Final
STAFF SUMMARY OF MEETING

HEALTH CARE TASK FORCE
Date:09/01/2005
ATTENDANCE
Time:09:19 AM to 04:18 PM
Butcher
*
Clapp
*
Place:SCR 356
Gordon
X
Johnson
E
This Meeting was called to order by
McCluskey
X
Senator Keller
Mitchell
E
Tochtrop
X
This Report was prepared by
Todd
X
Christie Lee
Frangas
X
Keller
X
X = Present, E = Excused, A = Absent, * = Present after roll call
Bills Addressed: Action Taken:
Second Health Care Task Force Meeting
Overview of Health Care Task Force
Presentation by The Children's Hospital
Overview of the State's Trauma System
Report on Hospital-Acquired Infections
Health Care Environment in Colorado
Presentation from Colorado for Health Care
The Role and Function of Specialty Hospitals
Ambulatory Surgical Centers in Colorado
Discussion of Hospitals in Colorado
Public Testimony
Closing Comments		-
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09:19 AM -- Call to Order and Overview of Health Care Task Force

Senator Keller gave a brief opening remark and noted that the Health Care Task Force would be hearing about the issue of hospital acquired infections and would allow testimony immediately following the discussion. She then introduced Larry Wall, the President of Colorado Health and Hospital Association, who explained that he and others would be covering a large array of topics in a short amount of time and mentioned to the committee that they could return at a future date to explain, in detail, any topics the committee needed more information on.

09:21 AM -- Presentation by The Children's Hospital

A notebook entitled "Kids Need a Kids' Hospital" was given to each of the committee members from The Children's Hospital. The notebook was a compilation of the power point presentations and a summary of what each of the The Children's Hospital presenters would be discussing. A copy of each of the powerpoint presentations is available on the Health Care Task Force web page at: http://www.state.co.us/gov_dir/leg_dir/lcsstaff/2005/comsched/05HealthCareTFsched.htm. A copy of the notebook is on file at the Legislative Council Office and at the State Archives.

Dori Biester, President and CEO of The Children's Hospital, began the presentation and talked about the role it serves in the community and region. She explained that The Children's Hospital specializes in treating children with complex, chronic or congenital conditions. Further, it provides preventative and primary care and serves as a safety net hospital for uninsured and under-insured children. The committee was then played a nine minute film about three of The Children's Hospital's patients. Ms. Biester indicated that children do better in The Children's Hospital then regular hospitals because it is geared toward children and has 47 medical specialties including pediatrician cardiology and heart transplantation.




Ms. Biester went over some of the current challenges The Children's Hospital faces with mental and pediatric care. She then responded to questions.


09:40 AM

Senator Gordon asked Ms. Biester what happens when a child comes into The Children's Hospital without insurance. She explained the child is treated the same as any other child and that they will work with the family to cover costs if they can using either Medicaid or a child health plan. Senator Keller asked if there are any clinics in the rural parts of the state. Ms. Biester said yes, and they include clinics in cardiology, gastrointestinal disease, and rehab consultation centers and are found throughout Colorado, Wyoming and Montana. Senator Keller then asked if any of those other states help support those clinics. Ms. Biester stated they do support them through Medicaid, for example, if a Wyoming child is sent to The Children's Hospital then they pay using Wyoming's Medicaid program.

Senator Keller asked if The Children's Hospital had any type of workforce shortage. Ms. Biester explained that the hospital has a low vacancy rate for nurses, around five percent, but they do have shortages in specialized areas from time to time. Senator Tochtrop asked if they offer any tuition forgiveness programs. Ms. Biester said they did not, but that they do encourage employees through scholarships to pursue other areas such as nursing.


