Whether it’s a nasty winter virus, chronic gastrointestinal distress from Crohn’s disease, or the occasional debilitating migraine, most of us understand what it feels like to be sick or to deal with pain. Unfortunately, not everyone knows what it’s like to get a prescription to fight a sinus infection or to ask for a second opinion on the cause of those headaches. That’s because a person’s ability to access health care depends upon a variety of factors, including income, geography, age, residency status, and insurance, among other things. A farmer on Colorado’s Eastern Plains, for example, may not be able to see a doctor about a persistent cough because there are no primary care physicians in his county. And a Denver-based freelance writer with a high deductible insurance plan will likely fight through a potentially dangerous fever instead of heading to the emergency room. In fact, of every five people you pass on the street in Colorado, at least three are in these types of medically vulnerable situations—scenarios that can turn easily treatable ailments into expensive, difficult-to-remedy maladies. Compounding the problem is the reality that many face not just one but multiple barriers to care. It’s in these intersections—where, say, age and geography or residency status and income level converge—that the largest obstacles to health care access exist. Fortunately, the Centennial State is full of hospitals, clinics, providers, businesses, and nonprofits working fervently to close these gaps in our medical system. Their solutions are saving lives.
Kids in Colorado Springs can’t easily get the specialty care they need. Children’s Hospital Colorado is here to help.
It’s one thing to live in an isolated area knowing you’ll need to travel to find care; it’s another to dwell in a city of 416,000 and still be unable to find pediatric specialists nearby. Such is the case for residents of Colorado Springs—one of just a few U.S. metropolitan statistical areas (urban regions with populations of at least 50,000) without a hospital exclusively devoted to tykes. That will change in early 2019, when Children’s Hospital Colorado opens a $154 million facility in the 719 area code.
The expansion is surprising given that more than half of El Paso County residents are covered by Medicaid or Tricare, the insurance system for military personnel and their families. Neither carrier is known for reimbursing health care providers appropriately. “We have a challenge in making the numbers add up,” says Greg Raymond, regional vice president of Children’s in southern Colorado. “But making sure all kids have access to pediatric specialists is critical to our mission.” Historically, Children’s has depended on philanthropy to help offset low reimbursements. Now, staff are looking at other ways to defray costs and get kids the care they need, including these three partnerships that will offer health services within the community before—and after—this new facility opens.
At School: School-based health centers* (SBHCs) are often the only places low-income or rural kids receive medical attention. Currently, Colorado Springs only has one SBHC. Children’s plans to make that center more effective at pinpointing at-risk kids by training providers to ask questions beyond the scope of traditional medicine. (Do you have a place to sleep at night? How often are you hungry?) Staff also hope to make the argument for more SBHCs in the area.
At Home: Based on their answers at the SBHC, some children will qualify as high-risk, and Children’s will pair their families with a community health worker who can help find resources to solve at-home issues. If a family struggles to pay for groceries, for instance, a health worker can send them to a food pantry. Consistent meals ensure kids not only have enough energy to play, but also to learn: Studies show that 84 percent of kids who come to school hungry perform poorly in class.
At the Inspection Station: A study in the Journal of Pediatrics found 26 percent of Colorado kids who died in car crashes were unrestrained or improperly restrained—higher than the national average. Children’s will work with local health care providers to ensure they’re sending the families they see to Colorado Springs’ nine car-seat inspection stations. There, technicians will check that car seats meet safety standards and show caregivers how to install them.
Diversity in the Workplace
A traveling exhibit hopes to nudge Latino kids toward careers in the health industry.
More than 20 percent of Coloradans identify as Latino, yet the Centennial State’s physician population is almost 90 percent non-Hispanic white. The Colorado Area Health Education Center* (AHEC) believes that disparity is partially caused by a lack of health knowledge in communities of color. So Colorado AHEC staffers teamed up with the Boulder-based Space Science Institute to create Discover Health/Descubre la Salud, a bilingual, health-themed exhibition that will travel to 11 Colorado libraries by June 2019. (Catch it at the Aurora Public Library until October 2.) The 800-square-foot display includes interactive activities—from a take-apart torso with fake organs to a green screen station that lets little ones travel inside the bloodstream of a sick patient—designed to teach kids of all ages about common health issues like cardiovascular disease, diabetes, and obesity. The hope is that making health information engaging and accessible to Latino children will encourage them to pursue careers in the health sciences, which could ultimately help hospital staffs better resemble the cultural makeup of the state.
