Final look at 2012: Health care industry in flux

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Health care is poised to change dramatically in years to come, but in 2012 those changes got under way — preparing for the 2014 full implementation of the Patient Protection and Affordable Care Act.

From consolidations of health groups to partnerships with former competitors, hospitals sought to create economies of scale in the face of widespread uncertainty and changes in the industry.

Penrose-St. Francis extended its partnerships into the San Luis Valley and deep across the Kansas border, taking advantage of its affiliation with Centura Health and Catholic Health Initiatives to expand its reach and its patient base.

Memorial Health System became part of University of Colorado Health, thanks to a 40-year lease agreement approved by voters this summer. UCH includes the University of Colorado and Poudre Valley Health Services. Both have national reputations for excellence, and the partnership allows local patients better access to clinical trials and research.

The collaboration is all part of preparing for the PPACA — which includes a new way insurance companies and government plans like Medicare will reimburse physicians and doctors. Instead of paying for every visit, payments will be bundled — and spread between general practice doctors, specialists and hospitals. Bonuses will be given for quality care, but if patients return to hospitals too soon, hospitals will pay the price.

Affordable Care Act

Commonly known as ObamaCare, the comprehensive health insurance reform package that includes state health insurance exchanges and mandatory insurance coverage, overcame a Supreme Court challenge. Last spring, the court ruled in favor of the mandatory, universal coverage clause in the PPACA, paving the way to implement the law in 2014.

However, the Supreme Court did remove one part of the law: States can choose whether or not to expand Medicaid coverage to people who earn 133 percent of the federal poverty level. Colorado has not yet signaled whether it will expand Medicaid coverage, although the General Assembly has expanded the program in past years through fees from hospitals. For every dollar raised by the state, the federal government matches it with $2, and bears much of the costs of the suggested expansion.

But the Affordable Care Act also was dealt a blow early in 2012 when the Department of Health and Human Services decided that the long-term care portion could not be funded sustainably. Originally, the plan was to have everyone over the age of 18 voluntarily pay into a long-term care insurance policy for five years before it can be used. But that money isn’t enough, said HHS secretary Kathleen Sebelius.

She cited difficulty in sorting out legal issues, solvency problems and rising health care costs as the reason she was unable to certify the program.

Health exchanges

Insurance companies are also scrambling to prepare for the new federal regulations. This year, the Colorado Health Benefits Exchange moved closer to its goal of opening for business in October 2013.

Analysts say Colorado is breaking ground with its exchange, moving far ahead of other states. The big news for 2012 was creation of the minimum health benefits plan — a list of required benefits every plan must have to operate in the exchanges.

It includes specifics such as coverage for mental health, preventive services, pediatric dental care and rehabilitative services.

It’s a big step, but negotiations about pricing, premium shares and out-of-pocket costs are still to come.

And earlier this month, Colorado’s exchange met another large benchmark: federal approval of its framework and conditional approval to open next October. It is one of only six states to reach that goal.

The exchange reached an additional goal near the end of 2012.

Its board of directors approved its financial framework, which now needs approval from the Colorado Legislature. That framework includes payments for enrollment, website advertising, grants, product offerings and transitional funding from Cover Colorado, an insurance plan for low-income, high-risk state residents who cannot get insurance elsewhere.

Mental health

Locally, a group of concerned mental-health professionals and community leaders began tackling a major regional problem: high suicide rates and lack of access to appropriate mental-health care.

A task force of about 100 professionals will examine educating more doctors about behavioral health issues, helping people navigate the complex system of care, and aiding people without insurance.

“We’re not going to be whining anymore; we’re not going to be pointing fingers anymore; we’re going to find solutions to these problems,” said Dr. Sara Qualls, professor of psychology and director of the gerontology center at the University of Colorado Colorado Springs. “And that means having a business plan attached. We’re going to come up with solutions, and we’re going to come up with how to pay for them.”

The community organized the task forces for one reason: the astonishing lack of mental-health access in Colorado Springs. Ideally, El Paso County would have 64 licensed psychiatrists. There are only 14.

“It’s the elephant in the room,” said Dr. Julie Sanford, chief medical officer at Peak View Behavioral Health, a recently opened psychiatric hospital seeking to stem the gap between providers, beds and the people who need their services.

The access problem leads to grim statistics. According to local mental-health experts, Colorado Springs has the nation’s second-highest suicide rate, only behind Las Vegas. The military isn’t the cause for the high suicide rate, she said. Those statistics are separate from the city’s numbers.

“We live at a high altitude, and there’s some correlation there,” Sanford said. “But we also have a lack of providers, a lack of beds and a lack of coordination of care. Colorado is a very poorly funded state for mental health.”