Government Health Metrics: A Solid B+ Even Though Some Medicaid Patients Cannot Get an Appointment

In accordance with federal law, Colorado hired Health Services Advisory Group (HSAG) to do an on-site review of Denver Health Medicaid Choice plan performance in 2013. Denver Health is one of Colorado’s biggest Medicaid contractors. It runs a hospital, a pharmacy, 9 satellite primary care clinics, 4 dental clinics, and 16 school-based health centers. HSAG’s report on Denver Health’s performance was published in April, 2014. All Medicaid clients with a Denver address are automatically enrolled in Denver Health Medicaid Choice unless they choose another Medicaid option. Denver Health scored well overall. It met 87 percent of all of the evaluative standards. Paperwork on coverage, utilization management, provider certification, and denial of claims documentation was in near perfect order. According to its annual Strategic Access Report, 99.8 percent of Medicaid members were within 30 miles of a Denver Health clinic and there were 54 bus stops within a quarter of a mile of its clinics. It had direct access to care for members with special needs, 24-hour emergency access, preventive health programs, and numerous “committees, workgroups, staff trainings, and evaluation of metrics regarding provision of interpreters and understanding of culture with respect to health care.” After scanning Denver Health’s performance metric scores, one would never guess that an unknown number of new Medicaid patients were unable to get medical care. HSAG conducted open shopper calls, discussions with focus group members, evaluated a Denver Health customer satisfaction survey, and reviewed of formal grievance filings. It concluded that an unknown number of newly enrolled Denver Health Medicaid clients ended up on informal “wait lists” for appointments. The situation was so bad that some patients ended up paying cash to outside physicians in order to get care. Unfortunately this did not help them get drugs or specialist care because they lacked authorization from a Denver Health physician, authorization was impossible to get without an appointment or a trip to the emergency department. Thanks to limited open enrollment periods for other Medicaid options, people who were automatically enrolled also found it hard to get out. HSAG concluded that, “given the transient nature of some of the Medicaid population, many members may experience ongoing difficulty in gaining access to a primary care provider in the [Denver Health] system.” Denver Health representatives acknowledged that their primary care clinics were operating at capacity. They reportedly said that openings for new Medicaid members were created by the “estimated 20 percent turnover in clients who move out of the area, disenroll, lose coverage, or die.” HSAG specifically noted that because there was no “clear documentation of wait times,” and because the metrics did not use the member satisfaction survey results to grade access, it “must score requirements for specific wait times as Met.” In Appendix C, over 70 pages into a 100+ page report, the report says, in bold print,

that “based on the process described to the HSAG surveyor, the appointment standards for any type of appointment for a new, unestablished patient would not be met.” As the U.S. Veterans Administration, the National Health Service, the Indian Health Service, Canadian provincial coverage, and the old Soviet bloc health plans have shown, there is no known way to make closed monopoly systems accountable. Accountability requires meaningful choice. This is why real health care reform, like real education reform, requires that people who feel that they are not getting the services they were promised can deliver an immediate evaluation by taking their money elsewhere.

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