Kaiser announced Monday that HCA HealthOne Rose and HCA HealthOne Presbyterian St. Luke’s would join its network immediately. Kaiser also added four hospitals owned by CommonSpirit Health to its list of in-network options in September.

The additions to Kaiser’s network come as Intermountain Health has said the insurer is moving away from using its medical facilities, which include Good Samaritan Hospital in Lafayette, Saint Joseph Hospital in Denver and the new Lutheran Hospital in Wheat Ridge.

In an emergency, patients can go to any hospital and expect protection from surprise bills. For scheduled care, they have to either stay within their insurer’s network or risk paying a larger share of their hospital bills, which can run well into the thousands.

Patients insured by Kaiser can start using the two newly added hospitals at in-network rates whenever they want, said Mike Ramseier, president of Kaiser Foundation Health Plan of Colorado. Both hospitals are in-network for all services they offer, though they expect patients will gravitate toward Rose for obstetric care and toward Presbyterian/St. Luke’s for surgeries, he said.

“At the end of the day, it really is their choice,” Ramseier said.

Under Kaiser’s model, physicians employed by the health network care for patients when they get admitted to hospitals it partners with. Doctors will start gradually shifting to work at the newly partnered hospitals sometime in the first quarter of 2025, Ramseier said.

The implications for some of Kaiser’s other hospital partnerships remain unclear.

After Kaiser and CommonSpirit announced their agreement, Intermountain Health last month said Kaiser was slowly shifting patients and doctors away from its hospitals, though they remain in-network for now. Intermountain recently sent a letter to patients that said Kaiser has “indicated their intention to eventually transition patient care away from Good Samaritan and Saint Joseph hospitals.”

On Monday, Ramseier said plans for where Kaiser’s doctors would work are still “evolving,” and that he couldn’t say whether Kaiser doctors would continue to see patients at Intermountain’s hospitals in the long term.

Presbyterian/St. Luke’s is less than a block from two Kaiser facilities in central Denver, which also are across the street from Saint Joseph Hospital, an Intermountain facility that Kaiser partners with.

Patients insured by Kaiser can also seek care at:

• HCA HealthOne’s Medical Center of Aurora, Sky Ridge Medical Center, Swedish Medical Center and Rocky Mountain Hospital for Children
• Intermountain’s Saint Joseph Hospital, Good Samaritan Hospital and Lutheran Hospital
• CommonSpirit’s St. Anthony Hospital, St. Anthony North Hospital, OrthoColorado Hospital, Longmont United Hospital, Penrose Hospital, St. Francis Hospital, St. Thomas More Hospital and St. Mary-Corwin Hospital
• Children’s Hospital Colorado
• Boulder Community Health’s Foothills Hospital
• Banner Health’s Sterling Regional Medical Center, North Colorado Medical Center, East Morgan County Hospital, McKee Medical Center and Fort Collins Medical Center
• UCHealth’s Memorial Hospital Central and Parkview Medical Center

Some plans may include other hospitals or not include every listed facility.

When patients visit a hospital that has agreed to in-network rates, they pay either a flat fee or a portion of the cost of their care. If they go to an out-of-network facility, they could get a bill for whatever their insurance declined to cover. Federal and state law prevent surprise bills when a patient has an emergency, but not for scheduled care.

The two parties reached a multiyear deal that ensures continued, uninterrupted network access to the health system’s hospitals, facilities and physicians for people enrolled in employer-sponsored commercial plans, individual family plans and Medicare Advantage plans, including group retiree and dual special needs plans, Cole Manbeck, a United spokesman, wrote in a news release to announce the deal.

“We thank our members and customers for their support and patience throughout this process. We are honored to continue supporting all of the people throughout Colorado who depend on us for access to quality and affordable health care,” the news release stated.

The two businesses’ existing contract ended Sunday, and the two sides struggled to agree on rates for the next contract. If they hadn’t reached a deal, patients covered by United would have paid more to use:

• Centennial Hospital

• North Suburban Medical Center

• Presbyterian/St. Luke’s Medical Center

• Rocky Mountain Hospital for Children

• Rose Medical Center

• Sky Ridge Medical Center

• Swedish Medical Center

• The Medical Center of Aurora

United accused HealthOne of making “unreasonable” demands for double-digit increases in rates, while HealthOne said United offered rates below market levels for the Denver area.

Health systems and insurers usually reach a deal before their contracts expire, but CommonSpirit Health left Anthem BlueCross BlueShield of Colorado’s network for more than two weeks earlier this year when they couldn’t agree on rates by the deadline.

At least 20 hospitals or systems had disputes with insurance companies nationwide in the second quarter of 2024, compared to at least 24 during the same period of 2023, . The true number could be higher, because the count relies on news reports, and some disputes could have ended quietly or happened in places without local media.

About 30% of the parties didn’t reach an agreement before their contracts expired, meaning the hospitals went out of network at least briefly, according to Becker’s, which is a trade publication.

United is the in the commercial and Medicare Advantage markets, while Tennessee-based HCA Healthcare, which owns the HealthOne hospitals, is the .

Reporter Noelle Phillips contributed to this report.

When a health system and an insurance company agree on rates, the system is “in-network,” meaning patients don’t pay as much out-of-pocket when they use its hospitals or clinics. If they can’t agree and the system goes “out-of-network,” patients have to choose whether to pay more to continue using the system, or to find new providers. Patients who have an emergency could still go to the nearest hospital, even if it is no longer in-network, without facing higher charges.

HealthOne’s contract with United Healthcare ends Sept. 1. If they don’t settle a contract or agree to an extension by then, patients insured by United would pay more to use:

• Centennial Hospital

• North Suburban Medical Center

• Presbyterian/St. Luke’s Medical Center

• Rocky Mountain Hospital for Children

• Rose Medical Center

• Sky Ridge Medical Center

• Swedish Medical Center

• The Medical Center of Aurora

United accused HealthOne of asking for an “unreasonable” double-digit increase in rates, which it said would drive up the cost of health insurance. It said customers could still use eight hospitals owned by other systems, as well as their affiliated clinics, if negotiations are unsuccessful.

HealthOne said United “mischaracterized” its position and was offering rates below what is typical in the Denver market. A statement from the health system said it intends to keep negotiating.