When federal funding could run out for Child Health Plan Plus (CHP+), a low-cost plan that insures about 60,000 Colorado kids and pregnant women who don’t qualify for Medicaid but can’t afford private insurance. Other legislative priorities could distract Congress from reauthorizing the program.
Life or Death
The reality of health care when you’re living illegally in the United States.
Hilda Cortez-Chavez had been vomiting for six months when she finally went to the ER at Denver Health. By then, her kidneys were failing, and she was diagnosed with end-stage renal disease (ESRD). To survive, she would need dialysis to filter toxins out of her blood. That’s relatively simple to get if you’re an American citizen. But for those living illegally in Denver, the only option is the emergency Medicaid program, which pays for health care if a noncitizen needs urgent medical attention. For Cortez-Chavez, that meant falling critically ill once a week and then receiving emergency dialysis, instead of getting thrice-weekly standard treatments.
In 2013, after her third cardiac arrest (studies link cardiovascular problems with kidney failure), the 29-year-old decided she couldn’t keep asking her eldest son to call an ambulance. Her physicians worked with adoption agencies to find parents for her two American-born boys. They also contacted the Mexican Consulate to get Cortez-Chavez a passport so she could go back to her home country. She died there on Mother’s Day in 2014.
Denver Health’s Dr. Lilia Cervantes was one of Cortez-Chavez’s doctors. Having grown up in some of Denver’s poorest neighborhoods, the internist was already passionate about serving low-income populations, but the experience kindled her interest in researching ESRD in immigrant populations. In April, she published an article in JAMA Internal Medicine detailing the experiences of Latino patients with ESRD who live in America illegally, and she’s currently researching the likelihood of death when ESRD patients receive emergency dialysis versus the typical three-times-a-week protocol as well as conducting a cost analysis. “I hope those two studies will change policy,” Cervantes says. “People will care about the bottom line.”
But Cervantes’ work won’t be done even when the numbers are fully crunched. She’s also found that Latinos with ESRD are more likely than their non-Hispanic peers to develop depression. To combat such issues, she created a program through which community health workers with cultural-sensitivity training translated for patients and connected them with appropriate mental health services. In the future, she wants to bring culturally congruent therapy to the bedsides of patients while they receive dialysis. It’s the kind of service that might have helped Cortez-Chavez cope with the pain of ESRD, which could have improved the situation for her sons as well. “Her doctors said she was sometimes unable to care for the boys because of her health,” says Christopher Gibson, the boys’ adoptive father. “Traumatic would be an understatement.”
Denver’s Spring Institute for Intercultural Learning operates a program called Project Shine, in which medical students and residents from the University of Colorado School of Medicine join the institute’s community navigators* on visits to the homes of refugees and immigrants. These are two scenarios they recently encountered.
The situation: Project Shine staffers check on a Burmese refugee family. While they’re talking with the parents about the supplements their kids need to take, the grandfather shuffles through the living room, short of breath. The navigator discovers that not only is the man’s oxygen machine broken, but he’s also been taken off of Medicaid, so he hasn’t been able to see a doctor.
Benefit to the patient: Project Shine secures a technician to fix the machine and figures out that the man needs to fill out a citizenship application before he can go back on Medicaid (because he’s lived in the United States for at least five years).
Lesson learned by aspiring physician: “It would be hard for me to figure out how to get a citizenship card and then Medicaid even in English,” says medical resident Dr. Diana Whitney. “This case reveals the huge barriers in the systems we have.”
The situation: Another Burmese refugee has had several strokes as a result of poorly managed diabetes. She can’t get around her apartment very well, so a medical resident working with Project Shine visits her home. The unit is crawling with baby cockroaches, and the resident realizes that the woman has been leaving food next to her in bed. The bug infestation and her disability made it difficult for her to cross the apartment to reach the insulin syringes in her fridge. Thus, her blood sugar stayed high.
