INTRODUCTION

The League of Women Voters has been interested in health care issues for many years and has published studies at the national, state and local levels since the 1980s. A Jefferson County study published in 1989 observed that at that time “medical costs are rising sharply, there is a rapidly increasing population of the medically uninsured, and the population of elderly needing medical care is growing. The causes of the crisis are multiple and complex.” All of which is even more true in 2003. “The cost of health insurance has been rising at double-digit rates for the last few years, and most experts think it will go higher soon” (Denver Post, October 21, 2002).

 The 2002 annual meeting of the League of Women Voters of Jefferson County agreed to re-examine local health care issues, options and policies, including Child Health Plan Plus (CHP+), and to update information on health care in Jefferson County. This report addresses that mandate.

The recent census shows that the population of children living in Colorado has increased by 28 per cent over the last decade. Only two other states in the U.S. had a higher growth rate. Additionally, Colorado’s children have come from increasingly diverse families. Over 34 percent of the children in Colorado represent minority groups. The most dramatic trend has been the statewide increase in the number of Hispanic families and children.

The 2000 census for Jefferson County enumerated a total population of 527,056, among whom there were:

Under 5 years of age       33,280

5 to 9 years of age          36,941

10-14 years of age          39,634

15-17 years of age          23,631

Total under 18              133,486

The 2002 KidsCount in Colorado, prepared by the Colorado Children’s Campaign, compiled child wellness data from across the state which included factors such as the child’s low birth weight, mother’s health, mother’s age, her marital status and her education. The current findings suggest that fewer Colorado women are smoking during pregnancy and that access to medical care through the Child Health Plan Plus (CHP+) and Medicaid has increased in the last decade. However, more babies are being born with low birth weight to single mothers, and to mothers without high school diplomas.

In 1998, the  number of Jefferson County children living in poverty was 10,145  (7.6 percent, compared with 14.2 percent statewide). The Teen Birth Rate was 16.0   per 1,000 females ages 15-17 (29.4 per 1,000 statewide). There were 592 confirmed incidents of child abuse or neglect in Jefferson County. Only 1.8 percent of Jefferson County children were enrolled in CHP+ (2.9 percent statewide), whereas 6.9 percent were enrolled in Medicaid (13.9 percent statewide).

The two largest incorporated cities in Jefferson County, Arvada and Lakewood, were highlighted in the 2002 KidsCount report. Arvada fares better than the state average on most indicators of expectations for optimum development. However, the percent of Arvada families at risk has risen. Although repeat births to teen age mothers decreased during the 1990s, first births increased. There has been an improvement in indicators of child health and a substantial decline in women delaying prenatal care.

 Lakewood fares better than the Colorado average on six out of nine risk factors. However, there is a downward trend on five of the nine measures, and births by young, single mothers with low levels of education increased. The children of Lakewood show greater diversity of race and ethnicity than children in Jefferson County as a whole.

 

                     HEALTH CARE DELIVERY SYSTEMS IN JEFFERSON COUNTY

 

Jefferson County Department of Health and Environment 

The Jefferson County Department of Health and Environment (JCDHE) is committed to promoting health and preventing injury and disease for the residents of Jefferson County. Its mission statement, “To create, promote and enhance health and vitality through innovation, collaboration and celebration”, depicts its driving force. It works with other community organizations. The JCDHE is governed by a five-member Board of Health appointed by the County Commissioners. Mark B. Johnson, MD, MPH, is Executive Director of the Department.

The Department of Health and Environment offers varied individual, community and environmental health services through its four main divisions. The number of clients served during 2001 is indicated below.

1. Community Health Services

Clinic Programs - Family Planning, HIV counseling and testing, sexually transmitted disease testing and treatment, cancer screening, child growth and parenting, physical examinations (20,600 clinic visits)

Communicable Disease Prevention and Control - Disease surveillance and intervention, immunizations, TB skin testing (17,200 vaccinations and skin tests)

Health Care Access - Provides assistance with insurance applications for Child Health Plan Plus (CHP+), Kaiser Connections and Medicaid, Health Care Program for Children with Special Needs, Early Periodic Screening, Diagnosis and Treatment (EPSDT), referral to community resources (13,500 EPSDT clients served and 1,940 CHP+, Medicaid and pregnant women served)

Community Health Nurse Home Visits - Provides prenatal and postpartum visits, Partners for Healthy Families (a nurse home visitation program for first-time, low-income mothers), parenting and child health visits (3,800 home visits)

Mental Health Program - Provides Mental Health Nurse Clinician Program to improve the mental health skill of staff and the mental health status of clients

2. Health Promotion and Lifestyle Management

Nutrition Services - Provides nutrition education and counseling, breast feeding classes and resources, Growth Clinic, Women, Infants and Children Program (WIC), Nutrition Services for Children with Special Needs

Community Health Education Classes and Outreach - Provides classes in tobacco-use reduction, teen health, teen outreach, bicycle helmet safety, resource library

Substance Abuse Counseling, Case Management and Education - Alcohol and drug use behavior-change counseling, and education, intervention for pregnant and postpartum women and women with dependent children

A total of 20,427 individuals were served in 2001, of whom 7,863 clients were in the WIC program.

