January-February 2020 Colorado Medicine

VO LU M E 1 1 7 N O . 1 J A N - F E B 2 0 2 0

COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE

LEGISLATIVE PREVIEW:

CMS CHAMPIONS ISSUES IMPORTANT TO PHYSICIANS

PLUS COLORADO GOVERNOR JARED POLIS OUTLINES HIS 2020 HEALTH POLICY GOALS

C O NTE NT S

What to expect in the 2020 Colorado General Assembly The 2020 legislative session is once again shaping up to be challenging to physicians, but real opportunities also exist for gains in streamlining credentialing, addressing the opioid crisis and promoting immunizations. The Colorado Medical Society champions issues important to physicians and patients while defending medicine’s interests.

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F E ATU R E S

10 HCPF RELEASES PRESCRIPTION DRUG COST REPORT The Department of Health Care Policy and Financing has released a comprehensive report on the primary drivers of prescription drug costs and recommendations for influencing these cost trends.

12 POLICY COULD INCENTIVIZE HEALTHY BEHAVIORS A leading voice on the Western Slope contends that the state of Colorado could incentivize healthy behaviors and reduce unhealthy ones with an innovative tax policy on commercial determinants of health.

14 THERE IS NO MEDICINE IN MEDICAL MARIJUANA A Colorado delegate to the American Medical Association urges doctors to oppose the term “medical marijuana,” providing evidence for its harms – medical use or recreational.

16 BEST PRACTICES IN PROCESS CHANGE FOR BETTER ED CARE Valley View Emergency Department in Glenwood Springs, a TCPi “exemplar” practice, outlines their strategies to enhance the patient experience and reduce costs.

32 FINAL WORD: COLORADO GOVERNOR LAYS OUT HEALTH POLICY PLATFORM Colorado Governor Jared Polis continues his focus on health care, outlining how he plans to address high costs that prevent patients from seeking care and administrative burdens that hinder physicians’ efforts to achieve better health outcomes.

I N S I D E

C M S

4 President’s Letter 11 Nominate yourself or a colleague for a CMS leadership position 20 AMA Interim Meeting report 21 CMS Corporate Supporters and Advantage Partners

D E PA R TM E NT S

22 Introspections 24 Reflections 25 COPIC Comment 28 Advantage Partner Spotlight: PatientPop 30 Medical News ▇ CMS secures reaccreditation for CME ▇ M ontrose Memorial Hospital receives accreditation with commendation ▇ S eeking volunteer opportunities for retired physicians ▇ A MA recognizes CU for efforts to reduce burnout 30 Classifieds

CO LOR AD O M E D I CAL SOCI E T Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 720.859.1001 • 800.654.5653 • fax 720.859.7509 • www.cms.org

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF 2019-2020 OFFICERS

BOARD OF DIRECTORS

AMA DELEGATES

David Markenson, MD, MBA President

Iris Burgard, MS Cory Carroll, MD Curtis Hagedorn, MD Mark B. Johnson, MD Jason L. Kelly, MD Lauren Loftis, MD Evan Manning, MD Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Brad A. Roberts, MD Kim Warner, MD Hap Young, MD

A. “Lee” Morgan, MD David Downs, MD, FACP Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD

Sami Diab, MD President-elect Patrick Pevoto, MD, RPh, MBA Treasurer Bryan Campbell, FAAMSE Chief Executive Officer Alfred D. Gilchrist Outgoing Chief Executive Officer Debra J. Parsons, MD, MACP Immediate Past President

AMA ALTERNATE DELEGATES Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Brigitta J. Robinson, MD Michael Volz, MD

AMA PAST PRESIDENT Jeremy Lazarus, MD

COLORADO MEDICAL SOCIETY STAFF Bryan Campbell, FAAMSE Chief Executive Officer Bryan_Campbell@cms.org Alfred Gilchrist Outgoing Chief Executive Officer Alfred_Gilchrist@cms.org Kate Alfano Communications Coordinator Kate_Alfano@cms.org Susanna Barnett Membership Coordinator Susanna_Barnett@cms.org Emily Bishop Government Relations Program Manager Emily_Bishop@cms.org

Mike Campo, PhD Director of Business Development and Member Benefits, and staff support for CMS Foundation and CMS Education Foundation Mike_Campo@cms.org Dianna Fetter Senior Director of Professional Services Dianna_Fetter@cms.org Amy Berenbaum Goodman, JD, MBE Senior Director of Policy Amy_Goodman@cms.org Dean Holzkamp Chief Operating Officer Dean_Holzkamp@cms.org Susan Koontz, JD General Counsel, Senior Director of Government Relations Susan_Koontz@cms.org

Krystle Medford Senior Director of Membership Krystle_Medford@cms.org Ms. Gene Richer, M Ed, CHCP™ Director of Continuing Medical Education Gene_Richer@cms.org Chet Seward Chief Strategy Officer Chet_Seward@cms.org Tom Wilson Manager of Accounting Tom_Wilson@cms.org Tim Yanetta Manager of IT/Membership Tim_Yanetta@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone 720-859-1001; outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance.

COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified.

Alfred D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor. Design by Scribner Creative.

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P R E S I D E NT ’ S

LE T TE R

CMS launches an ambitious plan to empower physicians and improve workplace satisfaction

David Markenson, MD, MBA President, Colorado Medical Society

As I outlined in my inaugural column in the last issue of Colorado Medicine, physician empowerment and both elevating and highlighting in the eyes of patients, business leaders, political leaders and stakeholders the true role of the physician is the signature project of my presidential year. I am honored to be leading the effort to launch initiatives in 2020 that will lay a solid foundation for the future to support the clinical autonomy, professional viability and wellbeing of physicians so we can provide quality, safe and cost-effective care without undue interference or barriers to our patients.

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OUR WORK STARTING IN JANUARY 2020 WILL COMPRISE SEVERAL PARTS.

1ST

2ND

3RD FINALLY

First, we must establish a sound baseline of understanding on the extent of physicians’ perceptions and insights into the current practice of medicine including physician workplace satisfaction or dissatisfaction, administrative and other barriers, and patient and stakeholder perception across multiple practice types through quantitative and qualitative discovery processes. To achieve this we will construct and administer a survey to measure and gain your insight into the critical factors that affect your ability to practice as a physician should and as patients need more than ever. We will also seek information on workplace satisfaction/dissatisfaction, wellbeing, administrative issues and relationships with patients, payers and other stakeholders. This data will provide a key basis for the ranking of issues and development of solutions.

Second in this effort will be a series of listening sessions with a variety of member and non-member groups: physician leaders from small-, medium- and large-group employed and private practices; hospital and system chief medical officers; medical students, residents, UGME and GME leaders, practice administrators, hospital and system leadership, patient and business groups, and others. The value of listening during a time of disruption, change and dissatisfaction cannot be overstated; your voice matters! These sessions will allow me and CMS to more deeply explore the issues and will provide an important supplement to the baseline of understanding set by the all-member survey.

Third will be a report that ties together the survey and the listening sessions into a set of recommendations to further engage all members. It will keep the conversation going and allow for comments and polishing.

Finally, recognizing that the top driver of physician satisfaction is providing high-quality care to patients and that Coloradans are placing a greater premium on the value of care provided, CMS will develop partnerships with other organizations that employ physicians, advocate for cost-effective care, and represent businesses, payers and health care systems to meet these dynamics through dialogue and collaboration around mutually beneficial goals that improve health status and address cost while assuring that physicians’ ability to practice as physicians is supported with viability of practices, maintenance of the physician-patient relationship, and wellbeing of physicians. I hope this effort will get us back to where health care should be: physicians in partnership with patients promoting health and minimizing the needs for care but, when care is needed, allowing the best care for the patient at the right time, in the right setting with the needed resources, and at the highest quality.

Acknowledging the scope of the physician empowerment initiative, we are committing significant resources over the next three years to this effort. I will continue to update you on our progress throughout the year. ■

C O LO R A D O M E D I C I N E 5

C OV E R

Legislative preview: CMS champions issues important to physicians and patients while defending medicine’s interests Emily Bishop, Program Manager, CMS Division of Government Relations

The 2020 legislative landscape is already shaping up to produce a challenging session for physicians.

It’s not without opportunity, however, with several CMS-authored bills, impressive goals in the public health arena, and ample opportunity for physicians to have a seat at the table.

COMPAC has been meeting diligently with key legislators throughout the session to continue friendly relationships and gain early supporters of key issues. Your generous support of COMPAC makes this work possible and will be even more crucial during the 2020 election season.

