A False Scarcity of Doctors
The Dirty Secret of Denver Health
I did most of my medical school rotations at the city and county hospital of Denver, where I learned medicine from the accoladed doctors of its hospital, specialty clinics, and community family health centers. But I didn’t learn anything about the politics of medicine until I opened my own office as a family doctor in Denver.
As background: I have a private practice where I see mostly Medicaid patients, by choice. They are almost entirely refugees, and I get no funding or grants to do this work, other than Medicaid reimbursement available to any doctor.
We all know that this country has a shortage of doctors, specifically a shortage of primary doctors, and more specifically a shortage of primary care doctors accepting Medicaid. Medicaid is the country’s health insurance program for the poor, and many doctors don’t see Medicaid patients because Medicaid doesn’t pay as much as private insurance, and Medicaid patients are often more complicated. Obamacare allowed more people to qualify for Medicaid, so in the last few months, the number of Medicaid patients has increased by 33,132 patients in Denver alone. Policymakers are scrambling to find a solution to the shortage of Medicaid providers, but in Denver, there is a catch.
It is called Denver Health Managed Care Medicaid. The Managed Care concept peaked 20 years ago, a failed attempt at reducing healthcare spending. The idea was to force patients to go to only one doctor or hospital system in order to save money; this rationing resulted in long lines, as predicted by simple economics. In Colorado the Managed Care effort included Medicaid, and in Denver this was Denver Health Medicaid.
This is where I would like to say that Colorado has realized rationing healthcare doesn’t work, and that the Denver Health Medicaid program closed a long time ago. But it hasn’t. I don’t know the exact history or logic behind the Denver Health Medicaid system, but I am very familiar with how it works today.
First of all: there are actually three kinds of Medicaid in Denver today. If a Medicaid patient has Regular Medicaid they can go to any provider (doctor, dentist, etc.) that takes Medicaid. If they have ACC Medicaid, they are part of the Accountable Care Collaborative, the current set of initiatives aimed at reforming Medicaid. In the ACC they are usually assigned to a primary doctor, but they can still go to any provider that takes Medicaid. And if they have Denver Health Managed Care Medicaid, they can only go to a Denver Health provider.
When someone in Colorado outside of Denver gets Medicaid, they are given Regular Medicaid, or sometimes are automatically assigned to the ACC. Either way they can go to any doctor that takes Medicaid. Compare this to when a Denverite gets Medicaid: they are “passively enrolled” into Denver Health Medicaid. This means that they can only go to Denver Health providers.
The outcome is the same that has been described with any managed care rationing effort: the lines at Denver Health are long. Not a day goes by without a few of my patients complaining that it takes months to get a primary care appointment at Denver Health, and you usually need a Denver Health primary care referral to get to a specialty clinic there.
So why would any Medicaid patient become part of Denver Health Medicaid? They wouldn’t if they understood it, and had a say in it. As far as I can tell, there is absolutely no benefit to being in Denver Health Medicaid other than maybe free glasses. The rest of your benefits are the exact same outside of Denver Health Medicaid, except that you can access them much easier.
The problem lies in the “passive enrollment” system, where a client is snail mailed a letter (written in English or maybe Spanish) stating that they are being put in Denver Health Medicaid, and if they want out, they have three months to dis-enroll. Otherwise they are stuck, and can only get out by asking during the two months before their birthday, and it will take effect on the first of the month after their birthday. To get out, they must call a number where the wait to talk to an agent is often very long, and the call often drops, especially if they try to find an interpreter. I know this because I often help patients make this call. This is not the free choice system that is intended.
Let’s count the problems with this: 1. Most Medicaid patients are transient, so don’t have a mailbox to receive a letter, nor a phone to call with. 2. If they have a phone, they don’t have the minutes to wait on hold. 3. Mail in low income housing is often lost (see picture below). 4. Most of my patients don’t read English, and many are illiterate in any language. 5. Even my white, American born, English speaking patients can not understand this warped game of “3 months at first or 2 months before birthday”. 6. Most of my patients live on East Colfax, a few minutes to the specialty care of University, rather than hours on multiple busses to the Denver Health campus.
Here is one such letter. If you received it, would you have any clue as to its significance?
Would you know that this makes the difference between you having health care and not having health care?
Here are the mailboxes where my patients live at Colfax and Yosemite.
For all of those reasons, these patients have no idea what hit them, why they are now stuck in Denver Health Medicaid, and even what it means. Again, even my educated American ones have no idea. They just know they are sick today, or their kid will get kicked out of school if they don’t get shots today.
I used to try to explain to them that they can only go to a Denver Health facility, like the nearby Lowry Clinic. But they are always quick to respond that they do not want to go to a Denver Health facility, that it is too hard to make an appointment, and they can not get in anytime soon even if they did want to go. Other than that, they look at me like “you are a doctor, why don’t you help me now?” So I do. My first job is to treat the patient. I see them for free. About 5 percent of my patient visits are Denver Health Medicaid patients, and my office isn’t even in Denver anymore.