3. Environmental Health Services

Consumer Protection - Insures food safety and sanitation, temporary food events, child care centers, pools, camps, penal facilities, educational classes for pool and restaurant workers, food-borne illness investigations, school safety, mobile home parks, establishment plan reviews, emergency response

Environmental Protection - Monitors hazardous materials, groundwater, pollution prevention, solid waste, environmental site assessments, water quality, radon mitigation, individual sewage disposal system inspection and review, zoonosis (animal-borne disease control), emergency response. Jefferson County has 23,000+ individual sewage disposal systems (ISDS). During 2001, there were 1,463 ISDS inspections, and 385 permits were issued

4. Administrative Services - Provides department administration, epidemiologist, vital records, purchasing and financial management

In 2002, the approved budget for the Department of Health and Environment had federal/state revenues of $3.8 million, Jefferson County General Fund revenues of $5.3 million and $1.7 million from fees, for a total projected budget of $10.8 million (up from $5.1 million in 1989).

On July 1, 2002, $300,000 was cut from the Jefferson County’s Department budget when Governor Owens vetoed the line item for per capita dollars that go to local health departments. More than twice that much must be cut from the 2003 budget.  The Jefferson County contribution (a dental assistant, supplies and equipment) to the “Kids in Need of Dentistry” (KIND) program has been cut and two health education positions have been lost. The approved 2003 budget for full-time equivalent (FTE) employees of 150 includes 7.25 positions on a hiring freeze.

The total projected budget for 2003 is $11.0 million. Substantial cuts have been made for 2003 chiefly by the state of Colorado. Although federal funding has increased to provide for preventing and reacting to possible bioterrorism activities, this funding cannot be used to provide much of the public health infrastructure and targeted services formerly supported by state funds. Jefferson County increased support to $5.9 million.

Colorado received about $100 million tobacco-settlement money and about $15 million went to the counties to hire staff for smoking-cessation programs. Some of the money has been kept in a trust fund, and some used for the Governor’s Read to Achieve program. Jefferson County’s Department of Health and Environment received about $395,000 and has 5.2 FTEs to work on tobacco prevention programs, such as “Getting Ready to Quit”. The Health Department staff cannot do programs in the schools but can train school staff. There are referrals from the WIC program to help pregnant mothers stop smoking.

The Jefferson County Department of Health and Environment is offering fewer and fewer direct health services. The Prenatal Health Program was cut in the year 2000. It has been picked up by several hospitals in the Denver metro region.

 

Jefferson County Public Schools

The Jefferson County School District serves 88,000 students at more than 150 sites. Twenty-two full-time nurses plus one half-time nurse provide consultation services, about six schools per nurse. Each nurse serves a population of 3,000 to 5,000 students. Seven additional nurses serve single programs, such as the ones at Fletcher Miller School and  the Outdoor Laboratory Schools, and serve with the Central Assessment Team, which assesses students who have suffered brain injuries. The nurses instruct, supervise and delegate work related to the daily needs of students to unlicensed personnel, such as the para-professional clinic aides on site at each school for five hours a day. The clinic aides meet the daily needs of students by administering medication, caring for the injured or sick, and giving specialized procedures such as nebulizer treatments.

In the last school year, more than 21,000 students who were served had significant health problems. Health-action plans, such as treatment of severe allergies, were in force for 2,750 students. Daily medications were administered to 8,500. Nine hundred and fifty tube feedings were administered by clinic aides. Vision and hearing screenings were completed for 74,798 students in kindergarten, first, second, third, fifth, seventh and ninth grades, and in all county preschools. Students needing complete audiological screening were referred to a school or private audiologist. Last year 1,860 follow-up exams were performed by school audiologists.

Yearly immunization compliance records are maintained for all students. If a student has a significant physical or psychological problem that prevents school attendance for at least four weeks, that student is provided with a teacher from the school health program.

In 1988, the U.S. Congress passed legislation improving school access to reimbursement through Medicaid and the Child Health Plan Plus (CHP+). The latter is discussed later in this report. The amended Individuals with Disabilities Education Act clarified that Medicaid’s financial responsibility precedes that of the school. Colorado legislation was passed in 1997 encouraging school districts to seek federal Medicaid reimbursement for nursing, occupational therapy, social work and psychology services, physical therapy, speech language therapy and special education instruction for students. All of these services can be provided as well as transportation assistance for community based services, assistive technology and training for students, case management, service to homeless students, and increased CHP+ outreach and training. Dental screening and education are provided only by a pilot program. In 2002, improved mental health services, increased service to homeless students, and enhanced assessment strategies were provided in areas with high mobility rates.

