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Medicaid Patients and Doctors Are Seeking a Cure for Denver Health's Managed Care

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Denver Health says it's not trying to keep patients from going where they want to go. "We see over 400,000 patients a year that want to come here," says Elbra Wedgeworth, chief government and community relations officer for Denver Health. "Why would we be going out and getting people and making them come here? That's not what we do."

Craig Gurule, Denver Health's government-products manager and the staffer who deals with these issues on a day-to-day basis, says the organization understands that if a patient already has a relationship with another doctor, they might not want to come to Denver Health. In those cases, Gurule says Denver Health informs them how to disenroll.

"Where some of the issues lie sometimes is that there are instances where we're not made aware that this individual has an existing relationship," he says, "and they're seen by a non-Denver Health provider and then that provider bills Medicaid...which says, 'No, you need to go to Denver Health,' and then that's the first time we become aware of the issue."

Other times, Gurule says, patients go to a pharmacy to fill their prescription and are told by the pharmacist that their Medicaid has been switched to Denver Health and they can't get their medicine. Patients on Denver Health's plan can only obtain their prescriptions at Denver Health pharmacies, which only fill orders from Denver Health doctors.

That's what happened to Rhanda Gibson's family. Her oldest daughter, Faith, has diabetes and asthma. In 2010, Faith became ill and needed a prescription. But when Gibson's husband, Anthony, went to the pharmacy to get it, he was told that Faith had been switched to Denver Health and that Medicaid wouldn't pay for the medicine that the family's doctor, Andrew Lieber, had prescribed. Lieber ended up paying for it out of his own pocket.

The anecdote landed in the Denver Post in a bigger story about a nine-year-old boy who died because a glitch in the computer system said he wasn't covered by Medicaid even though he was. The boy had asthma and wasn't able to get his medicine.

After Faith's story appeared in the paper, Gibson says, the state quickly put her daughter back on a plan that allowed her to see Lieber. "My kids have been going to him since they were born," says Gibson. "Nobody knows our children's medical history like he does."

But in August, another of Gibson's four daughters was inexplicably switched to Denver Health. Gibson, who has lived at her current address for three years, says she never received a letter. Instead, she got a call from Lieber's office on the morning of her kids' back-to-school checkups, informing her that the computer showed that her fourteen-year-old daughter, Tyra, had been passively enrolled into Denver Health's plan. Her other three daughters had not.

"They said it wouldn't happen again," Gibson says.

"And we're right here again," adds her husband.

Lieber isn't surprised. "They swore to me four years ago they would have a computer fix for this, and they've never done that," says Lieber. About 25 percent of the patients seen at his practice, Rose Pediatrics, are on Medicaid. After complaining about the system for years, Lieber says, he's given up. "I don't have it in me to fight with them anymore."

Lieber isn't the only provider who feels that way. Jim Doody, a physician assistant at Horizon Primary Care, says he tried to set up a meeting with Denver Health two years ago but was unsuccessful. He wanted to talk about the problems Horizon was experiencing at its Green Valley Ranch office. The office recently expanded in order to better serve families in that neighborhood, but Doody says that nine out of ten Medicaid patients who show up have been passively enrolled in Denver Health and don't realize it.

It used to be that Doody's office would see them for free if the patient started the process of disenrolling from Denver Health. But it has had to stop doing that. "It was too many patients and too many dollars out the door," he says. "We turn them away, which is unfortunate. We have availability in that office every single day."

Markson has also spoken up about the issue, including on several state Medicaid advisory committees. "There's a lot of head-nodding: 'Yes, that's a bad thing. Yes, we're going to do something about it,'" he says. But until recently, nobody was willing to follow through.
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Melanie Asmar is a staff writer for Westword. She joined the paper in 2009 and has won awards for her stories about education, immigration and epic legal battles. Got a tip? She'd love to hear it.
Contact: Melanie Asmar