including the double wake-up call one day when he saw how he looked on a super-sized Costco TV (from a pre-taped appearance). That same day, his 6-year-old cried and confessed that other kids were making fun of him because his dad was so fat. Miller now walks as much as 90 minutes a day and said that for the first time in years, he didn’t have to endure the humiliation of asking for a seat-expander when he flew to Denver.
• Want to be grossed out? Liz Neprorent, of ABC News (follow her on Twitter – @Lizzyfit) has written about a new gadget that lets people eat like pigs, then dump the calories. The pump allows patients to eat, wait 20 minutes, then pump 30 percent of their stomach contents into the toilet through a tube. The inventors call this a solution. I call it sanctioned bulimia. Click here to read more.
• Fighting obesity by focusing on the built environment has become a hot topic. But researcher Janne Boone-Heinonen of the Oregon Health and Science University has found that there’s not much evidence that food deserts are as common as we think. And while fast food outlets may be more common in neighborhoods where more people are obese, she’s not convinced that proximity influences what a person eats. Click here to read more.
• And while Mayor Michael Bloomberg, whom I think of as the de facto U.S. Surgeon General of the U.S., has been targeting super-sized sugary drinks, the soda marketing geniuses have been boosting the market share of diet sodas. For men who are attracted to the macho black cans of Coke Zero and women who are hooked on Diet Coke, it might be time to take a closer look. It turns out that fake sweeteners may actually be making us fatter. Listen here to a report by Pauline Dakin of the CBC.

James Hill, the head of the Health and Wellness Center, thinks our obesity epidemic began after World War II when work gradually changed and we became so sedentary that our bodies couldn’t keep up with our food intake.

In the 1980s, restaurants started serving much larger portions of food to entice people to spend money on restaurant meals after declines in the economy spurred them to eat more at home.

“Food is everywhere. Portions are large. It tastes great. This certainly has influenced our choices,” Hill says.

How do we fix it? We have to get what Hill calls the “energy balance system” back in balance.

But, he has some colleagues who are convinced that Americans — and increasingly the Chinese and Europeans who are fast adopting KFC, McDonalds and our other fatty habits — may simply decide to accept obesity.

Hill is not ready to succumb to the pessimists. He thinks we can succeed by making lots of little changes that would help us expend more energy or reduce calorie intake by as little as 100 calories a day.

Let’s hope that’s possible. Otherwise, I keep thinking of the images from Wall-E. Once upon a time, back in 2008, the Pixar flick seemed more sci-fi than reality. As Daniel Engber wrote in a great piece in Slate called Fat-E, “Wall-E tells us that if we don’t change the way we live, we’ll all get really fat and destroy the world.”

In the movie, humans get so big they can no longer walk and “are too lazy to think.”

That’s a bleak portrayal, but if obesity rates keep climbing, we all may be headed toward a life of perma-Barcaloungers with pumps that dump our stomachs.

By Katie Kerwin McCrimmon

The horror of 20 children being shot to death at Sandy Hook Elementary School shocked the nation and the world.

But Colorado researchers — who initially set out to study playground accidents — found that gun violence is harming children every day. Very few people know about these gun injuries because federal law has prohibited funding for research on gun accidents and fatalities.

The Colorado researchers combed through every single injury over an eight-year period at Denver’s two primary trauma hospitals that serve children, Denver Health and Children’s Hospital Colorado. They expected to find information about playground injuries and were surprised to learn that violence was harming a significant number of children every year.

On average, at least 14 children between the ages of 4 and 17 were suffering gun injuries every year between 2000 and 2008 in the Denver area alone. That doesn’t include the number of children who died of gunshot wounds or those who didn’t seek emergency care for their injuries.

Dr. Angele Sauaia is an associate professor at the Colorado School of Public Health. She and a team of researchers found that gun injuries among children are common.

“We realized that there was this horrible pattern of violence in the injuries,” said Dr. Angela Sauaia, a trauma researcher and associate professor of public health and surgery at the Colorado School of Public Health. “A large percent were due to knives, pieces of glass and guns.”