The school Medicaid program is in its sixth year in Jefferson County and is a federal/state matching funds program. The state and federal governments set reimbursement rates. Colorado’s annual funding of public schools is its part of the matching funds process. The school Medicaid programs are considered by the state to be part of the school system. Providers of services in the schools such as nurses, clinical aides, occupational therapists, physical therapists, speech therapists, social workers, psychologists submit their bills to the school administration, which then bills the state for monthly reimbursement. Administration is responsible for verifying information regarding children enrolled in Medicaid. Some of the problems experienced within this system include technical glitches, staffing issues, and getting providers at the school sites to submit monthly bills on time. The goal is to reach one million dollars in reimbursement which would reflect the true number of students eligible for such services. Presently funding is $782,000 from the federal government and $5,000 from CHP+ monies. A $35,000 request for money from the Rose Foundation is pending, but a request for a $9,000 Anschutz Grant related to homeless services was denied.

The CHP+ Medicaid outreach program has one staff coordinator, three full-time social workers, two full-time outreach/enrollment/events specialists and two support staff for homeless and at-risk families. Eligibility requirements are described in the discussion of CHP+.

For the school year 2001-2002,  the Jefferson County School Medicaid Program enrolled 920 children, contacted over 1,993 families, instigated 485 school visits and contacts, passed out 19,831 brochures, trained over 7,100 people regarding the CHP+ Plan in the schools and community, and had an appointment “show” rate of 80 percent. There are Wellness Centers at Eiber and Stein Elementary schools and at the Carin’ Clinic at Arvada Middle School, and another center is planned at Jefferson High School. These centers provide primary medical care and mental-health services five days a week by Certified Pediatric Nurse Practitioners and Master’s level therapists employed by the Jefferson Center for Mental Health. Well-child exams, treatment of common childhood illnesses, management of chronic illnesses, comprehensive asthma management, preschool, day care and sports physicals, evaluations for Attention Deficit Hyperactivity Disorder (ADHD) and Attention Deficit Disorder (ADD), and preventive dental services are available. These centers are joint projects of the schools, Metro Community Provider Network (MCPN), and Jefferson Center for Mental Health.

Additional services include training and certifying 1,240 employees in CPR/First Aid during the year within 94 different classes instructed by the area nurse consultants. As a partner in Jefferson County Child Protection Services, the schools reported nearly 20 percent of the total number of child abuse and negligent cases countywide. Homebound instructional services were provided to 215 students with significant physical and/or psychological needs that prevented regular attendance at their home schools.                                                                     

 

Other Health Care Resources for Uninsured and Low-Income Families

Metro Community Provider Network (MCPN). The Metro Community Provider Network service area includes Arapahoe and Jefferson Counties and the city of Aurora. MCPN receives funding from the U.S. Public Health Service. It also bills for services and is a provider under Colorado Access, a Medicaid HMO. MCPN receives 60 percent of its income from billable insurance and patient-generated revenues, 27 percent from Federal funding, 10 percent from the Colorado Indigent Care Program, and 3 percent from local money.  There are staff  fluent in languages other than English. A $7.2 million budget supports 110 employees throughout the network.

There are four MCPN centers in Jefferson County, all in Lakewood. First established, in 1991, was Jeffco Clinic at 8500 West Colfax Avenue, to provide primary pediatric, adolescent, and obstetric care for people with no other access to health care. Two other MCPN centers located at schools, Eiber Wellness Center at 1385 Independence Street and the Stein Wellness Center at 80 South Teller, provide pediatric care for children. The Estes Street Community Clinic, located at 8755 West 14^th Street at the Jeffco Action Center (JAC), targets JAC’s

 clients and is run in partnership with Exempla Lutheran Medical Center. All centers are staffed with nurse practitioners and have physician back-up.

Exempla Lutheran Medical Center. Exempla Lutheran Medical Center (ELMC) provides uncompensated charitable care and community benefits through varied health-care services and programs including maternal services. Through the Graduate Medical Education Program at Exempla Saint Joseph Hospital, physicians are trained for work in Colorado and serve in Exempla clinic partnerships such as those at the Caritas Clinic, the Family Practice Clinic and the new Estes Street Community Clinic. Clinical services offered include laboratory work, mammography, medical imaging, radiation oncology and emergency services. In addition, Exempla provides advocacy for the medically underserved through their work with health departments, the Colorado Coalition for the Medically Underserved, the Colorado Children’s Campaign and other organizations committed to improving the lives of people in the community.

