Health Relay

Falling in the gaps of health reform

Sandy Graham is the project manager and managing editor of Health Elevations, the Colorado Health Foundation's award-winning quarterly journal. The latest edition of Health Elevations focuses on changes in private insurance that are in the works or coming soon.

"You'd better look at this letter that came from our health insurance plan."

My husband's tone of voice did not bode well. I was just finishing the cover story for this issue of Health Elevations, detailing the big changes in private health insurance occurring through the 2010 federal health insurance reform bill, the Affordable Care Act: No denials for existing health conditions; Preventive care; Shopping for plans through an online insurance exchange; Covering adult children to age 26 on parents' policies.

Make that some adult children.

Ironically, despite all I had just written about the ACA's efforts to extend health coverage to more people, our daughter – the underemployed college graduate – would not be among them. The letter explained she was being dropped from our plan because she was no longer a full-time student – which we thought applied only to the "old days" before the ACA.

But when my husband called the plan, he was informed that the ACA does not apply to health plans such as ours, which is for retirees – not regular employees – of a large cable TV company.

Still puzzled, I contacted Marianne Goodland, the Colorado Division of Insurance's director of consumer education, and Karen Pollitz, senior fellow at the Henry J. Kaiser Family Foundation both of whom had helped on this issue of Health Elevations. They confirmed that letter was right: retiree-only plans did not have to comply with the ACA.

To me, it felt like the old bait-and-switch. What was going on?

Blame HIPAA, they said. The 1996 Health Insurance Portability and Accountability Act provides privacy protections for individuals' health information and helps preserve coverage for workers who change or lose jobs. HIPAA rules do not cover retiree-only plans. And the ACA was added to HIPAA. Therefore, the ACA does not cover retiree-only plans.

Congress would have to amend HIPAA to extend the ACA's promises to retirees and their families. This is opposed by businesses: According to an article in The Wall Street Journal, big employers say they might drop retiree coverage entirely if Congress were to do so.

The former employer did offer to continue covering our daughter through COBRA (the Consolidated Omnibus Budget Reconciliation Act). This would provide her with 36 months of coverage because of "loss of child dependent status" rather than the 18 months that the law offers following job termination. But the price tag was a staggering $489.24 a month for health coverage plus another $46 for dental and vision.

Instead, we talked to an insurance broker, compared several companies' offerings and ultimately chose a comprehensive plan (albeit, with a $1,500 deductible) for $143 a month that will let her stay with our family doctor.

On the plus side, when 2014 arrives, we should be able to buy our daughter an affordable individual policy through the ACA-mandated health insurance exchange – providing the exchange isn't nullified by lawmakers or the courts. Better yet, maybe she'll be gainfully employed with health insurance benefits to boot.

Only time will tell.

Policy Speakout: The business case for healthy food

Shepard Nevel is vice president of policy and evaluation for the Colorado Health Foundation.

Sometimes a call to battle can lead to victory for both sides. In the case of the food and beverage industry, and the marketing of unhealthy food to children that contributes to our nation's obesity epidemic, the free market may be cultivating a common-ground solution where industry, profit, job creation and health converge.

Like the rest of the nation, Colorado is experiencing an obesity epidemic. One out of every five Colorado adults is obese. In just four years, Colorado's childhood obesity rate plummeted from third leanest in the nation to 23rd. A new study estimates the cost of obesity to Colorado at $1.6 billion in 2009 alone, as the Colorado Health Institute's Emily King reported.

More than one-quarter of the increase in health care costs nationally can be attributed to the obesity epidemic, including 38 percent of the increased spending on diabetes and 41 percent of increased spending on heart disease, according to research by Kenneth Thorpe and colleagues published in Health Affairs magazine.

Among the many factors complicating the fight against obesity is the marketing of unhealthy food and beverages to children through network and cable television and new media.

According to a study by the Federal Trade Commission, food and beverage companies spend more than $1.6 billion per year on marketing their products to children and adolescents. Nearly 60 percent of those marketing dollars are spent on carbonated beverages, candy, frozen desserts and other products that tend to be high in calories, sugar and saturated fat.

The National Academy of Science's Institute of Medicine has reported "strong evidence" that television advertising influences the food and beverage purchase requests of children ages 2 to 11, as well as their short-term food consumption. The institute concluded that food and beverage marketing to children and adolescents are "out of balance with healthful diets and contribute to an environment that puts their health at risk."