That is: Denver Health cuts costs by having me see their patients for free. A Children’s Hospital representative told me that if I think not getting paid for one office visit ($50) is bad, consider that Children’s Hospital (also not even in Denver) doesn’t get paid for lengthy hospital admissions, which can cost Children’s (and save Denver Health) hundreds of thousands of dollars. This is a major cost shifting, leaving Denver Health looking like a money saver, while the costs are really borne by all of us neighbors (neighbors meaning not only Denver, but all counties surrounding Denver). I have been able to demonstrate that about 95% of such costs are “eaten” by neighboring providers.
It is easy to see someone for free if all they have is a cold, or are a kid needing shots—VFC pays for shots for uninsured kids, which these DH Medicaid patients basically are. But a Denver Health Medicaid patient in my office can’t get any meds: prescriptions are only covered by Medicaid if filled at a Denver Health pharmacy, and those pharmacies only take prescriptions from Denver Health providers. They can’t get labs, unless I pay from my own pocket, which I did for a Burmese child who needed stool tests last week. They can’t get any specialty care outside of Denver Health because the specialist won’t get paid (in rare cases, such as Dermatology or Urology, I can bypass the rule of referral from a Denver Health primary care doctor). And they can’t get dental or vision care unless they go to a Denver Health contracted facility.
The kicker is that when the patient first gets Medicaid (e.g. arrives as a new refugee), they are put in Regular Medicaid, so they form a relationship with a primary doctor like me, who already sees their whole extended family. The passive enrollment doesn’t happen until a month or two later, and suddenly the patient-physician relationship is broken. By then, the patient is obviously going to see me (which I do for free), rather than stand in line at Denver Health. I don’t think even Denver Health realizes the genius of this delay, in terms of shifting the costs to us other providers.
Also, many refugees have no address on arrival, so they use their refugee agency’s address (on Leetsdale or Downing, both unfortunately in Denver) on their Medicaid application, but then they are screwed even if their first home is outside of Denver. If you are going to apply for Medicaid, please use a non-Denver address!
Passive enrollment also happens when someone is born with a Denver address: we give them their two-month-old vaccines, then predictably, when they come in sick at three months of age, they are in DH Medicaid. So I see the sick baby for free, and hope to get them out of jail by their four month shots. Or, when someone loses Medicaid, reapplies, and is reinstated, even if a minute later, the computers make them fresh meat for the Denver Health passive enrollment machine. Or, if they move from Arapahoe or Adams County to Denver County, they become eligible for passive enrollment, and are scooped up. This is unfortunate for refugees, because most of them live near Yosemite and Colfax—the intersection of these three counties—and they often move back and forth across the lines.
The goals of a medical home come naturally when your patient base is built entirely on customer service and word of mouth, as in a private business like mine. The opposite happens if your customer base is just handed to you; instead of focusing on customer satisfaction, you focus on meeting criteria for various awards, certifications, and grants.
The horror stories from this are numerous and varied. One Oromo refugee last week paid $833 for his 5 year old boy to get his teeth fixed at his usual dental home, because the kid was put in DH Medicaid, so his usual dentist wouldn’t get paid from Medicaid. The rest of the family is not in DH Medicaid, and we continue to see the kid for free. Another patient, a Nepali boy with club foot, needed a child physical therapist, which Denver Health certainly didn’t seem to have, so the DH staff conceded to letting him out of DH Medicaid. Ditto for a teen from Congo who needed a sleep study—DH doesn’t seem to do those for kids, and he can’t go to Children’s Hospital until his Medicaid is changed. A Somali youth with cancer, was suddenly put in DH Medicaid, interrupting her treatments at Children’s Hospital. An older Ethiopian woman had great control of her diabetes until passively enrolled, then her numbers spiraled upwards because she couldn’t get an appointment, and couldn’t afford her insulin when I prescribed it. I have seen numerous patients where pathology advances, increasing morbidity and mortality, while patients wait for Denver Health appointments. In the meantime, non-DH providers would see them tomorrow if they could.
A young Burmese (ethnicities changed for privacy) refugee was diagnosed with cancer on arrival in the U.S., and I sent her to Jewish and PSL hospital for care. She was put in DH Medicaid a couple months later, for a few months, and then somehow got out. She didn’t realize this until many months more, when her husband started geting thousands of dollars in bills from those non Denver Health providers.
What is the purpose of having Medicaid if you can’t use it? What was the purpose of Medicaid expansion under Obamacare?
I’m not even talking about a shortage of doctors accepting Medicaid. I am suggesting that there are doctors who could see these patients, but are not allowed to!
In Denver Health’s defense: they tell me that if the patient has an emergency and can’t wait for a DH appointment, they will pay for a taxi ($50?) to take the patient from my office to the DH ER ($1,000 visit?) today, rather than paying me ($50) to just see the patient. Also, recently they started letting me use a fax form to dis-enroll folks, which means I don’t have to wait on hold. Finally, they recently started paying me to see patients who are in their first three months in Managed Care, but the process to get paid is onerous, almost not worth our staff time.