Between 1995 and 2002 three Enterprise Zone care sites were operated by the Lutheran Medical Center: 1) at the Jeffco Action Center; 2) at the Family Tree women’s shelter; and 3) at the Golden Resource Center (later Carin’ Clinic). The Enterprise Zone Care program provided two mid-level providers twice a week at JAC and a volunteer doctor once a week. To receive care, patients were required to be Jefferson County residents, lack health insurance, and have no primary care medical provider. ELMC contracted with the University of Colorado School of Nursing faculty to staff the program. By 2002, there was no longer Enterprise Zone funding and a decision was made to consolidate Enterprise Zone Care and help establish and create the Estes Street Community Clinic at JAC. A grant totaling $900,000 was awarded to JAC , Exempla Lutheran Medical Center, and MCPN to build the fourth medical clinic at 14^th and Estes with tobacco-settlement money contributing to the remodeling at the JAC building.

Saint Anthony Hospital provides indigent care to Jefferson County citizens although the hospital is not located in the County. Swedish Hospital provides such care as well.

Estes Street Community Clinic. The Jeffco Action Center (JAC) was founded in 1968 by concerned members of the community as a non-profit organization to provide an immediate response to basic human needs and to promote self-sufficiency. The new medical clinic helps to meet those needs.

The clinic accepts referrals from JAC for comprehensive health screening, diagnostic care and treatment. At the present time (December 2002) MCPN is the main provider of medical services. JAC funds the facility costs and provides case management services. Exempla Lutheran funds the full-time position of Clinical Nurse Manager and some other operational costs. The hospital also provides capital equipment and access to ancillary services such as laboratory and medical imaging. Remodeling and expansion of the JAC building was completed in October 2002. Tobacco settlement money was not available to assist with operating costs. Before construction completion, the clinic operated in temporary trailers in the parking lot.

Administrative oversight of the Estes Street clinic is shared by David Myers, executive director of MCPN, a designated clinical nurse manager from Exempla Lutheran, and Nancy Nicholas, executive director of JAC. Each director is responsible to his/her respective board of directors or departmental chairperson.  Medical liability insurance is carried by MCPN with JAC as co-respondent on a policy held through the Colorado Association of Non Profit Organizations (CANPO).

Presently, additional funds are being sought for the operation of the new medical clinic. The Jeffco Action Center sees 85 to 100 families per day, more during holidays such as Thanksgiving and Christmas. In 2001, 30,000 homeless, near homeless, and working poor were served at JAC. For the fiscal year 2001, 670 clients were seen for medical assistance. It is anticipated that those needing medical care will increase following increased insurance costs and cutbacks in funding for indigent care.

The Jeffco Action Center serves Jefferson County residents who are homeless or marginally housed and need medical care as well as other JAC human services to help stabilize their situation. Some clients do have Medicaid or support from the Colorado Indigent Care Program (CICP) but do not have a provider. While the clinic is structured for drop-in clients, it is also planning to offer appointments. As part of implementing client self-sufficiency, JAC helps those who are eligible for medical insurance learn how to apply for such insurance. Those clients who have some income but no insurance or provider will be seen on a sliding scale and eventually referred to MCPN’s Colfax clinic which is just around the corner from the Jeffco Action Center. Currently there is a waiting period to get into MCPN’s system .

 

                                                         FUNDING AND ACCESS

Jefferson County Department of Human Services

Medicaid eligibility for residents of Jefferson County is processed through the Jefferson County Department of Human Services. There is a wide variety of access points at which application for Medicaid can be initiated. These access points are outlined throughout this report.

Jed Ziegenhagen, Manager of the Data Section for the Colorado Department of Health Care Policy and Financing, reports that there were 22,597 individuals in Jefferson County eligible for Medicaid during November 2002. This does not include those needing prenatal care, Old Age Pension populations, and those retroactively eligible. It does include people dually eligible for both Medicare and Medicaid who receive their health care through Medicare but with Medicaid paying their Medicare premiums. 

 

Child Health Plan Plus (CHP+)

Child Health Plan Plus (CHP+) is a low-cost health insurance program for uninsured Colorado children age 18 and under who are members of financially qualified families. A family of four living on $18,100 would qualify at the low end. The high end is 185% of Federal Poverty Level [FPL]. Legislation passed at the federal and state levels created the State Children’s Health Insurance Program (SCHIP) in 1997. All states have a SCHIP program. Benefits provided vary from state to state. In Colorado the CHP+ program was created as our version of SCHIP.                                                                            

Two-thirds of the funding is provided by federal money and one-third comes from the state. For every dollar the state contributes, the federal government contributes $2 up to a capped amount. The state of Colorado will spend $57.9 million on CHP+ families in 2002, the first time the state has spent all the money it gets from the federal government. States have three years to use their allotment.  Unused money is returned to the federal government for distribution to states that exceed their allotment.

CHP+ has set three goals: to encourage preventive and early primary care by removing the financial barriers to health care; to improve the health status of Colorado children by improving access to appropriate medical care; and to reduce overall health care costs.