If HealthOne goes out-of-network, some patients could stay with their current doctors temporarily, including those who are pregnant and those who were just diagnosed with cancer or are undergoing treatment. Others would have to seek care from one of eight other hospitals that are in-network.

Health systems and insurers usually reach an agreement before their contracts expire, but CommonSpirit Health left Anthem BlueCross BlueShield of Colorado’s network for almost three weeks earlier this year while they continued bargaining over rates. UCHealth also went out-of-network with certain Anthem plans for one year in 2021.

Both sides of the current dispute are giants. United is the in the commercial and Medicare Advantage markets, while Tennessee-based HCA Healthcare, which owns the HealthOne hospitals, is the .

It works, until it doesn’t.

Since 2022, Denver Health has been in one of those crisis periods, necessitating millions in bailout funds from the state and donations from other health care organizations after providing more than $260 million in uncompensated care. The money has helped keep the hospital afloat, but doesn’t solve the fundamental dilemma: Not enough well-paying customers use Denver Health to offset the disproportionate number of patients who are covered by Medicaid or have no insurance at all.

The problem has no easy solution. Treating any patients living in Denver, and people with emergencies from elsewhere in the state, is the core of Denver Health’s mission: The hospital can’t simply turn away those who are unable to pay. Nor can Denver Health easily attract enough patients with better-compensating commercial insurance to balance its books.

Without many other options, the health care system has sought more government support, a shaky proposition when the city of Denver is dealing with an influx of new immigrants needing services and the state’s budget is always tight.

The safety net has always been “fragile” in the United States because of a lack of investment on multiple levels, and Denver Health’s situation is emblematic of that, said Dr. Patricia Gabow, who served as the system’s CEO from 1992 to 2012.

“If you open your doors to everyone, including the most vulnerable, you’re going to be stressed financially,” she said. “I used to say, ‘What we need to be able to do is print money,’ but no one gave us that printing machine.”

So far, the legislature’s one-time cash infusions have helped Denver Health, but don’t solve the underlying imbalance. Safety-net hospitals around the country have faced the same problem, and none offer a clear model for Denver Health. Some have closed when they couldn’t make the numbers work, straining nearby hospitals. While Denver Health isn’t facing imminent failure, it also won’t get out of the cycle of living on the financial edge without a major change in how the country funds care for those who can’t pay — a development even the hospital’s supporters say isn’t likely to come any time soon.

The Denver Post spoke to current and former Denver Health officials, Colorado lawmakers, health care experts and city officials to better understand how the city’s 164-year-old safety-net hospital landed in its current financial predicament, what could happen if it failed and what it would take to stabilize the health system.

Earlier this year, the Colorado Department of Health Care Policy and Financing that Denver Health needed supplemental funding to keep it out of a “death spiral” after significant financial losses, though the agency added later in its request that it believes the system isn’t too far gone to get back on firmer financial footing. The department requested another one-time payment to “jump start” changes to make Denver Health more sustainable, including cutting costs and expanding services that bring in more revenue.

Donna Lynne, the health system’s CEO, said reports of a death spiral were exaggerated, but Denver Health needs more public support if it’s going to continue serving Colorado’s growing uninsured population. The state’s increasing migrant population and the loss of continuous Medicaid coverage when the COVID-19 public health emergency ended both will push up the number of uninsured. Many hospitals, including Denver Health, have reported sharp increases in uncompensated care since 2020.

In 2023, the legislature fast-tracked an $5 million one-time payment to Denver Health to help keep the hospital and its clinics operating. At the time, lawmakers on the Joint Budget Committee expressed hope that a larger solution was in the works, and that the funding they sent would act as a stop-gap measure.

That hasn’t happened. Lawmakers made another $5 million special appropriation this year. That’s a relatively small infusion for an organization with an annual budget of more than $1 billion and around 8,000 employees.

Safety-net hospitals consistently have narrow financial margins because they treat an above-average percentage of patients who are uninsured or covered by Medicaid, which pays less than the cost of care, said Beth Feldpush, senior vice president of policy and advocacy at the trade group America’s Essential Hospitals.

That makes such hospitals vulnerable any time a shock hits the industry, whether that’s the need to cancel elective surgeries at the beginning of a pandemic, rising prices for supplies and labor, or disruptions to payments from a cyberattack, she said.

No one has found a clear way out of the financial bind that the safety-net mission creates, Feldpush said. Increasing Medicaid rates and other sources of government revenue would help, but the political and fiscal realities mean those hospitals more often have to focus on fending off cuts, she said.

“It would take a historic shift” to make safety-net hospitals’ finances less precarious, she said.

Part 1: How did Denver Health get here?

Denver Health has hit rocky financial patches before.

The hospital regularly ran $30 million deficits when it was fully owned by the city, Gabow said. Denver Health’s financial situation started to improve after it became a separate entity in the late 1990s and started receiving “disproportionate share hospital” payments, she said. (The federal payments, known in the industry as DSH, partially compensate hospitals that have more patients who are uninsured or covered by Medicaid.)

“There were even people who wanted to sell (the hospital). Of course, nobody wanted to buy it,” she said.

The legislature in 1994 to give the hospital more flexibility and reduce its dependence on government funds, and the city transferred the hospital and other health care assets to the authority in 1997 under the first operating agreement.

The authority allowed Denver Health to make changes to be more efficient, including raising salaries to keep up with the market, resolving contracts faster than the city could, seeking its own bonds for capital improvements and joining purchasing cooperatives with other hospitals, Gabow said. Denver Health also remodeled wards to give patients more privacy and upgraded the information technology infrastructure, she said.

“We did well, and the city did very well” because Denver no longer needed to subsidize the hospital at the same level it had before, Gabow said. “The old Denver Health with four-bed wards wasn’t going to attract a lot of patients with commercial insurance, who had a choice.”

In the first operating agreement, the city agreed to make up the difference between what Denver Health took in and what it needed to care for patients, Gabow said. Since then, the agreement has changed, and Denver has contributed about $30.8 million annually even as the amount of unpaid care has skyrocketed, she said. Denver Health reported about $120 million in uncompensated care in 2022 and $140 million in 2023. The 2023 total was more than double the 2018 level.

Denver spokeswoman Laura Swartz said the city was never obligated to cover Denver Health’s full uncompensated care costs, and the city’s contribution was always based on what it could afford.

