Coloradans struggle with long waits for medical care as pandemic catch-up continues [PAYWALL - ARTICLE IN COMMENTS]

ARTICLE TEXT 1

When Meredith O’Harris broke out into painful hives, her doctors agreed she should see a dermatologist quickly, and she expected to get an appointment within days.

Instead, O’Harris, of Arvada, was told it would be a year before she could see a doctor specializing in skin conditions — though if she were willing to meet with a physician assistant, the dermatology office could fit her in within a week.

“The nature of the issue is that it’s emergent. I could wait about a day,” she said.

Her doctor was concerned not only that the hives were painful, but that they could be a sign of lupus, a condition where the body attacks its own tissues, O’Harris said. Untreated lupus can cause damage to the kidneys, heart and other organs, meaning a quick diagnosis is important.

By the time she saw the physician assistant in the dermatology office, she’d gotten some relief from a steroid injection her primary care doctor had given her, and while blood tests ruled out lupus, they couldn’t answer what had caused the hives or how she might avoid them in the future.

“I never really got an answer,” she said. “That’s why the delay mattered.”

It’s difficult to say with certainty if wait times for medical care have increased in the Denver area, since surveys are infrequent and the data is almost always out-of-date by the time it’s published. But some patients and providers believe it’s getting harder to schedule an appointment promptly. More than 60 people who identified themselves as Colorado residents told The Denver Post they had faced what they thought were excessive waits for care, ranging from routine physicals to cancer screenings to consultations before surgery.

People covered by Medicaid always have struggled to get timely care, because many doctors limit the number of Medicaid patients they take because of its lower payment rates, said Dr. Michael Pramenko, a primary care physician in Grand Junction. Now, patients with other types of insurance are starting to have the same problem, he said.

While providers leaving medicine during the pandemic have been a factor, the bigger issue is that the supply of new doctors hasn’t kept up with the needs of an aging, chronically ill population, Pramenko said. Since the country hasn’t taken steps to reduce the number of people developing illnesses caused by poor diet, it largely falls on the health care system to manage the consequences, he said.

“We’re producing chronic disease at a rate that’s unsustainable in the United States,” he said.

Wait times have become an issue in Kaiser Permanente Colorado’s negotiations with its employees, with the union demanding the health care network take steps to bring on more staff. Tonya Stoner, a licensed practical nurse and steward with Service Employees International Union Local 105 in Denver, said she was told a patient would have to wait eight months for a colonoscopy at a Banner Health hospital near their home in northern Colorado, or until April 2024 if they wanted to go to a Kaiser-owned facility. The patient got on a waiting list in case someone cancels an appointment sooner, but it’s upsetting for people to face long delays in their care, she said.

“When you’re talking about urgent, emergent care, it’s not appropriate to wait that long,” Stoner said.

Amy Whited, spokeswoman for Kaiser Permanente, said the organization and a coalition of unions representing employees had reached an agreement to add 10,000 new workers nationwide in 2023 and to speed up the hiring process. The organization has hired “thousands” of people since 2021, she said in a statement. Gastroenterologists, who perform colonoscopies, aren’t represented by the union and weren’t part of the hiring agreement.

“Right now, every health care provider in the nation is facing staffing shortages and fighting burnout, and Kaiser Permanente is not immune,” she said.

Alan Hendrix, of Golden, said he got a message in February from Kaiser Permanente that it was time to schedule his screening colonoscopy, but then learned no appointments were available for a year. The scheduler told him to try back and see if anyone had canceled an appointment before then, but that’s not a good solution, he said.

“I can’t be on the phone with Kaiser every other week,” Hendrix said.

Whited said Kaiser Permanente hired additional gastroenterologists and is offering home stool-testing kits to members who don’t have colon cancer symptoms. It also expanded its network of outside providers recently, and will start notifying patients waiting for a colonoscopy that they can get it elsewhere without extra costs. Demand is high now because of tests that were postponed during the pandemic, and because the recommended age for a first colonoscopy dropped from 50 to 45, she said. “We understand that longer wait times for routine colonoscopy appointments may be frustrating to some of our members, and Kaiser Permanente is taking this concern very seriously,” she said. “Members with urgent concerns or symptoms will be scheduled into priority colonoscopy appointments.”

Hendrix said he doesn’t have any symptoms that would suggest colon cancer, but he’s tried to be diligent about keeping up with screening after having polyps removed a few years ago. People who have a history of polyps are at an increased risk for cancer, though the size of that risk depends on the number and type of polyps. “It feels like you always hear about the Canadian system and the British system, that you can’t get in. It feels the same here,” he said.