Benefit to the patient: Project Shine partnered with an adult daycare center to find the woman a home care aide.
Lesson learned by aspiring physician: “There are things going on at home that I don’t know about in my office—things that really prevent people from taking care of themselves,” Whitney says.
The University of Colorado School of Medicine is one of a small number of schools in the country where a doctor who wants to practice in a rural area can actually learn her craft.
If you live in Denver, Boulder, or Lakewood—cities groaning under the weight of newly arrived transplants—it’s easy to forget that 73 percent of Colorado is considered rural. Dr. Mark Deutchman wants to remind us. The family medicine doctor created the University of Colorado School of Medicine’s rural track in 2005 to train physicians for primary care practice in the state’s isolated regions, which are often desperate for health care professionals. In fact, 36 of the 47 rural or frontier (six or fewer residents per square mile) counties in the Centennial State are designated by the U.S. Department of Health and Human Services as Health Professional Shortage Areas.* Here’s what CU’s rural medicine program is doing to reduce that number.
The Selection Process
If a CU med school applicant is interested in the rural track, he’s required to submit an essay describing his experience in rural areas of the state and why he’d like to eventually work there as a physician. Rural track students typically comprise 10 percent of the 184 spots in each class; about half of those doctors eventually go on to practice in rural areas. The majority of those train in family medicine, a versatile specialty that prepares physicians to diagnose and manage a variety of health conditions across a wide range of ages, a necessary skill when working in regions without many specialists.
The Practical Skill Labs
Medical students in the rural track have exclusive access to hands-on workshops that cover everything from stitching up wounds to using real sheep eyeballs to learn about eye injuries, says alumna Dr. Kelsey Walker, who now practices family medicine at a critical access hospital* in Del Norte. Traditionally, practical clinical skills like wound repair are learned during residency, but Deutchman goes beyond standard practices to teach his students about the diverse responsibilities they’ll have as rural doctors—and to convince them that they are truly up to the challenge.
Four rural Colorado towns—Lamar, Trinidad, Del Norte, and Montrose—provide $30,000 to $40,000 in scholarships to CU School of Medicine students who agree to practice in their particular hamlet after graduation. “It takes at least seven years to get someone through medical school and residency,” Deutchman says. “These are towns that have the foresight to invest in their future workforces rather than wait till they have a crisis.” It’s a smart move that could offer a solution for towns in Eastern Plains counties like Bent and Cheyenne, which are home to zero physicians.
There’s an inexpensive telemedicine platform just for Coloradans.
Cheaper E-Health There’s an inexpensive telemedicine platform just for Coloradans. Thanks to state legislation that went into effect in November 2016, Coloradans can now use telemedicine* services from the comfort of their own homes—without having to see a provider in person first. That’s a huge boon for rural residents, who often don’t have easy access to a doctor. Yet that doesn’t solve the issue of cost, which continues to be a problem as insurance companies hike up fees. A Boulder-based company thinks it’s found a way to mitigate some of those expenses. Hippo Health, which debuted June 20, provides telemedicine services via a smartphone and desktop app—one that anyone can use, regardless of insurance status. The for-profit company charges $19 per month for individual users (and $37 per month for families with up to seven members). That’s $13 less than the average copay to see a GP and hundreds of dollars less than the typical ER copay. In exchange, users can consult with Colorado doctors—all nine providers are practicing emergency medicine physicians—about basic symptoms ranging from sore throats to itchy rashes. And if a Hippo Health doctor determines that you do need to see a provider in person, she can use her connections across the state to find the best option in your area.
Equality of Care
How to get better treatment despite your health insurance.
The strength of your health insurance often determines which doctors you can see and how much you have to pay to see them. That’s generally bad news for people who struggle to afford insurance on a consistent basis, those on Medicaid, and even Coloradans who have purchased bronze plans, the lowest tier in the state’s health insurance marketplace. Over the past several years, though, local organizations have been working to level the insurance playing field. Their solutions address problems associated with different insurance plans, but in the end, they’re all cutting costs for consumers while increasing the quality of care.