A , written by Gabow and two other physicians working at Denver Health at the time, laid out the system’s possible future financial challenges even as the authors argued that integrating the public hospital and the outpatient safety-net system had served Colorado well. They noted that government revenue hadn’t kept up with the cost of serving the uninsured, and that the ability to save costs by making patients healthier isn’t infinite.

“One of the challenges actually springs from the success of the system. The burden of uncompensated care falls disproportionately on Denver Health since it has been able to provide this care,” the authors wrote.

For a time, the system had enough paying customers to offset the uncompensated care: In 2018, Denver Health turned a $56 million profit. But even in those good years, the profit margin was below 5%, which was smaller than other metro-area hospitals and didn’t allow Denver Health to build up significant reserves for lean times to come, CEO Lynne said.

Margins on patient care started to decrease in 2019, which a report from the consulting firm Ernst & Young attributed to fewer employers choosing to use the Denver Health Medical Plan, which steers their workers toward the health system for care. The plan had gotten too expensive, because too many people with serious medical needs had signed up, according to the report.

Denver Health also earns less than some nearby hospitals when insured patients do use it. Both Aetna and United Healthcare — two of the larger plans in Colorado — pay Denver Health less on average than they do for care at Rose Medical Center and Saint Joseph Hospital, according to consulting group Turquoise Health. Rates are based on what a provider and an insurer negotiate, and largely reflect market power.

Stimulus funds meant to offset increased costs and lost revenue during the early stages of the COVID-19 pandemic brought the hospital into the black in 2020, but that money started to dry up at about the same time workers began to burn out and the “Great Resignation” drove up labor costs in health care. Typically, a nurse on a short-term contract costs two to three times as much as one on staff, but with so many people leaving their jobs as the pandemic dragged on, Denver Health had no option but to pay to plug those gaps, Lynne said.

“You can’t close one day a week” because of lack of staff, she said. “We’re not as flexible in health care as a restaurant would be.”

Supply costs also rose at the same time as inflation took off, and Denver’s homeless population continued to increase, rising 39% since 2018. The problem isn’t only that patients who are homeless frequently can’t pay for the immediate care they need, but also that Denver Health doesn’t have anywhere safe to discharge them, Lynne said. The hospital gets paid for treating a homeless patient’s frostbite if the person has Medicaid coverage, but not for providing housing where that person can recover, she said.

Denver Health partnered with the Colorado Coalition for the Homeless to fund units where unhoused people can recuperate after a hospital stay, but in some cases, the hospital still can’t find a safe place to discharge patients and has to keep them in its beds.

Other Colorado hospitals dealt with some of the same problems, though most in the Denver area had more reserves to draw on during lean times. Profits in the Colorado hospital sector as a whole dropped about 70% in 2022, though the majority still made money.

Denver Health lost about $35 million in 2022 and about $2 million in 2023. But that smaller loss last year came after the state’s cash infusion and an additional $10 million donation from Kaiser Permanente Colorado.

Four months into 2024, the trends haven’t turned around.

Lynne told members of Denver’s City Council in January that treating the needs of undocumented and uninsured migrants would “break” the health system unless it receives additional support. The number of new arrivals to the city has leveled off somewhat since then, though uncompensated care costs are still rising as Medicaid continues going through its rolls and Coloradans lose insurance following the end of the federal public health emergency, which had prevented disenrollments.

“Our plan this year is to break even,” Lynne said in March. “That����ap not a long-term strategy.”

An additional challenge is that Denver has more providers offering relatively well-reimbursed care like trauma services than it did a decade or two ago, but less-compensated services like primary care, school-based clinics and behavioral health treatment still disproportionately land at Denver Health, Gabow said. That means the system doesn’t have as many opportunities to offset the cost of those under-reimbursed services, she said.

All safety-net providers are struggling to serve both the newcomers and their existing patient base with no reimbursement for the care they provide, said Cathy Alderman, chief communications and public policy officer at the Colorado Coalition for the Homeless. The coalition had to stop accepting new patients at its clinics because it couldn’t take on more newcomers, who aren’t covered by Medicaid and can’t pay out of pocket, she said.

“It’s really throwing our revenue models completely out of whack,” Alderman said.

Part 2: What would happen if Denver Health failed?

Revenue from patient care covers only about 69% of the cost of operations at Denver Health, and the system largely relies on government funding to close the gap, according to the Ernst & Young report.

Consultants told a city budget committee in January that other urban safety-net hospitals are seeing the same pattern of expenses rising faster than revenues. They noted Denver Health provided care at a lower cost and had above-average quality compared to a group of similar hospitals, suggesting wasteful spending wasn’t the primary problem.

Since 2020, safety-net hospitals have closed in , . Others didn’t close, but drastically curtailed services, with hospitals in the , Philadelphia, and dropping inpatient care since 2020. Unlike Denver, however, none of those cities had just one safety-net hospital.

If safety nets close, other hospitals must prepare for an influx of patients. When one Philadelphia safety-net facility, Hahnemann University Hospital, closed in 2019, a nearby hospital to its emergency department. Emory University Hospital Midtown in Atlanta at its emergency department after a safety-net hospital closed in that city.

Other hospitals don’t necessarily want the customers who previously went to a safety-net facility, because they can’t pay much, if anything, said Nancy Kane, a professor emerita of health policy and management at Harvard School of Public Health.

“It’ll hurt your payer mix,” she said.

Regardless of whether their patients are desirable or not, Denver Health takes care of so many people that the sheer number would create a problem for surrounding hospitals, said Julie Lonborg, senior vice president of communications at the Colorado Hospital Association.

Last year, about 270,000 people made a combined 1.3 million visits to Denver Health’s hospital and clinics. In comparison, Hahnemann University Hospital treated about 50,000 people in its emergency room and had about 16,000 inpatients annually, and didn’t run a comparable network of outpatient clinics.

“I don’t know if there’s enough capacity in the system if a hospital of that size and magnitude made a dramatic shift in services,” she said. “It would be a significant challenge.”

While the effect on other hospitals is clear, less data is available on how many patients instead go without care after a safety-net facility closes. Federal law requires all hospitals to stabilize patients who show up during a medical emergency. But hospitals have no obligation to continue treating patients who can’t pay once they’re stable enough to be sent home or transferred to another facility.