09:46 AM

Dr. Marianne Wamboldt introduced herself as the chair of Psychiatry of Behavioral Sciences at The Children's Hospital and gave a power point presentation on the challenges in children's mental health. She stated she would be giving an overview of what child psychiatric problems look like, what the economic realities are in treating those children, and what the The Children's Hospital is doing in this area. She explained that if illnesses such as anxiety are not treated early, there is an increase in pregnancy, school failure, unemployment, and marital instability through childhood and into adulthood. Dr. Wamboldt said the rate of these disorders is increasing. When asked why by Senator Keller, she responded by stating she was not sure but they think it is due to decreased structure and values in families, exposure to traumatic events (hurricane, 911), obesity, and less funding for school programs such as sports, music, and art that can help children cope.
Dr. Wamboldt then explained that children are going untreated due to economic realities: Colorado's public funding per capita for health care is below the national average, and private insurance is hard to access, thus a lot of parents have to pay out of pocket for therapy. She stated they see six patients in the emergency room every day and about two or three of those are suicide attempts. She said many of the inpatient clinics have closed because they are not getting appropriately reimbursed for the care they deliver. Senator Keller asked if it would be helpful if the adolescent unit at Fort Logan was re-opened. Dr. Wamboldt replied that a long-term inpatient unit in Fort Logan or Pueblo would be more helpful then having private residential treatment centers.




09:59 AM

Senator Keller asked what the average length of stay was for their patients. Dr. Wamboldt replied about seven to eight days, and then the hospital attempts to transfer them so the total length of stay on average is about twenty days. Senator Tochtrop asked why the kids are not being diagnosed early. Dr. Wamboldt stated that a lot of pediatricians, family care doctors, and primary care providers need more training in how to diagnose these kids early because either they do not know how to identify the symptoms, or if they do, then
they do not know what to do with them or where to refer them. She explained that the hospital has submitted grants to try and place mental health professionals in primary care clinics to train them to intervene early so it does not get severe. She stated that she thinks that is where psychiatry needs to go in the future that they need to be consultants to primary care providers.

Representative Frangas commented on the possibility of having a consulting psychologist available for police officers or social workers to call for assistance, and asked if that would fit into what Dr. Wamboldt was talking about and if so how the state could help in supplying that. Dr. Wamboldt stated that child psychologists should be used as consultants because they are highly trained but unfortunately private payment for consultation is almost nonexistent. She said that if the state could subsidize the salary for them there were some great people that would be very interested.

Representative Butcher asked what role the schools have in identifying those types of children. Dr. Wamboldt stated she was not aware of any formal screening by school nurses. Representative Todd asked if there is any collaboration between The Children's Hospital and teachers such as a program that would inform teachers about mental health. Dr. Wamboldt stated currently the Rosenberry conference is held each year for social workers, nurses and teachers.


10:08 AM

Joan Bother, M.D. and Vice President of Physician Services and Ambulatory and Satellite Operation showed a power point presentation and discussed the trauma services at The Children's Hospital, the only level one trauma center in the region for pediatrics. Dr. Bother explained that the majority of their patients are between ages zero and five and are most commonly treated for falls, motor vehicle accidents, child abuse and burns. Dr. Bother stated that the death by trauma rate at The Children's Hospital is 2.9 percent and the number one cause of death is child abuse from shaken baby syndrome. She added that they provide the majority of paramedic training on pediatrics in the region. Dr. Bother discussed the hospital's advocacy and outreach efforts and goals to prevent traumatic injury through research, education, product safety education through community outreach and specialized training for pediatric emergency care givers.

Representative Frangas asked if legislation that would attach a 2 percent increase on auto insurance coverage to cover costs of catastrophic care would alleviate some of the hospital's problems. Dr. Bother stated that is would alleviate some of the problems but the adult trauma centers need it more than they do because The Children's Hospital is different in its immediate availability to sub-specialty coverage. Dr. Bother concluded her presentation.




