By Cara DeGette

Rebecca Yanes recently joined an elite club. It’s not a club she wanted to join. In fact, it’s one that some health professionals across Colorado and the country are working to shut down.

Yanes, 54, exemplifies the 1 percent of the U.S. population that is spending 30 percent of the money that feeds the country’s healthcare system.

The Colorado woman’s nightmare began last Christmas, when she cut her foot. It didn’t appear to be a serious injury, she said. But Yanes, who is diabetic, went to the hospital emergency room. A doctor treated it and sent her home. On New Year’s Eve, Yanes noticed pus around the wound. Another emergency room doctor treated it, and sent her home. The wound didn’t heal. Over the course of the next several weeks the infection spread, resulting in repeated emergency room visits.

“A day before Valentine’s Day, they took my toes,” Yanes said. The operating doctor casually notified her, as they were prepping her for the surgery, that he would be amputating, she said.

“He said, ‘you know we’re going to have to remove some of your toes, right?’ ” Yanes said.

Rebecca Yanes’s medical nightmare began just before Christmas. Help from a team of healthcare hot-spotters ultimately helped the Colorado woman recover from a traumatic surgery. Photo by Cara DeGette/Colorado Public News

With the help of a team of medical professionals, including a psychotherapist, Yanes says she was ultimately able to mentally reconcile the loss of her toes. She is physically healing as well.

“Hot-spotting is really looking at data and targeting a geographic area,” said Eliana Mastrangelo of Together Colorado, a community-organizing group. “Also, targeting the folks who are the highest utilizers. Who are those high cost, high needs patients … who need the most help?”

The term was originally coined to describe the work done by Dr. Jeffrey Brenner, a general practice physician in Camden, N.J. Using data and working in teams, medical professionals identify the sickest patients who are costing the most money, and work with them to reduce unnecessary emergency room visits and hospital stays. Brenner’s model is now being replicated in many parts of the country, including in Aurora and other parts of Colorado.

“The sickest one percent of us are responsible for 30 percent of the costs,” Brenner said during a recent trip to the state. “And by and large, we ignore those patients. We ignore them and move them around our healthcare system in incredibly inefficient ways.

“We’re going to have to think about how we’re using our money, because good care does not look like what we have now.”

In 1960, healthcare expenditures in the United States accounted for five percent of the gross national product. That figure has ballooned to 18 percent – far more than any other major industrialized country.

According to the U.S. Department of Health and Human Services, in 2004 the United States spent $1.9 trillion on healthcare. That averaged out to about $6,280 a year for each man, woman, and child. By last year the cost has risen to $8,233 per person every year.

A study completed by the federal Agency for Healthcare Research has determined that, “actual spending is distributed unevenly across individuals, different segments of the population, specific diseases, and payers.” Among the findings:

• Half of the population spends little or nothing on health care, while 5 percent of the population accounts for almost half of total health care expenses.
• The 15 most expensive health conditions account for 44 percent of total health care expenses.
• Patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition.

In the year since Dr. Mark Wallace began hot-spotting in northern Colorado, he said thousands of patients have been contacted via phone and personal contact.

Wallace, chief medical officer of the North Colorado Health Alliance, said he recently hired a business analyst to help determine a dollar amount that has been saved from the work his group has been doing. But he described one scenario to underscore a real example of cost savings – and an improvement in the quality of life for one patient.

The patient, he said, was a woman whose weekly emergency room visits grew to 30. In addition, she had been hospitalized several times. Estimating just the ER visits at $1,500 each, the cost was $45,000, Wallace said.  When Wallace’s organization launched their hot-spotting program, the woman landed at the top of the list.

“We were able to take her from using the ER over 30 times to not having an ER visit,” he said. “And over eight months and we were able to reduce her hospitalization to zero.”

Wallace recently expanded from Weld and Larimer counties into rural Yuma and Washington counties. He said medical professionals from across Colorado have contacted him for pointers to help them replicate efforts in other parts of the state.

“We’re sharing information with anyone who comes to visit,” he said.

By Ann Imse

Beginning July 1, Colorado patients will start saving hundreds and even thousands of dollars on medical equipment because, after a 10-year delay, Medicare is switching to competitive bidding in the Denver and Colorado Springs metro areas.