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THE FOLLOWING ISSUES WILL BE TOP PRIORITIES IN THE SECOND REGULAR SESSION OF THE 72ND GENERAL ASSEMBLY, CONVENING JAN. 8 AND ADJOURNING MAY 6.

PHYSICIAN CREDENTIALING Delayed credentialing can compromise patient access to care by delaying in-network availability of crucial providers. CMS has identified, through consultation with partners and other stakeholders, that insufficient incentive for health plans to process a health care professional’s credentialing application in a timely manner is hindering access and opening patients to financial risk when compelled to access out-of-network providers.

CMS has found a solution, however, authoring a bill to require timely and transparent credentialing processes.

The legislation would require health care plans to adhere to strict deadlines regarding the process and load times.

It would also require plans to treat applicants as a participating provider in certain circumstances for the purposes of payment, prescribing, referrals and prior authorization. CMS worked closely with the Colorado Chapter of the Medical Group Management Association (CMGMA) to draft this legislation and

is excited about the benefits to both patients and providers of a streamlined credentialing process.

“CMGMA is delighted to work with CMS in developing meaningful bills that will provide much needed reform and transparency,” said CMGMA Legislative Liaison Eric Speer, M BAHA , FACM PE . “The credentialing act will help providers expedite the ability to see patients, and consequently give Coloradans more access to care.”

WORKERS’ COMPENSATION ARBITRATION The CMS Workers’ Compensation and Personal Injur y Commit tee worked closely with stakeholders to develop an arbitration bill, which CMS will be running in the 2020 session. Some payer-provider agreements contain arbitration clauses that prevent providers from using the Division of Workers’

2020 legislature: Anticipated challenges

Compensation’s streamlined Medical Dispute Resolution Process. CMS is concerned this weakens the workers’ compensation system and discourages providers from participating. It also hurts the interests of injured workers. This bill would allow stakeholders to better utilize the division’s dispute resolution

process and would eliminate the high costs and long wait periods often associated with arbitration. WCPIC Committee members see this as an opportunity for fairness in dispute resolution that would benefit both providers and patients.

2020 LEGISLATURE

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STATE HEALTH INSURANCE OPTION PHYSICIAN CREDENTIALING

UNKNOWN

MALPRACTICE CAPS INCREASE

OUT-OF-NETWORK LAW ADJUSTMENTS

PUSH TO NARROW DEFINITION OF

CORPORATE PRACTICE OF MEDICINE

WORKERS’ COMPENSATION

SPECIALTY SOCIETIES

COMPONENT SOCIETIES

THE OPIOID EPIDEMIC

IMMUNIZATIONS

PROVIDER COSTS

SCOPE OF PRACTICE PHARMACEUTICAL COSTS

C O LO R A D O M E D I C I N E 7

C OV E R LE G I S L ATI V E P R E V I E W: C O N T

THE OPIOID CRISIS “Addressing Colorado’s opioid crisis is [a] priority heading into 2020,” said Senate President Leroy Garcia, D-Pueblo. “We made great strides last year on addressing addiction through pilot programs, but we still have work to do toward bridging gaps in treatment for our communities.”

Generally, physicians should be in favor of the slate of draft bills from the Opioid and Other Substance Use Disorders Interim Study Committee this year, which is building on two prior years of work on this issue. The 2020 bills address prevention, harm reduction, criminal justice system reform, treatment and recovery.

$

“The interim study committee has made substantial gains in areas that state government can impact, thanks in no small part to our strong partners in the provider community,” said Sen. Jack Tate, R-Centennial. “Our goal this session is to consider ways to improve access to prevention services and treatment for substance use disorders, and support criminal justice response. As always, we need to hear from providers about how proposed legislation will affect your patients and practices.”

tier as opioids alternative pain treatments such as acupuncture and physical therapy. Benzodiazepines are expected to be added to the mandatory PDMP check.

CMS continues to work with partners to enhance the ability to integrate PDMP with electronic health records and health information exchanges, while decreasing the cost of doing so.

CMS is par ticularly focused on the proposed prevention bill, part of which requires carriers to cover on the same

HEALTH CARE COST AND QUALITY

CMS anticipates cost reform to be another hot topic in the coming session and is prepared to advocate for the importance of quality and network adequacy in all cost reduction efforts.

“One of the most pressing issues our state continues to face is finding affordable care, particularly outside the Front Range,” says Senate President Garcia. “We’re committed to

bringing dow n health care cos t s and increasing access and quality of care for all Coloradans, especially rural communities.”

STATE HEALTH INSURANCE OPTION CMS has been an active stakeholder in the public option process from the start: the Work Group on Health Care Cost and Quality submitted a proposal to the Division of Insurance and Department of Health Care Policy and Financing this summer and has convened meetings to discuss the state’s proposal several times since. Following many interactions with state leaders, the draft proposal neither sets physician rates nor requires physician participation in the plan.

The CMS Board of Directors voted to suppor t the State Health Insurance Option proposal, with recommendations for improving the plan. Once the proposal is drafted into bill form, the Council on Legislation will take a close look to determine CMS’s final position.

The governor’s of f ice has thanked CMS and the physician community for a constructive and collaborative approach to this issue so far.

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WORKING FOR YOU

THREATS TO LIABILITY According to sources, the No. 1 issue for trial lawyers in 2020 will be to erode the corporate practice of medicine doctrine that makes it difficult for a health system or professional corporation to be sued for a physician’s negligence.

“The Colorado Medical Society, through its CMS Board-appointed Council on Legislation (COL), is uniquely prepared to evaluate, discuss and take positions on state legislative and ballot issues,” said COL Chair Kim Warner, MD. “The COL is comprised of representatives from specialty, county and component societies to comprehensively assess proposed legislation and take positions on behalf of the House of Medicine. The Council has, over the years, represented the physician view on such important legislation as scope of practice, liability reform issues, credentialing, opioids, physician wellness, health care quality, cost and access, and many more.”

This push would expand the potential value of a lawsuit by targeting the deep pockets of large hospitals and physician groups, and could result in those systems and groups eroding a physician’s independent medical judgment.

An attack on the noneconomic damages cap is always in the trial lawyers’ arsenal.

Reportedly, should the narrowing of the corporate practice of medicine fail to get off the ground, the trial lawyers may shift their resources toward caps. CMS, in partnership with COPIC, is gearing up to once again defend the stable liability climate from liability increases of any kind.

The team of professional advocates at CMS works hard on behalf of the members to pass meaningful, workable health care legislation in Colorado. Surveys show advocacy is ranked as the first priority for a majority of our members across the state. Physician involvement and participation is necessary for success on all of the issues that face organized medicine as we head into the 2020 session.

CONSIDER GETTING INVOLVED by contacting president@cms.org or visiting our website, www.cms.org/membership/explore. ■

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C O LO R A D O M E D I C I N E 9

F E ATU R E

HCPF releases report on reducing prescription drug costs in Colorado Kate Alfano, CMS Communications Coordinator On Dec. 12, 2019, the Department of Health Care Policy and Financing (HCPF) released a comprehensive report, “Reducing Prescription Drug Costs in Colorado,” that outlines the primary drivers of prescription drug costs in Colorado and how the state of Colorado can influence these cost trends. HCPF stated in a news release that “left uninterrupted, the prescription drug cost trends will continue on an unsustainable, upward trajectory.”

“Prescription drug costs represent over 20 percent of premium dollars in the individual market where costs are especially high,” said Dave Downs, MD, FACP, chair of the CMS Work Group on Health Care Costs and Quality. “Drug costs are also the fastest rising component of health care costs. There is ample evidence that prescriptions are frequently not filled or are ‘rationed’ due to cost.”

“The legislature, administration, business and consumers are all focused on drug costs and there will be bills introduced into the legislature in the coming session to help address what has become a growing problem for our patients,” Downs continued. “This report is an excellent guide for those interested in policy and also for potential solutions that are likely to be proposed. For those interested in health policy as it relates to cost of care, it is a must-read. Of particular interest are the sections dealing with drug price trans-

HCPF Executive Director Kim Bimestefer announces the report’s release.

parency and the concept of a Prescription Drug Affordability Board for Colorado.”

The report identifies key primary cost drivers as the following: • Lack of transparency and pricing practices – ranging from pricing methodologies that are unrelated to research, development, manufacturing and distribution costs; to variation in pricing between dispensing settings.

• Anticompetitive practices – such as patent policies and other practices that delay access to less expensive generic drugs.