10:20 AM

Mr. Dryer introduced himself as the CFO of The Children's Hospital and provided a powerpoint presentation about the impact of Medicaid on the hospital. He talked about how Medicaid and uninsured patients are growing at the same rate and that there is about the same number of uninsured patients as Medicaid patients now. Mr. Dryer pointed out that although children make up half of the Medicaid enrollees, they only make up fourteen percent of the expenditures. Senator Keller asked about the impact of indigent children from other states. Mr. Dryer stated that those children are a small number and most of them have their own state's Medicaid. However, the hospitals cannot continue to pass on their Medicaid shortfalls to the State of Colorado. He explained that hospitals are not being reimbursed their costs from Medicaid and that recently it has been getting worse. Mr. Dryer stated that those costs are shifting to employers who cannot handle it anymore. He went on to say that the cost shifting is causing higher deductibles and small companies to not insure their employees. Senator Keller asked if The Children's Hospital has been audited on their reimbursement levels because of the $10 billion cut federally and Mr. Dryer responded that yes they had, and that they audit themselves as well. Mr. Dryer explained that the $10 million cut is mostly for drugs, and that their biggest fear is that people just will not get them and then and the kids will not get the medicine they need.
Representative Butcher asked what percent of full cost is The Children's Hospital not billing or over-billing. Mr. Dryer stated their cost of service and charge for service used to be close to the same amount twenty five years ago, but now in order to make up for Medicaid shortfalls, for every fifty cents in cost, they charge about a dollar to commercial insurers. Mr. Dryer also discussed how the hospital deals with uninsured patients. He stated the hospital will charge thirty percent of its charge to those patients, and in some low income cases they limit the patient's hospital costs to ten percent of the family's yearly income. He also mentioned that The Children's Hospital had about a $38 million dollar loss last year and explained how it is getting harder to pass the loss onto commercial insurers. Senator Keller commented that employers cannot afford the cost shifting anymore and asked Mr. Dryer if he had any ideas on how Colorado can maintain solvency in hospitals. Mr. Dryer stated the HIFA waiver would be a wonderful thing and would allow children to get primary care. Mr. Dryer finished his presentation with a summary noting that The Children's Hospital has the largest percentage, based on revenues, of Medicaid compared to any hospital in the state.


10:41 AM

Dori Biester, President and CEO of The Children's Hospital, returned to the table to close the presentation stating that she hoped the committee now understood the role The Children's Hospital plays in Colorado. Ms. Biester stressed that solutions, such as medical homes, need to be made because the current situation is not sustainable.

10:42 AM -- Overview of the State's Trauma System

Mr. Kline introduced himself as the Executive Director of the Colorado State Fire Chiefs' Association and gave an overview of the state's trauma system. Mr. Kline distributed a handout entitled "Key Messages for the Health Care Task Force" from the Trauma Care Preservation Coalition (Attachment A) and explained that their mission is to address the funding crises in the state's trauma system that was a result of the switch from no-fault automobile insurance. Mr. Kline stated that motor vehicle accidents make up more than half of trauma patients which is why the change from no-fault to tort has had such a big impact. Mr. Kline pointed out that there has been an annual decrease of $100 million since the switch. Senator Keller asked if that money was money that was uncollected, late or no payment. Mr. Kline stated it was the difference between the amount of money brought in that year. He also mentioned that after the switch from no-fault to tort it takes more time to determine who was at fault and so it takes the emergency service providers longer to receive payments from patients. Mr. Kline discussed how the trauma services are given immediately but payments are not received for two years sometimes and he explained the impact this has had on trauma services. Representative Frangas asked if there was anything on the books that makes the insurance companies pay. Mr. Kline said the insured patients have protections to pay but uninsured and under-insured patients do not.

Mr. Kline continued talking about how the unpaid insurance claims are worse for emergency services because they cannot cost shift like hospitals can. Mr. Kline expressed concern that without revenue, the hospitals cannot handle all the patients brought in by the fire departments but the patients need to go somewhere and the longer it takes for a patient to get to the emergency room the more complications they will have and the less likely they will be to survive. Mr. Kline stated that practical long term nonpartisan solutions were needed to bolster the state's trauma system, such as state subsidies, an additional surcharge on moving violations, trauma vouchers, or an additional charge on vehicle registration fees. Mr. Kline discussed problems with TABOR and stated that referendum C and D are important to his association.


11:02 AM

Representative McCluskey asked about the reimbursement levels. Mr. Kline stated that they are able to deal with the time delay in payment and can build that into their system, but the overall uncompensated care is their biggest burden. Senator Keller asked how they handle uninsured patients and how many of those patients use the emergency system for non-emergencies. Mr. Kline stated that uninsured people do use the emergency room since patients know they can always go through the emergency room for care. He explained that the use of emergency services for primary care has increased. Representative Clapp asked for the current numbers from the trauma centers and highly encouraged Mr. Kline to get the data from the Department of Health in order for the legislature to determine what needs to be done. Mr. Kline said he could provide those numbers to her in the afternoon. Mr. Kline concluded.