A found mixed positive and negative effects when hospitals closed in Los Angeles County. People who reported needing to travel farther to a hospital were more likely to say they had found a usual doctor and less likely to rely on an emergency room for care. Uninsured people were more likely to report difficulty accessing health care, however, and deaths from heart attacks and accidents increased.

Unlike Los Angeles, however, Denver has only one safety-net hospital and a handful of federally qualified health centers that provide outpatient care to people without insurance. If Denver Health were no longer in business, the other safety-net clinics couldn’t meet the demand, said Alderman, of the homeless coalition. Other hospitals likely would try to step up and serve Denver Health’s patients, but they aren’t built around serving highly vulnerable people, she said.

“We have other great hospital partners in the Denver area. They’re just not serving the same population,” she said.

The two closest general hospitals, Rose Medical Center and Saint Joseph Hospital, didn’t make executives available to discuss whether they would be able to absorb a wave of patients if Denver Health were to close. Saint Joseph released a statement saying that caring for the “poor and vulnerable” was always part of the the hospital’s mission, while Rose said it could draw on resources from the rest of the hospitals and urgent care centers HealthOne owns in the area.

“Because of our scope of ERs across metro Denver, we are able to meet the needs of any one facility which is experiencing a more significant surge by sharing nurses, technicians, space, supplies, best practices, etc.,” Rose officials said in a statement.

Part 3: What can Denver Health do?

Denver Health has made some changes to limit expenses. In 2023, the health system stopped seeing uninsured people who weren’t already patients for nonemergency care. It also left about one-third of its psychiatric beds unfilled because it would cost too much to staff them, and reduced planned cost-of-living pay increases for employees.

The system cut its contract labor costs roughly in half in 2023, because it was able to hire and retain more employees, CEO Lynne said. The hospital can’t totally eliminate the need for contract labor, though, because of seasonal surges in demand, she said.

“I am not just looking for more revenue,” Lynne said. “My responsibility is to be as efficient as I can.”

Typically, safety-net hospitals in financial difficulty start by cutting expenses, which is more straightforward than raising revenue, said Feldpush of America’s Essential Hospitals. They usually first pause any expansions or new projects, then reconsider services they don’t get reimbursed for or which cost too much, she said.

For example, clinics might cut social workers who assist patients with finding resources like food assistance, because they can’t bill Medicaid or other insurance for that, or cut back hours to save on staffing, Feldpush said. One hospital that she works with is considering dropping a contract to have an obstetrician experienced with high-risk births on call at all times, because it has to weigh the benefit to patients against the $1 million annual cost, she said.

That said, new revenue almost certainly has to be a part of the solution for Denver Health. Lynne said the system has unsuccessfully sought to recoup money for care given to people from other counties. About 68% of the hospital’s uncompensated care went to Denver residents, 30% went to people from other Colorado counties and the rest was for people who live out-of-state.

In theory, Denver Health could at least partially solve its chronic revenue shortfalls by attracting more patients with commercial insurance, which pays more than Medicare and Medicaid. But the hospital’s clinics are largely located in low-income areas, and most people aren’t willing to travel far out of their way for care — with the exception of the uninsured people and non-English speakers who come from surrounding counties because they feel more comfortable at Denver Health, Lynne said.

“We’re not in Cherry Creek,” she said. “Your geography partly determines your destiny.”

Bringing in commercially insured patients can be a valid option, but only if a hospital has significant capital on hand to build or purchase facilities in affluent areas — which doesn’t appear to be the case for Denver Health, said Kane, of Harvard’s School of Public Health. Another option is to affiliate with another system that’s willing to subsidize them, but not many profitable systems are looking to ride to a safety net’s rescue, she said.

In addition, Denver Health doesn’t have a lot of open appointments or beds to take additional patients, even if people with insurance suddenly decided to seek care there, Lynne said. That leaves two levers: increasing what the hospital gets paid for caring for Medicaid patients, and making sure it gets paid something for care to the uninsured, either by signing them up for Medicaid or through additional government funding.

“I think the city needs to recognize the dimensions of this uncompensated care problem,” Lynne said. “There’s no question that the work we do benefits the city, and the metro area, and other hospitals.”

So far, efforts to raise public support have yet to yield results, other than the $5 million one-time payments from the legislature in 2023 and 2024. During a City Council committee meeting in January, Stephanie Adams, Denver’s deputy chief financial officer, spoke about giving further support to the hospital as a worthwhile endeavor, but not one that gives the city an obvious win.

“For an additional million, or an additional $10 million, what investments can we make in our community?” she said. “Not that it’s not worthy to provide additional money to safety-net hospitals, there’s just no additional thing that we get.”

Councilwoman Shontel Lewis said she believes Denver needs to contribute more, but it can’t close Denver Health’s gap in uncompensated care, which was about $109 million in 2023. Last year, she unsuccessfully proposed increasing the city’s $30.8 million annual contribution by another $15 million, but council members are still discussing what might be feasible this year, she said.

Denver purchased an additional $94 million in services from Denver Health in 2023, including paying for health care at the city’s jail, and has contributed about $230 million for capital projects over the last 20 years, city spokeswoman Swartz said. The city also is working with Denver Health to see how else it could help, she said.

“The structural issues facing the hospital’s finances are complex and beyond the scope of what can be addressed through the city’s annual budget. They are also not unique to Denver Health but can be found in safety-net hospitals across the country,” Swartz said in an email.

Mayor Mike Johnston was unavailable for an interview, but released a statement saying Denver Health is a “key partner” in improving Denver’s health and reducing homelessness.

“The city will continue to work closely with and advocate for Denver Health at all levels to ensure our safety net hospital remains a hallmark of our community,” he said in an email.

Lewis said she floated the idea of seeking a congressional earmark to help fund Denver Health, and that other local governments need to pitch in.

“It shouldn’t fall entirely on the shoulders of Denver,” she said.

A spokesman for Rep. Diana DeGette, a Democrat who represents Denver, said that under current congressional rules, members can’t add earmarks to the health and human services budget. Even if that were to change, each lawmaker gets a limited number of earmarks and has to decide among competing priorities, he said.

DeGette did introduce a bill that would give states more flexibility in how their governments distribute Medicaid supplemental funds, allowing them to consider whether a hospital offers other services like ambulances and dentistry, said Jeremy Springston, director of reimbursement at Denver Health. The bill doesn’t include any additional funding, though, so it’s unlikely states would make changes that shift dollars from some hospitals to others, he said.