Eligibility requirements are as follows: age 18 and under; not eligible for Medicaid (higher income levels are allowed); living in a financially qualified family; must be a Colorado resident; permanent resident who has had an alien registration number for at least five years; and not covered by other creditable health insurance.

Services include: check-ups and shots; other doctor visits; hospitalization, lab and x-rays; prescribed medications; mental health services; glasses, vision exams; audiology services and hearing aids; dental services; prenatal care; home health care; therapies; durable medical equipment; emergency care and transportation; skilled nursing facilities; and transplant services.

It is estimated that there are about 70,000 kids eligible for CHP+ in the state. Currently, 43,118 are enrolled in the program. As of July 2002, Jefferson County had 2,873 CHP+ enrollees out of an estimated 7,031 eligibles, which indicates that only 41 percent of those eligible were in the program.

Applications are taken at CHP+ offices, local county human services/social services offices, Satellite Eligibility Determinations (SED) sites or Presumptive Eligibility (PE) sites across the state. These are in hospitals, community health centers, clinics, offices or other local organizations that have agreed to function as representatives of the CHP+ program.  A family may request and submit an application by mail as well.

SED and PE sites are able to determine Medicaid eligibility during the same interview. Applications are taken for the program for which the family is eligible and forwarded to that program. CHP+ applications may be submitted using the on-line eligibility system available at most of these sites. The date of eligibility for benefits is the date the application is received in the CHP+ office.

Enrollments are for 12 months. After 10 months, families will be sent a new application which must be completed and submitted to continue coverage. Some families move from Medicaid to CHP+ and back again, depending on the changes in their financial situations.

If an application is denied, the family is sent a letter that tells them the reason for the denial and outlines an appeal process. They have 30 days to file a written appeal.

Applications must contain income documentation from at least the previous  month. All family income and assets are considered in making the determination. Certain expenses will be deducted from the income determination such as child care expenses, payments being made for current medical or dental bills for family members, alimony, child support, insurance premiums for others in the family, and dependant elder care expenses.

Initially, patients are covered by the CHP+ Network but must select an HMO and/or a Primary Care Physician from a list of network providers within 30 days. The current list of HMOs includes Colorado Access (the largest with 18,000 CHP+ members), Denver Health Medical Plan, Community Health Plan of the Rockies and Rocky Mountain Health Plan (United Healthcare and Kaiser recently dropped out of the CHP+ network). HMOs are not available in all Colorado counties. Some counties may have the CHP+ Network only.

There are a limited number of physicians that accept CHP+. Certain areas on the western slope have no participating physicians. Lately, physicians have begun to drop out of the program across the state due to inadequate reimbursement. In August the state received more than 4,000 applications for CHP+. At the same time physician groups were dropping out of the program, leaving few doctors who will take CHP+ patients. Only 13 percent of 1,913 Denver-area doctors who could participate in CHP+ were accepting new patients as of September 30, 2002. “Physicians say they are losing money on every kid with a CHP+ membership who walks through the door.” (Denver Post, October 13, 2002). Doctors and hospital administrators say it is easier to get paid by Medicaid which allows electronic billing and is an older, much larger program. However, state CHP+ funds are federally matched at a 2 to 1 rate, while Medicaid funds are only matched dollar for dollar.

There is an annual enrollment fee for families whose income is at or above 151% of the Federal Poverty Level (FPL) of $25 for one child and $35 for two or more children. Families whose income is below 150% of the FPL do not have an annual fee. There is a per visit co-pay of $2 for families from 101% to 150% of FPL and a $5 co-pay for families from 151% to 185% of FPL. No co-pays are charged for preventive care, which includes well-child check-ups and immunizations.

Physicians are paid on a fee schedule a little higher than Medicaid but not as much as private insurance pays. CHP+ paid an average of $42 to physicians in a large pediatric group practice in Aurora that recently dropped out of the program. Their average costs per patient were $65, not including the physician’s salaries. Hospitals and other providers are paid according to negotiated contracts. The rates are similar to Medicaid payments.

 

Medicaid

The Federal Government has three programs dealing with funding of health care entitlements: Medicare, Medicaid and the State Children’s Health Insurance Program (SCHIP). They are administered through the Centers for Medicare and Medicaid Services (CMS) headquartered in Baltimore, Maryland, with eight regional offices. The Denver Regional Office covers a six-state region that includes Colorado. Medicare is a federally-financed health insurance program for the elderly and disabled.

Medicaid is a federally operated health insurance program for eligible persons of limited means. CMS oversees and generally provides the rules and most of the funding for Medicaid, but the specific administration of Medicaid is handled by each state. CMS writes and enforces Medicaid regulations on eligibility, coverage and reimbursement by expanding the broadly written provisions of Title XIX of the Social Security Act. Each state administers its Medicaid program under a state plan, an agreement each state has with CMS.