When the Centers for Disease Control and Prevention and other federal agencies developed – at the direction of Congress – voluntary nutritional standards for food and beverages marketed to children, food and advertising industries launched what the Washington Post described as a "multi-pronged campaign to squash" the effort, portraying the guidelines as "job-killing, government overreach."

So it seems that two compelling interests are colliding – the rising public health and economic concerns about the obesity epidemic and the sizeable political influence and importance to our economy of the food and beverage industry.

While this battle will continue, there is reason for optimism that the free market, driven by consumer demand and the creative entrepreneurship that drives our economy, can reconcile industry profit and public health.

A report by the Hudson Institute's Obesity Solutions Initiative analyzed several of the largest food and beverage companies and found that healthier products (described in the report as "better for you") accounted for nearly three-fourths of sales growth. The Institute's director, Hank Cardello, a former food and beverage company executive, says the focus should be on the business not moral argument – the profitability of healthier products. He notes that many food, beverage and restaurant corporations are "making their profits and doing what's better for their customer's well-being." Cardello says "it's time that the food companies take custodianship over their customer's health and well-being. The only way to engage the food industry in helping is to show them how to make a profit while doing the right thing."

Others are making the business argument as well.

A global market review of health convenience food in 2012, published by Research and Markets, forecasts that the on-the-go health food market will reach a value of $74.9 billion in the U.S. by 2012 and concludes that the "food industry can no longer ignore the convenient and health food market. It has fantastic growth and profit potential for...manufacturers, retailers and suppliers."

While important policy and regulatory issues will continue to drive differences between health advocates and the food and beverage industry, encouraging and supporting the industry's shift toward healthier products and healthier profits offers fertile ground for consensus in the campaign against obesity.

How social workers fit into health care

Laura Gabbay is the executive director of Project WISE, a nonprofit that helps low-income women advance in personal and economic self-sufficiency.

As the Affordable Care Act nudges the health care sector to a more "integrated" approach of delivering services, social workers have much to offer. Indeed, social workers have historically played a major role in coordinating care for people with mental health issues such as depression, anxiety and traumatic experiences.

A social worker who co-locates with a primary care provider could detect non-clinical factors that influence patients' health. For example, a social worker at an integrated, primary care clinic might ask about the patient's housing arrangements, her legal situation, if she and her children have food, or if she's in an abusive relationship.

Because social workers receive a broad education around psychology, they tend to be "generalists," able to nimbly and effectively provide services to many different individuals.

Social workers are exceptionally good at community-based work and being culturally responsive. This is particularly important as we encourage individuals to be more engaged in their own health care decisions.

Pairing social workers with primary care providers also effectively mitigates concerns many Coloradans have about the increasing strain on the current health care system as our state grows and our population ages.

Betsy Clark, executive director of the National Association of Social Workers, predicted that public health social work may be the future of social work. "The ability of the public health social worker to bridge prevention and intervention, individual and community, and practice and policy will be increasingly valued by our changing society," Clark said in 2006.

Project WISE supports an "empowerment model" that encourages our clients to embrace an understanding that they are in charge of their lives, and thus, their health. Many of the new models of health care dovetail nicely with this model.

We see that unhealthy life choices, poor role modeling and high levels of unmanaged stress are harmful to women – particularly those in their late teens and 20s. Integrated health care offers innovative solutions. We embrace the notion that more underserved women in our community should regularly receive primary, mental health and oral care – with our counselors being committed to good frequent communication with the primary care provider community.

Partnering social workers with primary care providers addresses some important challenges to the successful integration of mental health services into primary health care settings. Let's work together to create new innovative care delivery models for women with low incomes in our community – invite a social worker to the table and begin a conversation that's a win-win for everyone.

Teammates in health

EDITOR'S NOTE: Christine Rios lives in Brighton. She has been a part of the Colorado Regional Integrated Care Collaborative for three years. As the program evolves into the Accountable Care Collaborative, she is hoping she can continue working with her Colorado Access care manager, Janise Friedland.

This narrative originally appeared in the Fall 2011 edition of Health Elevations, the quarterly journal of the Colorado Health Foundation.