“Any potential changes at the federal level, that’s probably more in the long-term solutions,” he said.

The homeless coalition and Denver Health have been pushing for federal action to pay for care to migrants, because neither states nor local governments have the resources to make hospitals whole, Alderman said. So far, though, the federal government hasn’t responded, she said.

More aid isn’t forthcoming at the state level, either.

Rep. Shannon Bird, a Westminster Democrat and vice chair of the Joint Budget Committee, said the group hopes the Department of Health Care Policy and Financing, which runs the state’s Medicaid program, will work with Denver Health. The state government “will never have the resources” to plug the full budget hole, so everyone needs to find creative ways to fund the system, she said.

“We all recognize that Denver Health is that critical safety-net hospital not only to Denver but to the entire state,” Bird said. “We have a strong interest in making sure we do everything we can.”

If the state had to come up with money to fill in Denver Health’s 2022 loss of $35 million, it would have cost about what Colorado will spend on the Department of Labor and Employment in the .

The Colorado Department of Health Care Policy and Financing declined to make staff available to discuss how the agency could work with Denver Health, but issued a statement saying the agency would consider ways to bring in more federal Medicaid dollars to support the system’s work.

Hopefully, other hospitals will agree to take on a larger share of uncompensated care or would pay something toward Denver Health’s services, particularly if they get some prompting from the state, Bird said.

“Ideally, people in this space would see the benefits to working this out among themselves,” she said. “It’s in everyone’s interest that they be successful.”

The state has taken some steps to assist all hospitals that treat significant numbers of patients covered by Medicaid. The legislature by 2% across the board in 2022 and 3% in 2023 — an improvement, though not enough to fully cover the cost of most services.

The state also could change its formula for dividing up supplemental payments through Medicaid, which go to hospitals with disproportionate shares of uninsured and publicly insured patients, though it has no plans to do so this year. That wouldn’t necessarily be an easy step either, however, since any change would produce losers as well as winners.

Ultimately, Denver Health needs more money, and no level of government has a significant pot of dollars without competing priorities, Springston said.

“In the short term, there aren’t a lot of opportunities,” he said.

The Colorado Hospital Association is advocating for the state to increase the total supplemental funds available by increasing the provider fee hospitals pay, which could draw down “tens of millions” in additional matching funds, Lonborg said. While the hospitals would pay more upfront through provider fees, they’d also receive more in matching federal funds, meaning most would come out ahead.

“What we think is, we should try to raise all boats instead of one hospital here and there,” she said.

The Department of Health Care Policy and Financing said the board that oversees the provider fee could opt to raise it, but the state hasn’t done that in the past because it wants to leave some cushion to avoid overpayments. If the federal government miscalculated and sent too much money, the state general fund could be stuck repaying it.

For now, though, the only relief Denver Health is sure to get this year is the second $5 million payment that lawmakers approved earlier this session.

The state’s one-time payments are helpful to entities that have gotten them — and the Coalition for the Homeless wouldn’t turn that money down, if offered — but what Colorado ultimately needs is a commitment to fully fund care for its most vulnerable residents, Alderman said.

“Those one-time payments are not going to solve this problem,” she said.

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The hospital ordered a backup boiler from Texas and planned to run its heat and hot water systems off the second 50-year-old unit in the meantime. But 18 days later, on the morning of Oct. 30, that second boiler failed — and the backup was not yet in Denver.

The broken boilers forced Porter officials to evacuate more than 100 patients and to close the entire hospital for 10 days, state officials said. But in their public communication about the hospital shutdown, AdventHealth Porter officials never disclosed that one of the facility’s boilers had been taken offline because it failed an inspection weeks before the second unit broke.

The Denver Post discovered the report detailing the Porter boiler’s inspection during a review of records in Colorado’s state boiler database.

Hospital closures can complicate the care of sick people and they’re costly to hospitals’ bottom lines. They are a rare occurrence and lead to involvement from multiple local, state and federal agencies, including the federal Centers for Medicare and Medicaid Services and the state Department of Fire Prevention and Control.

Rachel Robinson, an AdventHealth spokeswoman, said in a written statement that the hospital’s operations team diligently administers regular maintenance checks of the building’s boiler operating system, but the string of boiler breaks was “a confluence of events” that led to the need to close the facility.

“We are now operating with triple boiler redundancy,” she said in a statement.

Colorado’s chief Bob Becker said the crisis likely was “a run of real bad luck.”

However, one health care economist told The Post that it would be fair to question AdventHealth Porter’s risk-management strategy and its financial well-being after the closure.

Hospital closures due to failed equipment are rare and avoidable, said Ge Bai, a professor of health and policy management at Johns Hopkins University in Baltimore.

“As hospital management, it����ap your job to make sure risks are mitigated,” Bai said. “It’s fair to blame management.”

Porter is a private, nonprofit hospital and is not required to disclose its financial statements. Robinson declined to share them when asked by The Post.

“Not safe to operate”

On Oct. 12, a boiler inspector working for a company that insures the hospital discovered serious problems with one of Porter’s boilers during a routine inspection.

“This boiler is not safe to operate,” the inspector wrote in a report on file in the maintained by the Colorado Department of Labor and Employment’s Division of Oil and Public Safety.

The state issued a deficiency notice to Porter the day after the Oct. 12 inspection that said the boiler was in violation of state regulatory laws and the hospital had 60 days to fix it. Failure to repair boilers can carry criminal charges or result in fines of up to $1,000 for every day the boiler remains broken.

Tubes on Porter’s boiler had failed and those broken tubes were clogged with cement, according to the inspector’s report. Another part that provides insulation for the boiler had broken and had not been properly repaired, causing a hot spot to develop on a piece that insulates the boiler, the report said.

The boiler also had undergone three major repairs between June 2016 and August 2022 that would have involved welding, the inspection report said. Welding work on a boiler requires workers to have a special certification and those repairs must be signed off on by state inspectors, Becker said. The report did not specify what those prior repairs entailed and further information was not immediately available online.

The new problems discovered in the Oct. 12 inspection would not have required the state to approve any repair work because welding would not have been involved, Becker said. Once Porter made the repairs, hospital staff could turn the boiler back on and the hospital would be in compliance with state law.

At no point was the damaged boiler a public safety hazard, Becker said.