In Colorado, the Medicaid program is administered by the Colorado Department of Health Care Policy and Financing (CDHCPF), 1575 Sherman Street, Denver. This agency has a number of contracts with private companies for the performance of various Medicaid functions.

Health care under Medicaid includes care from physicians, hospitals, nursing homes, pharmacies, dentists (generally children only), durable medical equipment, clinical lab and x-ray, home health care, physical therapy, long term care (one of the most expensive programs), early periodic screening diagnosis and treatment (EPSDT) for children. All states are required to cover some services while others are optional.

The federal government provides 50 to 75 percent of the Medicaid program costs (the money paid to reimburse providers), the rate varying from state to state, determined by economic indicators. Colorado, as a more prosperous state, receives about 50 to 55 percent of its Medicaid program costs from the federal government. A state’s Medicaid administrative costs are reimbursed by the federal government at rates of 50, 75 or 90 percent, according to the particular function being reimbursed.

After education, Medicaid is Colorado’s costliest state funded program. Because of state budgetary cuts, Medicaid reimbursement rates to health care providers were cut June 2002 for the current state fiscal year (see Denver Post and Rocky Mountain News June 14-15, 2002).

Traditional Medicaid is a fee-for-service based system. Health care providers enroll in the program by signing an agreement with the state for reimbursement of claims. Medicaid clients receive health care from any of these providers. Each provider submits to the state’s Medicaid fiscal agent a separate claim for payment for each service rendered to each client. The fiscal agent (a private company with which the state has contracted for this purpose) processes the claims electronically and each week providers are sent a check.

States are able to request a waiver from the usual CMS rules for the operation of certain Medicaid programs. Colorado has waivers for the operation of programs for the developmentally disabled and for “Home and Community Based Services” (HCBS) which provides home health care for the frail and disabled. The state or its counties contract with providers or private agencies for the services needed under these waiver programs, providing case management services to clients and otherwise overseeing, directly or through contractors, the care of these people.

Colorado recently has moved as many of its Medicaid clients into managed care as possible, hoping for cost savings compared to the traditional fee-for-service system. New Medicaid clients are asked to select one of the managed care organizations (MCOs) with which the state has previously contracted that offers services in the client’s geographical area. The state pays each MCO a set fee each month for each Medicaid client enrolled. The MCO is obligated to provide all state required Medicaid services to its enrolled Medicaid clients. The MCO profits to the extent that its fees from the state exceed the cost of the services it provides to its clients.

The MCOs with which Colorado has contracted for Medicaid (and SCHIP) services are: Colorado Access, 76,500 Medicaid clients; Rocky Mountain HMO, 28,000; Community Health Plan of the Rockies, 18,300; United Healthcare, 11,500; and Kaiser Permanente, 2,300. United dropped out of the program October 31, 2002, because it was losing money. Kaiser and Rocky Mountain have also said they are losing money. (Denver Post, September 5, 2002)

Those eligible for Medicaid are adults with children, pregnant women, foster children, the elderly, blind and disabled, and those with income and assets below certain poverty levels. The former category includes, but is not limited to, everyone who would have been eligible for Aid to Families with Dependent Children (AFDC) were that program still in place. The latter category, generally speaking, are those people who would qualify for Supplemental Security Income (SSI) under the Social Security Act. The rules for Medicaid eligibility are very complex.

Colorado has one of the poorer records in the country for the timely processing of qualified applicants into Medicaid. Applications may take weeks, from the date of the first appearance of the applicant to the county eligibility technician, to be approved. The county must respond within forty-five days of initial application. CDHCPF staff see the delays as caused in part by a process in which all applications, even those qualifying based on SSI, must go through the county government offices. A related problem exists in the uneven application of complex eligibility rules from county to county, which can mean one county may qualify an applicant, but another county may erroneously disqualify an identical applicant. CDHCPF frustration is aggravated by the fact that, while they are responsible for the Medicaid program as a whole, they have very little control over the county-based Medicaid application and eligibility determination process.

The situation involving eligibility determination at the county level was made worse when the Aid to Families with Dependent Children (AFDC) program was replaced by Temporary Assistance for Needy Families (TANF). County eligibility technicians since TANF have generally given their primary attention to applying TANF, that is to getting clients off welfare and into jobs. Sometimes those clients who were dropped from welfare were also erroneously dropped from Medicaid.

Because of these problems and others, such as the antiquated and poorly functioning automated system maintained by Colorado Department of Human Services (CDHS) which processes eligibility determinations, CDHCPF staff have long sought a more centralized system.  Such a centralized process would give CDHCPF substantial control.  A new automated system is being  developed jointly by CDHCPF and CDHS through contractors. The new system would  itself determine Medicaid eligibility using criteria input to the system by CDHCPF staff. The role in the field in Medicaid, eligibility determination would be reduced to little more than obtaining and inputting the applicants raw data. This system, called the Colorado Benefits Management System (CBMS), is to be implemented in stages beginning in late 2004.