Many insurance companies set their prices for medical equipment based on the prices paid by Medicare, the government health plan for people 65 and older. So observers say lower Medicare prices could push down costs for private patients as well in the coming year.

Medicare has been wildly overpaying for home medical equipment for years, according to repeated reports from news media, the inspector general overseeing Medicare, and the congressional General Accounting Office.

For example, a 2004 federal report found that a power wheelchair cost Medicare a median price of $5,297. By comparison, the same wheelchair cost consumers $3,863 and wholesalers $1,550.

Under the new bid system starting July 1 in Denver and Colorado Springs, Medicare will pay $1,849 for new or $1,387 for used power wheelchairs. Patients pay 20 percent of that and Medicare pays 80 percent.

Kyrzia Parker, a student at the University of Denver, said help from the government to pay for her power wheelchair is essential. Born missing fundamental joints in her arms and legs, Parker said, “I wouldn’t be able to do anything without it.” She said lower costs for expensive parts and eventually a replacement will help her enormously, because “I live on soup and sandwiches.”

Medicare patients in the rest of Colorado, including Boulder, will continue to pay the higher prices until Congress orders the bidding program expanded, said Medicare spokesman Mike Fierberg.

The change – at least along the Front Range – comes 10 full years after Congress first ordered it. But it was Congress itself that set the original prices. Then it was Congress that ordered bidding delayed, after complaints from equipment suppliers.

Suppliers are fighting back, because many of them did not make the cut and say they will be out of the Medicare business. One of them is Doug Coleman, CEO of Major Medical Supply with outlets in Greeley, Longmont, Fort Collins, Brighton, Leadville, Colorado Springs and Denver.

Coleman, who is also head of the state association of medical equipment providers, said very few Colorado companies won bids, and smaller ones may go out of business. Using his own company as an example, Coleman said he bid about 30 percent below current prices, but others came in 45 percent lower. He said his higher prices were justified because most of his costs are servicing the equipment and Medicare’s complex billing, not the equipment itself.

Patients will suffer, he said. “Will Walmart deliver a walker to a hospital?” he asked. (The chain discount retailer is listed on www.Medicare.gov as a supplier of walkers in the program.)

Medicare spokesman Fierberg defends the bidding program, which has been operating in nine trial markets for a year. Over the next decade, savings are expected to reach $25 billion for taxpayers and $17 billion for patients.

“Legislation to end the competitive bid system is backed by the very same entities who are currently being vastly overpaid,” Fierberg said.

In fact, medical equipment is the one area where Medicare now pays more than private insurance companies do. Anthem Blue Cross Blue Shield vice president Janet Pogar said her company pays 70 percent of the Medicare price, and she “absolutely” expects the new Medicare fees to drive down prices across the industry as contracts renew. In contrast, Medicare pays doctors so much less than private insurance that many doctors won’t take a new Medicare patient in Colorado.

Fierberg also noted that the bid program slams the door on what has been a common scam: Fake providers billing Medicare for service and equipment for patients who don’t actually exist. Now, only winning bidders with contracts will be paid.

Nationally, the American Association for Homecare is pushing Congress to delay and change the bidding program. As part of its argument in support, the association cited a woman whose provider is switching her off her preferred type of portable oxygen. Medicare’s Fierberg said providers may not change a doctor’s prescription.

As with wheelchairs, people who use oxygen concentrators to help them breathe also have been paying far more than market prices. In 2004 the inspector general found that Medicare suppliers could receive $7,215 for 36 months of renting a machine that cost an average of $587 to buy.

Beginning July 1, Medicare is cutting its rental payment in the Denver and Colorado Springs metro areas for oxygen concentrators nearly in half, from $177 to $92 a month.

That cost is still high for long-term users, as a used concentrator can be purchased for $450 including shipping from Oxygenplusmedical.com. But under orders from Congress, Medicare won’t pay for purchase except through a 36-month rent-to-own plan. So Medicare and patients still will pay $3,312 for a type of machine that can be purchased new for $707 online.

Medicare’s rental price includes servicing the equipment, but the inspector general found that most of that maintenance can be done by the patient.

