Just Read: State of Transgender Person Health, the dawn of primary care in Colorado

This is a new report published by One Colorado (@One_Colorado) that’s a non-randomized survey of 417 transgender and gender nonconforming Colorado residents. Even though it’s not randomized, that’s a pretty large sample size for this population. A few findings that caught my eye:

Survey participants reported being much more likely to have a college degree, yet were more likely to be out of work or living in a low-income household than the general population, leading to shocking income inequality for transgender Coloradans.

The Dawn of Primary Care for People who are Transgender

In the health space I noticed some metrics about the impact of having regular primary care that’s inclusive (which 61% of respondents report, contrasting to 88% of physicians who reported comfort in a previous survey):

Impact of having an inclusive provider on mental health

The data regarding mental health for this population tracks what I have seen in previous surveys in terms of high suicide rate attempt – Just Read: The exceptionally higher suicide attempt rate for trans* persons who have sought medical care | Ted Eytan, MD – although the questions in this survey and the one before it are slightly different. It isn’t known for sure what aspects of medical care may improve mental health, it’s just known that there are significant problems that are not being addressed.

The “dawn of primary care” part is the fact that access to medical care is now being measured, and is measurable, because of Colorado’s leading position in assuring medically necessary care for the LGBT community, much like Washington, DC (have to put in a plug for the #epicenter).

The Colorado Independent (@coindependent) story on this report mentions the example of a patient who know has regular (and comprehensive medical) primary care through… Kaiser Permanente Colorado (@KPColorado), where it denied at the VA (see: Thanks for publishing my photo and a bright spot in transgender person health, Colorado Independent | Ted Eytan, MD)

The second part is the fact that with regular primary care, a lot more appropriate medical care for total health will be administered, so “transgender person health care” will just be “health care.” For example, conventional wisdom is that every transgender man should have a hysterectomy, because it is unlikely that they will receive regular cervical cancer screening, because of a host of factors. This is partially based on inadequate access to care and inappropriate treatment in the health care system, and may change.

As more people are able to live, there are more people who they’ll know / Gallup – behind the times….

Gallup has been tracking this question for 30 years:

Do you have any friends or relatives or coworkers who have told you, personally that they are gay or lesbian?

As predicted, the numbers have flipped, the the majority of Americans currently “do.” (See this nice graph over at The Economist)

The Gallup (@Gallup) behind the times part is that the question excludes people who are transgender, and I’d argue, most of Gallup’s site does – the heading of this section is “same-sex relations” and the URL is “gay-lesbian rights”, where’s the rest of LGBT?

Even though we don’t have the data today (I hope we’ll start collecting it), it’s likely that we’ll see a same trend in terms of knowing someone who is transgender. This will be accelerated by access to medical care because more people will get to live in their identity, in good health, with employment, and the rest will be history….

I did a quick look and I actually can’t find a poll question anywhere that asks “Do you currently know someone who is transgender?” – if anyone out there knows of one please contact me or add a comment, thank you! And thanks One Colorado for documenting the state of health and its future improvement.

Thanks for publishing my photo and a bright spot in transgender person health, Colorado Independent

Today, Winners is employed as an engineer and has health insurance through Kaiser Permanente (Colorado).

The insurer gives transgender clients a list of preferred providers trained in transgender-specific care.“The biggest change is actually having a primary care physician that’s not only educated about transgender health care but passionate about advocating for transgender people,” Winners said.Winners’s latest health care experience is indicative of major ground won by transgender people and their advocates. Even so, her previous experience of exclusion still persists for many in the transgender community.

Thank you, Colorado Independent (@coindependent) and Tessa Cheek (@TessaCheek) for highlighting challenges in transgender person health as outlined in the new One Colorado Report “Transparent” (separate post coming on that), AND an example where a change in approach is happening, as described above. Congratulations, Kaiser Permanente Colorado (@KPColorado) in being a leader. I am familiar with their work and it’s impressive.

Here’s the rest of the story, published verbatim, because The Colorado Independent allows republishing of their content, just like I do. I really like the 21st Century, don’t you? 🙂

Thanks for publishing my photo for this story, taken in Washington, DC, March, 2013 – View on Flickr.com

Link to the original: Report: Transgender Coloradans still struggle to receieve adequate health care | The Colorado Independent, and

Thanks for publishing my photograph to illustrate the story. It was taken in another 21st Century Place, Washington, DC, USA, where people believe anything is possible, because it is.

A lot has changed for Kallie Winners since she first sought medical treatment to begin her male-to-female transition in 2011. Winners, who spent 10 years in the military, initially visited Denver’s VA Medical Center where she quickly discovered doctors had not been trained to treat transgender patients. She was ultimately denied care.