• Marketing and lobbying – t his includes, but is not limited to, directto-consumer and direct-to-physician marketing that increases prices and results in increased utilization of higher-cost drugs.

CMS President-elect Sami Diab, MD, participates in a panel discussion on the report.

The authors note in the report that specialty and branded drug costs grew significantly faster than inflation, approximately 28.5 percent and 5 percent per year, respectively, from 2012-2018.

According to HCPF, spending continues to shift from traditional to specialty medicines, which now account for $384 of the $895 per person per year spent on medicines nationally. In 2012-2018, Health First Colorado’s (Colorado Medicaid) prescription drug benefit costs rose 51 percent – an average of 8.5 percent each year – before manufacturer rebates.

HCPF agrees with the federal CMS’s prediction that over the next decade, spending for prescription drugs will represent the fastest growth health category and will consistently outpace that of other health spending.

“HCPF’s prescription drug cost report is a good opportunity to address the rising cost of prescription drugs for Coloradans,” said CMS President-elect Sami Diab, MD. “Many patients are not able to afford their medications and this is a real issue that needs to be addressed. CMS will be engaged with HCPF to discuss policies and legislation that would reduce anti-competitive practices, allow consumers to benefit from drug rebates, and prevent delay strategies that block generic and biosimilars from arriving to the market. It is time to address practices that are harmful to consumers in order to protect Coloradans.”

READ THE FULL REPORT AT: www.colorado.gov/hcpf. ■

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INSIDE CMS

2020 CMS Election: Call for nominations

The nomination period for the 2020 Colorado Medical Society all-member election is open through Jan. 31, 2020. The Colorado Medical Society encourages all members to consider nominating a colleague or self-nominating for one of the open leadership positions: president-elect (one position open) or AMA delegation (two positions open).

The election manual is available on CMS.org. This guide provides all the information a potential candidate needs about the duties, eligibility, terms of office and honorarium for each open position, as well as candidate requirements, campaign guidelines and the election process. Questions? Email dean_holzkamp@cms.org.

As of Dec. 20, 2019, the following CMS physicians have announced their candidacy: President-elect • Mark Johnson, MD, MPH AMA Delegation • Alethia (Lee) Morgan, MD, incumbent • Katie Lozano, MD, incumbent To nominate yourself or a colleague, go to tinyurl. com/2020-cms-election to download templates for the candidate profile, CV and personal statement; then complete the documents and email to president@cms.org. Thank you for your participation. ■

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C O LO R A D O M E D I C I N E 1 1

F E ATU R E

Editorial: Innovative tax policy could incentivize healthy behaviors and reduce unhealthy ones Michael J. Pramenko, MD

Sadly, despite the highest per capita health care spending in the world, our statistical life expectancy in the U.S. has declined for three years running. It’s past time to address the issues of chronic disease at the root of this trend.

But to do so, health insurance needs to take a few lessons from auto insurance. Auto insurance companies regularly offer discounts for safe driving. Conversely, traffic accidents and speeding lead to rate increases. In addition, CarInsurance.com reports that a DUI can increase an individual’s auto insurance rates anywhere from 80 percent to 371 percent.

Without these potential auto insurance policy rate increases, our roads would be less safe while being more expensive for the habitual safe and responsible drivers.

Interestingly, nobody ever decries these traffic law and auto insurance policies as “nanny state” techniques.

Auto insurance rewards healthy driving while penalizing poor driving.

On the other hand, health insurance fails this sustainability test.

Via commercial insurance, Medicaid and Medicare, rates and taxes rise for everyone because of the unhealthy behavior of some, while offering insignificant rewards for healthy behavior. This is a perfect recipe for financial unsustainability in any health care system, let alone within the most expensive one on the planet.

So what is the health insurance equivalent of speeding or driving under the influence of drugs or alcohol? More important, what happens to an individual’s health insurance premium for avoidable and well-established behaviorally related health problems? Other than some rate adjustments for smoking – nothing. Worse yet, as the total cost of care for a population 1 2 C O LO R A D O M E D I C I N E

increases from avoidable chronic disease states, health insurance rates increase for everyone. Plus, we pay more in taxes to fund Medicaid and Medicare.

The challenge in health insurance is to find a method to reward healthy behavior without driving up health insurance premiums for the chronically ill and those with unfortunate health-related events of no fault of their own.

We could offer relatively inexpensive health insurance to a healthy cohort of patients. Unfortunately, this policy would drastically increase health insurance rates for the sick and chronically ill. Given the extraordinary cost of health care in the United States, it is necessary to spread the cost of care over the majority of the population.

So how does a community, state or nation rise to the challenge and find a mechanism to reward healthy behavior while disincentivizing unhealthy behavior?

An advanced society with affordable health insurance will boldly address this challenge.

The answer lies in the ability to utilize the health insurance equivalents of speeding or reckless driving. Fortunately for us, the Centers for Disease Control (CDC) has

already accumulated the necessary data.

The CDC has identified the most costly behaviors relevant to health insurance: the use of tobacco, alcohol and sugarbased beverages. As per the CDC, the United States’ health care system spends over $700 billion per year treating acute and chronic disease related to the use of these products.

In effect, the “safe drivers” among us are paying this annual $700 billion tab. It’s time for a refund.

We mus t begin rewarding healthy behavior in health insurance. Currently, the cost of public and private health insurance includes the cost of caring for many chronic diseases caused by human behavior. The public can smoke, vape, drink, chew, eat and ingest a well-documented variation of unhealthy products.

Correspondingly, the price of health insurance increases for everyone.

This is why the largest physician organization in the state of Colorado has enacted policy that could help Colorado lead the nation in addressing the chronic disease epidemic. In November, the Colorado Medical Societ y voted to suppor t

increased taxes on alcohol, tobacco and sugar-based beverages as long as those taxes are used to address the high cost of health care by addressing chronic disease where it starts and by rewarding those who choose a healthy lifestyle.

The Mesa County Medical Society led the charge.

The policy does not support taxes on these products if the revenue is allowed to go to the general fund. If revenue is used for prevention and reducing premiums, there is a healthy return on investment for a Colorado consumer who chooses a healthy lifestyle. It is a tax that is then returned to the well-deserved healthy consumer of health insurance.

This tax policy works like our traffic laws.

Healthy living is rewarded while we simultaneously work to reduce the rate and ill effects of unhealthy behavior. At the same time, we preserve the insurance pools such that health insurance rates don’t go up for the chronically ill with “no-fault” health problems.

With enough support, Colorado could pilot this innovative health policy design for a nation in desperate need of more value per health care dollar.

TO LEARN MORE – view Dr. Pramenko’s TED Talk: “Marketing Healthy Behavior,” at https://tinyurl.com/uh7e3ey. ■ Michael J. Pramenko, MD, is the Executive Director of Primary Care Partners. He is Chairman of the Board of Monument Health and is a Past President of the Colorado Medical Society.

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F E ATU R E

Editorial: There is no medicine in medical marijuana Lynn Parry, MD

Marijuana (tetrahydrocannabinol or THC) as well as other “natural” cannabinoids such as CBD (cannabidiol) are not medicines but substances. Colorado was one of the first states to legalize marijuana in the form of “medical marijuana” (2000), followed inevitably with legalization of recreational marijuana (2012). The promise of social justice from decriminalization and increased tax income to the state and local municipalities for infrastructure support have either largely not been met or have been surpassed by increased health dangers, increased hospital emergency room visits, increased crime and increased threats to our youth.

Marijuana has been in use for thou- than other health treatments except for incorporated into statute by non-medsands of years. THC plants were grown small, evidence-based studies on HIV/ ical advocates and industry lobbyists. in backyards, dorms and between the AIDS or cancer-related wasting and Perhaps the most alarming aspects are rose bushes. Hemp has contained CBD cachexia. Recent large-population stud- the rapid escalation of THC concentrafor the history of the fiber industry. What ies for chronic pain have, in fact, shown tion especially in the “medical” market. has changed? Marijuana is no longer little to no evidence of superior effective- To compound the risks, dose management is in the hands of individuals. a cottage industry where typical “weed” contained 3.8 percent THC. In terms of true medical safet y Science has increased the natural Science has increased the natural and efficacy, there are THC and potency of grown flowers to 20 CBD FDA-approved medications: percent and concent rates can potency of grown flowers to synthetic THC (dronabinol and reach nearly 100 percent. It is now nabilone) for HIV/AIDS and cancer a mega-industry; while there are 20 percent and concentrates wasting, and plant-based CBD (epidregulations prohibiting marketing iolex) for rare childhood seizures. But to youth, some buy into the belief can reach nearly 100 percent. even with safe, effective and true that marijuana is safe because it is medications available, my pediatric authorized by physicians to treat ness or lower risk but have demonstrated neurology colleagues tell me that parents medical ailments. significant increases in cost to the health still want CBD rather than the safe, There is no evidence that inhaled or care system1 . Meanwhile, in states like FDA-approved medication for their child’s ingested THC is safer or more effective Colorado, the medical “indications” are epilepsy because it is more “natural.”

