Jan-Feb-2013 by Colorado Medical Society

January/February 2013

Volume 110, Number 1

Bridging the gap

Colorado Medicine for January/February 2013

Award-winning publication of the Colorado Medical Society

Colorado Medicine for January/February 2013

cont n ent nt ns nt Jan/Feb 2013, Volume 110, Number 1

Features. . . Cover story

The November elections results all but guarantee two key proposals for bridging the gap between the uninsured and insured will become reality. Read more about CMS strategy surrounding Medicaid expansion and the Health Insurance Exchange starting on page 8.

Inside CMS 5 7 31 32

President’s Letter Executive Office Update Reflections COPIC Comment

Departments 33 36 37 41

New Members Member Benefits Spotlight Medical News Classified Advertising

Colorado election results–The November election brought many new faces to the Colorado Legislature. Learn more about the post-election significance to medicine.

CP of Colorado Initiative–The Cerebral Palsy Care Project has drafted a legislative proposal that will create a five-year project to provide needed resources to CP birth families.

AMA President report–Colorado’s own Jeremy Lazarus, MD, AMA President, shares how the AMA gives doctors a powerful voice in post-election issues.

AMA Interim Meeting report–Read how the Colorado delegation passed two important resolutions and other highlights of the November AMA Interim Meeting.

Responsible opioid prescribing–Colorado physician experts come together to educate providers on how to provide responsible acute and chronic pain management.

Patient Safety Congress–The Colorado Medical Society and the Colorado Hospital Association invest collaboratively to move patient safety initiatives forward.

Patient safety survey – Recent flash survey shows physicians and hospital management are generally optimistic about patient safety initiatives underway.

Final Word–Former CMS President Dave Downs, MD, FACP, discusses how engaged benefit design programs can improve care and reduce health care cost.

Editor’s note: Articles appearing in Colorado Medicine without a byline represent the collaborative work of CMS leadership and staff.

Colorado Medicine for January/February 2013

C OLOR A D O M EDICA L S O CI ET 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 CONNECTION

2012/2013 Officers Jan M. Kief, MD

President

John L. Bender, MD, FAAFP President-elect Kay D. Lozano, MD

Treasurer

M. Robert Yakely, MD Speaker of the House Brigitta J. Robinson, MD Vice-speaker of the House Alfred D. Gilchrist Chief Executive Officer F. Brent Keeler, MD Immediate Past President

Board of Directors Amy Beeson, MS Charles W. Breaux Jr., MD Robert A. Brockmann, MD Ellen M. Burkett, MD Naomi M. Fieman, MD T. Casey Gallagher, MD Jan Gillespie, MD Ripley R. Hollister, MD Johnny E. Johnson, MD Donald Luebke, MD Randy C. Marsh, MD Gary Mohr, MD Lucy Loomis, MD Jeffrey A. Moody, MD Edward A. Norman, MD Tamaan Osbourne-Roberts, MD Bianca Pullen, MS Scott Replogle, MD Ranee M. Shenoi, MD Alisa B. Lee Sherick, MD Stephen V, Sherick, MD Sean Slack, MS Thomas H. Soper, DO Kayla Steffensmeier, MS

Board of Directors Michael Volz, MD H. Dennis Waite, MD Michael Welch, DO Jennifer Wiler, MD Harold “Hap” Young, MD AMA Delegates A. “Lee” Morgan, MD M. Ray Painter, Jr., MD Lynn Parry, MD Brigitta Robinson, MD AMA President Jeremy Lazarus, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Mark Laitos, MD Tamaan Osbourne-Roberts, MD CMS Connection Mary Rice, President

COLORADO MEDICAL SOCIETY STAFF Executive Office

Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Donna Jeakins, Manager, Accounting, Donna_Jeakins@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org Dianna Mellott-Yost, Executive Assistant to CEO and General Counsel, Dianna_Mellott-Yost@cms.org

Division of Communications and Member Benefits

Brad Pierson, Art Director/ Manager, Communications, Brad_Pierson@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org

Division of Health Care Policy

Chet Seward, Senior Director, Chet_Seward@cms.org JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

Division of Information Technology/Membership Tim Roberts, Senior Director, Tim_Roberts@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org

Division of Government Relations

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Chris McGowne, Program Manager, Chris_McGowne@cms.org

Colorado Medical Society Education Foundation Colorado Medical Society Foundation Mike Campo, Staff Support, Mike_Campo@cms.org Donna Jeakins, Staff Support, Donna_Jeakins@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, Colorado, 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 Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Brad Pierson, Art Director, Assistant Editor; Chet Seward, Assistant Editor. Printed by Spectro Printing, Denver, Colorado