“From what I understand, these conditions were found during the internal inspection and that����ap the purpose of the internal inspection: to identify anything that needs correction,” he said.

The second boiler broke on the morning of Oct. 30.

Robinson’s statement said the unit “unexpectedly failed due to extreme temperatures.” Becker said a tube split, causing a leak.

Required boiler inspections

The 45,000 boilers registered in Colorado are inspected twice a year — once for external problems and once for internal problems. Internal inspections require facilities to shut off the boiler so inspectors can look inside, Becker said.

About 40% of the inspections are performed by state employees and the rest are conducted by insurance companies. But those insurance inspectors have the same credentials as the state inspectors and are approved to work within the state’s system, Becker said.

Porter’s second boiler had been inspected on Sept. 19 and no deficiencies were found. A certificate to operate was granted, according to Colorado’s boiler database.

Both boilers were built in 1973, according to state records. It’s not unusual for 50-year-old boilers to still be in operation because they are built to operate for a long time, provided they are properly maintained, Becker said.

When Porter officials realized one of the hospital’s boilers would be out of commission for repairs, they ordered a rental boiler to serve as a backup, Becker said. But it did not arrive before the second boiler broke.

“In order to retain redundancy, they had ordered the temporary boiler,” Becker said. “It just hadn’t made it there yet.”

Porter officials ordered an emergency backup from American Steam Incorporated in Wylie, Texas. That company loaded a boiler onto a flatbed trailer and drove it to Denver.

It arrived by 4 a.m. Nov. 1, and engineers from American Steam flew into town to start it, according to a news release from the company. By Nov. 3, the hospital had the heat, hot water, steam and sterilization capabilities that are necessary for its operations, the news release said.

Porter plans to permanently operate with three boilers, Robinson said. A third permanent boiler eventually will replace the temporary unit.

Porter had to undergo inspections from multiple state agencies before the hospital could reopen. The facility resumed clinical services on Nov. 9 and elective surgeries restarted Nov. 13, according to an email from Gabi Johnston, a spokesperson for the Colorado Department of Public Health and Environment.

Hospital closures are very rare

It is exceedingly rare for a hospital to evacuate patients and temporarily close, said Scott Bookman, the state health department’s senior director for public health readiness and response.

The last time a Colorado hospital evacuated all of its patients was Dec. 30, 2021, when Centura-Avista Adventist Hospital in Louisville was threatened by the raging Marshall fire. But that was an external crisis.

In 2010, Rose Medical Center in Denver evacuated patients after its backup generator failed during a power outage caused by a transformer blowout in the neighborhood.

“These happen a couple of times a decade at the most because of an issue internal at the facility,” Bookman said.

The patient evacuation went smoothly, said Elaine McManus, director of the state health department’s Health Facilities and Emergency Medical Services Division. State records show 125 patients were at the hospital for various services at the time.

Porter needed to transfer 77 patients to other facilities and found space for 70% of those patients at other AdventHealth hospitals in the region, Robinson said. Another 74 were discharged.

At no point were any lives at risk, McManus said.

“We had an awful lot of lessons learned over COVID and we set up systems that enhanced what our emergency response would have been prior to the pandemic,” McManus said. “I’ll sort of brag that we’ve gotten pretty darn efficient.”

Porter also was inspected by the Colorado Department of Fire Prevention and Control before it reopened, said Chris Brunette, chief of the agency’s fire and life safety section.

In 2018, Porter suspended surgeries for nearly a week after state inspectors learned it was not properly sterilizing surgical equipment, increasing the risk of infections for thousands of patients. The investigation was launched after a doctor found a bone fragment on an instrument during spinal surgery. That incident resulted in a lawsuit filed by more than 60 former patients.

The controversy surrounding the dirty surgical instruments followed by the broken boilers was alarming to Bai, the Johns Hopkins health policy and management professor.

Risk management at hospitals is imperative, she said. Executives need to run scenarios of what can go wrong and address problems before they emerge.

“It����ap a wake-up call for them to improve risk management. It����ap a warning for other hospitals,” Bai said. “It can blow up into a big event and you can have a big financial hit.”

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Ann Sassano, of Chicago, said her daughter was taken by ambulance repeatedly while being treated in Denver last fall, with about eight round trips to three different hospitals for emergencies. Their insurance, Blue Cross and Blue Shield of Illinois, said there were no in-network ambulance providers, meaning the family faced a $15,000 deductible for out-of-network care before the plan would start paying, she said.

Altogether, her daughter received about $20,000 in bills, which would have wiped out her savings, Sassano said. Though their insurance ultimately agreed to pay some of the bills, her daughter is paying about $30 a month to stay out of collections while appealing the remaining ones, she said.

“It’s just a very frustrating situation,” she said.

Blue Cross and Blue Shield of Illinois said it couldn’t comment on individual members’ situations, and that coverage is based on each member’s plan.

“Not all ambulance providers are contracted as in-network providers. Certain ambulance providers may charge amounts in excess of a member’s plan benefits, and this may subject members to a bill from the ambulance provider,” the company’s statement said.

Colorado law offers some protection from surprise bills to people with state-regulated insurance plans, but even they could still receive a larger-than-expected bill if an ambulance provider is a public entity. And of course, that doesn’t help people whose plans are federally regulated, or get their insurance in a different state. The federal No Surprises Act, which limits the circumstances where patients can receive a bill for a larger amount than their insurance covers, doesn’t apply to ground ambulances.

Most ambulance providers haven’t reached agreements with insurance companies on in-network rates, and since they have the option to bill patients for whatever their insurance didn’t cover, it doesn’t create a strong incentive to get into their networks, said Adam Fox, deputy director of the Colorado Consumer Health Initiative.

In fairness, though, there are legitimate concerns as-is about the financial viability of emergency medical response, especially for smaller and publicly owned units, he said.

“If you get in a ground ambulance, the chances are it’s out-of-network,” he said.

An earlier this year estimated about 59% of ground ambulance rides taken by people with private insurance were out-of-network in 2022, which was down from previous years. It didn’t specify how large those bills were, though had estimated averages of .

A found about 10% of working-age adults who reported medical debt said at least some of it came from an ambulance trip. Respondents could report more than one source of debt.