I'm 60 years old and the mother of three grown children. But I live by myself now, and my health is really bad. I lose my balance a lot and I fall. Five years ago, I had a stroke. Now I don't remember things like I used to.

I'm on Medicaid, and three years ago I was told I would be part of a new program through Colorado Access, the Colorado Regional Integrated Care Collaborative. It provides care management to a select group of Medicaid patients. My case manager is Janise Friedland, and she has been wonderful. She explains things to me that I don't understand. I go to the doctor once a month, and Janise goes with me and explains everything to me in a way I can understand.

Like when I was having trouble swallowing and the doctor told me I had Barrett's mucosa, which is a narrowing of the esophagus. I got very anxious because I was afraid I wouldn't be able to eat. Janise talked to me about how I could make smoothies and use my blender to mix up some of my favorite foods.

Another time, the brace that I wear on my leg was rubbing against my skin and irritating it. Janise suggested I take a little piece of moleskin and put it over the area that was rough. Now it doesn't rub against my leg anymore. Before my stroke, I probably would have known to do that, but not now.

Not too long ago, I thought I was having a heart attack. An ambulance took me to the hospital, but it turned out it wasn't a heart attack, so they told me to go home. But by then it was 1 a.m. and I didn't have anyone to call to come and get me. I normally use a transportation company, but I was told it was too late to call them. So the hospital called a taxi for me, and the ride home cost me $66.

The next day, I called Janise and told her. I figured I just wouldn't eat this month because I don't have $66 to spare. But she got on the phone and called a customer service representative at the transportation company, and when they told her there was nothing they could do about it, she asked for the manager. She didn't stop until she got my $66 back.

I know I'm living much healthier and safer now, thanks to Janise.

'Holiday blues' underscore Colorado's mental health needs

Andrew Keller, Ph.D., a founding partner of TriWest Group, is the lead author of "The Status of Mental Health Care in Colorado (2003)" and "The Status of Behavioral Health Care in Colorado (2011)." A clinical psychologist, Keller helps behavioral health and human services systems across the country develop, expand and fund effective services.

With the holiday season in full swing, we're bombarded with images of happy families coming together to celebrate the season. But, for many the holidays are a time for stress, depression and loneliness. In fact, the number of Coloradans in need of mental health or substance use disorder (SUD) care during the holidays and throughout the year may surprise you.

Each year, three in 10 Coloradans (1.5 million people) need mental health or SUD treatment. Approximately 450,000 of these people have a severe need. These numbers are highlighted in a report that was released on Dec. 7 by Advancing Colorado's Mental Health Care (ACMHC). Titled "The Status of Behavioral Health Care in Colorado," the report is the most comprehensive assessment of the state's mental health and SUD systems to be published in almost a decade.

In 2003, a group of eight Colorado foundations jointly funded "The Status of Mental Health Care in Colorado." This groundbreaking report published information about the state's many fragmented and underfunded systems for providing mental health services. In response, the Caring for Colorado Foundation, the Colorado Health Foundation, The Colorado Trust, and The Denver Foundation partnered to form ACMHC. The $4.25 million project supported six community collaboratives over five years – bringing together mental health care providers, human services agencies and other local partners to address the tremendous needs detailed in the 2003 report.

Other key findings of the 2011 report include:

• There are too few providers with specialized skills willing to serve Coloradans with the most complex needs, given current reimbursement rates and gaps in specialized training. As a result, these people are accessing services through multiple systems, too often receiving ineffective, uncoordinated care and driving up overall health care costs.

• There is a critical shortage of providers in rural and frontier areas of the state. Eighty-two percent of practicing psychiatrists, 86 percent of child psychiatrists, and essentially all psychiatrists specializing in SUD treatment and geriatrics practice in Denver and Colorado Springs.

• Specific populations – including sexual minority groups, veterans, and Coloradans of color – struggle to access mental health/SUD care. When they do receive care, Coloradans of color are disproportionately served in correctional settings.

• Colorado has the sixth-highest suicide rate in the country.

• Colorado is considered a leader in providing behavioral health care in primary care (connecting the head to the body) settings, which improves outcomes and cuts costs.

In addition to seven observations of behavioral health care, the report offered several recommendations for stakeholders to consider.