11:07 AM -- Report on Hospital-Acquired Infections

Susan Dolan, President of the Association for Professionals in Infection Control and Epidemiology (APIC), distributed a handout of her powerpoint presentation entitled, "Mandatory Reporting and Public Disclosure of Healthcare Associated Infections" (Attachment B) and talked about hospital acquired infections. Ms. Dolan explained that hospital acquired infections are ones that patients do not come in with, rather they acquire them at the hospital. Senator Keller asked how the hospital knows the infection was not dormant. Ms. Dolan stated that there are certain criteria to determine if it was acquired in the hospital, including the review the patient's chart, looking at information in their medical records, and talking with the patient as well. Senator Keller asked how often the infections are caused by improperly sterilized tools to which Ms. Dolan explained it varies, they have tried to mechanically disinfect but if they are rushed, a step in properly cleaning a tool can be skipped. Senator Keller asked if there are designated staff in charge of only sterilizing tools. Ms. Dolan stated they do have sterile processing department staff that handle sterilization, and that those staff are certified. Senator Keller asked if there was uniform certification and, if not, is there a need for it. Ms. Dolan stated there are standards, but no mandatory certification is required and that it would help if there were uniformity, such as a national standard, but it takes a long time to pass federal legislation so the states have picked it up. Ms. Dolan explained that the APIC is in support of public reporting of hospital acquired infection data so the consumer can make an educated decision on which hospital to attend.

Senator Tochtrop asked if the APIC takes into consideration the ratio of professional staff when they look at studies and whether that correlates with the rate of hospital acquired infections. Ms. Dolan responded by explaining the APIC does not do use staffing ratios, but there are currently definitions provided to the APIC to determine the rate of hospital acquired infections. She added that these definitions provide numerators that tell them how to determine if the infection occurred in the hospital and denominators that are based on individual things, such as, the amount of surgeries performed and risk adjustment depending on the type of surgery.


11:24 AM

Ms. Dolan continued her discussion about a national standard and the role that APIC will play in developing this standard. She discussed the issue of the state creating a standard and then possibly a national standard being developed later. She talked about what the APIC is looking at regarding what to report related to infection rates, and what data will be relevant to the stake-holders such as the hospitals. She stated that high risk areas are the ones that need to be focused on when developing a standard.

Ms. Dolan discussed some of the challenges to developing an infection standard. She talked about the possibility that a provider may turn away high risk patients in order to avoid having bad numbers associated with their facility. Senator Keller asked whether states with infection reporting requirements have any data about providers turning patients away. Ms. Dolan stated that this information was more anecdotal than statistically based.


11:33 AM

Ms. Dolan discussed a bill sponsored by Representative McCluskey in the 2005 session (HB 05-1128). She stated that if this bill idea is attempted again, issues that should be looked at include: timing of the reporting, the timing of releasing the data to the public, allowing a task force to study the issues, educating providers on how to accurately report, and providing adequate funding for the reporting.



Representative McCluskey commented on Ms. Dolan's presentation. He thanked The Children's Hospital for their involvement in the 2005 bill. He added that timing issues in the bill do need to be looked at, and that Colorado should review the experiences in other states when drafting a new bill for 2006. He added that he was not comfortable in waiting for the federal government to implement an infection reporting standard.


11:42 AM

Senator Keller asked whether anyone was present to provide public testimony on the issue of hospital infections. David Cassidy, representing himself, commented on the issue of hospital-acquired infections and distributed a handout that included the fiscal note from Representative McCluskey's bill and some newspaper articles that discussed hospital acquired infections (Attachment C). He spoke about the fiscal notes that were prepared for HB 05-1128, and stated that it is important to pass a bill that requires hospitals to report all hospital-acquired infections that occur. He discussed a personal experience he had with a hospital-acquired infection. Representative McCluskey thanked Mr. Cassidy for coming, and encouraged him to be involved with a bill in 2006.


12:01 PM

Senator Keller polled the members about their schedules and the committee decided to work into lunch in order to catch up on the agenda.

12:03 PM -- Discussion of a Variety of Issues Related to the Health Care Environment in Colorado

Larry Wall, President, Colorado Health and Hospital Association, talked about a variety of health care issues touching specifically on the reporting of hospital infection rates. He distributed four handouts: 1) a report on Colorado Hospital Quality (Attachment D); 2) a powerpoint presentation entitled "An Analysis of Community Benefits of Colorado Hospitals" (Attachment E); 3) a report on Colorado Hospital's Operating Expenses (Attachment F); and 4) a report on "The Cost of Caring: Sources of Growth in Spending for Hospital Care" (Attachment G).