Sassano said the majority of the bills have been taken care of, but she’s still fighting three that total more than $4,000. One was from Denver Health paramedics when Sassano’s daughter was taken to Rose Medical Center, and two were from American Medical Response, for separate trips returning her to the  Eating Recovery Center and taking her to an imaging center so she could get a feeding tube placed in her abdomen.

American Medical Response said that its records showed Blue Cross and Blue Shield of Illinois sent a check to the Sassano family instead of paying the ambulance service directly, which is confusing for patients. Colorado could reduce the odds of that happening by requiring insurance companies to pay ambulance providers correctly, it said in a statement.

“AMR recognizes the complexity of what happens after an emergency illness or injury and has a dedicated team of patient advocates to assist our patients through the transport billing process. If a patient is experiencing a financial hardship, we work with them to find equitable solutions,” the ambulance service’s statement said.

In some cases, their insurance company agreed to cover the trip to an emergency room but not the trip back, or vice versa, Sassano said. In one case, it paid half of the bill for a ride with Denver Health paramedics to University of Colorado Hospital, but didn’t explain why the other half wasn’t covered, she said. Their insurance opted to pay the other half of the bill more than a year after she went in the ambulance.

“There’s no rhyme or reason to it,” she said.

April Valdez Villa, a spokeswoman for Denver Health, confirmed someone had called 911 requesting help for Sassano’s daughter on the dates Sassano named, but said she couldn’t discuss the trips because of privacy concerns. It’s the paramedics’ job to figure out if the patient needs to go to a hospital, but that’s separate from how insurance companies decide what they will and won’t cover, she said.

Sassano said, as far as she can tell, whether a bill is covered may come down to whether someone at the emergency room checked the right box. While not every time her daughter was transported may have been an emergency by their insurance’s definition, she also wasn’t given the option to just call a cab, she said.

“She had absolutely no choice,” she said.

That’s typically the case when patients are transferred between facilities, which means there isn’t much that people can do to avoid significant bills before getting in an ambulance, Fox said. The main option is to go through the insurance company’s process of challenging a bill, or to complain to the Colorado Division of Insurance, he said.

“It’s always important for people to understand they can appeal,” he said.

Sassano said she’s fortunate to be able to assist her daughter with handling the appeals, because it’s taken more than a year, sometimes involving hours on the phone at a time. Not everyone can do that, meaning they may end up stuck with bills they can’t pay, she said.

“You’re at their mercy,” she said. “This is how people go homeless.”

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When Maj. Gen. Maurice Rose, who lived in Denver, was killed in a World War II battle in Germany 78 years ago, his death and service to his country were front page news. Over the years, Rose’s stature and story dimmed from the public consciousnesses, but a newly dedicated memorial sculpture casts Rose, and his accomplishments, in a new light.

At the time of his death, on March 30, 1945, and in years that followed, Rose, who was raised the son of a rabbi, was the talk of Denver, as well as Jewish and military circles. His men loved him so dearly, they raised funds, along with local Jewish leaders, to build a hospital — The General Rose Memorial Hospital, now known as Rose Medical Center — to honor the general who made the ultimate sacrifice, giving his life on the battlefield. Gen. Dwight D. Eisenhower came to Denver twice in 1948 and 1949 to be involved in the dedication of Rose hospital.

As the years passed, however, the memory of Rose’s valor and sacrifice faded.

A portrait of Rose and an encased display of his World War II helmet, with two bullet holes in it from his shooting death, inside the lobby of the hospital were removed in 1973 during a remodel of the facility, said Marshall Fogel, 82, a retired attorney. The memorial items didn’t return when the remodel was complete.

“I always remembered the helmet and the portrait as a young boy,” said Fogel, a lifelong Denver resident who authored a book, “Major General Maurice Rose, The Most Decorated Battletank Commander In U.S. Military History” that was published in 2018. “As a young boy, I played soldier and army, like a lot of kids. I always wondered about General Rose, but never knew much about him.”

Fogel’s youthful lack of knowledge about Rose changed dramatically over the years. Fogel is among a growing number of locals who champion the memory of Rose and the general’s service to the nation.

In 2019, Paul Shamon, a Denverite and history buff, attended a lecture by Fogel. Shamon soon contacted Fogel and the two men agreed to pay renewed homage to Rose and reacquaint the public with the general and his feats.

Both of Shamon’s children, now adults, were born at Rose Medical Center.

“I thought, like many other people, that Rose Hospital was named after a flower,” Shamon said. “It was crazy, nobody knew who he was, and we should change that.”

The pair worked together to commission a 10-foot-tall bronze statue of Rose designed by and architect Seth Rosenman, which was dedicated at an April 16 ceremony that included members of Rose’s family in Lincoln Veterans Memorial Park west of the Colorado State Capitol. Fogel and Shamon drove the statue project from conception to completion. The sculpture is the only state monument in Colorado to honor a Jew, Shamon said.

Born on Nov. 26, 1899, in Middletown, Conn., Rose was 3 when his family moved to Denver. He attended East High School and enlisted in the . A second lieutenant at age 18, Rose was assigned overseas, to the in World War I and was wounded in France. While in the hospital being treated for shrapnel wounds, Rose listed his religion as Protestant and maintained that record throughout his military career, according to . There is no record that he formally converted.

“A lot of Jewish soldiers did that,” Shamon said. “In those days, there was so much anti-Semitism in the military, he likely wouldn’t have rose to be a general.”

Rose returned to the United States from World War I as a captain, eventually marrying Virginia Barringer and fathering a son, Maurice Roderick “Reece” Rose. He went back into battle for World War II, where he commanded the and became the highest-ranking American officer to be killed in action in Europe. He was also the highest-ranking Jewish officer in the U.S. Army.

On the day of his death, Rose and his staff, surrounded by Nazi troops, were attempting to surrender. A German tank soldier shot Rose, killing him instantly. Rose’s personal aide, Maj. Robert Bellinger, witnessed the shooting. In news reports, Bellinger said that Rose, who habitually rode with the advance elements of his command, had his driver turn around to check on reports of some men cut off behind them. Barreling down a road they thought had been cleared, their Jeep encountered a column of German tanks, so they fled across a field, only to run into more Tiger tanks.

Rose got out and walked with arms raised toward an armed tank soldier, while Bellinger followed. The Nazi soldier shot Rose dead. Bellinger made a dash for the Jeep, yelling at the driver to take off and they escaped. American forces returned to recover Rose’s body. He was 45 when he died, leaving behind his wife and son.