While Colorado has taken steps to improve behavioral health delivery over the past decade, we must focus on redeployment of current resources, as well as future investments as the economy recovers. This is absolutely necessary to help rein in costs and improve outcomes for the 1.5 million Coloradans who need treatment each year.

Visit www.ColoradoMentalHealth.org to read the full "Status of Behavioral Health Care in Colorado" report.

Team-based learning for health professionals

Holly Newby is a student at the Regis University School of Pharmacy.

Though pharmacists often work in enclosed workspaces at groceries or retail outlets, they're hardly isolated from the increasingly team-oriented health care system. That's why the integrated, team-based learning curriculum at Regis University's School of Pharmacy gives its students a competitive edge in the rapidly changing field.

As a student at the university, I participate in a unique and innovative educational experience. The program recognizes that successful, patient-centered care involves the collaboration of many health professionals within an interdisciplinary, problem-solving community.

While I didn't have any pharmacy experience prior to entering the program, the team-based approach has given me the ability to walk into a professional pharmacy environment with confidence. Using the team-based approach, students and teams evaluate case studies to solve drug-related problems and support their answers to the class at large.

This has enabled me to advocate for things that I want to learn while participating in experiential internships. Team-based learning teaches me to be a responsible teammate. I must go to class prepared ahead of time and work closely with a team of five to six individuals. Working on a team provides instant motivation to learn as much as you can so that you are a positive force on the team and you don't feel you are letting them down.

This sense of responsibility is important to the team dynamics in class as well as within the professional community. If I am a responsible teammate, I will be a supportive and knowledgeable pharmacist, which will enhance patient care. In a team-based learning environment, we are constantly developing new problem-solving techniques to help us make important clinical decisions. We constantly bounce ideas off of one another and constructively argue our way through tough situations. We also evaluate each other's progress to make sure we perform at our highest levels.

But the main reason that I enjoy my team-based education is that it is fun! We don't sit and listen to lecture after lecture. Our class is loud, interactive and friendly. Through the team-based approach I am becoming an active, lifelong learner dedicated to patient care. The experience will prepare me to become a leader in the team-based service of others.

For more about team-based approaches in health care, check out the Fall, 2011 edition of Health Elevations, the Colorado Health Foundation's award-winning quarterly journal.

Holiday health and hygiene go hand-in-hand

Roberta Smith, RN, MPH, is a nurse and preventionist at Children's Hospital Colorado. Daniel Hyman, MD, MMM, is the chief quality officer at Children's Hospital Colorado.

The holiday season brings many opportunities to eat, drink and be merry with family, friends and co-workers. But as we line up behind the buffet table and exchange handshakes or hugs with colleagues and friends, we're more susceptible to viruses that could leave us bedridden for the rest of the year.

That's why good hand hygiene and infection prevention is a sound public health practice for everyone. Those of us in health care have become familiar with efforts to improve hand hygiene practices. After all, cleaning our hands is the most important preventive measure we take in protecting our patients from hospital-acquired infections. But the need for good hand hygiene goes well beyond the walls of our health care organizations.

In the winter months, people from all walks of life spend a majority of their time inside small spaces where viruses can reside for days – sometimes weeks – at a time. For example, influenza virus can spread for two days on some surfaces. Hepatitis B virus can last up to seven days. Norovirus (also known as the cruise ship gastrointestinal virus) has survived in carpets for up to 12 days.

Everyday, we touch railings, tables and doorknobs – then proceed to touch our eyes, nose and mouth. Monitor yourself: How many times do you touch your face in the course of an hour? How about touching others? This is why hand hygiene is so important.

Here are two effective strategies for keeping your hands clean:

• Alcohol-based hand sanitizer sprays and gels for when your hands are not visibly soiled – Remember this motto: "Liberally apply, rub your hands until dry, it's as simple as pie!"

• Soap and water whenever one's hands are dirty (and of course, after using the toilet) – While frequent hand cleaning can dry out the skin in Colorado's dry climate, hand lotions can reduce this problem and help to eliminate cracks in the skin that can harbor germs.

Have you ever heard someone say "we wash our hands too much these days" or "I want to build up my immune system" as an excuse for not practicing good hand hygiene? Humbug! Spraying your hands with a bit of alcohol rub is much more pleasant than running to the bathroom every 15 minutes with a stomach virus or being stuck at home with a fever, cough and flu.