Colorado Benefits Management System would enable CDHCPF to allow more sources to submit Medicaid eligibility data to the state’s automated system. Although clinics and other non-county sources today assist potential clients in completing application forms, they do not themselves submit the data into the state’s system. CDHCPF staff want, when CBMS is implemented, to allow private health providers, such as hospitals and clinics, to submit application data directly to CBMS. Counties are opposed to this effort. They see it as an attempt to reduce their control. They argue that private providers would have an ulterior motive to present an applicant’s data for inappropriate Medicaid eligibility. Changes to Colorado statutes are required to extend the authority to non-public employees. CDHCPF drafted the necessary statutory changes in late 2000, but has been unable to find a suitable sponsor in the legislature.  CMS has concerns about extending  the ability too far to submit eligibility data to CBMS.

 

                                                                   INITIATIVES

Colorado Coalition for the Medically Underserved

Dr. Gary VanderArk of the Colorado Coalition for the Medically Underserved delivered a lecture at the annual meeting of the Jeffco Action Center which raised serious questions for the county and for the state regarding available medical treatment for low income families. Jefferson County ranks last in the state for the number of primary care doctors available to low income people. The state itself ranks 49^th among states in Medicaid budget with 700,000 people in Colorado having no health insurance at all.

Unemployment in Colorado exceeds that of many other states. Bankruptcy rates are rising. Health insurance rates have shown a 15 percent increase and the number of those uninsured is increasing. Local hospitals find themselves losing money with federal payments down and emergency rooms increasingly used for health care by the uninsured. Overcrowded emergency rooms are sometimes forced to go on “divert” status. Divert occurs when the capacity in the Emergency Department is exceeded; patients need to be routed to another facility for care. Capacity is the availability of qualified staff, beds and equipment to safely care for patients and is based on the acuity of the patients currently present in the units. Prior to going on divert, every effort is made by responsible parties to increase capacity. Overriding criteria for divert  includes cardiopulmonary arrests, imminent cardiopulmonary arrests and unmanageable airway problems, or trauma.

The Colorado Coalition sets four goals: 1) work to expand the governmental programs already in place; 2) expand the CHP+ program; 3) develop a prescription drug program; and, 4) develop a much needed health care plan for everyone.

Colorado Capacity Assessment Project (COCAP)

The COCAP project is a comprehensive look at the accessibility of physicians across Colorado. Colorado Access took the lead on the project and provided staffing and funding. The data are provided by region (18 total regions) with Jefferson County included in the Tri-County region (Jefferson, Gilpin, Clear Creek) .

The Tri-County population by insurance status is as follows:

76 percent        Insured

11 percent        Medicare

3 percent          Medicaid (12 percent statewide)

10 percent        Uninsured

In this region, there are 0.5 primary care physicians who accept Medicaid patients per 1,000 Medicaid eligible people. Further, only 0.01 primary care physicians offer a sliding fee scale per 1,000 uninsured people. This is the lowest rate in the state. Of the primary care physicians who see Medicaid patients, only five percent accept new Medicaid patients. Of the specialty physicians who see Medicaid patients only four percent accept new Medicaid patients. If there are no physicians who will accept new patients in the specialty required, no care is available. The percentages of physicians accepting new Medicaid patients is similarly low in every region of the state.

Medicaid aside, the Tri-County Region ranks 15^th out of 18 regions in the number of primary care physicians per 1,000 persons. Clearly access to health care is an increasing problem.

Healthy People

The U.S. Department of Health and Human Services has suggested health objectives, for the first decade of the new century, which can be used to develop programs for improved health. The goals include increasing quality and years of healthy life and eliminating health disparities. “Leading Health Indicators”, intended to serve as focal points for coordinating improvement, are: “1) physical activity; 2) overweight and obesity; 3) tobacco use; 4) substance abuse; 5) responsible sexual behavior; 6) mental health; 7) injury and violence; 8) environmental quality; 9) immunization; and, 10) access to health care” (Healthy People 2010).

Meanwhile, it is reported that the Colorado public health system is in crisis because of inadequate funding by the state (Rocky Mountain News, October 21, 2002) and because the poor are losing options as doctors leave the CHP+ plan (Rocky Mountain News, October 13, 2002).