Prior to his death, Rose lead many a charge with the 3rd Armor Division, which was the first division to cross the German border, the first to capture a German town, and the first to capture a major German city, .

Rose’s division, during the winter of 1944-45, helped stem the German advance in the Battle of the Bulge. The 3rd captured Cologne on March 7. Less than a month later, the division made the longest one-day advance, 100 miles, through enemy territory by any Allied division during the war, according to Falk Kantor in a story published by Jewish War Veterans.

Rose was awarded the Distinguished Service Cross, Distinguished Service Medal, and Purple Heart with an Oak Leaf Cluster among other medals and awards during his life of service.

On a cloudy May day, Gilbert and Barb Cerise, of Seattle, were visiting Denver and took in the Major General Maurice Rose Monument in Lincoln Veterans Memorial Park.

Barb, who was born in Wray, attended the University of Colorado School of Nursing in the mid-1960s. Her dormitory was close to Rose Hospital and she worked multiple rotations at Rose as part of her schooling.

“I didn’t know that,” she said of Rose being the namesake of the hospital. “I think it’s amazing, it’s a great part of the heritage of our state.”

Gilbert Cerise, 79, who was raised in Montrose and spent time in Denver, didn’t know of or recall Rose prior to seeing the monument.

“I’m proud of them,” Gilbert said of veterans, especially those who died in battle. “They did a great service for our country.”

Rose is buried in the , The Netherlands, along with more than 8,000 U.S. servicemen who died in WWII.

Editor’s note: This story was updated on May 30 to correct Rose’s birthplace, he was born in Middletown, Conn. 

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The break was in a 30-inch conduit that brings water to smaller water main lines, and Denver Water said crews will work to repair the break throughout the day.

The break has been isolated and crews will work on repairs throughout the day. PLEASE AVOID THE AREA.

There are no customers out of water due to this main break. We'll provide more info as it becomes available.

— Denver Water (@DenverWater)

No customers are without water.

Denver Water asked people to avoid the area while crews work.

Dr. Michelle Barron, senior director of infection prevention and control at UCHealth, said about half of the system’s female patients between the ages of 18 and 44 have been pregnant so far this year. During the 2019-2020 flu season — the last normal one before the pandemic — only about 17% were, which is more typical, she said.

“Seventeen percent to 50% is a huge jump, based on historically what we’ve seen,” she said.

also shows a disproportionate share of hospitalized patients of childbearing age were pregnant. The CDC defines patients with childbearing potential as girls and women ages 15 to 49, and has found about 40% of those hospitalized in that group were pregnant at the time they got sick.

In previous seasons, the CDC only collected data on pregnancy up to age 44, so comparisons over time aren’t exact. Still, it appears the odds a severely ill patient will be pregnant have increased compared to the 2018-2019 flu season, when about 26% of those hospitalized in that group were. The data comes from .

The CDC estimated about 47% of people who were pregnant as of December , down from 62% in December 2019. The estimates are based on electronic health records from nine systems, however, so they may not represent the situation everywhere.

This season’s dominant flu strain, H3N2, is one that the world has seen before and which isn’t specifically worse for pregnant people, Barron said. That suggests low rates of flu vaccination may be driving the difference, since misinformation about the COVID-19 vaccine spilled over into general hesitancy among pregnant women, she said.

“Flu is here, and is behaving like it did before,” she said.

During pregnancy, the body suppresses its T cells, the part of the immune system that identifies invaders and tries to destroy them, Barron said. That prevents the immune system from attacking the fetus, but leaves both mother and baby more vulnerable to infections, she said.

People who are pregnant were than nonpregnant people with the same age and chronic conditions (or lack thereof), and certain types of are particularly risky during pregnancy.

“The number of deaths in pregnant people from COVID was mortifying, because these are young, healthy people,” she said.

The B cells, which produce antibodies, continue to work well throughout pregnancy, though. That means that a pregnant person will typically develop a normal protective response after being vaccinated, Barron said. While there are a that pregnant women can’t receive because they contain a live virus, the flu shot isn’t one of them, and it’s recommended for anyone who is pregnant, she said.

Not all Colorado hospitals saw an increase in pregnant patients with flu.

Denver Health reported the number of pregnant women with flu in its hospital was in line with previous years. HealthOne, which owns seven general hospitals in the Denver area, reported a small increase in pregnant flu patients earlier this season at Rose Medical Center, but said the other locations have seen typical volumes.

Dr. Susan Lipinski, an obstetrician-gynecologist at Presbyterian/St. Luke’s Medical Center, said she encourages anyone who is pregnant or planning to be in the near future to get the flu shot as soon as possible, even though it’s now later in the season.

The shot reduces the odds of complications for both the mother and the fetus and offers the baby some protection after birth, she said. Babies can receive the flu shot once they’re 6 months old, but are at elevated risk from the virus until that time.

“The flu vaccine is safe in any trimester of pregnancy,” she said. “I have taken care of patients in March or April (the last months of flu season) with severe influenza.”

In addition to altering the immune system, pregnancy puts extra stress on the lungs, which makes respiratory viruses particularly risky, Lipinsky said. The lungs are being asked to take in more oxygen to support the fetus, while at the same time they have less room to expand because of pressure from the growing uterus, she said.

In the worst cases, the baby has to be delivered early to give the mother’s body a better chance of fighting the virus, Lipinsky said. Even in less-severe cases, a fever , particularly if it comes during the first trimester, when important organs are forming.

In addition to getting the flu shot, people can protect themselves by avoiding others who are sick, wearing masks in crowds, washing their hands frequently and seeing a doctor about antiviral treatment if they get infected, Barron said. While the current flu wave is going down, it wouldn’t be unusual for a different strain to start circulating later in the winter, she said.

“Flu season is not over,” she said.

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The incident happened on Sunday, police said in a Wednesday tweet.

Brandon Camacho, 31, was arrested on investigation of theft from a motor vehicle at the City Set underground parking garage, 600 S. Colorado Blvd., and at AMLI Apartments, 801 S. Cherry St., police said.

While in custody Camacho “became unresponsive,” police said, and he was taken to Rose Medical Center where he fought with staff and officers and escaped.

Anyone who knows of Camacho’s whereabouts is asked to call police at 303-639-4328.