Representative McCluskey asked Mr. Wall to expound on the chart in his packet that addresses infection rates across Colorado. Mr. Wall talked about a national effort that is going on to reduce the number of deaths from infections in many hospitals across the country. This data will be reported nationally, and this data will be available to the public. The effort is just starting.


12:14 PM

Mr. Wall talked about workforce shortage issues in Colorado. He added that workforce issues are increasing in Colorado and will create additional problems in the future in the provision of health services. He stated that the nursing shortage is large, but that pharmacists, medical technologists, and radiation technologists are also experiencing big shortages in Colorado and nationally.



Representative Butcher asked what is being done to address the shortages, adding that nurses are doing tasks such as changing bed pans that should fall to other hospital staff. She discussed other problems that are also effecting workforce issues such as not providing full-time employment opportunities and the long waiting lists at nursing schools. Mr. Wall responded stating that he agrees with Representative Butcher's assessment of the issues, but added that this problem is bigger than what the hospitals alone can solve, rather it seems to require a strong public private effort to address these issues.

Senator Tochtrop commented on the nursing shortage issues as well. Mr. Wall responded to the committee's questions about other outreach efforts hospitals are undertaking such as a hospital in northern Colorado that has provided a PhD nurse to assist in the education of graduate level nurses at the University of Northern Colorado. The committee continued to discuss the nursing shortage, and talked about how the Board of Nursing also needs to be brought into the discussion of this issue.


12:33 PM

Mr. Wall discussed a study that was done on the issue of community benefit of Colorado hospitals (Attachment E). He stated that he was not going to address the whole presentation, rather he directed the committee to the pages that deal with hospital reimbursement rates and charity care. He touched on high deductible plans and bad debt, and stated that these components result in cost shifting that was discussed earlier in the meeting. He also talked about the impact that the uninsured population has on bad debt and cost shifting.

Senator Keller asked about current law related to hospital special taxing districts. Mr. Wall stated that there are 18 public hospitals in the state, and some county hospitals, and added that many of these entities have taxes in place to support the facilities. He also stated that a bill passed in 2005 allows mental health facilities to impose taxes for funding as well.


12:40 PM

Mr. Wall discussed a document that was prepared for the Joint Budget Committee (Attachment F) that addresses operating expenses for hospitals in Colorado, and Medicaid payments as a percentage of costs. He also commented on an upcoming 4.6 percent reduction in Medicare reimbursement rates that he fears will drive more physicians away from serving Medicare patients thus driving patients into the emergency departments of hospitals.

Representative Butcher asked whether there are clinics that specifically work with indigent persons rather than having the hospitals deal with them. Mr. Wall stated that there are these types of facilities in Colorado; however, if the patient goes first to the emergency department, triage services and an evaluation (under federal law) must be conducted before they are transferred to the clinic, so cost is still incurred. He added that if people went directly to these clinics, some of these problems would be addressed.

Representative Frangas and Mr. Wall discussed the problems with serving Medicaid patients including the heavy paperwork burden.



12:55 PM

Mr. Wall commented on the final handout (Attachment G) which provides an overview of what is driving costs in hospitals.


12:57 PM

Recess.

01:38 PM -- Call to Order

Senator Keller explained that the workforce shortage issue can be brought up in more detail possibly on October 13th or another date and requested that people let the staff know if they would like to testify.


01:39 PM -- Presentation of Report Entitled: "Sky High Health Care Costs in the Mile High City: How Denver Hospital Systems Have Driven Up Health Care Costs and What We Can Do About It"

Julia Green, Director of Colorado for Health Care, stated they are working on educating the voters on referendums C and D and talked about why health care is surging. She distributed three handouts 1) a report entitled "Sky High Health Care Costs in the Mile High City" (Attachment H); 2) a review of the Denver Consolidated System's Response to the report (Attachment I); and 3) an article by Malcolm Gladwell entitled, "The Moral-Hazard Myth" (Attachment J). Ms. Green then introduced Mr. Tom Moore.


01:45 PM

Mr. Moore introduced himself as the principle for the Center for Strategic Health Purchasing that has begun to work for various state and local settings around the country trying to bring together pertinent research to support local efforts to understand the dynamics of the health industry and what is going on. He commented on the morning presentations and how the health care system is in disarray. He stated it reflects a structural problem in health care delivery: we do not get the information, we do not analyze, and we do not plan.