“Just when demand for Medicaid is likely to increase because of a slowing economy, states are much less likely to be able to support this growth” said Alwyn Cassil, spokeswoman for the Center for Studying Health System Change, a nonpartisan think tank in Washington, D.C. (Denver Post, November 19, 2002). In Colorado, Karen Reinertson, Executive Director of the Colorado Department of Health Care Policy and Financing (the agency that administers Medicaid) says future budget cuts to be made by the end of June 2003 to an already bare-bones program will be difficult. She feels that her choices are to make it harder to qualify for the program,  to reduce payments to providers, or cut back on health-care services. Any cuts will cost Colorado millions of dollars in federal matching funds. Who will pay for these cuts? Many in the community predict it will be the hospitals through increased visits to emergency rooms. Dr. Ben Honigman wrote a provocative article (“Health care for the poor: Is anyone listening?” Rocky Mountain News, September 2000) about the overuse of emergency rooms in hospitals for primary care treatment. He asked, “Can we address [these] needs if we, as a society, are unwilling to acknowledge that there is a problem?”                                                                              

Referrals for indigent care from primary care clinics are becoming more and more difficult to make. The question of ethics has been raised by some doctors. Can disease screening be ethically implemented when, after finding positive cases, it is so difficult to find specialists or hospitals to deal with the problems. Is it ethical to tell a woman she has breast cancer if there is no place she can turn for treatment?

Headlines in the Denver Post on December 17 and 18, 2002, announced “Hospital [University of Colorado Hospital, Denver] treating fewer poor, Indigent cases fall 25%” and “Hospitals to lose state funds due to indigent-care changes.” University Hospital will lose $700,000 in addition to $4 million slashed from the hospital’s budget earlier in 2002. State rules call for Denver Health Medical Center (city hospital and clinics) to treat Denver’s indigent patients and for University Hospital to treat those from outside Denver. “These people [indigents] will go to the emergency room, maybe get some sort of care, [but] it takes them three months to get back in to see another doctor. They are in danger of dying,” said Dr. Barry Martin, medical director for the Metro Community Provider Network.

Even as funding from all levels for public health care services is being cut severely, the costs of providing health care are rising sharply, and the cost of health insurance for individuals, families, and businesses is escalating dramatically. In addition, we have a rapidly growing population of the elderly who live longer and need increased medical care, and we find ourselves facing the challenge of possible health care emergencies and bio-terrorism. Myriad private troubles become a major public issue.

                                                                  REFERENCES

Code of Federal Regulations, Volume 42, sections 430 through 456 (Medicaid) and

 Volume 42, section 457 (State Children’s Health Insurance Program ( i.e. SCHIP).

Denver Post, “Our Children’s Futures”,  August 25, 2002.                              

 “Doctors’ exodus hurts program for poor kids”, October 13, 2002.                                        

“The higher cost of health”, October 21, 2002.

“Budget cuts a blow to needy patients”,  November 19, 2002.

Giving Back, A Community Benefit Report of Exempla Health Care.

Healthy People 2010. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Washington D.C.

Jefferson County Department of Health and Environment, 2001 Annual Report.

KidsCount in Colorado 2002. Colorado Children’s Campaign, 225 East 16^th Avenue, Suite B300, Denver, CO 80203. 303-839-1580.

Johnson, Mark, MD, MPH., Director of Jefferson County Department of Health and Environment. Letter to Governor Owens, June 3, 2002; Memo to Jefferson County Commissioners and Board of Health, June 3, 2002; letter published in Rocky Mountain News, October 21, 2002, “Public health system in state in crisis”.

Lakewood Sentinel,     “Action center expands, improves”, LeRoy Standish, November 15, 2002.

Rocky Mountain News,  “Health care for poor: Is anyone listening?”, Dr. Ben Honigman, September 1, 2000.

Yondorf, Barbara, Healthy Colorado: First Thoughts on a Plan to Ensure Coverage for All Coloradans”, Colorado Coalition for the Medically Underserved, August 2001.

Interviews

Braden, Nancy, Communication Coordinator, Health Communications Office, Jefferson County Department of Health and Environment.

Cavanaugh, Sandy, Vice President for Community Development Health Care, Exempla Lutheran Medical Center.

Gray, Corinne, coordinator of the Jefferson County Child Health Plan+/Medicaid Outreach program in Jefferson County Public Schools.

Lubell, Elise, Smoking Cessation Program, Jefferson County Department of Health and Environment.  Meyers, David S., Executive Director, Metro Community Provider Network.

Nicholas, Nancy, Executive Director, Jeffco Action Center.

Salzmann, Carol, RN, Director, Community Development, Exempla Lutheran Medical Center.

Springer, Jeanne, Director of Administrative Services, Jefferson County Department of Health and Environment.

Websites

http://jeffcoweb.k12.co.us/isu/medicaid

www.cchn.org/health_centers/map/mcpn.asp (MCPN)

www.coaccess.com (Colorado Capacity Assessment Project)

http://health.co.jefferson.co.us

hhtp://web.health.gov/healthypeople                 

www.coloradokids.org                                    

http.//www.exempla.org/care/facilities/clinics/ezcare          

http://cms.hhs.gov/medicaid

http://cms.hhs.gov/schip