“It’s hard to describe to somebody who’s not transgender what it’s like to live your entire life in a body you don’t recognize,” she said. “To go to the place where I felt I could get care, which was the VA, and to be denied was awful. It was so awful, I didn’t step foot in a VA for the next three years.”

Even though she was finishing college, Winners ended up paying for her transition out of pocket at an average annual cost of $1,800.

Today, Winners is employed as an engineer and has health insurance through Kaiser Permanente. The insurer gives transgender clients a list of preferred providers trained in transgender-specific care.

“The biggest change is actually having a primary care physician that’s not only educated about transgender health care but passionate about advocating for transgender people,” Winners said.

Winners’s latest health care experience is indicative of major ground won by transgender people and their advocates. Even so, her previous experience of exclusion still persists for many in the transgender community.

A new report from LGBTQ rights organization One Colorado entitled Transparent sheds light on the successes and challenges transgender Coloradans have found in the rapidly evolving health care system. The passage of the Affordable Care Act (ACA or Obamacare) and Colorado’s decision to expand Medicaid led to some of the more radical changes in accessibility.

“The ACA includes gender identity in its nondiscrimination clause,” said Leo Kattari, the Health Policy Manager at One Colorado, noting that state statute makes a similar prohibition.

“At the state level, it gave those of us in Colorado the opportunity to work with the Division of Insurance to release a bulletin saying that exclusions in health care policies targeted to transgender people is discrimination.”

Since March 2013, when bulletin B-4.49 was released, Kattari says transgender patients can no longer be denied care or asked to pay more for it than everyone else. 

“Testosterone, for example, was covered for a cis man. But a person who is female to male would go to a doctor for a testosterone prescription and get denied. That’s blatant discrimination,” said Kattari.

Though Colorado is one of just seven states with similar protections for transgender patients, it’s one of 27 states, plus Washington D.C., to expand Medicaid.

Kattari noted that the expansion has lead to an 8 percent jump in the number of transgender Coloradans with health care through Medicaid since 2011.

“That’s a huge jump,” Kattari said. “But income disparity is part of why a lot of folks now qualify for Medicaid.”

Indeed while the new One Colorado report indicates that the overall number of transgender Coloradans with healthcare has jumped from 73 percent to 86 percent since 2011, far fewer of them receive benefits through their employer than cis Coloradans. In fact, transgender people are more than twice as likely to rely on Medicaid, in large part due to astonishing income and employment gaps:

Screen Shot 2014-11-13 at 1.17.06 PMScreen Shot 2014-11-13 at 1.17.15 PM


As a result, though coverage has improved, transgender Coloradans are still uninsured at higher rates than the general population (14 percent to 11 percent) and 40 percent still say cost is their primary barrier to accessing care.

Perhaps unsurprisingly, given the history of structural exclusion in health care, just under a third of transgender Coloradans say fear of discrimination is the second-biggest barrier to their accessing care. Kattari notes that discrimination against transgender people is hardly limited to the doctor’s office but extends into the everyday, from navigating social norms surrounding gender presentation and public bathroom use to being routinely addressed with the wrong pronoun. The net effect of exclusion from care and often daily discrimination paints a troubling picture of mental health for those in Colorado’s transgender community.

Screen Shot 2014-11-13 at 2.43.14 PM

“These high levels of depression and anxiety are not because folks are transgender, but because of repeated experiences of prejudice and stigma,” said Kattari. “It’s hard to find a doctor who knows to ask for your preferred name and pronoun or is willing to prescribe hormones. To get access to a provider you trust is hard.”

One Colorado did find that having an inclusive provider was a serious indicator of better mental health among transgender people, though it didn’t bring patients mental health totally in line with the general population. For example, transgender people with an inclusive provider were half as likely to have attempted suicide in the past year, but still seven times more likely to have attempted than the general population.

“Until the medical community understands who transgender people are and has studied the data on the health disparities they face, transgender Coloradans’ health care needs will never truly be addressed,” Kattari concluded in the report’s release. “We have worked hard to begin tackling the barriers that transgender Coloradans face in our health systems, but there is much more work to do to ensure that all of us are receiving the care and the coverage we deserve.”


[Graphics from the Transparent report. Lead photo by Ted Eytan

Photos Friday: GlassMakesFriends across the USA

Ben Chatelain (@phatblat), Senior iOS Developer, Kaiser Permanente Mobile Center of Excellence (View on Flickr.com)

This is the final batch of photos from my Google Glass (@projectglass) across America experience. I really enjoyed introducing friends, new, and not so new, to Google Glass for the first time and seeing their reactions. Technology is meant to bring people closer together, and that’s what I experienced here. It was great.