By practicing some basic public health principles (such as hand cleaning, getting annual flu immunizations, staying home when you are sick and covering your cough with the inner crook of your elbow), we can all do our part to protect ourselves and others from getting sick during the holiday season ... and throughout the year.

Fiscal challenges will persist despite good economic news

Jeffrey A. Roberts is a research analyst at the University of Denver's Center for Colorado's Economic Future.

It is heartening to know that Colorado's economy is finally showing some signs of recovery. As you may have read in a recent article in The Denver Post, more than 30,000 jobs have been added since the start of 2011, and employment growth in the state from September to October was at its highest level since March 2007.

For state government, a healthier employment picture should boost the collection of sales and income taxes – the revenue that finances major General Fund programs including K-12 education, Medicaid and higher education. But this bit of good news hardly spells the end of Colorado's fiscal troubles – which will persist in both the short- and long-term.

In the short-term, General Fund revenues for fiscal year 2012-13 are projected to be 5 percent lower than the pre-recession peak of fiscal year 2007-08. That doesn't sound too bad until you consider that the demand for state services has grown substantially since the recession began. For example, Medicaid enrollment will have increased 72 percent through next fiscal year, the Children's Health Plan Plus (CHP+) caseload grew by 19 percent and higher education enrollment swelled by 20.5 percent.

As the name implies, the Center for Colorado's Economic Future looks at the long-term – and that is where you will find state government's most confounding fiscal problem. It is a structural problem that requires a structural solution.

According to "Financing Colorado's Future: An Analysis of Fiscal Sustainability of State Government," the combined growth rate of the General Fund's three largest programs (education, Medicaid and prisons) will far outpace the growth rate of revenues through fiscal year 2024-25.

Authored by the Center, the report also shows that even a strong economic recovery will not help the state avert the inevitable. Furthermore, absent sweeping policy changes, total state expenditures in fiscal year 2024-25 will exceed tax collections by 20 percent – or $3.5 billion. Expect that gap to widen even more beyond our forecast horizon as the aging baby boom generation causes Medicaid long-term care costs to skyrocket.

An additional and potentially expensive factor that our study did not account for is the impact of the Dec. 9 court decision in Lobato vs. State of Colorado. In that case, a Denver District Court judge ruled that Colorado's school finance system is not as "thorough and uniform," as the state's constitution requires. The decision could increase the state's education funding obligation by billions of dollars a year, depending on the outcome of a likely appeal to the Colorado Supreme Court.

How can we address the $3.5 billion structural imbalance that the Center projects? Cuts alone would drastically change the very nature of state government. We modeled a long-term scenario that protects health care programs (so as not to risk leveraged federal dollars) as well as the prison system and functions required by the state constitution including the governor's office and court system. Balancing the budget this way (and putting the Lobato ruling aside), public school funding by the state would be cut by nearly 20 percent in most years. By fiscal year 2024-25, funding for 10 departments – including higher education, public safety and public health – would be reduced by more than 90 percent.

The magnitude of the projected revenue/expenditures gap suggests that a combination of cuts and tax increases is necessary. But to illustrate how it could be bridged with new revenues alone, we developed a package of taxes designed to grow in step with future spending, limit volatility and better reflect the economy, among other criteria. It includes a sales tax on personal services, a graduated individual income tax and a phased-in uniform mill levy aimed at reducing the state's share of total K-12 education costs.

Our latest effort involves demonstrating how such a package, if fully implemented, would affect median households in each school district. Understanding that most people don't match the median, we are redesigning interactive features on the Center's website so that any Coloradan may calculate how the package might affect his or her own household.

Meanwhile, we continue to brief policymakers and the public on our findings. So far, we have made – or are scheduled to make – more than 80 presentations. A narrated version of our PowerPoint presentation is online.

How can the state solve its long-term and short term budget quandary? Post your thoughts in the comment box below.

Connecting the HIT dots

Mark Wallace, MD, MPH, is president of the North Colorado Health Alliance and director of the Weld County Department of Public Health and Environment. Dr. Wallace is featured in a new report, "Healthy Connections in Colorado: A Primer for HIT Success". Published by the Colorado Health Foundation, the report looks at the impact of health information technology on Colorado safety net organizations.

