Dr. Roberta Capp moved from Brazil to the United States at age 14, when her mother, Elizabeth, decided to pursue a better life for her family. Thanks in part to her mom’s encouragement, Capp earned her M.D. from Harvard and a master’s in health science from Yale. But Elizabeth wasn’t as focused on her health as she was on her children—until severe abdominal pain sent her to the emergency room, where she was diagnosed with ovarian cancer.

Without health insurance at the time, Elizabeth was able to fill out an emergency Medicaid application and get the care she needed—but she was one of the lucky few, Capp says. “As I went into emergency medicine [at University of Colorado Hospital], I served a lot of patients with late diagnoses for cancer,” she says. “If they’d had a screening earlier, it wouldn’t have killed them or wouldn’t have cost them the dollars it did.” But many of these patients with Medicaid or Medicare don’t have primary care providers to consult, partly because they don’t understand where to turn for basic preventive care or when a medical problem comes up. Only 18 percent of American adults have a proficient understanding of basic health information, and that low health literacy rate—which often results in patients using the ER for primary care—costs the system more than $100 billion each year.

5280 Health January 2018
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Given her personal and medical experience, Capp thought she could help and began conducting pilot programs at UCHealth focused primarily on Medicaid patients. In one program, called Bridges to Care, researchers met with those who had visited the emergency room two or more times during the previous 180 days—defined as “high utilizers”—to figure out why they weren’t going to a primary care doctor. Then the researchers connected patients with resources to address those obstacles; a patient might get a list of local doctors who are taking new Medicaid patients or a coach to explain how the health care system works. In another example, called the Hot Spotters program, graduate and undergraduate students teamed up to address the needs of patients with complex medical issues, such as smoking, substance addiction, obesity, and mental illness all at once. Now, based on what she learned about the patients and barriers to proper care, Capp is creating an algorithm that will predict what type of solution each high utilizer needs—saving time for everyone from ER docs to psychiatrists to patient advocates. “Data analytics have become so much more sophisticated,” Capp says. “Now, how can they tell us the kind of help patients need most?” She’s well on her way to finding out.

“It’s an ethical dilemma. If you only pay for five years of Meals on Wheels, what happens in year six?” –Jayla Sanchez-Warren, director of the Area Agency on Aging

Basic Needs

How to solve the health problems that can’t be fixed with medicine.

We often think of poor health in terms of chronic diseases like cancer or obesity. But what if 82-year-old Jim can no longer drive, lives alone, and doesn’t have a way to get to the doctor’s office? This type of external factor, known as a social determinant of health, isn’t an issue that a physician can address, but it’s a crucial—and sometimes costly—piece of the health care web. That’s why, in May 2017, the Centers for Medicare & Medicaid Services (CMS) provided five-year grants to 32 organizations nationwide to screen patients for social determinants of health such as lack of transportation, food insecurity, and housing instability. The Denver Regional Council of Governments (DRCOG), which is the Denver metro area’s expert on issues senior citizens face, is one of two Colorado recipients; the group has 16 partners and $4.5 million to help determine whether local patients face these challenges and which ones are most prevalent. The catch: CMS won’t necessarily pay to fix any problems identified, even if the evidence is strong, because the possible solutions often require a long-term commitment, says Jayla Sanchez-Warren, director of DRCOG’s Area Agency on Aging. “It’s an ethical dilemma,” she says. “If you only pay for five years of Meals on Wheels, what happens in year six?” She is hoping the scientific proof of the problems she’s seen for the past 30 years will prompt funding groups (public and private) to act. We hope so, too.