By Katie Kerwin McCrimmon

AURORA – Just beyond the gleaming new towers at the Anschutz Medical Campus, low-income patients with cancer and other complex medical problems often cannot find a specialist to care for them.

A group of primary care providers and patient advocates who work in Aurora now are begging leaders at the University of Colorado Hospital to increase access to specialists.

“What we really need is that door to open just a little bit,” said Bebe Kleinman, executive director of Doctors Care, a group that works to get health care for underserved people.

“You have some specialists who push the envelope and you have some who resist that,” Kleinman said.

“If a doctor normally takes one (low-income patient) could they take two? There are safety-net organizations in the community to depend on. If that person is difficult and comes with pain management and mental health (complications) put that back on us,” Kleinman said. “We’ve got to get that door open to the specialists.”

Deanna Tolman, an advanced practice nurse who operates an independent practice in Aurora, said for decades University Hospital served as the state’s safety net for people who couldn’t get care anywhere else. Now she says she can’t get her patients in the door.

“That’s our frustration. We’ve always been able to use University (as the hospital of last resort). With Medicaid expansion, now what do we do? They (Medicaid patients) need primary care. I can do that, but I can’t take people’s gall bladders out or manage their chemo,” Tolman said.

With University of Colorado Health’s expansion to both southern and northern Colorado, advocates for low-income patients worry that Colorado Springs and Fort Collins will also struggle with poor access to specialists.

Top University of Colorado Hospital officials met last week at Anschutz with more than a dozen primary care providers, patient advocates and Colorado Medicaid experts so both sides could share their challenges.

“We see serving the community in which we reside as critical to our mission. We also are a receiving hospital for the state and region,” said John Harney, president and CEO of the University of Colorado Hospital.

But, added Harney, “There are limits in terms of what one can provide.

“We do not get any state funds to subsidize any free care that is provided to underserved patients,” Harney said.

That contention drew the ire of Sen. Irene Aguilar, D-Denver, chair of the Senate Health and Human Services Committee, and a primary care provider who used to work at Denver Health and now sees patients at a clinic for underserved patients called Clinica Tepeyac.

Aguilar, who attended the meeting, said that University Hospital gets plenty of money from the state through the Colorado Indigent Care Program (CICP).

“Those are state funds,” Aguilar said.

“We don’t receive any general funds from the state,” Harney said, clarifying his earlier comments.

But Aguilar pointed out that University gets taxpayer funding for residents through the federal government and that Medicaid reimbursements cost Colorado plenty.

“Health care is the second largest driver of state funds (other than education) because of Medicaid. I feel like it’s not fair to say that you don’t get state funds,” Aguilar said. “It’s a huge part of our budget.”

University Hospital officials said that “total gross charges” for patients who didn’t pay added up to $371 million in the 2013 fiscal year. That figure includes costs for CICP, all additional indigent and charity care and write-offs for bad debt. Officials said that was an 11 percent increase over the previous year.

They did not, however, share their newest numbers for uncompensated care this year. A study by the Colorado Hospital Association earlier this year found that hospital costs for uncompensated care have dropped dramatically — by about 36 percent for urban hospitals — since the beginning of 2014. That’s when Colorado expanded Medicaid, adding tens of thousands of previously uninsured people to the state’s Medicaid rolls. Colorado now has more than 1 million people on Medicaid.

University of Colorado Hospital spokesman Dan Weaver said final figures for charity care won’t be available until later this month, but he said the hospital has been seeing similar trends to those reported statewide.

University Hospital officials did tell the primary care providers that they are the “second largest ‘safety-net’ provider” in the state.

Denver Health provides the most charity care in the state, according to annual rankings by the Denver Business Journal.

For the 2013 fiscal year, Denver Health’s uncompensated care was $452 million in costs (not gross charges). That figure includes both charity care and unpaid debts, according to spokeswoman Kelli Christensen.

Like other hospitals in states that expanded Medicaid to more low-income people, Denver Health has experienced a significant increase in Medicaid patients and a corresponding drop in uncompensated care.

In the first seven months of 2014, uncompensated care at Denver Health has amounted to $130 million, down significantly from $260 million in the first seven months of 2013.

Christensen noted that “all hospitals in Colorado work hard to provide care for the low-income and uninsured residents of Colorado.”

In 2013, HealthONE’s network of hospitals provided $125.5 million in uncompensated care. The HealthONE system owns multiple Denver-area hospitals — including the Medical Center of Aurora. Spokeswoman Stephanie Sullivan said the system does not release data on uncompensated care by individual hospital.

At University of Colorado Hospital, managers say financial pressures are hitting from all quarters. Dr. Tina Finlayson, associate dean of clinic affairs and associate medical director for University Physicians Inc., said health insurance carriers are aggressively negotiating to reduce reimbursements by 10 percent and government health insurance programs don’t cover patient costs. She said University Hospital is already taking a loss on patients with publicly funded insurance from Medicaid, Medicare and Tricare, programs that cover low-income people, seniors and military families respectively. Patients from those three government insurance programs comprise about 60 percent of patient load, Finlayson said. And she called that a tipping point.

Cost is the primary reason that University Hospital officials say they can’t care for more low-income patients.

“None of our practices don’t want to take Medicaid. Everyone takes it up to the level that they think they can survive. We do a ton of emergency care,” said Finlayson.