Insurance Level: Organization
Medicaid: Health First Colorado, Colorado’s Medicaid program
No Insurance: Kaiser Permanente Colorado, a hybrid insurance plan and doctor network
Medicaid, No Insurance, Bronze, or Silver-Level Plans: Doctors Care, a clinic that serves south metro Denver
Insurance Level: Initiative
Medicaid: Medicaid divided the state into seven regions and assigned them care coordinators who connect patients with nonmedical services and collect data on costs and health outcomes. Plus, the organization helps each patient find a designated doctor, who receives bonuses from Medicaid if his patients meet certain benchmarks (think: fewer ER visits).
No Insurance: Primary care providers at six local safety-net clinics can email Kaiser Permanente doctors in nine specialties—from dermatology to gastroenterology—for advice regarding any of their uninsured patients. Patients can also see the specialists in person for free, as long as the visit occurs within 90 days of the initial clinical consult.
Medicaid, No Insurance, Bronze, or Silver-Level Plans: Staffers met with patients and asked them questions such as, “In the past six months, did you forego going to the doctor because you couldn’t afford it?” Centura Health, one of Doctors Care’s partners, then bought silver-level plans for those who scored high on the assessment.
Insurance Level: How It Works
Medicaid: In the Centennial State, only 70.4 percent of doctors accept new Medicaid patients. The kind of coordination created by Health First Colorado’s initiative incentivizes doctors to accept new Medicaid patients and to spend more time with them. This better care has helped save the program $139 million in avoided medical costs.
No Insurance: If you don’t have health insurance, you likely won’t be able to afford an appointment with a specialist. That’s why Jorge Pacheco Chumba, a construction worker living in Federal Heights, had gone three years without treatment for skin cancer. Once Kaiser’s e-consult program started up, though, he was able to get his tumor removed free of charge.
Medicaid, No Insurance, Bronze, or Silver-Level Plans: A silver plan has lower out-of-pocket costs than bronze (or no insurance), so participants can pay for doctor’s visits—instead of waiting until their symptoms get bad enough to go to the more expensive emergency room as a result. (Monthly fees are higher for this plan, which is why it’s helpful that Centura covers that portion.)
Insurance Level: Future Steps
Medicaid: Phase II of the program kicks off in July 2018 with some important changes, including bringing mental health care providers into existing clinics so patients can get checkups and therapy in the same location, creating a more streamlined process.
No Insurance: Kaiser Permanente Colorado is now trying to help nonprofit clinics create their own programs to improve access to specialists, specifically for the uninsured and those on Medicaid. In May, the organization announced that it’d be doling out grants totaling up to $1 million.
Medicaid, No Insurance, Bronze, or Silver-Level Plans: Centura’s funding for this pilot program runs out in December, but Doctors Care has high hopes that Centura will not only renew its funding but also that other hospitals will jump on board.
What insurance looks like when you’re self-employed.
When you decided to quit your corporate job for a more flexible lifestyle, health insurance may not have been the first thing on your mind. But it should have been: Just ask the 23,000 self-employed Coloradans who navigated the frustrating process of buying it for 2014. That’s why Eric Smith, owner of Boulder’s CO Health Brokers, chatted with us to explain how you can be a smarter shopper.
You should know…to check a plan’s out-of-pocket maximum.*
Most people know to check the premium (monthly cost) and the deductible (how much you pay for visits and procedures before your insurance covers anything), but don’t ignore a plan’s out-of-pocket max, which can be eyebrow-raising.
You should know…when you shouldn’t get insurance.
If you don’t have much wrong with your teeth, Smith recommends foregoing dental insurance (the Affordable Care Act doesn’t require you to have it) and paying out of pocket for preventive care ($82 on average for a cleaning).
You should know…why you didn’t qualify for that tax deduction.
If you make a profit from freelancing, you can deduct your health insurance premiums from your taxable income. But if you’re just starting out and in the red, you won’t be able to get this break.
Health care starts to look a little different when patients pay what they can—and make all the decisions.