Much has been said about the "potential" of health information technology (HIT) and health information exchange (HIE) for improving care quality and efficiency in health care. Thanks to the collaborative efforts of our partners, the North Colorado Health Alliance is now among many safety net organizations in the state who are turning that potential into reality.

NCHA is an alliance of health care providers in Northern Colorado, including the Weld County Department of Public Health and Environment, Sunrise Community Health Center, the Banner North Colorado Family Medicine Residency Program, the North Range Behavioral Health and the Larimer Center for Mental Health. Members of the alliance serve a combined population of about 175,000 people – many of whom are uninsured or underinsured.

Years ago, NCHA's ability to use health information was hampered by an archaic computer network. As a result, the patients we served experienced delays in appointments and duplications of services on a regular basis simply because the partners' systems were not adjoined.

In 2003, NCHA embarked on a $1.8 million project to improve its HIT. Going into the project, we knew that we would need to find new ways of doing things. That meant developing different record-keeping and reporting systems and appointment calendars. By exploring our HIT options, we learned about the Colorado Health Foundation's Healthy Connections initiative.

With help from a $300,000 Healthy Connections grant, NCHA augmented its local HIT system to include three new organizations and added comprehensive behavioral health to its mix of services. Fast forwarding to 2011, we've achieved a level of integration that enables new capabilities. For example, we can now access our database and gain a greater understanding of the health status of people with asthma or diabetes and smokers within our population. We also can efficiently and securely access health information for those who've visited a number of different clinics in Northern Colorado – ensuring the patient's health information is available to the clinician they're seeing.

Healthy Connections has not only helped us to improve our technical capacity, it has transformed the way the partnership operated – building a common language between all of our partners. As an organization, we are now focused on shared success and accomplishment.

Health policy in plain English

Bob Mook, editorial manager of the Colorado Health Foundation, has attended five Colorado Health Symposiums. He is the author of a new report, "Insights: 2011 Colorado Health Symposium," summarizing highlights from the event.

As a one-time health care journalist and as a current member of the Colorado Health Foundation's communications team, I've long considered the Colorado Health Symposium the highlight of my professional year – the work-related equivalent of the holiday season. One of my colleagues even likened the three-day event to the health policy wonk's Woodstock – the historic 1960s music festival – only with no mud and a better venue.

At the Symposium, my peers and I can leave behind any pretense of managing a "work-life balance" and immerse ourselves fully in discussions about health care reform and how public infrastructure impacts health in low-income communities. When the planned activities run out early in the evening, I head over to the Keystone Lodge to talk health policy with other Symposium participants. I do this because I genuinely enjoy talking about health policy and because the issues discussed at the Symposium are critically important – not just for health policy wonks, but for everybody.

That's why I hope the recently published "Insights: 2011 Colorado Health Symposium" will appeal to many Coloradans who weren't at this year's event. In writing the 24-page summary, I favored "plain English" that speaks to those both inside and outside the industry over the wonkish language that sometimes characterizes these kinds of reports.

Whether you're an expert in health policy or someone who simply cares about health, the report provides some interesting answers to the most provocative questions in health care today, including: Should the Affordable Care Act be saved? How do we build healthier communities? What can businesses do to improve health for their employees? Those answering the questions include:

• Kavita Patel, MD, a fellow and managing director of the Brookings Institution, who served in the Obama Administration as director of policy for the Office of Intergovernmental Affairs and Public Engagement

• Grace-Marie Turner, founder, president and trustee of the Galen Institute, a public policy research organization based in Washington, D.C.

• Kelly Brownell, co-founder and director of the Yale Rudd Center for Food Policy and Obesity

• Will Allen, founder and CEO of Growing Power, a farm and community food center in Milwaukee

• Pedro Jose Greer, Jr., MD, a physician who founded several free clinics for the homeless, undocumented and migrant poor of Miami

• Larry Cohen, founder and executive director of the Prevention Institute, an Oakland, Calif.-based organization which advocates prevention to improve health and reduce costs

Read the report to see why I'm already looking past the holiday season and counting down the weeks to the next Symposium, scheduled July 25-27 at Keystone.

For more Symposium-related resources, check out recorded video on Ustream and insights from plenary speakers on the future of health care on "Colorado State of Mind,". Also, contact us by email to receive information about the 2012 Symposium or to obtain hard copies of the report.