High demand, insurance restrictions contribute

A nationwide poll by KFF, formerly known as the Kaiser Family Foundation, in February and March this year asked about 3,600 people if they’d had various problems with their insurance, including being unable to get an appointment with an in-network provider when they needed one. About one-quarter of those who answered said they weren’t able to secure an appointment with a doctor they needed to see. People with insurance through the individual marketplace or employer-sponsored coverage were more likely to report that particular problem than those with Medicare, suggesting that private insurance networks may not have enough providers, at least in some areas and specialties, said Kaye Pestaina, co-director of KFF’s program on patient and consumer protection.

Some people may have been able to find care with another provider, but there may not be an alternative for certain specialties, and not everyone has time or energy to shop around for a covered doctor who’s available, she said.

“For a high percentage, they just gave up” after running into a problem with their insurance, Pestaina said.

Difficulty getting prompt appointments isn’t a new problem.

The Colorado Health Access Survey found about 19% of people said they couldn’t get an appointment as quickly as they needed one in 2021. Generally, the number who said yes to that question fluctuated between 15% and 22% when the surveyors asked about it every other year. What counts as an excessive wait time varies from person to person, though, and it’s possible that doctors disagreed with dissatisfied patients about how urgent their needs were.

In the survey, Coloradans reported waiting an average of seven days for routine care with their doctor and 19 days for specialty care. Both averages were slightly lower than in 2019, the last time the question had been asked.

Julie Lonborg, senior vice president of communications and media relations at the Colorado Hospital Association, said wait times may have increased because some hospitals have had to cut back on services due to increased costs and the state’s focus on keeping costs down. When a service isn’t sustainable, or the only provider who offers it in a rural area retires or leaves, that pushes patients into the remaining facilities, increasing wait times, she said.

In addition, Colorado’s population has grown, especially along the Front Range, and hospitals had to put off expansions during the early stages of the pandemic, Lonborg said.

“We’re still catching up from that population growth,” she said.

The most recent information on wait times specific to Colorado is from spring 2022, when consulting firm Merritt Hawkins contacted a sample of 10 to 20 physicians’ offices in different specialties in 15 cities, including Denver. They asked how long it would take to get an appointment for a type of routine care offered in that specialty. The quoted wait times in Denver were:

• Cardiology: Seven to 99 days, averaging 33 days
• Dermatology: One to 66 days, averaging 27 days
• Gynecology: Five to 89 days, averaging 39 days
• Orthopedics: Four to 46 days, averaging 14 days
• Family medicine: One to 77 days, averaging 21 days

The average wait time was up compared to 2017 in cardiology, gynecology and orthopedics, though the difference was less than three weeks. Average quoted waits were actually down in dermatology and family medicine, with most cities showing decreased wait times to see a primary care doctor.

Dr. Sterling Ransone, the American Academy of Family Physicians’ board chair and a primary care doctor in eastern Virginia, said he’s not seeing shorter wait times now, though, and the problem will probably get worse as the population ages and primary care remains underpaid compared to specialties.

Patients who put off care during the earlier stages of the pandemic need more attention now, and doctors have to take time to catch them up on their screenings and debunk misinformation that’s still running wild on social media, he said. “It’s nationwide,” he said. “A combination of those is putting us behind and not leaving us a lot of wiggle room to get new patients in.”

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“Squeaky wheel gets the grease”

Some patients waited considerably longer than the quoted times.

Mark Shapard, of Aurora, said his dermatologist at UCHealth recently retired, and he was told he’d have to wait for a “new patient” appointment to check a growth on his left eyelid that looked like a large pimple. That was in December, and he was told the next available new patient appointment would be this summer. While no one did anything wrong, the delay allowed the growth to keep expanding, he said.

By February, the growth was at least a half-inch long and he could see it out of his peripheral vision. Shapard said he was told he’d have to consult with a surgeon who wouldn’t be available until August, though his doctor tried to get him in sooner. Going elsewhere wasn’t an option because the health insurance he gets through his wife’s job at the University of Colorado didn’t have other systems in-network, he said.

Another patient canceled, allowing him to see the surgeon in March, but the mass had grown enough that he needed a more complicated surgery that removed a larger portion of his eyelid, Shapard said.

The growth was cancerous, and while, fortunately, the surgeon was able to take out all of it, his left eye doesn’t close completely, leaving a sliver of white exposed when he sleeps. He expects to eventually need another operation to repair the eyelid, but for now, is using eye drops and plastic wrap — like the kind that covers leftovers — to keep the eye from drying out.

“If I could have been seen a month or two sooner, it would have been a lot easier to remove,” he said.

A primary care physician at one of UCHealth’s clinics, who spoke on the condition of anonymity for fear of reprisal, said it’s a common problem that new patients or those whose doctors retired face long waits to establish care. At the practice where he works, patients are being scheduled out as far as January, because providers need to be available for their current patients’ scheduled care and for urgent problems that pop up, he said.