Outside Denver and Colorado Springs, Medicare patients across Colorado still will be paying the higher prices until Congress orders the bid program extended. Here are a few resulting price differences for several commonly used pieces of medical equipment:

- $58 a month to rent a standard, non-power wheelchair. (Denver and Colorado Springs patients will pay $25 for the same equipment)

- $66 to purchase a walker. (Denver and Colorado Springs patients will pay $44 to $45 for the same equipment. NOTE: Walmart sells walkers to the public for $32)

- $6,372 to purchase an oxygen concentrator. (Denver and Colorado Springs patients will pay $3,312 for the same equipment. NOTE: Oxygen concentrators can be purchased online for $707 new.)

Rabah Kamal and Terrence Gibson contrbuted to this story.

By Carol McKinley

Evidence suggests that people who sit for hours at a time have an increased potential of developing life-shortening diseases.

In an era when students and professionals are increasingly hunkering over their computer monitors for hours at a stretch, health professionals and some Colorado employers are embracing a new concept: Just stand up. And let the workspace stand up too.

“I think every kid at school should have a desk that allows them to stand up rather than sit,” said James O. Hill, Executive Director of the Anschutz Health and Wellness Center in Aurora. “I know [stand-up desks] cost money, but in the scheme of things, the benefit you’re going to get in preventing disease would be well worth the cost.”

Hill said employers are increasingly taking responsibility for getting workers out of their seats. “Awareness is higher than it’s ever been,” he said.

A recent study published in Archives of Internal Medicine by public health researchers in Australia found that prolonged sitting in front of a computer monitor – 11 hours or more – significantly increases the risk of dying earlier.

Another study published by the American Journal of Epidemiology determined that people who spend six hours sitting are 20 percent more likely to develop chronic diseases, including diabetes, cardiovascular disease and breast and colon cancer, than those who sit for half of that time. In another study, conducted over a 13-year period at Louisiana’s Pennington Biomedical Research Center, scientists found that 54 percent of the people who sat all day long were more prone to fatal heart attacks.

Further research detailed in the October 2010 British Journal of Sports Medicine suggests that prolonged sitting results in adverse metabolic and health effects, “even if people meet the current recommendation of 30 minutes of physical activity on most days each week.”

Increasingly, employees and their employers are adjusting their work habits, including routinely getting up and moving around – and installing desks that allow them to stand up for at least a good part of the day. In Colorado, many companies have joined the movement for movement.

This fall, for example, the Denver Metro Chamber of Commerce is replacing its stationary desks with moveable ones and getting rid of outdated straight-backed chairs to make way for rotating chairs with lumbar support.

On a recent outing to a merchant specializing in ergonomic workplace furniture, about a dozen Denver Chamber employees – most of them in their early 30’s – moved continuously around a conference desk in comfortable swivel chairs. In one corner, employee Laurie Troge walked a slow steady pace while working on her computer at a treadmill desk. Another desk moves up and down on a hydraulic pump at the touch of a button so that no matter how tall or short, anyone can stand and work.

“We know that it is going to be expensive but we really consider this an investment in our employees’ long term health,” said Kate Horle, the organization’s director of communications and marketing.

Other ergonomic-friendly furniture allows workers to use moveable computer pads that allow them to sit in different positions over their laptops. Employees said they are looking forward to the new equipment – and a new way of working.

“I spend 90 percent of my time sitting down … when I get home, I’m more exhausted than if I had a hard workout,” said accountant Ronnika Smith.

Hill, of the Anschutz Health and Wellness center, says he has recently consulted with several other Colorado companies about improving employee productivity through exercise. “More and more, management is adopting a new attitude that ‘If you work here, you have to take care of yourself,’” he said.

Full Contact, a Denver-based digital contact management company last month invested $1,000 each for 32 new hydraulic desks for employees.

“Our old desks and card tables weren’t popular,” said CEO Bart Lorfung “I surveyed the company and asked everyone if they were really going to use [the new desks], and people were dying for them. I’m looking around the room and half of my employees are standing up. They sit and stand depending on how they feel and some people actually stand all day long.”