Mr. Moore went through some slides that captured the points in the "Sky High Health Care Costs in the Mile High City" report (Attachment H). He discussed how hospitals consolidated in order to be more efficient and stated that although that may be the case, prices went up as well. He pointed out that consolidation has been profound in Denver in that it went from a fairly wide and diverse group of community hospitals into essentially three private systems and one public system causing a tremendous amount of market control. He stated that one result that has come along with consolidation is the levels of unprofitable community service have gone down. Mr. Moore defined unprofitable community service as services for which there is no fundamental revenue or reimbursement stream. He gave the example of mental health services that have gone away due to lack of funds in order to increase funds in more profitable areas. He added that Denver's operating margins are high above the national average, health care premium costs have risen sharply, and smaller employers (between 0 and 50 employees) are carrying the heaviest load because they have low bargaining power. He stated that when health care costs go up health care declines, and that there is an unpredictability in costs and an increase in the number of people who can pay to cover the costs of those who cannot pay.




Mr. Moore stated that another effect of consolidation is that it allows the provider to set prices and those prices may not resemble the cost but rather may be set at what people will pay. He stated the core of his argument is that health care can no longer be left to the market.

Senator Tochtrop brought up the certificate of need program that was around twenty years ago and if a program such as this would help lower health care costs if it were to return. Mr. Moore agreed and discussed with Senator Tochtrop how certain hospitals have too much technology. He added that it would be more effective to place the technology in hospitals where it is needed rather than where the patients are located in order for the hospital to make a profit. Senator Keller asked about bed availability and Mr. Moore stated that the cost and quality of medical care is driven more by available beds then the need for care.

Senator Tochtrop commented on the difference between the economics of health care and other areas, and Mr. Moore added that the health care industry is more secretive than others as well. He said that in any other area you can find out anything you want to know, but with health care you cannot.

Mr. Moore talked about how the problems with declining coverage may have a ripple effect in the economy and reduce the number of small businesses, etc. He stated there needs to be some type of systematic oversight on health care. Mr. Moore then took questions from the committee

Senator Keller asked Mr. Moore if he saw a role for insurance companies. He said there was a role for third parties. He discussed how health plans offer preferred hospitals for specialty treatment based on the fact that they serve their marketing purpose rather than on evidence of outcomes and performance of the facility. He stated that secrecy is intolerable.

Representative Butcher commented on the previous presenters and Mr. Moore's reasons why the cost of health care is growing. She believes the real issue is we do not know how to manage health care and what is missing is the information from the health care insurance providers. She stated that she did not think it mattered what a hospital provides but rather how much it costs to provide that care. Mr. Moore agreed and stated that disclosure is where they have to start, and talked about the need for a federal minimum standard, but that it would be more effective to have local laws.

Representative Frangas asked that if every hospital had to disclose how much they charge for care, would that encourage all the hospitals to increase their charges to the highest charge because they would know how much people are paying for care. Mr. Moore stated that if the lower cost hospitals raised their costs to meet the higher cost hospitals then the consumer would just refuse to pay, instead, it will cause all hospitals to lower the cost or explain themselves to the consumer.


02:24 PM

Mr. Moore concluded his presentation urging the committee to read the study (Attachment H).


02:29 PM -- Recess.

02:29 PM -- The Role and Function of Specialty Hospitals

Senator Keller introduced the next topic related to the role and function of specialty hospitals and welcomed Wendy Bitner to the committee. Ms. Bitner introduced herself as a Registered Nurse and Clinical Operations Officer for the Animas Surgical Hospital. She gave a brief history of the loss of community hospitals, consolidation, and of the Animas Surgical Center. Ms. Bitner explained that the hospital began as an ambulatory surgery center that focused on out patient services (stay is limited to less than 24 hours) and then expanded to a surgical specialty hospital with a 24-hour emergency room whose focus is patients with surgical needs. She stated the facility is economically and technologically driven and the savings they receive from being so are passed on to the communities and workers. She also mentioned they are clinically driven and have a zero percent infection rate.