Tom Gronow, president and CEO of University of Colorado Hospital, said it would be unusual for new patients to face a long wait for new primary care appointments, with about half of those seeking primary care on the hospital campus getting it within two weeks. Like many providers in the Denver area, however, UCHealth often has a six- to nine-month wait for specialty care, he said.

“Do we want (the wait) to be six months? Absolutely not. Can we fix it overnight? No,” he said.

UCHealth has expanded its outpatient appointments from about 3.9 million in-person and virtual visits in fiscal year 2019 to about 6.7 million in the fiscal year that ended in June 2022. Some of that growth has been from hiring new providers and opening more offices, but the health system also has prioritized on maximizing staff time by having them focus on the most complex tasks they’re qualified to do, Gronow said. For example, experienced nurses can triage patients and decide who needs to be seen most quickly or needs the level of care at an academic medical center, he said.

In theory, there should be enough primary care providers in the Denver area, though not in some parts of the state, the UCHealth doctor said. He’s not sure why patients are struggling to find timely care, but said it could be that insurance networks limit patients’ ability to consider different providers; that too few practices take Medicaid, putting a squeeze on those that do; or that patients may not know where to start, and just call a health system they’ve heard of, he said.

It’s also difficult to know how many people are truly waiting, the UCHealth doctor said. In one case, he had a patient scheduled for a first-trimester pregnancy visit, but by the time her appointment came up, she’d already delivered the baby. She had found care elsewhere and forgotten that she’d gotten on the waiting list at his clinic, he said.

“If I were a patient, that’s what I’d be doing, trying to get on as many waiting lists as possible,” he said.

The UCHealth doctor said he hasn’t seen any patients sustain clear harm while waiting for their initial visits, but worries that someone who doesn’t have a primary care provider for months will ignore a serious symptom like chest pain. His practice tries to get new patients in if their needs sound urgent, but there’s no systematic way to do that, and some people are much more comfortable speaking up for themselves than others.

“It’s kind of like a ‘squeaky wheel gets the grease’ situation,” he said.

Stephen Cory, of Denver, said patients have to take the lead if they need quick care. He normally gets his care from UCHealth, but was told it would take a month and a half to see an ear, nose and throat specialist after experiencing sudden hearing loss in one ear. While some people recover without any particular treatment, others need steroids or antibiotics, and delaying care can reduce the odds of full recovery. Cory, who works for an electronic health records company, said his experience with the health system gave him an advantage when he was seeking out care. He looked up other ear, nose and throat doctors in his insurance network and spent a few hours reading their reviews and making calls, eventually finding one who could see him the same day.

Other people who are facing a long wait time for what they believe is an urgent health need should start with their insurance company’s customer portal, or call its customer service line to find out about other options in their network, Cory said.

“Unfortunately our system relies on the patient to do a lot of the legwork sometimes. It is usually a lot simpler for the patient to stay within one organization of affiliated providers,” he said. “But when that isn’t meeting your health care needs, it’s important to advocate for yourself and take on that research role.”

Pramenko, the physician in Grand Junction, advised patients to contact their primary care doctors to see if they can avoid a visit with a specialist. Their doctor may also be able to persuade a specialist to see them sooner, if the need is urgent, he said.

Patients don’t always have the time or resources to advocate for themselves, though.

Amy Blackman, of Denver, said she had been dealing with increasing pain and numbness in her extremities, especially her left hand. An MRI in late March was concerning enough that her primary care doctor referred her to a neurosurgeon at Denver Health, but as of early July, she still hadn’t heard anything about when she might get an appointment, and her primary care doctor couldn’t do much to help.

Dr. Connie Price, chief medical officer at Denver Health, said she couldn’t comment on any individual’s case without knowing details, but it generally takes about two weeks for someone with an immediate need to see a neurosurgeon. Less-urgent needs, such as back pain, can take up to 60 days, which is in line with other community health systems, she said.

Wait times are about a week longer, on average, than they were before the pandemic, Price said. That reflects the bottleneck as people returned for delayed care; the loss of health care workers in the “Great Resignation”; the aging population; and the increasing volume of uninsured patients seeking care at Denver Health, she said.

“Access to care is a problem in this country, in this state, in this city,” she said.

Blackman said her symptoms gradually have worsened to the point she can’t move her left ring finger, which makes it difficult to keep up with the typing she needs to do for her graduate degree program. She said she was told to call each morning and see if someone canceled an appointment, but that’s not a good solution for busy patients.

“To be put on a waiting list at the end of March, then to call back three months later to be told it is the exact same situation is suspect, and very disappointing,” she said.

Price urged people who are facing a long wait for care not to get discouraged, and to try their provider’s patient advocate, if they have one.

“We don’t want people to give up,” she said.