#GlassMakesFriends – click any photo to enlarge

And here are the rest of my photos, taken with a regular camera of my journey involving Glass. As I mentioned in the companion post to this (The USA #ThroughGlass – Photos | Ted Eytan, MD) I learned a ton about America on the journey. What a wonderful country still so full of promise :).

Of course comments welcome, what would you like to do with Glass? I’d like to hear ideas beyond the typical.

For example, several people commented that my #throughglass photos showed them a perspective that they had not experienced before – that of a 6 foot tall person walking around. If you’re not that height, the world looks different to you. What else?

Presentation: Why be Social (Media) – Kaiser Permanente Colorado – “Destination Leadership”

I realized when I uploaded this presentation to Slideshare that it didn’t have a title, so I made one up just now. Everything doesn’t have to have a title, does it?

I was invited to be a part of a great learning program put on by the HR/Talent team at Kaiser Permanente (@KPColorado) yesterday, for all the managers in the 6500-person, 550,000 member-health-improving, every-day-innovating organization.

I was joined by one of my mentors in this honor as well, Diane Gage-Lofgren (@dianelofgren), who you can see on stage telling a personal story about her journey to take risks while taking great care of people, in addition to a roster of leaders across the spectrum of industry and the generations.

As it shows in my slide deck below, you’re more than worth it for all that you do, Kaiser Permanente Colorado!

I’ve included the video snippet that features Regina Holliday (@ReginaHolliday) talking about what she’d like from health care in social media. There’s a little bit of science in there about social networks, which I’ll expand on in another post. 

The last slide’s call to action brought me pages of SMS’s that I am just looking through now – we learn a lot in integrated care, every day, as I suspected 🙂

Enjoy, comments welcome.

The USA #ThroughGlass – Photos

I am on my way to spend time with colleagues at Kaiser Permanente Colorado (@KPColorado) to discuss leadership and communication, and decided to take the journey through the perspective of my actual eyes, wearing Google Glass (@ProjectGlass).

I was actually inspired by our DC friends at Silica Labs (@silicalabs) who wrote a nice piece of glassware that sends Glass photos right to WordPress, no need to go through the Google cloud. I set up a blog to try it out: GlassBlog | Life #throughglass.

Since I write this blog about what I learned the day before, I can say that I learned a lot about the United States yesterday. The Glass device does offer a different perspective than a regular camera, see what you think.

Click any photo to enlarge, and see you in Denver.

Ok, back to taking photos, including of new Glass friends, technology brings people together to talk about the future 🙂

What member / patient engagement looks like #iRetreatKP

When people ask me to talk to them about “patient engagement,” I admit, what’s going through my head is, “I think you’re asking me to tell you how to listen to people?” I don’t believe “engagement” is “rephrasing things so patients do what we tell them” or “telling patients what we’re working on so they can lower their expectations.”

Thanks to Barry Gutierrez Photography, I can tell a lot of my colleagues agree with me. These are the photos from the session I mentioned previously: (#iRetreatKP – My favorite things are Member Voice and Mentorship | Ted Eytan, MD) Look at them and how they are not sitting at the table rounds – some are sitting on the stage itself, as four articulate people we serve, from GenY to Baby Boomer, tell us how much they want us to be the best we can for them.

So it’s not just the patients who are engaged in this room at the Kaiser Permanente Innovation Retreat :).

Thank you again, Farooq, Mackenzie, Regina, Brian, and my colleagues who stood to listen and learn.

#iRetreatKP – My favorite things are Member Voice and Mentorship

Voices of Members For our Health (view on Flickr.com)

I just got back from this year’s Kaiser Permanente Innovation Retreat (#iRetreatKP) and am so delighted that I had the opportunity to do the two things I enjoy the most with so many people I enjoy the most: Bring the member/patient voice into the conversation, and mentorship.

I stress the word “opportunity” because the retreat is not my event (it is hosted by our Chief Information Officer, Phil Fasano – @fasanophil ), and I collaborated with a lot of people, most notably:

The members

We have over 9,000,000 of them, and Farooq Qureshi, Mackenzie, Regina Holliday (@ReginaHolliday), and Brian Swart, are four examples of how exceptional each one is. In reality, they do all the work, achieving their life goals supported by optimal health. What we are doing is respecting their contribution.