Senator Keller commented that because of the nature of specialty hospitals, they handle the more profitable surgery such as short term surgeries rather than long-term illnesses such as cancer that are passed on to the general hospitals to handle. Ms. Bitner stated she did not know what effect their surgery specialty hospital had on the local general hospital but did note that a hospital can profit more with efficient care. She also mentioned that their hospital accepts uninsured, Medicare and Medicaid patients. Senator Keller asked if they would accept auto accidents into their emergency room Ms. Bitner said they would accept them but they have not had one yet since ambulances do not bring victims to their facility.

Representative Butcher commented on other surgery hospitals that do not take Medicare or Medicaid and the fact that they are still all taking the short term surgeries and not the long term care patients. Ms. Bitner explained that the government took 80 of the 100 specialty surgery centers and compared them to a neighboring general hospital and the results were counterintuitive in every case, the surgery centers did not impact the hospitals.

Representative Butcher asked why Animas Surgical Hospital is classified as a specialty hospital if they have an emergency room, hospital beds, and accept any type of patient. Ms. Bitner stated she did not know because they do have many different specialties and are licensed as a general hospital. She added that there is no specialty hospital license in Colorado, rather, they are given a general hospital license. Representative Todd asked how it is determined where patients get their surgery. Ms. Bitner stated that a lot of it is patient and physician driven, and because the have a zero percent infection rate, many physicians will recommend their patients to go there. Senator Tochtrop asked if Animas is a for-profit hospital, and Ms. Bitner stated that it is for-profit and physician owned.

02:56 PM -- The Role and Function of Ambulatory Surgical Centers in Colorado

Scott Wasserman, Director of Government Relations, Colorado Ambulatory Surgery Center Association distributed two handouts: 1) a federal memo about surgical centers from 1969 (Attachment K); and 2) a press release from the Federated Ambulatory Surgery Association about the need for more procedures in Ambulatory Surgery Centers (Attachment L) and mentioned that the previous presenter did a great job and so he would try not to overlap too much.

Mr. Wasserman stated it was important to note that surgery centers are not new and referred the committee to the federal memo handout (Attachment K) that showed they have been around since the late 1960s. He stated the surgery centers' largest number of surgeries are out patient surgeries and in 1981 they started to be accepted for Medicare and Medicaid patients and that now about thirty percent of their patients are Medicare patients.



Mr. Wasserman directed the committee to the second handout from the Federated Ambulatory Surgery Association about the potential to lower costs in the Medicare program. He mentioned a debate that is going on at the federal level regarding what procedures are covered in the program for example they cannot operate on a lesion bigger than a certain size and so on. He stated that currently, Medicare does not cover implants at surgery centers but they do in hospitals.

Mr. Wasserman indicated that Colorado surgery centers are distinguished from hospitals and are covered under chapter twenty of the Health Department regulations, they have their own statutory definitions, are treated differently, and they are licensed by the Department of Public Health and Environment. He stated most of the centers have state of the art technologies. Then he discussed that surgical centers exist because physicians are fed up with how hospitals are set up. For example, in a hospital, surgical patients can get bumped causing them to be under anesthesia for longer than they should. He stated surgery centers are more efficient. Mr. Wasserman stressed that the centers are providing advanced affordable care and access to that care. He explained that the centers have the resources to handle a lot more procedures then they currently do. Senator Keller asked why. Mr. Wasserman responded that it is because a lot of people do not know about surgery centers and not all surgery centers have access to insurance networks.

Representative McCluskey asked how many surgery centers are physician owned. Mr. Wasserman stated the majority are physician owned, some are company owned and some are partly owned by hospital systems.


03:13 PM

Jennifer Arellano spoke about the Pueblo Surgery Center where she has been the Administrator for six years. She stressed that ambulatory surgery centers are there for the people and their communities. She talked about the centers current Medicare mix and what the center provides. Ms. Arellano stated that ambulatory centers provide another choice to patients and physicians and provide a safe, friendly, and comfortable environment. Ms. Arellano closed by inviting the committee to visit an ambulatory surgery center.

Senator Keller brought up a concern that physicians might refer their patients to the surgery centers for profit reasons. Mr. Wasserman disagreed and stated that rarely would a physician sit in an emergency room and pick out the patients they wanted, and even if they did, they would be breaking a bunch of ethical rules. Ms. Arellano added that if a doctor who is a partner in their center, refers a patient to their center, the patient is informed that the doctor has is a partner in the center.