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It is now a mega-industry; while there are regulations prohibiting marketing to youth, some buy into the belief that marijuana is safe because it is authorized by physicians to treat medical ailments.

Lynn Parry, MD, presents “There is no medicine in medical marijuana,” to the Organization of State Medical Association Presidents (OSMAP) during the AMA Interim Meeting.

Finally, Colorado surveys demonstrate that while marijuana use did not increase in children and teens after legalization, the perception that marijuana has risks has plummeted to half the national average2.

CBD use has also now joined the potential harm-inducing substances in massive quantities with the passage of the recent farm bill that removed protections to the public. This scenario appears likely to play out as each state considers legalization.

Like previous attempts to prohibit alcohol, constraining marijuana use is likely to be ineffective against societal pressure. But the medical community can and should continue to demand that evidence inform appropriate use of all substances of risk, including marijuana and CBD. The Colorado Medical Societ y has removed any reference to “medical marijuana” from its current policies and refers to all cannabinoid products as requiring evidence and regulation for any health-related use. The profession has an obligation to oppose the use of the term “medical marijuana,” which is a legal and/or statutory term. It should continue to advocate for public health and safety regulations that require measured potency standards that are limited to less than 50 percent. FDA-like (or FDA) processes that utilize prospective studies with dosage, benefits and risks identified should guide any health-related claims. ■ 1. www.nice.org.uk/guidance/ng144/ evidence/b-chronic-pain-pdf-6963831759 2. https://rmhidta.org/files/D2DF/ FINAL-Volume6.pdf

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C O LO R A D O M E D I C I N E 1 5

F E ATU R E

Changes to process and approach enhance patient experience and save money for Valley View ED team Laurale Cross, APRN, NNP-BC, Nursing Operations/Clinical Administration, Emergency Department/Administrative Director; Shana Foley, RN, BSN, CEN, Emergency Department Director The Transforming Clinical Practice Initiative (TCPi), which worked with close to 200 practices during its four-year time frame, submitted about 20 “exemplar practice” stories to the Centers for Medicare and Medicaid Services directory. TCPi is a federally funded, governor’s office initiative that ended Sept. 30, 2019. The following is an edited version of the story that illustrates some of the work Valley View Emergency Department did to earn the “exemplar” designation.

Valley View Emergency Department (ED), which is part of the Valley View health care system in Glenwood Springs, Colo., strives to be the destination of choice for all who aspire to heal and be healed. By focusing on what is best for patients, the team has improved patient satisfaction and experience scores, saved hundreds of thousands of dollars and achieved high quality, safety and cost efficiency/cost savings.

The emergency services practice team is made up of 13 physicians and a staff of 31, which sees an average of 13,000 encounters, with 17 percent of those being admissions. The site is a level-3 trauma center that averages 2,800 patient visits per year for trauma-related care.

There is a new, dynamic leadership group for the trauma program that has reached out to the local schools to teach programs like “Stop the Bleed,” which gives high school students knowledge about basic hemorrhage control through education and hands-on training. The team has completed training with 800 students to date and is planning to teach clinical and non-clinical hospital staff. The Trauma Team is attending staff meetings all over the hospital to train additional instructors who will in turn spread this vital education to our community.

Another high school initiative is the “Seatbelt Challenge,” which stresses the importance of always wearing a seatbelt and resulted in 15 percent more students wearing seatbelts during the six-week challenge. This was validated by direct observation as students entered the parking lot.

The team also attends health fairs throughout the valley, reminding community members to wear helmets when skiing and biking, which are common activities in the area, and distributes free helmets to those who don’t have one.

A PATIENT-FOCUSED APPROACH Katelyn Kulacz, a nurse resident, initiated a new process for patient callbacks in 2017 that illustrates how focusing on patients benefits the entire team. A team member calls each patient the day following hospital discharge to ensure the patient understood all of the instructions and filled prescriptions, and to field questions.

The team is making 20 to 30 patient calls daily and have seen Press Ganey scores for patients’ level of understanding discharge instructions move from 68 percent to 93 percent during a six-month period.

This is especially significant considering the research shows that patients who receive calls from care teams are more satisfied with their care and have fewer readmissions.

The team also improved its referral process. Instead of telling patients to call for a specialty or primary care appointment and handing them a business card, the team sends an official referral request to the recommended practice with pertinent patient information. Staff have worked with local practices to identify contacts for referral requests to expedite the process. During follow-up patient calls, staff ask if the appointment has been scheduled and, if not, they help schedule urgent appointments.

These steps help close the loop and make suggestions for care less overwhelming.

The team has sustained Kate’s initial work to reform the referral process and added the ability for doctors to flag patients for special attention during follow-up calls. Staff can attach documentation to a patient’s initial emergency department visit in the

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electronic medical record, which helps with patients who have repeated visits and unexpected outcomes. Kate’s enthusiasm helped overcome initial obstacles and embed the process in the culture. The team recognized that unnecessary test duplication, which was common with imaging, was wasteful for the system and exposed patients to higher risks and costs. Instead of routinely ordering imaging studies, staff use the health information exchange to check for recent, relevant tests/images to avoid duplicating tests whenever possible.

The team continues to improve processes to see patient care data from a broader perspective instead of limiting that picture to the western Colorado region.

chronic pain patients to see whether the primary driver was lack of primary care and effective care plans. The team met individually with two patients in the pilot (who had accounted for 14 emergency department visits during three months with an average per-visit cost of $3,570) and connected them with a primary care provider who designed a plan to prevent a pain-related crisis. The team also offered acupuncture at no cost.

These patients are now primarily managed outside the emergency department, receiving much simpler protocols such as IV fluids and oral medications such as Zofran, and only come to the ED if these approaches fail. Once a solid plan was in place, both patients were seen just three times in the ED during a three-month period and are satisfied and engaged with their care. Previous to the pilot program both patients were unhappy with their care and engaged in a grievance process.

Their combined ED costs during the three months dropped from about $50,000 to $10,700, which represents $40,000 in cost savings for that time period.

CHRONIC PAIN The team appreciates the effect high utilizers of hospital services have on community resources and piloted an intervention with

Since then, there have been months when the patients did not visit the ED, which makes the estimated savings from these efforts more than $160,000 per year for these two patients. The next step is to replicate this success with other high ED utilizers. A dashboard allows the team to see the number of patient visits and identify opportunities for intervention. It’s a long-term project and will require many resources to meet patients’ needs.

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F E AT U R E S VA LLE Y V I E W: C O N T

The hospital invested in Tableau, a powerful data repository that allows the team to pull large amounts of data from multiple sources. “Heat maps” demonstrate how busy the department was (by color ranging from green, yellow, orange, red) according to real data instead of guesses, which also helps with taking action to improve satisfaction and experience scores.

During the past year we have given staff meaningful and timely feedback regarding performance, Press Ganey survey comments, chart audits, etc. By establishing open and honest lines of communication and being straightforward with expectations, staff are meeting expectations. Providers are also receiving immediate feedback regarding patient grievances/complaints.

Whenever possible this feedback is given directly by patients via emails and phone messages, which is more powerful than a second- or third-hand conversation from leadership. The power of the patient’s voice was illustrated with one provider, who had four active grievances from patients during a six-week period in 2018. After changing our process, it has been almost a full year without a single complaint regarding that provider.

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THE PATIENT VOICE Along with many improvement efforts, patient satisfaction has improved. The overall Press Ganey score increased from 72 in January 2017 to 82 by October 2018. One area we are still working to improve is keeping patients apprised of wait times. We encourage the use of white boards in each room for the nurse to note timing of tests and what is next with a patient’s plan of care.

As we round on patients, we notice the boards are being used more regularly and expect this score to improve in the near future.