We did a few innovative things on this special panel in addition to the nationally recognized hug timer. We did a “turn the panel into the audience” at the end when they asked Kaiser Permanente the questions, and Danielle Cass (@DanielleCass) was on hand to create just the right amount of tension. Oh, and I asked everyone to come right to the stage, bring a chair, stand or sit, to be as close to the people we serve as possible. Pacing, moving around, light calesthenics are all fine, tuning the neurochemistry for a lasting impression.

This is the first group of members I have hosted that span the generations, from Gen Y all the way through Baby Boomer. And guess what, they defy stereotypes, they have as much in common as they do not, and the things they ask for are a what we are here to do anyway.

I don’t have photographs of the actual panel because I couldn’t shoot photos and facilitate at the same time :). I’m working to get some that were taken by our professional photographer and will put those up when I get them. It was gratifying to see the videographer nudge their way into the crowd to capture what was happening, and then tell me later that our members’ voice was meaningful for them, too.

Reminder of a few tenets of member/patient inclusion (and yes, we get the badge):

  • Any member is better than no member.
  • Don’t spend time looking for the “right” member to participate. They are all the right member.
  • Don’t say you couldn’t find anyone or that they are too busy to help you. They will help, all you have to do is ask.
  • Inclusion means listening as much as talking.
  • Listen. Really listen. And then teach back. Just like we ask them to do with us.

The mentors

I have at least 9,180,000 of those (members + Kaiser Permanente staff + all of Washington, DC + … ) too, with a few special ones in attendance and in leadership.

Katie Rovere (@katierovere) and I have been in a Co-mentorship relationship (GenY/GenX) for a year now, and she was present and leading a conversation about Generation Y in the workplace, as Board Member of GenKP, the Business Resource Group for Generation Y employees. GenKP, by the way, was just honored in Forbes magazine as #3 on this list: The 10 Companies With The Happiest Young Professionals – Forbes.

When Katie and I began our journey, I don’t think we could have imagined that her work would become so recognized in our organization and across the nation. The best part is, she did it herself.

I have many other co-mentors and I aspire for people to call me co-mentor, too. Here are the photographs of just some of those people.

The secret to failure is bouncing a ball alone, so why would we want to do that? Luckily, we don’t have to. Partnership always works better.

Thanks a ton to April Kennedy and Deanna Konrath from Kaiser Permanente Information Technology for creating the space for all of us to serve better in.

Participation in Science, too – at the Denver Museum of Nature and Science

It’s an often repeated refrain in my life : “I’m not that smart, my ideas are not unique, if someone is doing something better than I, I’d like to know about it.”

Luckily there are people like Steve Krizman (@SteveKrizman) , Diane Gage-Lofgren (@dianelofgren) and really a community of curious people who have the same philosophy. With that in mind, Steve and Diane brought us (myself, Keith Montgomery, Karen Blair) to the Denver Museum of Nature and Science (@DenverMuseumNS) to see the Expedition Health exhibit there , which also happens to be supported by Kaiser Permanente’s Community Benefit.

Expedition Health has won major awards for Visitor Experience. What better place to learn about experience outside of health care, then. We were guided on our tour by a most impressive scientist, Nicole Garneau, PhD who has an accessible twitter alter-ego in @YoPearlSciGirl . Nicole is actually the Curator and Department Chair in Health Sciences, and she has what I have been calling lately, a very high humility/high accomplishment ratio. She’s passionate about science and about citizen participation in science. Let me understate things a bit and say that she’s an off-the-charts role model for women in science, and science in general.

I had heard about participation in medicine / health care (of course), but not in science. Nicole is a grant funded researcher and operates The Genetics Lab, which is

the first community-based and community-run genetics lab in the country

They are serious about participation here, and not just for participation sake. In The Genetics Lab, they are working together, as a community, to unlock the science of taste. If you have an interest in health and obesity prevention, it doesn’t take long for you to venture into the science of taste. To see that some of that science is being generated here by people who feel involved in the answer is a great thing. 

As Nicole explained to us, the exhibit is tuned for involvement, and in promoting a person’s body in the positive. As I did a little research for this blog post, I found some information on Participatory Mueums and Participatory Science Centres. As I live in a city with a lot of museums, I have noticed this type of design more and more, and I didn’t realize how much I could learn from it until I saw it a little behind the scenes.

The other often repeated refrain for me is “as usual, I saw lots of analogies to clinical medicine.” The reason we are on this quest, by the way, is because we want to know what supports the people we serve in experiencing a healthy future for themselves, their communities, and society. The right experience allows the people we serve to leverage excellent medical care to achieve their life goals, and if health care has the ability to contribute to creating that, it should. With a national budget of $2.7 trillion dollars, I don’t think this is an unreasonable expectation. Fortunately, there are so many people and institutions paving the way.