However, Hill said special equipment isn’t always required to improve better habits at work – or at home. The simple act of circling the office twice to get a cup of coffee or taking the stairs instead of the elevator can add months to a lifetime, he said. At home, simply walking the dog can help get the blood flowing.

“Research suggests that maybe there’s something we can do to mitigate the negative impacts of sitting,” he said. “Break it up every hour. Get up and take a five minute break to move around.”

By Rabah Kamal

Coloradans are four times more likely to die of suicide by gun than homicide by gun.

“There’s far greater likelihood that a gun in the home will be used to kill somebody in the home, despite the perception … that you need guns for protection,” said Dr. Carol Runyan, a public health professor at the University of Colorado.

According to the state health department, Colorado recorded 571 firearms-related deaths in 2011. Of those, 442 were from suicide. Another 105 were homicides. The remaining 11 were ruled as accidents.

“The vast majority of homicides are by people who know you. They’re not by strangers,” said Runyan. “And, horrific as the incidents were in Columbine, in the Aurora theater shooting, in Newtown, Connecticut – those are extremely rare.”

When public health professionals focus on gun violence, they look for strategies that will reduce the highest number of deaths. That’s why they are more concerned with suicide, accidents, and violence in the home than murder by strangers.

Researchers say gun deaths can be reduced by limiting access to guns by children or people who are suicidal, and by building safer firearms. It’s the same concept as improving safety in automobiles.

“It’s not about taking away things that people like to have,” Runyan explained. “It’s about making those products safer.”

Some skeptics say restricting gun access will not prevent suicide.  Dr. Marian Betz, a researcher and emergency doctor at the University of Colorado Hospital, says that’s not the case.

“A majority of people who attempt suicide, and don’t die, don’t go on to kill themselves in the future,” said Betz. “I think we really need to stop looking at suicide as this inevitable thing … We wouldn’t treat people with cancer that way and say, ‘Well, they’re just going to die.”

The National Shooting Sports Foundation (NSSF), a gun manufacturers’ trade association located in Newtown, Conn., advises on its website that every owner of a firearm should “take steps to prevent firearm accidents, theft and misuse.” The company further stresses that guns should never be kept loaded. That’s a suggestion rejected by some owners who say firearms used for protection should be ready to fire.

Another simple safety step is a $10 gun lock, currently sold with new firearms, and available free for older guns from some police departments. The locks are provided under a program called Project ChildSafe. The NSSF recently dedicated more money to the program, which also distributes information about keeping guns away out of hands of children.

In Colorado, the Lakewood Police Department has been distributing free locks through the program for almost nine years. “It’s a needed thing if it saves one kid, if it keeps somebody from committing suicide,” said Agent Mark Mansanares of the department’s crime prevention unit.

Researcher Runyan also advocates designing guns that will physically permit only the owner or other pre-approved user to fire them. Such firearms could offer the sense of protection many gun owners want, while also helping prevent avoidable deaths, she said.

However, Hollywood’s James Bond seems to be the only one with such a so-called “smart gun” right now. In the movie Skyfall, Bond’s “smart gun” scans for his unique grip before it can fire – and saves him when an enemy tries to use the gun against him.

Other gun designs being developed will fire only if a user is wearing a special ring or watch that activates the firearm through radio transmission or magnets.  One gun manufactured by Armatix in Germany requires a special watch and a PIN number.  The weapon deactivates if it’s picked up by someone not wearing the watch.

The federal government funded research into smart guns more than a decade ago, but such weapons are still not available in the United States, the manufacturers’ association said. NSSF Senior Vice President Lawrence Keane estimated the cost of such a firearm at upwards of $1,000 – far more than standard guns.

Keane said manufacturers support development of identification technology, but oppose any law requiring it.  Such legislation has been passed in New Jersey and is being debated in California.

Colorado Public News contacted 10 gun shops around the state seeking comment on whether customers want locks or biometric technology. All declined to weigh in.

Biomac Systems is a Los Angeles company working on smart gun technology, including developing firearms that can have multiple authorized users, said company communications director David Shugarts.

Shugarts said that while smart guns may not yet be 100 percent responsive, biometric technology can make Americans’ gun habits less dangerous. He cited a study in 2000 that found 43 percent of gun owners living with children kept an unlocked gun in the house. In another study, households with teens with major depression were advised to remove guns from the house. Still, 73 percent kept their guns.  