Sauaia and her three research partners found that over one-third of the trauma cases related to violence stemmed from gun injuries. The number of gun-related trauma cases has stayed relatively steady, and Sauaia said she expected that the number would have remained consistent from 2008 to the present.

The findings were published Tuesday in the Journal of the American Medical Association.  (To read a JAMA Q & A with Sauaia, click here.)

“With New Town and the Aurora tragedy happening, we decided it was important for people to know that kids are being injured by guns on a routine basis,” Sauaia said.

The researchers also found that a stunning 14 percent of the gun injuries were self-inflicted. Either the children accidentally shot themselves or some were trying to commit suicide. Self-inflicted gun wounds were more common in children ages 10 to 17.

“We don’t know if they were intentional or by accident,” Sauaia said. “Regardless of intention, these kids managed to get ahold of an unlocked, loaded gun. Nobody would think that children should have unsupervised access to unlocked, loaded guns.

“So, regardless of where you stand, that’s good common ground for all of us to work on,” Sauaia said.

The researchers conducted their work without any federal funding. Sauaia said there are major gaps in knowledge about gun injuries and deaths because funding has been so difficult to attain. She said the number of children and adults who die from guns is small compared to those who suffer injuries. So there’s a great need for new research on gun injuries.

Regardless of how much researchers know about the causes of gun injuries, the consequences are clear and ominous, Sauaia said.

“If your child is hurt and the wound is due to a firearm, they are 10 times more likely to die than any other injury,” she said. “Most victims of trauma don’t die, but they suffer consequences for the rest of their lives.

“People tend to only pay attention to gun safety issues after these mass killings but this is happening all the time to our children and it’s totally preventable,” Sauaia said. “Are we as a society willing to accept that 14 or more children shot each year is an acceptable number?”

Conducting the research with Sauaia were Joshua Miller, a former student at the Colorado School of Public Health; Dr. David Partrick, a pediatric trauma surgeon at Children’s Hospital Colorado; and Dr. Ernest “Gene” Moore, head of surgery at Denver Health.

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 Katie Kerwin McCrimmon

As Colorado’s health exchange managers sprint toward an October 1 launch, a top manager warned board members on Monday that a recent decision to build a new “eligibility” IT system poses the greatest risk of delay and could undermine the quality of the online health marketplace.

Adele Work, who is leading implementation for the exchange, made a presentation about “key implementation risks” during a technology update for the board.

No. 1 on that list of risks is the new decision to divide one planned IT system into two. The report to the board said that IT developers for the exchange are now having to contract with a “team of eligibility experts” to develop the new engine that will determine if customers of the exchange qualify for federal subsidies. State Medicaid managers are building their own separate system to determine if exchange customers are eligible for Medicaid. Previously, Medicaid and the health exchange were planning to operate one “shared eligibility service,” the report said.

“This decision was made about a risk to our ‘go-live’ date,” Work told board members.

In order to try to open the exchange on time, Work also told board members that IT developers will delay some functions to future years.

Exchange board member Eric Grossman, an expert on health care technology who works for TriZetto, a health care technology company, asked about planning in case IT systems don’t work.

“The best laid plans go awry,” Grossman said. “What’s plan B? We can’t just keep dumping stuff on the plan.”

Exchange Executive Director and CEO Patty Fontneau responded that she’s putting a halt to any new components.

“We can’t do anything else,” Fontneau said. “We’re done. At this stage, we’re drafting a letter to HHS (the U.S. Department of Health and Human Services) saying, ‘if you tell us something else, we can’t do it.’”

Fontneau also warned board members that the exchange would need to hire and absorb extra costs in the first year for more workers to do jobs by hand in the “back office.” She previously anticipated those functions would be automated through tech systems.

Overall, Work said that IT projects are on schedule, but that lack of time could be problematic.

“We’re on track with the plan,” Work said. But she added, “it’s a highly aggressive plan. It would be silly to tell you it’s easy.”

The other greatest risk, according to Work’s report, is that there could be “functionality gaps or coding errors” in the basic exchange IT systems. And there will be little time to fix them.

“We will not know the full impact until later testing phases,” the report said.

Solutions reported on March 27 on a variety of tech troubles that could hobble the health exchange. Fontneau and communications consultants declined repeated requests for interviews on the problems. Asked Monday if she wished to talk about how the exchange is handling technology challenges, Fontneau said: “No comment.”