When Denverite Jean Sisneros was depending on $600 of child support a month, she had trouble coming up with $20 for each of her five children’s sports physicals—let alone a trip to the doctor’s office. Then she found out about Colorado’s Metro Community Provider Network (MCPN). The federally qualified web of 20 health centers* provided medical, dental, and mental health services to more than 50,000 residents of suburban Denver last year; 64 percent were at or below the federal poverty level ($24,300 for a family of four). Sisneros, who now serves as chair of MCPN’s board, explains, in her own words, what it’s like to be one of the safety-net provider’s* patients.
I grew up in Denver, been here all my life. The only time I had health insurance was when my mom was married to my dad, and he was in the service. We were living paycheck to paycheck. We didn’t do food stamps or anything because my family believed you took care of yourself. You did the best you could.
As a parent, I tried to make sure I took care of my kids. When they were grown, they told me, “Mom, we never knew we were poor.” But then I got sick. The Tri-County Health Department had a wellness program for women, and they diagnosed me with diabetes. From there, I was given a referral to be seen at MCPN. I didn’t have any insurance or way to pay, but they said it was OK. I’ve been a patient there almost nine years now. I go every three months and get a lot of diabetic education and see a dietitian, which is all free.1 Heck, who wants to go to a doctor? But the providers at MCPN are so passionate about their patients. You’re more comfortable knowing the people there are taking care of you as a person, not a number.
When you have a chronic illness like diabetes, you have a tendency to have depression. I can tell you it’s very nice that when you see the doctor, they ask if you’d like to see somebody for mental health counseling,2 too, rather than trying to find transportation on a different day that you might not be able to get off of work. It makes me feel good that they care about every part of me, not just the need I came for.
The majority of us board members are patients.3 It helps us make decisions to ensure we—and the patients we represent—get the care we need. I’m very passionate about it. It makes me cry—not out of sadness, but because I’m happy I can be part of this organization and try to give back what’s been given to me.
- As a federally qualified health center, MCPN receives slightly higher reimbursements for its Medicaid patients and offers a sliding fee scale, meaning patients pay whatever they can afford. The center also pulls in millions in state and federal grants each year.
- One of MCPN’s most impactful innovations to date involved adding mental health counseling and dental care to standard medical visits. This is efficient for patients, but it also helps doctors get insight into health issues.
- MCPN is required to elect patients to more than half of its board seats. That way, the board can make informed decisions around advancements in care and is able to give a voice to the oft-marginalized.
Less Money, More Problems
A low income can drastically decrease your life expectancy.
If you look at a map that breaks down Denver’s life expectancy by neighborhood, it reveals discrepancies between areas only a few miles apart. In Globeville, for instance, residents live to be 73 years old on average, while those in Washington Park often reach the age of 84. The key contributing factor: poverty. But why exactly do those with lower incomes live shorter lives? Dr. Bill Burman, the executive director of Denver Public Health, suggests some reasons.
Smoking Kills: Studies have shown that smoking takes an average of 10 to 12 years off a life. Yet people are still buying cigarettes, with those below the federal poverty level lighting up at higher rates—26.3 percent versus 15.2 percent—than their wealthier peers. Had it passed in 2016, Amendment 72 would have raised cigarette taxes, but it failed after the tobacco industry spent $18 million to sway Colorado voters.
Needing Nourishment: If an area doesn’t have convenient access to a full-service grocery store—as in 49 percent of low- and moderate-income Denver ’hoods—the niche tends to be filled by sugar-heavy convenience stores. The Denver Department of Environmental Health is trying to fight the spread of junk food with its Healthy Corner Stores Initiative, which helps stores stock shelves with produce instead.
Gunned Down: Studies show that gun violence affects low-income areas disproportionately. To wit: Montbello and Northeast Park Hill—both with levels of poverty above 30 percent—have each seen more than five homicides in the past two years, while tony Cherry Creek has experienced none. Fortunately, the Denver Youth Violence Prevention Center is working to reduce violence in those high-risk regions.
Caring for Grandma
How a local company helps seniors live full and active lives.