Shugarts, along with many Colorado public health experts, concur that achieving safer guns is a long-term process. Again using the safe automobile comparison, they note that seat belts and airbags spawned decades of debate before they were mandated.

Betz and Shugarts share the hope that gun owners and sellers don’t want people to kill themselves with guns, or have anyone accidentally killed by a gun.

“If you’re going to own a gun,” said Betz, “wouldn’t you want it to be a gun that your child can’t fire?”

By Ann Imse

High alcohol consumption is dragging down health in many Colorado counties, from Denver to the mountains, according to the annual County Health Rankings produced by the nation’s largest public health foundation.

In Colorado, Pitkin and Douglas counties ranked No. 1 and No. 2 on overall health, based on numerous factors, from residents’ own reporting of their health, to rates of smoking, obesity, and coverage by insurance and primary care doctors. A prime source of information is a national phone survey by the CDC that reaches 500,000 people a year. Details of this year’s Robert Wood Johnson Foundation report can be found at www.countyhealthrankings.org.

High alcohol use is the third leading lifestyle-related cause of death in the United States, causing 80,000 deaths a year, the report said. Excessive drinkers are more likely to drive drunk. Heavy alcohol use also increases the risk of heart attacks, injuries, violence, fetal alcohol syndrome and sexually transmitted diseases, the report said.

The highest incidence of excessive drinking came in Routt and Pitkin counties, home to the Steamboat Springs and Aspen ski resort communities. Some 31 percent of adults in Routt County and 30 percent in Pitkin said they drank at one of two levels defined as unhealthy by the Centers for Disease Control and Prevention. Heavy drinking is averaging more than one drink a day for women and two for men. Binge drinking is defined as four beverages in two hours for women – or five for men.

These levels were set by the CDC and the National Institute on Alcohol Abuse and Alcoholism, because they have “a deleterious impact on health,” said Amanda Jovaag, an epidemiologist with County Health Rankings and Roadmaps, which compiles the data.

Teaching people to consume alcohol only at healthy levels is tough, Jovaag said. That’s because “research shows a certain amount of drinking may have positive impacts on health, if it’s the right kind of drinking and done at the right rate. But levels above that can be very harmful to health,” she said.

Overall, about 18 percent of Coloradans said they exceed these standards, nearly triple what the authors said would be a healthier rate of 7 percent of adults.

The report didn’t factor in teen binge drinking – which is nearly as common, according to another recent study, the Colorado Health Report card. That study found the state average for adults to be significantly higher at 23 percent for binge drinking alone.

Excessive drinking tends to be higher both among Latinos and people with more money and education.

Pitkin County otherwise ranked No. 1 in the state for overall health, in part because residents said they felt poorly less often than other Coloradans. Pitkin also had fewer preventable stays in the hospital. In addition, only 8 percent of adults smoke, compared to 28 percent in Las Animas County in southeastern Colorado. And only 14 percent in Pitkin County are obese, compared to 27 percent in Kit Carson County on the Nebraska border.

Douglas County, south of Denver, ranked No. 2 in health with similar reasons.

La Plata County, home to Durango, came in at No. 6, with low numbers for teen births, children in poverty and preventable stays in the hospital.

Sparsely populated Yuma County in northeastern Colorado ranked No. 7, in part due to the very low 6 percent of adults who drink heavily and a small number of fast food restaurants. People there reported having few days when they felt ill, but the county ranked near the bottom for having insurance and enough primary care doctors.

Weld County, home to Greeley, ranked No. 21 with high obesity, poor reported health, a high number of preventable stays in the hospital, and a serious shortage of dentists and primary care physicians.

Mesa County on the Western Slope ranked No. 33 with poor reported health but low numbers of preventable stays in the hospital, good rates of screening for diabetes and more primary care physicians than typical in the state.

In the southern past of the state, El Paso County came in at No. 34 with high rates of premature death and babies being born at an unhealthy low weight. It has significantly fewer primary care physicians per resident as well.

Denver County ranked No. 40, with high rates of premature deaths, child poverty, heavy drinking and people without social or emotional support. But it has plenty of primary care physicians.