“We’re constantly trying to find more ways that we can take care of more people,” she said. “Demand is definitely greater than our resources, but we will always try to use our resources as best as we can.”

That policy still leaves many patients suffering without anywhere to turn for specialty care. (Click here to read Cardiologist works to change ‘unfair’ health care system.)

Sen. Aguilar said that when she sees patients who live outside Denver city limits and need specialty care, she sometimes can offer little help. If they’re desperate, she tells them to move to Denver, where they can access specialty care through Denver Health. Aguilar is on the board for Denver Health and said the system keeps costs low enough to survive with reimbursements from payers like Medicaid and Medicare. About half of Denver Health’s patients are insured through Medicaid and about 14 percent are uninsured.

Weaver, the University of Colorado Hospital spokesman, could not say exactly what percentage of patients are uninsured or covered through Medicaid at University. He did say that total hospital volume for Medicaid, indigent and uninsured patients is up 16.5 percent from the 2013 to the 2014 fiscal year.

While hospital finances keep managers busy balancing competing demands, they don’t mean much to desperate patients.

Deanna Tolman, the Aurora nurse practitioner, told of a patient in her 50s who had lost her home, had recurrent lymphoma and had not been able to afford a scan for six years.

“I called the oncology clinic (at University Hospital). I was told they were taking one CICP (indigent) patient per year. We’re trying to get appointments in clinics and we’re not able to,” Tolman said.

“In the last couple of years, the expenses are higher. You have all these beautiful buildings,” Tolman said. “If only I could get patients in to Advanced Dermatology or Denver-Vail (Orthopedics’) clinic. I’ve had physicians tell me they could only do one knee (for low-income patients) per month. Tell that to the patient who needs both knees.

“This is really about money,” Tolman said, acknowledging that Medicaid does not reimburse providers enough to cover their costs at CU and elsewhere in the system.

One of the most promising programs for saving money is an effort called Bridges to Care. (Click here to read Health detectives use house calls, ‘hotspotting’ to cut costs.  And click here to read ‘Hotspotting’ health revolution comes to Aurora.)

A pilot program affiliated with Dr. Jeffrey Brenner’s “hotspotting” program in New Jersey, Bridges to Care helps identify Aurora patients who need better primary and behavioral health care so they can stay out of costly hospitals. Bridges to Care sends health care workers to patients’ homes to check up on them and try to keep them healthy. The health workers keep in close touch with workers in hospital Emergency Departments.

“There is a lot of money to be saved if we can intervene with people with high needs,” said Dr. Barry Martin, a family physician with the Metro Community Provider Network, one of the Bridges to Care partners.

“We’re at the end of our second year and we’ve demonstrated some good success. We have lots of connections at University that had never been there before.”

Martin said the challenge now is to capture money saved “downstream” in lower billings to Medicaid and Medicare, and spend that money “upstream” instead on better preventive care.

Martin also said that more time and money should be available for patients who truly need specialty care if care coordinators and primary care workers can do a better job of caring for high-need patients who don’t need higher-level care.

“We’re taking the burden off so they can see the ones we want them to see,” he said.

“That’s the way these relationships can be very beneficial,” said Finlayson, the hospital’s associate medical director.

“It’s a model that has a lot of promise for the future,” Martin said.

University Hospital emergency physician, Dr. Roberta Capp, said community health workers are now stationed right in the Emergency Department. If Bridges to Care patients come in, workers can meet with them on the spot and ask, “Why are you here? Can I get you an appointment in the clinic?”

The group of primary care providers hopes to meet again with University officials and to get CEOs of several hospitals together to try to create more sensible systems for creating access to care for those who need it, while trying to give better alternatives to those who don’t.

“We all know that we underpay specialists,” Aguilar said after the meeting. “We just have a huge demand for state funds. Unfortunately, we also underpay for education. This is just another one of those areas.”

Aguilar said she’s pleased with all the pilot programs that focus on getting patients much better care for a lot less money.

Sharon Adams, executive director of ClinicNET, a group that supports safety net clinics, said it’s critical for providers to talk with hospital managers.

“Everybody’s going to be better served if we’re doing this collective acknowledgment and problem-solving,” Adams said.

Dawn Fetzko, a solo-practice nurse practitioner in Aurora who sees a higher percentage of Medicaid patients, organized last week’s session. She said she’s hopeful that the doors of University Hospital will begin to swing both ways. She said she often gets calls from the Emergency Department asking her to accept low-income patients. Then, when those patients need specialty care, Fetzko said she can’t get anyone to return her calls.

“I think they heard us,” Fetzko said of the meeting with hospital leaders. “They heard that we’re all a little bit frustrated, that there’s a little bit of a disconnect. They know there’s grumbling. But I’m hopeful.”

Jeff Thompson, director of government and corporate relations for University of Colorado Hospital, also expressed some optimism.

“We’ve just started some of this dialogue,” Thompson said. “We’re obviously dealing with a whole new world now. It’s creating a lot of challenges. These kind of dialogues are going to be important.”

Correction: An earlier version of this story said that Barb Hanson made comments to University Hospital officials on behalf of Doctors Care. That was incorrect. Bebe Kleinman, executive director of Doctors Care, is the name of the person who spoke.