In September 2018, we implemented supply software that keeps real time counts on department supplies and allowed us to charge patients for supplies we use for their care. It was a big learning curve and adjustment for nurses, techs and doctors to log in and pull supplies this way, but the reward is also big. We are saving thousands of dollars each month. Monthly supply cost went from around $3,000 to $300, due to reducing charges to patients and department waste. The savings from the latter allowed us to reinstate a position by demonstrating revenue capture. We now have a department secretary who answers calls during peak activity times and assists patients with discharge planning and referral appointments.

PROCESS IMPROVEMENTS During 2018 we saw alarming medication errors in the ED that were attributed to inaccurate patient weights. We discovered that the accepted practice was to use “stated weights” obtained from patients or their families. One medication error for a critical anticoagulant resulted in under-dosing of Lovenox, which required transfer to a higher level of care. Another case was related to an inaccurate weight that was used to calculate weight-based antibiotics for a case of severe pneumonia.

The team uses Tableau to create a report that shows the data source for weights. In the initial data collection, 75 percent of patient weights were based on stated weight and only 25 percent on actual weights. Today the “stated weight” rate has decreased to less than 2 percent and actual weights are at 98 percent by weighing incoming patients as part of their triage assessment and using three new stretchers that weigh patients in bed.

A new pediatric scale shows weight in kilograms, which also decreases room for error. The team continues to strive for zero stated weights in the ED.

Due to the success of the efforts described in this article, change is now common in the VVH ED and providers and support staff are familiar with quality improvement. As a result, resistance to change has been significantly decreased. Small, successful changes and celebrations of these wins are powerful motivators for future improvements. The team will continue to focus on controlling costs and providing value to patients.

Success in the ED most likely translates to fewer visits with cost savings to the community.

Decreased patient visits will also result in less revenue for the department and the team is looking at ways to be leaner. Much of our work aligns with value-based payments. TCPi participation has provided us with resources and opportunities that we were not aware of previously and have helped support transformation efforts. ■

This is the first of a series of articles that highlights the work practices engaged in TCPi do to earn “exemplar” status with the federal CMS. LEARN MORE ABOUT THIS FEDERALLY FUNDED, GOVERNOR’S OFFICE INITIATIVE AT www.co.gov/healthinnovation/tcpi, a website that will be maintained as an archive through July 2020.

Valley View’s goal is to improve patients’ pain management and return them to a maximum quality of life while controlling the inherent risks of prescribing highly addictive medications like opioids. The Colorado ALTO Project is an initiative based on the successful Colorado Hospital Association (CHA) Opioid Safety Pilot in which a cohort of 10 hospital EDs decreased the prescriptions for opioids by 36 percent while increasing the use of alternatives to opioids (ALTOs). The ED at Valley View was one of the first EDs beyond the initial 10 pilot sites to test reproducibility of the initial results in October 2017. Recent data show success.

The VVH team is also working to reduce opioids prescribed at discharge. We can report provider-specific patterns and show a significant reduction in discharge opioids prescribed by providers as a group and by provider.

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I N S I D E

C M S

CMS Delegation to the AMA represents Colorado physicians at the AMA Interim Meeting Kate Alfano, CMS Communications Coordinator Your elected delegation to the American Medical Association attended the 2019 AMA Interim Meeting in San Diego Nov. 15-19, to present and participate in educational sessions; hear speeches from AMA leaders like President Patrice Harris, MD, MA; testify on resolutions to the AMA; and vote on new AMA policies. They joined 2,500 physicians, residents and students from all 50 states and over 115 specialties in the meeting, which concluded with 74 resolutions and reports adopted.

Of note, Colorado’s Lynn Parry, MD, presented “There is no medicine in medical marijuana,” to the Organization of State Medical Association Presidents (OSMAP); see page 14 for a summary of her presentation. Also, both resolutions brought by Colorado passed as policy; one supports the appropriate use of scientific studies and data in the devel-

Colorado medical students participate in the AMA Interim Meeting in San Diego. From left, Colorado medical students Jessica Pollard, Alysa Edwards and Halea Meese.

opment of public policy. And the Young Physicians Section (YPS) pushed for the AMA to ensure its pilot childcare program is now permanent, which YPS hopes will dramatically increase involvement from physicians with young families.

New policies were passed by AMA delegates to ban conversion therapy; protect residents and fellows displaced by unexpected teaching hospital closures; urgently advocate for regulatory, legislative or legal action at the federal or state levels to ban the sale and distribution of all e-cigarette and vaping products; modernize public health surveillance to alleviate the burden on physicians and improve data; support free sunscreen in public spaces to prevent skin cancer; and oppose collecting DNA of refugees.

AMA President Harris detailed the AMA’s ongoing efforts to reinforce science and

evidence-based approaches as it works to remove barriers to patient care. She told delegates, “In this era of distrust, I would submit to you … that the AMA is just what the doctor ordered. And we – both individually and collectively – are more than a match for this moment. … As I said just a few months ago, we, the physicians of the AMA, believe we can uplift our entire profession. We believe we can improve care for ALL of our 300-plus million fellow Americans … and stand as leaders in health care across the globe. … We can do this because people trust us … and because we will always strive to be worthy of their trust.”

CMS ENCOURAGES ALL COLORADO PHYSICIANS TO JOIN THE AMERICAN MEDICAL ASSOCIATION. VISIT https://member.ama-assn.org/join-renew to access the online application. ■

Students tour the USS Physicians enjoy an evening out in San Diego.

Midway. From left, Iris Burgard, From left, Lynn Parry, MD; Herb Fried, MD; Edwards and Meese.

Deb Parsons, MD; and Dave Downs, MD.

Colorado Delegation to the American Medical Association THANK YOU TO THE PHYSICIANS WHO SERVE ON THE STATE DELEGATION TO THE AMA. AMA Delegates

AMA Alternate Delegates

David Downs, MD, FACP Jan Kief, MD A. “Lee” Morgan, MD Tamaan Osbourne-Roberts, MD Lynn Parry MSc, MD

Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Brigitta Robinson, MD, FACS Michael Volz, MD

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I NTR O S P E C TI O N S

Making time to be present with patients Angela DiCosola

Critical reflective writing holds a prominent place in the Medical Humanities curriculum at Rocky Vista University, College of Osteopathic Medicine. Beginning in the first semester of Medical Ethics, students engage in critical reflection to explore their own assumptions and biases and how their values impact their practice. This submission is selected and edited by Nicole Michels, PhD, chair of the Department of Medical Humanities; and Alexis Horst, MA, writing center instructor.

Angela DiCosola is a fourth-year medical student with a passion for internal medicine and pediatrics.

After residency, she plans to pursue hospital medicine with the hope of completing a pediatric critical care fellowship. She grew up in Chicago and received her bachelor’s in Public Health from Saint Louis University. In her spare time, you can find her curled up with a good book, exploring a new running trail, or spending time with her friends and family.

Modern health care technology and innovation has allowed us to practice medicine in ways generations before would have thought miraculous. After four years of undergraduate education and two additional years of countless lectures, lab sessions and sitting for national board exams, I was beyond excited to witness these miracles and discover how the medical world operates.

The thought of rotating through a range of specialties – internal medicine, surgery, pediatrics, obstetrics and gynecology – and becoming part of a new team of providers each month thrilled me. I would finally get to do what I came to medical school for: take care of patients.

However, I soon found that regardless of the specialty, today’s physicians spend hours hunched over a computer, writing daily progress notes, cranking out discharge summaries, documenting every detail. Even more of their time is spent on hold with outside providers or navigating the nuances of insurance companies. At first, I eagerly performed every task I could to assist in making my team operate at the highest level of efficiency. The number of times I used a fax machine throughout my third year rivaled that of a seasoned office admin. I constantly

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had small slips of paper in my white coat pockets with checkboxes of tasks to do. Put the consent form in the chart for the surgeon to sign, check. Fill out the FMLA paperwork, check.

Put in morning lab orders, check. Call the case manager to discuss skilled nursing placement for Mrs. J, check. Dictate Mr. X’s admission H&P, check. I found this unexpected reality to be a majority of my day in medicine, and I would be remiss if I said it did not take up a good amount of my mental and physical energy. There were days I felt exhausted before even seeing my patients.

In my effort to accomplish my continuously growing to-do list and impress my residents and attendings with competent documentation as well as my ability to discuss complex medical issues, I recognized I was spending less and less time with the patients themselves. I found myself trying to find polite ways to end tangential conversations my patients had started. I stopped sitting and chatting with my end-stage renal patients while they received their weekly dialysis. I asked a hospital volunteer to bring Mrs. J her newspaper one afternoon because I had to go see a new consult.