Exchange managers also declined repeated interview requests on Monday and Tuesday to explain the new decision to shift technology plans at such a late date. The exchange board did not vote on this decision.

Despite the fact that the health exchange is a public entity that is spending tens of millions of taxpayer dollars and must be responsive to the public, exchange managers are now refusing to conduct interviews about exchange operations with Solutions and will only answer questions in writing.

In a written response from communications consultant George Merritt, managers said that: “COHBE (the Colorado exchange), HCPF (state Medicaid managers) and OIT (Colorado’s Office of Information Technology) collectively decided earlier this year for COHBE to build the portion of the eligibility system related to access to new federal financial assistance to reduce the cost of health insurance and for HCPF to build the system that determines eligibility for Medicaid and CHP+.

“This plan is on the back end, does not affect the customer experience and will not cost more. Customers will still apply (sic) be able to apply for coverage through COHBE or through PEAK (the state benefits system) and our systems will share information. This plan creates a path to a successful launch in October that best serves Colorado consumers,” Merritt wrote.

State Medicaid managers also said consumers should not be affected by the change.

“The engine decision will not impact clients as both the exchange and Medicaid will have a ‘no wrong door’ approach so that no matter which system a client chooses to use, they will be able to apply for benefits,” Rachel Reiter, communications manager for HCPF said in a written statement.

Among other technology updates, Work reported that:

• IT contractor CGI, which the exchange is paying $66.3 million for technology, is taking commercial, off-the-shelf products, making changes to them and delivering the software in six releases.
• So far, exchange managers say they have received the first four releases. “There is some method to the madness in terms of building a plan. We have a lot of work to do in a very short period of time,” Work said. But, “We and CGI have met all of our milestones to date.”
• While outside analysts say the federal data services hub — with which exchanges must communicate in real time to determine if customers are citizens and eligible for federal subsidies  — is only 40 percent complete, Work’s report said there’s been “significant improvement” on the hub. She expects to begin testing with the hub by May.
• Exchange workers and contractors have been working to fix problems uncovered through an outside analysis by First Data. Work said three of six problems uncovered in First Data’s initial analysis have been fixed. The compressed completion schedule will make it difficult to excel in all categories that the analysts monitor.

On other matters related to the exchange, the board voted to allow customers who call insurance companies directly or who are renewing insurance policies to purchase new exchange products directly through insurance companies.

Exchange staffers estimate that about 400,000 Coloradans currently buy health insurance through the individual market and about half of them or 195,000 people will probably be eligible for new tax credits and subsidies through the exchange.

George Lyford, a lawyer for the Colorado Center on Law and Policy, urged board members not to allow insurance companies to sell exchange products directly to consumers.

“That means they will never access this state-of-the-art marketplace,” Lyford said. He said consumers won’t have key information they need about subsidies and may not understand their options.

“How will they select a plan that is best for them?” Lyford asked.

Exchange staffers estimated that between 30 and 50 percent of individual health insurance polices sold in Colorado are the result of a consumer who contacts an insurance company directly. The board will require sales staffers at insurance companies to inform consumers about the health exchange and let them know they may qualify for public health insurance or federal subsidies.

Exchange managers are also planning to set up six “assistance networks” throughout the state. Under three different scenarios, the health exchange would spend between $12 million and $20 million a year offering in-person assistance to exchange clients. Managers expect clients to need as much as 90 minutes each to explore health plans and learn about options they might choose. One of the staffers who tried filling out the necessary forms said it took her nearly 40 minutes and she’s savvy about health insurance.

Board members also received an update on a new communications plan.

The exchange contracted with a group called Corona Insights in Denver to analyze who the potential customers might be.

The typical uninsured Coloradan will most likely be a young man ages 25 to 34 who is a cook or works in the construction or entertainment industry. He would earn about $25,000 to $49,000 a year.

The typical customer who purchases individual insurance in Colorado has a household income of about $100,000 or greater, is between 55 and 64, and is white. Both men and women fit into this group and are most likely to be managers or sales people in the restaurant or construction industries.