In 2016, the average monthly cost of residing in an assisted living facility in the Denver metro area was $4,250. It would be far more cost-efficient if senior citizens could stay in their own homes—almost 90 percent of them say they want to—but as they grow older, they become more likely to need assistance. Enter the Program of All-inclusive Care for the Elderly (PACE), a national initiative that helps aging seniors live independently by busing them to integrated health centers that provide medical and supportive services like adult daycare. We chatted with Dr. Lisa Price, the chief medical officer of InnovAge (a Denver organization that serves as the largest provider of PACE services in the country; call 303-869-4664 to sign up), to hear how this model serves the needs of the oldest generation.
5280: What are common issues seniors encounter that can be detrimental to their health?
Dr. Lisa Price: The longer you live, the more opportunities you have to accumulate comorbidities, or diseases. When you’re carrying more diseases, you have more medications and more physicians involved in your care, so there’s the challenge of getting everybody on the same page. As you lose your vision and have cognitive problems, you might not be able to drive anymore. Lack of access to transportation affects multiple things—not only is it difficult to get to your doctor, it’s hard to get anywhere, so it can be socially isolating.
What does InnovAge offer to address those issues?
Dr. Price: Our care center has an adult day program, a clinic, physical therapy, and occupational therapy. We also provide home services—if somebody needs help with showers or setting up their medications, a therapist might go to their home directly. And we have buildings, one in Thornton and one in Aurora, that offer affordable senior housing. We basically did that because it’s difficult to find good housing in Denver, period.
How does your care center work?
Dr. Price: Typically, buses start bringing patients to the center around 9 or 9:30 a.m. They could be coming just for socialization or for appointments. Each participant is assigned an interdisciplinary team. If I’m seeing a patient in my clinic, I might talk to them about what foods you can eat if you’re watching out for diabetes, but not in the same way our registered dietitians do.
Do we have enough providers to handle the uptick of seniors in the next decade?
Dr. Price: We don’t have a lot of geriatricians now. And if PACE cannot expand beyond the 31 states it’s currently in, we’re at risk of becoming irrelevant in the health care discussion. But we want to grow so that we can serve these folks. It’s an endlessly challenging and gratifying job.
Deciphering Medicare requires a super expert.
As an “ex-researcher, scientist, and inquisitive mind,” Kirk Beattie figured he could navigate Medicare by himself. The Grand Junction resident quickly realized he was wrong. And Beattie’s not alone. About 30 percent of people who think they understand Medicare can’t explain what kind of coverage they have. That lack of comprehension sometimes results in delayed retirement or penalties.
Beattie was lucky to find Lew Barr, an insurance agent with Medicare expertise. After an introductory phone call, Barr visited Beattie at his house, and Beattie’s frustrations evaporated. “Lew took a lot of stress off me and set me on the right course,” he says. Barr, who works statewide, doesn’t charge for his expertise; the only way he benefits is if a client signs up for the Medicare-approved Walgreens prescription plan he sells. He sees his status as a Medicare specialist as key to his success. “Some insurance agents who sell car and homeowners insurance don’t even want to mess with Medicare,” Barr says. “If I’d realized how crazy it would be, I probably wouldn’t have. But I’m glad I did.”
If you come across a wonky word with an asterisk after it, look to our vocabulary ticker for a definition.
*School-Based Health Center: A clinic that provides low-cost primary care within a school setting. In rural areas, these centers sometimes provide the only health care in the county for kids and even adults.
*Area Health Education Center: An organization that offers education and training to those who work (or aspire to work) in a health care profession.
*Community Navigators: Trained workers who help patients address problems that affect their health, like lack of transportation to doctors’ offices.
*Health Professional Shortage Area: A federally designated region with a high poverty rate that has fewer than one health care provider per 3,500 residents.
*Critical Access Hospital: Federally designated hospitals that have 25 or fewer beds and are 35 miles away from another hospital.
*Telemedicine: When health care providers use electronic communications—video, phone calls, email—to diagnose and treat patients.
*Out-of-Pocket Maximum: The most you’ll have to pay per year after your insurance starts to pick up some of your health care tab.
*Federally Qualified Health Centers: Clinics that offer pay-what-you-can systems for those making less than 200 percent of the federal poverty level.
Other Medicare Help:
Trozan Insurance: Fort Collins insurance brokers who specialize in Medicare and other insurance for senior citizens.
State Health Insurance Assistance Program: A government program with free Medicare advice from trained counselors.