It was not until a patient asked me directly why I was not visiting her as often as I used to that I acknowledged how far I had strayed from the humanism with which I began my third year. I was able to participate in her care earlier, during my surgical rotation. I would often check in on her, making sure she used her incentive spirometer and asking if she wanted me to sit and keep her company since her family was from out of town. As she lay before me months later on my internal medicine rotation, I could not find the words to answer her question. I am ashamed to say how easy it was to lose sight of why I chose this career in the first place. I wanted to be in the business of taking care of people, and I was failing at it in the most basic way possible: not being present for my patients.

Given the very real demands faced by physicians today, it has become increasingly more important for providers to listen and identify their patients’ concerns in an often limited time frame. I am best able to advocate for my patients and work together to establish goals when I am not the one doing most of the talking.

While it is unrealistic of me to spend an afternoon chatting in the dialysis suite, it is very possible to let a patient express concerns without interrupting them. I believe above all else that patients want to feel heard by their providers. Therefore, I challenge

myself every encounter to not interject, to do less talking, and to listen to not only what is being said but also a patient’s body language and emotions. In a constantly evolving field with increasing time constraints, it is this mindset that will allow me to live up to the ideals I have set for myself. To know I have been successful in these efforts, I must turn to my patients. My patients may not remember all the medications I prescribed, the lab tests I ordered or the imaging I reviewed. They will, however, remember how they felt during the experience.

Now as I complete my final year of medical school and look toward residency, I do so with one simple goal: I will be there for my patients. I hope to pour myself into patient care: my patience when I am running behind schedule, my sense of humor when it is needed, and my empathy and compassion always. I will strive to be the physician that is not looking for an immediate way out of my patients’ tangential stories. I will aspire to be the one that brings the newspaper to a patient instead of asking someone else to and, ultimately, the physician that practices in such a way that makes patients feel truly cared for. There will be times when I may lose the forest for the trees, but I will always remain appreciative and grateful for the role I am privileged to hold and, in doing so, I will be there for my patients. ■

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R E F LE C TI O N S

Massive abruption Amanda F. Tompkins

Amanda F. Tompkins is a third-year medical student at the University of Colorado School of Medicine. Originally a psychology/philosophy major, Amanda worked for several years as a CNA, then EMT, prior to starting medical school. She is passionate about the human connections involved in providing excellent care for patients and believes that knowing the patient’s psychosocial context is essential for facilitating true healing. She plans to pursue a career in internal medicine, possibly with a focus on substance use or palliative care.

The attending releases my hand on the retractor. “Okay, let it relax. You can switch places now.” I step back from the body of this patient four years younger than me. We’ve spent the day together, and now, masks, gowns, sterile gloves, bright lights and metal keep us apart. I had held her hand for a moment before the surgery and told her she was in good hands. It felt weak at the time. It felt like I was being too emotional or soft…as a third-year medical student who hadn’t seen many cesarean sections; maybe I was making too big a deal out of this. It was going to be fine. And now, as I back away from the sterile field to assume my place at the bottom of the bed, I feel my feet dragging through something on the floor. I look down to see a red lake of her blood that I have been standing in for the past several minutes. More red is pouring in a steady stream off of the sky blue drape. It feels like an eternity before I snap back into this moment. The baby is still not out. There’s still no end in sight. There’s still no conclusion. How does this end?

The OB attending turns to the pediatric team. “Abruption.

Massive abruption,” she states. In her sterile disguise, all I can see is her eyes. They don’t look panicked. They don’t look fearful. They look calm. Concerned. Determined. The words echo in my head “Massive abruption.”

wrong by this point. Is her husband afraid? Is someone keeping him informed?

“Pressure, pressure, lots of pressure!” I hear the resident exclaim.

I know what that means. “Pressure!” means “we’re doing something horrific right now. We hope the drugs are working!”

My mind is flooding with thoughts. I can’t handle this. I need to leave. This is too much. And as my mind races, out comes a small, blue, silent baby. Every sterile person gathered around the patient begins to rigorously clean her off.

Cry, Isabella. Do something, Isabella. Don’t be dead, Isabella. I am frozen. Isabella is limp. “Fifteen seconds!” shouts someone from across the room….

“Thirty seconds!” Everyone else is rubbing.

I am frozen.

Isabella’s eyes pop open and her arms sprawl out widely. She is staring at me. Her head is long and stretched from so much pushing. Her skin is dark blue and her eyes are black. Breathe Isabella. Breathe…

As I pull down on the bladder blade, I watch the obstetricians tear into her uterus. Clot begins pushing forward. Dark. Red. “45 seconds!”… A weak cry . Her body is changing color. Like the Black. Death. The resident reaches into the gaping hole in the early dawn sky after a sleepless night, the pink spreads rapidly uterus and out pops a hand. Small, delicate, blue fingers. She across her torso, and then her face and arms. shoves it back in and begins scooping deep into the uterus.

They call for the nurses to help from underneath the drape. To Another weak cry. Someone hands me scissors. push the baby’s head out from where it sat, deep in the pelvis. I assume an awkward position as I extend my right hand, gripping “One minute!” the voice cries. the bladder blade and moving my body out of the way as the nurses climb underneath to reposition the patient’s legs and “Cut between the clamps,” someone reminds me. enter the birth canal.

I cut. She is whisked away.

I’m so hot. I can’t do this. I hate every moment. If this baby dies.

If this mom dies. What happens to her four children? She’s had What now? ■ other C-sections…she and her husband must know something is Reflective writing is an important component of the CU School of Medicine curriculum. Beginning in the first semester, medical students write essays, stories or poetry that reflect what they have seen, heard and felt. Reflections is edited by Steven Lowenstein, MD, MPH, and Tess Jones, PhD. It is dedicated to the memory of Henry Claman, MD, Distinguished Professor of the University of Colorado, founder of the Arts and Humanities in Healthcare Program, and original co-editor of this column.

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C O M M E NT

Update: Colorado Medical Board Rule 400 CHANGES IN PRACTICE/REGULATION OF PHYSICIAN ASSISTANTS Gerald Zarlengo, MD, Chairman & CEO, COPIC Insurance Company

WHAT YOU NEED TO KNOW: Colorado Medical Board (CMB) Rule 400 outlines the rules and regulations regarding the licensure of and practice by PAs.

During the 2019 Colorado legislative session, House Bill 19-1095 was passed, which established requirements for the supervision of PAs in the Medical Practice Act (MPA).

As a result of the passage of HB 19-1095, some sections of CMB Rule 400 regarding supervision and review requirements were removed because they are now included in the MPA.

HB 19-1095 changed the MPA as follows: • A licensed physician can be responsible for the direction and supervision of up to eight PAs at any one time.

CMB Rule 400 and the MPA are interrelated and should be viewed together for all the requirements for PAs and their supervising physicians.

• A licensed physician shall not be made responsible for the direction and supervision of more than four PAs unless the physician agrees to assume the responsibility; the physician has sole discretion to assume or refuse such responsibility; and an employer shall not require a licensed physician to assume such responsibility as a condition of employment.

• The bill increases the number of PAs who sit on the CMB from one to two.

SUPERVISORY PLANS AND PRACTICE AGREEMENTS CMB Rule 400 was revised to state: “The requirements for a Supervisory Plan or a Practice Agreement applies to all supervising physicians and physician assistants

as of August 2, 2019.” In other words, a PA must be operating under either a Supervisory Plan (new PAs) or a Practice Agreement (all other PAs).

Within 30 days after a new PA completes 160 working hours, the primary supervising physician must complete an initial performance assessment and a supervisory plan for the PA. PAGE 26 ⊲

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Elements that should be incorporated in a supervisory plan may include, but are not limited to: • Nature of the clinical practice (areas of specialty, practice sites, populations ser ved, ambulator y and inpatient expectations, etc.); • Specific expectations and duties of the PA; • Expec tations around physician(s) support, supervision, consultation and back up; • Methods and modes of communication, co-management and collaboration; • Specific clinical instances in which the PA should ask for physician backup;

• Plan for ongoing professional education and skills development for the PA; • List of secondary supervisors anticipated to participate in the PA’s practice; • Schedule of performance assessments and anticipated modalities by which the practice will be assessed and domains that will be assessed; • Other pertinent elements of collaborative, team-based practice applicable to the specific practice or individual physician and PA.