Thanks again Nicole, Steve, Diane, Karen, Keith, Kaiser Permanente Colorado, and the Denver Museum of Nature and Science for embracing curiosity and inspiring a whole community to learn and teach about better health! More photos below, enjoy.

Real-Time Virtual Consults, Kaiser Permanente Colorado

I didn’t know what to call this post, so I just used the signature line on every one of Jan Ground’s (@janground) email these days:

newsflash!!! REAL-TIME VIRTUAL CONSULTS now live with Colorado Permanente Medical Group dermatologists AND NEUROLOGISTS

Jan is Kaiser Permanente Colorado (@KPColorado) “Innovation Hunter.” There’s a person like Jan in every region of Kaiser Permanente who help usher in the future, so when I let Jan know that I would be visiting, she suggested I go see the specialties of…. Neurology and Dermatology.

This is Dr. Tim Grayson (@tim_grayson). He’s the Chief of Dermatology for Kaiser Permanente, Colorado (@KPColorado). I went to see him (and shadow, of course!) at the building photographed below his, Kaiser Permanente Rock Creek Medical Offices, with three of my colleagues, including our Chief Communication Officer, Diane Gage-Lofgren (@dianelofgren).

The day prior, I spent time in the practices (shadowing, of course!) with Peter Bergmann, MD, Lynsee Hudson Lang, MD, and the Chief of Kaiser Permanente Colorado Neurology, Robert Schabbing, MD.

When you think of telehealth, typically people think about dermatology as a great specialty to do this work. Neurology comes up, but usually not for outpatient care, usually for stroke medicine. And in dermatology people usually think about “store and forward” rather than real time video, which is happening for both specialties, as Jan points out in every one of her emails.

Real time , HD quality video (what it looked like to me), allows the physicians/clinicians to interact with the patient, and get to know each other as people, to add life to a a clinical consultation – the patient, who may be in their primary care physician’s office leaves feeling “seen,” whether they are 1 mile away or 30 miles way from the consulting specialist.

What’s happening here, then, is not trying to apply technology to make the specialty run smoother, it’s applying technology to make patient’s lives run smoother.

Members/patients have an interest in getting consultations quickly, of course, AND they have an interest in their doctors collaborating better in the long run. This is harder to do in systems where physicians get paid for every consultation “unit,” but in integrated care, where specialists are paid to ensure the skin health or neurological health of an entire population, the collaboration comes naturally.

I’m going to quote myself from a post just this past friday, that was rolled into another blog post (see: Community Medicine – Total Health – Dialogue with and from the future at Penn State Hershey | Ted Eytan, MD – there was a lot going on in Colorado):

  • Dermatologists, who are using video technology to connect to their primary care peers (and their patients) to make sure they are excellent clinicians in their own practices, and make themselves available as clinicians as well. We were told the average time to see a dermatologist at Kaiser Permanente Colorado is now 3 days. Let’s repeat that: 3 days.
  • Neurologists, who are doing the same, using video technology also to connect, and in the foreground, synthesizing for every patient a substantial amount of thinking and knowledge across all their specialty colleagues for every single patient. A complicated neurology case can have 2, 3, 4 specialties consulting, and to have their work bundled together in one comprehensive electronic medical record is beyond priceless. And, it’s not just the bundling of their knowledge, it’s the bundling of their collegiality. To be part of the same medical group delivering the care brings a level of respect and commitment to that person and their family in the exam room that’s hard to replicate.

Disclosure/disclaimer: I did not actually see any live video consults when I was in Colorado, just a demonstration of the technology (but did observe excellent care being delivered through shadowing). Neurology has just begun its service, Dermatology is farther along.

If a consult did come in while I was there, it would have been interesting to see, but really the interesting part is the fact that a primary care physician/clinician (and their patients) throughout this region have access in real-time to a specialist who’s willing to teach, and learn about their patients. That’s what I saw from both Chiefs and colleagues – the desire to be there, wherever “there” is for patients.

Thanks again, Jan, and our colleague Bill Marsh, MD (@MDAI) for continuing to push the boundaries of being there, Debbie Lantz, RN, my guide in Neurology (and also care provider for a touch of altitude acclimation), Tim, Rob, Lynsee, and Peter, and the members of @KPColorado for hosting and teaching us. As much as the Center for Total Health (@kptotalhealth) in Washington, DC is a vision for the future of health, all we are really doing is showcasing what’s already happening every day in places like Colorado.