This is not a trivial issue, but it is a grossly unrecognized one in Denver. Well, I recognize it, as do most other doctors and hospital in Denver, who are not part of Denver Health. It is also recognized by CCHAP, any hospital billing staff, and even most staff at the Department of Healthcare Policy and Financing (HCPF, which runs Medicaid). I had one meeting (in early 2013) with some of the heads at HCPF, where I learned that HCPF leadership want this system to end, but don’t have the political clout to take on the Denver Health machine so readily. I was later invited to another meeting, where HCPF brought in a consulting group to examine this problem.
That meeting was 12/5/13. There were about six non-Denver Health folks from various organizations, reciting the problems I identified above, and about six Denver Health folks, running defense for a system that should have disappeared decades ago.
A leadership representative from Denver Health (Dr. Melinkovich) was there; he said that Denver Health exists mainly to serve the Denver Health Managed Care members, and has no mandate to serve Regular Medicaid members. He also stated that they are a private entity that does not need to respond to public interests like the ones being brought up at that meeting. I had to remind him that Denver Health gets tremendous public funding, apart from Medicaid reimbursements, so should be responsive to the public. (In case my notes here are incorrect, the other attendees can attest to the exchanges, as can the consulting group HSAG that coordinated the meeting.) This from a hospital that prides itself on delivering care at low cost. It isn’t enough that Denver Health already gets paid more than me for seeing the same patients, but Denver Health has an outright monopoly on indigent care in Denver.
That consulting group’s report (April 2014) from the meeting stated “The lack of capacity in the DHHA primary care clinics has resulted in a closed system of care that is not capable of accommodating all populations as the “safety-net” provider for the region”
Our city has a scarcity of doctors in underserved medicine, by design!
In summary: Denver Health does great work, but can not handle the needs of Denver’s large and growing Medicaid population by itself. There are other providers who could see the patients today, but we can’t because of the outdated, politically entrenched systems of Denver Health Managed Care and especially passive enrollment. It is time to reopen the Denver indigent care marketplace and allow the people to get the care mandated by the Affordable Care Act. This is a bipartisan issue, as it involves constraining free markets and hindering entitlements. Totally free market capitalism may not be the answer, but neither is Managed Care, and the current reform efforts of the ACC are meaningless compared to the barriers created by Denver Health passive enrollment.
first published 5/20/14.
I may have a running stream of some of the worse horror stories below. I am often asked what are the biggest barriers to indigent care (in Denver, with refugees, or generally): Denver Health is pretty high on the list.
6/4/14: saw an elderly Nepali woman in office today, she moved from Texas to Denver April 2014, applied for Medicaid, started Regular Medicaid May 2014 and saw me twice; I filled out papers so she got into Adult Daycare services, and got a wheelchair from Medicaid. Unfortunately on 6/1/14 she went to the University ER, and was admitted with acute renal failure, caused by inability to pass urine, caused by a longstanding uterine prolapse pushing on urethra. Admitted 2 days. While there, they incidentally found a liver mass, highly suspicious for cancer. Discharged on 6/3/14 to follow up with PCP (me), and I saw her on 6/4/14: Guess what? As of 6/1/14, she is in Denver Health Medicaid. That means University doesn’t get paid for the 2 day stay, and I don’t get paid for visits…. and worse, the patient can’t get her meds (insulin is expensive!), and can’t get further workup for that liver mass. So she has to cash pay her insulin for a month ($100 or so, luckily son has a job), and I put a tickler on our calender to do a CT of the liver on July 1 (actually July 3 by the time the prior auth goes through). (we now signed the paper to get her out of DH MCD effective July 1). She could get these things free if she could get them done at Denver Health, but she must first have a PCP appt there, and first PCP appt is months away. So here we have cancer brewing in the liver, while she waits for Denver Health. Oh she also can’t go to her daycare in the meantime. Her son asks me in broken English “Why they make this so hard on the old people?”
Updates:
6/7/14: a Burmese family moves from Indiana to Denver. We see one little boy (KS) on 2/21/14, they had just applied for Medicaid, and we were able to backbill this date. Then on 3/4/14 we saw him, he was in Regular Medicaid (not in the ACC, not in Denver Health MCD). Then on 5/5 we saw him, and he had ben in Denver Health Medicaid since 5/1. We got the signature and got him out. Then today on 6/7/14 we saw him, he was back in Regular Medicaid. Observe: the Denver Health passive enrollment happened at least 9 weeks after he got Medicaid, and in that time he saw us twice (because the whole extended family already sees us).
Ok I realized it would take tremendous time to keep posting additional horror stories, so I won’t.
See the petition related to this topic. Scroll to the bottom to read hundreds of comments from all type of local healthcare providers and patients.
See the related Westword article on this topic.
Myself and a few other doctors had a meeting with HCPF leadership and state Senator Aguilar in July, 2014, then again in September. HCPF states that it will take 2 years to change the computer system that is causing passive enrollment. Myself and those other doctors are very skeptical of this statement, mostly because those other doctors have been trying to address this issue for years, and have been getting various similar (or different) excuses from HCPF and Denver Health for years. There is very little trust and I too am increasingly believing that indeed this will not change anytime soon.