The supervision of PAs who have practiced at least 12 months and are new to a practice area or new to Colorado, and all other experienced PAs (those who have practiced in Colorado at least three years) is determined by a practice agreement. The practice agreement must include: • A process by which a PA and a supervising physician communicate and make decisions concerning patients’ medical treatment that utilizes the knowledge and skills of the PA and the supervising physician based on their respective education, training, and experience; • A protocol for designating an alternative physician for consultation when the supervising physician is unavailable; • The signatures of the PA and supervising physician; • A termination provision that allows the PA or the supervising physician to terminate the practice agreement after providing written notice of his or her intent to do so at least 30 days before the date of termination. If a practice agreement is terminated, the PA and the PA’s primary supervising physician must create a new practice agreement within 45 days after the date the previous practice agreement was terminated.

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Reza Ghafoorian, MD, JD (202) 656 8387 rghafoorian@g2zlaw.com

In addition to these components, a practice agreement may impose conditions concerning specific duties, procedures or drugs. If the terms or conditions of a practice agreement change, both the PA and the supervising physician must sign and date the updated practice agreement.

Previously, a supervising physician was required to complete a performance assessment for an experienced PA at least annually, but now there must be a “periodic” assessment, with more frequent assessments for new PAs or those new to a practice setting (see chart below). The components of a performance evaluation have not changed in Rule 400.

CATEGORY

New PA (Less than 3 years)1 New practice area5 (Practiced at least 12 months.

If new to CO, less than 3 years, use this standard.)

All other experienced PAs9 (more than 3 years in CO)

ON-SITE SUPERVISION

• First 160 hours • At least 25% by primary supervisor2

PRACTICE AGREEMENT

PERFORMANCE EVALUATION/ ASSESSMENT

Within 30 days of completion of 160 hours3

N/A

Within 30 days of completion of the 160 hours; periodic thereafter4

N/A

Yes7

At 6 and 12 months; periodic thereafter8

N/A

Within 30 days of beginning practice11

Yes12

SUPERVISORY PLAN

• First 80 hours • At least 25% by primary supervisor6

• Per practice agreement10

COPIC has created a guide on Rule 400/supervising PAs that includes this information along with additional details about PA and supervising physician responsibilities, special requirements for acute care hospital settings, and prescription and dispensing of drugs by PAs. You can download this at www.callcopic.com/resource-center/guidelines-tools/practice-management-resources ■

References: 1 CRS 12-240-114.5(2) 2 CRS 12-240-114.5(2)(a) 3 CRS 12-240-114.5(2)(c); CMB Rule 400; 3 CCR 713-7.1(D) 4 CRS 12-240-114.5(2)(c) 5 CRS 12-240-114.5(4) 6 CRS 12-240-114.5(4)(a) 7 CMB Rule 400; 3 CCR 713-7.1(A) 8 CRS 12-240-114.5(4)(c) 9 CRS 12-240-114.5(3)(a) 10 CRS 12-240-114.5(3)(a)(I)– (IV) 11 C RS 12-240-114.5(3)(a)(I) – (IV); CRS 12-240-114.5(3)(b) and (c) 12 CMB Rule 400; CCR 713-7.1(D)

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Attracting and retaining more patients in the era of consumerization Jared Jost, Vice President of Marketing, PatientPop

Ninety percent of health care providers are currently in a competitive market, according to a PatientPop survey, and nearly four in 10 describe their situation as highly competitive. This should come as no surprise to physicians who run their own practice.

With the proliferation of urgent care centers, walk-in clinics and telehealth, it’s become increasingly more challenging for practices to attract new patients. The solution for 2020? Adapt to the mass online migration.

In a 2019 patient perspective survey, three of four people say they’ve looked online for care, but that’s just the start: patients are assessing doctors, sharing feedback, seeking medical information and regularly making appointments. This instant access to information, coupled with established online “shopping” habits, have fueled today’s consumerization of health care.

The digital tactics you implement now can dictate your potential growth over the next decade. Here’s how to begin improving your online presence and effectiveness.

Claim your online listings Every practice is listed across a variety of online directories and health care websites – Google, Yelp, Facebook, Vitals – where patients check everything from your location to your most comprehensive services. If you haven’t claimed your profiles, you can’t control what prospective patients see, including inaccurate information.

Claim your profile on review websites and listings directories, prioritizing sites that are most visible and familiar to you and your patient base. Within each profile, list your business essentials (name, address, phone number). Share details about providers, services and staff. Add photos. Build trust at first sight by bringing your practice to life.

Optimize your health care website You have the most control over your health care website, so take advantage of it. Identify services for which you most want to be found and create a single webpage for each. Stay consistent with the terms you use for symptoms, services and your approach to treatment.

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Then, create a webpage for each provider, and include those key terms you’ve established elsewhere on the site. Develop a blog with a fresh page for every post (one post per month, at minimum).

All this website production tells search engines you have relevant, well-organized, authoritative information that can satisfy patients’ search queries – and position your site to rank well in search results. You may not move the needle immediately but you’ll be on your way.

Offer online scheduling Don’t force interested patients to pick up the phone to make an appointment. Give them the convenience to do so online, right where they find your practice. Online scheduling should be a must on your own website and the functionality also exists on many listings websites.

Focus on reputation

Put it all together

When choosing a doctor, patients consider reviews the most influential online resource: In a 2019 PatientPop survey, 70 percent of patients said positive reviews are important or very important.

Taking on any of these actions can help nudge more patients toward your practice. But the real practice growth occurs when the entire patient journey is addressed, from the first time a person searches online for care through receiving post-visit communications. With an all-in-one service to guide the way, practices can attract and satisfy more patients in 2020.

A strong reputation impresses across three key review elements: total number of reviews, average star rating and frequency of reviews. To boost all three, you must start by asking your patients for feedback. They are far more likely to submit a review when asked, and the majority of patients have only shared positive experiences.

Monitor your reviews daily and respond to patients’ negative feedback. Doing so is critical because nearly all review readers (97 percent) also read how businesses respond, according to research from B right Loc al. Addi t ionall y, PatientPop research shows the rate of patient satisfaction roughly doubles when negative comments are addressed. Just make sure your replies are prompt, polite, professional and free of protected health information (PHI).

PatientPop is the leader in practice growth with the only all-inone solution that empowers health care providers to improve every digital touch-point of the patient journey. As experts in the health care technology space, PatientPop makes it easy for providers to promote their practice online, attract patients and retain them for life.

TO INSTANTLY SEE HOW YOU COMPARE TO OTHER PRACTICES IN YOUR LOCAL AREA AND SPECIALTY: compare.patientpop.com/cms. ■ Jared Jost is vice president of marketing at PatientPop, the market leader in health care practice growth technology. He has deep expertise and experience implementing integrated marketing campaigns, and helping businesses achieve their revenue goals.

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Accreditation status assures CME opportunities for CMS members The Colorado Medical Society’s continuing medical education (CME) program is an important component of the services CMS provides to organizations and physicians around the state, enabling the society to promote lifelong learning and professional growth for physicians and health care teams through the provision of high-quality CME activities accredited by the Accreditation Council for Continuing Medical Education (ACCME). These activities address identified practice gaps in health care and systems of care, patient safety, access to care and other significant public health concerns. Through its provision of CME, CMS strives to improve the practice of medicine and the health of the citizens in the Colorado region.

After several months of preparation, CMS has completed the reaccreditation process consisting of three parts: a self-study that describes the CMS CME program, performance-in-practice

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review of CME activities, and an interview to clarify information from the self-study and activity files.

ACCME has reviewed and awarded Accreditation for four years (12/09/2019 - 11/30/2023) to CMS as a provider of CME for physicians. Accreditation in the ACCME System seeks to assure the medical community and the public that Colorado Medical Society delivers education that is relevant to clinicians’ needs, evidence-based, evaluated for its effectiveness, and independent of commercial influence.

The ACCME System employs a rigorous process for evaluating institutions’ CME programs according to standards that reflect the values of the educator community and aim to accelerate learning, inspire change, and champion improvement in health care. Through participation in accredited CME, clinicians and teams drive improvement in their practice and optimize the care, health and wellness of their patients. ■

N E W S

CMS CPEA awards accreditation with commendation to Montrose Memorial Hospital The Colorado Medical Society Committee on Professional Education and Accreditation recently awarded its highest accreditation level to the Continuing Medical Education (CME) program at Montrose Memorial Hospital.

This honor, “Accreditation with Commendation,” is awarded to CME programs that adhere to all 22 CME criteria of the Accreditation Council for Continuing Medical Education with an emphasis on addressing community health issues. To receive commendation, Montrose Memorial Hospital (MMH) had to demonstrate D E PA R TM E NT S :

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using CME as a tool to improve quality performance and health outcomes – utilizing provider’s insights and community input to address important issues, therefore improving quality of care.