03:21 PM -- Discussion of Hospitals in Colorado

Allen Harrison, Vice President of Development at HealthOne distributed a one-page handout about HealthOne in the Community (Attachment M). He talked about the many types of health centers that exist other than a doctor's office and a hospital that have developed over the last twenty years. He explained that surgery centers handle procedures 1) where the total stay is 23 hours or less, 2) where there is low blood loss, 3) when the surgery is not life threatening, and 4) when the patient is typically in and out in the same day and at a low-cost. He continued explaining that convalescent care centers are places for patients to recover, low intensity, and do not treat acute illnesses. He pointed out that HealthOne can handle all of the above cases. Senator Keller asked if nursing homes were included. Mr. Harrison replied that no but the only real difference in the length of stay, they do not have long-term care like a nursing home.




Mr. Harrison continued and gave some general comments on specialty hospitals and how they select the surgical procedures with high profit margins. He stated that although surgical hospitals do accept all types of payors, if the patients do not come in through the emergency room, which most surgery centers do not have, they have to be scheduled in advance which allows the center to screen the patients they accept. He then explained full service hospitals and referred the committee to the handout. He talked about how hospitals are the safety net and must accept patients regardless of their ability to pay and they create high paying jobs and long term employment.

The committee asked Mr. Harrison about market share, transparency and rural areas. Mr. Harrison responded and welcomed the committee to visit.

03:35 PM -- Public Testimony

Senator Keller opened the committee for public testimony.


03:35 PM

Barb Hostrup and Jule Monnens, both registered nurses from major Denver centers, addressed the committee and distributed a handout (Attachment N). They discussed how all hospitals receive most of their funds from Medicare and Medicaid and that private insurance makes up the rest. They shared some personal stories from their hospitals and the problems uninsured patients have faced to help show the deep concern the health care community has for their patients. They discussed the uninsured population and how most are either working individuals who just cannot afford insurance, children, or young adults. The registered nurses talked about their licensed duty to advocate for the rights and well being of all patients regardless of who they are and their ability to pay.


03:41 PM

Ms. Monnens agreed with the previous discussion for the need to have a certificate of need program. They mentioned that many hospitals are moving out of the urban areas to the suburbs to avoid Medicaid shortfalls and are leaving a big burden on the remaining urban hospitals.

Ms. Monnens and Ms. Hostrup discussed the nursing shortage and that a big part of the problem is that nurses are choosing to leave and that a nurse with a Master's degree gets paid more to be a nurse than to teach so there is a lack of teachers to teach in the nursing programs. They stressed that retention is cheaper than recruitment and talked about the high turnover rate and the reasons for it including: problems with benefits and retirement, lack of control over work schedules, low pay, heavy work load, and constant training of new staff. The nurses went through what types of benefits they currently receive.


03:59 PM

Senator Gordon commented on health care as it is today and how it is seen as a commodity and Representative Frangas commented on how important hospitals are to communities. Senator Keller commented on the movement of the most profitable hospitals to the suburbs to avoid Medicare and Medicaid patients and the burden it leaves on the city. Ms. Monnens and Ms. Hostrup concluded their testimony.

04:07 PM -- Closing Comments by the Chair

Senator Keller asked the committee if there was any legislation they would like to draft at this point. Representative McCluskey stated that he would like to bring up his hospital acquired infection bill again and that only minimal changes should need to be made. Senator Keller polled the committee about whether an acquired infection bill should be drafted for the September 27 meeting. The members present concurred. Representative Frangas mentioned he would be interested in a bill to fund trauma care, and the committee decided that would be better left to the Auto Insurance Committee because they are currently working on that issue. Representative Frangas stated he was also interested in a bill to find alternative ways for funding trauma care.

Senator Keller informed the committee that the next meeting would be held on September 27th and it would address telemedicine issues. The following meeting October 13 would cover the workforce shortage issue. Representative Frangas stated he would also like to look at fortifying urban hospitals. Senator Tochtrop said she would like to have the insurance providers come in to speak because they have yet to explain, from their view, why costs are so high. Representative Todd stated she would like to look at the mental health services for adolescents and Senator Keller informed her that is a huge discussion and it has already been looked into by the JBC and the issue is beyond what the Health Care Task Force is capable to do.


04:17 PM

Adjourned.