In addition to meeting the educational needs of providers, the CME committee works with area agencies to develop educational opportunities to address community health concerns.

MMH is one of only a few hospitals in the state that require physicians to complete CME as par t of their medical staff membership. ■

N E W S

Seeking volunteer opportunities for retired physicians A group of retired physicians under the leadership of CMS past president M. Robert Yakely, MD, has been working with COPIC to develop an online catalog of volunteer opportunities for retired physicians who have elected to keep their Colorado medical license and malpractice insurance in force. Active or retired members who know of any such opportunities for physicians

who wish to continue to make contributions to their communities to remain engaged are encouraged to contact ryakely@hotmail. com to add to this online list. Find the current list of volunteer opportunities at https://www.callcopic.com/resource-center/ colorado-volunteer-physician-resources. ■

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AMA inaugurates recognition program in fight against physician burnout TWENTY-TWO ORGANIZATIONS ACKNOWLEDGED FOR ACHIEVEMENTS THAT IMPROVE JOY IN MEDICINE The American Medical Association (AMA) recognized 22 health care organizations as the first recipients of the inaugural Joy in Medicine™ Recognition. The new distinction offered by the AMA recognizes health care organizations that have committed to efforts that improve physician satisfaction and reduce burnout.

The sole honoree in Colorado is the University of Colorado School of Medicine in Aurora.

“It is a great honor to recognize the outstanding achievements of the organizations selected for the Joy in Medicine Recognition,” said AMA Board Chair Jesse M. Ehrenfeld, MD, MPH. “These organizations are true leaders in promoting physician well-being and continue to make a difference in the lives of our nation’s health care workforce.”

Candidates and their achievements to reduce physician burnout were evaluated against criteria demonstrating competencies in commitment, assessment, leadership efficiency of practice environment, teamwork and support. The Joy in Medicine Recognition Program is a component of the AMA’s Practice Transformation Initiative, a new course of action to advance evidence-based solutions that fill the knowledge gap in effective solutions to the physician burnout crisis.

“The Joy in Medicine Recognition Program is designed by the AMA to serve as a guide and catalyst for organizations who are interested, engaged and committed in efforts to fight the root causes of physician burnout,” Ehrenfeld said. “The AMA is optimistic that the program will serve as a road map to reduce burnout within organizations and unite the health care community around systematic changes that will energize physicians in their life’s work of caring for patients.”

The founding of the Joy in Medicine Recognition Program was influenced by three timely and prominent sources – a call-toaction blog post in Health Affairs titled “Physician Burnout is a Public Health Crisis: A Message to our Fellow CEOs,” a research article published in JAMA Internal Medicine titled “The Business Case for Investing in Physician Well-being,” and the multi-stakeholder effort resulting in the Charter on Physician Well-being.

The AMA continues to work to address the physician burnout crisis through research, collaborations, advocacy and leadership. ■

MICHAEL C SPARR, MD • DWIGHT R LEGGETT, II, MD • STEPHEN M SCHEPER, DO We are seeking a Board Certified, or Board Eligible physician in the practice of Physical Medicine and Rehabilitation. A qualified applicant will have expertise in the treatment of a large variety of musculoskeletal injuries and should be fellowship trained or experienced in fluoroscopic guided spinal injections. The qualified applicant will have exceptionally strong judgement, an ability to “think outside the box”, have a love of helping people and compassion for patient care. The applicant must have excellent communication skills both verbal and written, exceptional people skills, a sense of humor, the ability to have fun and a strong commitment to family. Finally, this individual will enhance our patient and employee culture. We are seeking the type of individual who is passionate about patient care, someone energetic, enthusiastic, modest and empathetic.

Accelerated Recovery Specialists offers a total compensation package that includes competitive salary and bonus structure, exceptional benefits, and the potential for partnership. We are an equal opportunity employer and do not discriminate on the basis of race, age, color, sex, national origin, religion, veteran status or physical handicap.

We fully respect confidentiality by interested parties and assure them that their backgrounds and interests will not be discussed with anyone without prior consent, nor will reference contacts be made until mutual interest has been established.

Qualified applicant should send CV with references to: admin@acceleratedrs.com or you may contact Donita at telephone number 719-636-3333 or fax information to 719-636-0025

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FINAL WORD

Reducing health care costs for better outcomes for all Colorado Governor Jared Polis

Doctors know that all roads lead to health. Our ability to work and make ends meet, to plan for our future, to enjoy time with family and friends and do the things that make life worth living – are all contingent on our health.

When people get sick, everything should be secondary to recovery. The last thing people should be worrying about is how to pay for their care.

But we know that’s not the case in the United States. Every day, millions of Americans struggle to afford the care they need when they have an accident or get sick.

One in five Coloradans report forgoing care because they can’t afford it. Nearly one in three Coloradans report failing to comply with prescriptions or cutting pills in half to delay refills because of costs.

And even if you’re well, the cost of health insurance is eating up a larger and larger slice of the family budget, which makes life harder for countless hardworking Coloradans who are tr ying to make ends meet.

Health care financing in the United States is like an ice cube. It gets passed around the system so everyone can get their hands wet – insurance companies, hospital administration, drug companies – and by the time it reaches the point where doctors are actually interacting with patients, there’s not always enough money left over for actual health care delivery.

As a result, we pay more than any other country for a health care system that leaves tens of millions without basic coverage while producing middle-ofthe-pack results and one of the lowest life expectancies in the developed world.

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The system isn’t just inefficient, unsustainable and immoral – it makes your job as medical professionals harder.

As study after study finds, stress exacerbates most health problems, and nothing is more stressful than worrying about how you can afford to feed your family, keep a roof over your head or send your child to school, while you’re trying to recover from an illness or an injury, or pay off the debt associated with the care you or a family member received.

Furthermore, when people can’t afford their medications or don’t have first-dollar coverage for early intervention, their health problems worsen, become more expensive and require more intensive treatments. As you well know, preventing an illness or disease is always less expensive and better for the patient than treating one.

And finally, you went to medical school and worked hard your whole lives to administer care and help people get better, not to spend your valuable hours navigating complicated payer requirements.

For all these reasons, I have made reducing health care costs one of my core priorities as governor.

In the short-term, we’re focusing on how to reduce costs for Coloradans today. Our biggest accomplishment this past legislative session was our bipartisan reinsurance program that is bringing down health insurance rates on the individual market by an average of 20.2 percent across the state, with even bigger savings in rural areas where some Coloradans are paying some of the highest premiums in the nation.

This program will have ripple effects beyond the individual market. When health rates are lower, more people can afford insurance, which means less uncompensated care.

But we know that we need to do more in the long term to address the systemic, under l y ing c auses of high heal t h care costs.

We passed a major hospital transparency bill to identify and address the root causes of outrageous hospital bills. We passed a plan to import cheaper prescription drugs from Canada, and we plan to pass legislation requiring more drug price transparency this session.

We’re working to reward primary care and prevention so that providers can prevent and address health problems before they become full-blown emergencies. In fact, Colorado’s Primary Care Collaborative just published its first report on how to make better primary care investments in the state.

We’re retooling our behavioral health system, and exploring innovations in health care financing like the consumer purchasing alliance model in Summit County that cuts out the middleman and lets employers negotiate directly with providers for better rates.

But the most important thing we are working on is a public option to lower insurance rates by reducing the actual cost of care and ensuring more competition in our individual insurance markets.

Twenty-two counties currently have no choice of carrier. A public option will fix that and increase competition.

It’s simple economics – when insurance companies have to compete for customers, rates get lower, which saves money for families who already have insurance, and puts coverage in reach for families that are currently going without.

I’m grateful to have the Colorado Medical Society as a champion and partner in this work. By standing behind this new option, you are putting patients first, ensuring that they will be able to afford the care they need.

None of this work is easy. But consider the alternative. If we don’t act, the unsustainable growth of health costs will continue. Fewer families will be able to afford insurance or prescription drugs, which means more of your patients will go without needed care. There will be more uncompensated care, which will lead to even higher prices, and most importantly, a less healthy state. If we want to avoid this future, we must act swiftly to address the underlying cost of care.

An af fordable, ef ficient health care system is central to our success as a state and your success as doctors. By pursuing these key reforms, we can reduce headaches for medical practitioners and instead allow you to focus on the very thing you entered this profession to achieve: better health outcomes for all.

I look forward to working with you to ensure that all Coloradans have access to quality, affordable health care. ■

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