Colorado Medicine for January/February 2013

Inside CMS

president’s letter Jan Kief, President Colorado Medical Society

A race for the stability and productivity of our profession When I assumed this office, I proposed to my colleagues a race car theme for what will be a very fast track this coming year – REV: Relationships, Evolution and Voice. From my metaphorical point of view, these are the engine components that will keep our profession on the track that promises to have lots of steep hills and sharp turns. The next 12 months will be a race for the stability and productivity of our profession. Congress is in a race to prevent driving our federal budget over the sequestration cliff, dragging the SGR and the economy with it. Meanwhile states are racing to meet federal deadlines (or drive away from them). Both sides of the aisle in Denver and Washington are revving their engines in anticipation of the contests and collisions that start in January. Relationships We have long preached the doctrine that relationships are as important as the issues. Your grassroots work in this election cycle, supporting friendly incumbents who rode with us as well as the candidates and challengers who are headed our direction, have forged and strengthened relationships. Equally important, we have methodically built a sense of community in our profession and a sense of direction, and extended those relationships to our allies in the world of health care delivery.

this challenging terrain, and helping our colleagues perform at optimal levels. We are gratified with the initial report from the Regional Care Collaboratives and hope to glean some valuable data in the future that can help us guide and coordinate care. CMS is convening the RCCO directors early in 2013. We are excited to have three practices in the four-year Comprehensive Primary Care Initiative. Cutting edge initiatives are underway in all areas of our state with physicians taking leadership roles. We are one of six states that will have practices involved in a joint AMA initiative where the RAND corporation will evaluate physician satisfaction and enhanced practice viability. Also we have been asked to form a task force for the Center for Improving Value in Health Care (CIVHC) to help design its physician report card for the All Payer Claims Database. Voice Our homegrown, locally-driven methods of building a physician consensus have led to legislative successes that have set national standards for physi-

Evolution Colorado is on track to spread practice evolution across all practices. We are innovating patient-centric, communitycentered medical homes, coordinating Medicaid in the same fashion, and delivering care with unprecedented results. We are evolving and adapting to Colorado Medicine for January/February 2013

cians’ rights and advocacy. Public officials and the thought leaders in health care policy listen and work with us. On the road ahead I see the gears grinding and jamming as our legislators work

“. . .Congress is in a race to prevent driving our federal budget over the sequestration cliff, dragging the SGR and the economy with it.” on the Medicaid Reform and Expansion, and health insurance exchange vehicles. I see the usual potholes and trip wires set by trial attorneys to break the axle of medical liability stability. But I also see the finish line: the acceleration of practice evolution, and the strengthening of our ties as a profession and medical and health community Ladies and gentlemen, REV your engines. The race is on. n

Join COMPAC Now!

Colorado Medical Political Action Committee Call 720-858-6326 or 800-654-5653, ext. 6326 or e-mail Chris_McGowne@cms.org

Inaction vs IN ACTION We understand the difference The Litigation Center of the American Medical Association and the State Medical Societies fights to protect doctors and uphold the highest standards of patient care. In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession. Whether we are challenging managed care organizationsâ&#x20AC;&#x2122; payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physiciansâ&#x20AC;&#x2122; rights. Learn more on how The Litigation Center can help you.

ama-assn.org/go/litigationcenter

Membership in the American Medical Association and the Colorado Medical Society makes the work of The Litigation Center possible. Join or renew your memberships today by calling the CMS at (800) 654-5653.

The Litigation Center is proud to have Alfred Gilchrist, CEO of the Colorado Medical Society, serve on its executive committee.

ama-assn.org

cms.org Colorado Medicine for January/February 2013

Inside CMS

executive office update Alfred Gilchrist, Chief Executive Officer Colorado Medical Society

The fork in the Medicaid road Medicaid as we know it could soon go the way of the dinosaur. The federal package is on the table and is now politically viable after the November elections. Over the course of the next six months our state legislators and the executive branch have the opportunity to build what hasn’t been politically possible since the program’s inception decades ago. Many physicians are understandably cautious about the growth of Medicaid, given the sheer enormity of the task of transforming the program into a high-performing delivery system. This enormous undertaking, already well underway in the Hickenlooper Administration and heading in the right direction, will soon be considered by a state legislature that is philosophically predisposed to expansion and reform. The process won’t be short of spirited dissents and competing proposals. With more than 35 freshmen and 22 sophomores, a plurality of the legislature will be participating in first-time policy debates on a subject of immense complexity. The consensus medical view reflected in statewide polls, listening sessions at September’s Annual Meeting and in other physician forums is for CMS to be there, on the ground, in the Capitol, and fully engaged.

this tipping point in health care delivery, there is no more waiting for things to gel. The pot is boiling. There has been extensive preparation for this once-in-a-career opportunity by both CMS and an impressive array of health policy advocates, experts and thought leaders. In September 2005 the House of Delegates first directed CMS to develop strategies to bridge the gap between Colorado’s insured and uninsured, putting us on the field pressing the case for what became Senate Bill 208, which was enacted and signed into law by then Governor Bill Owens. This work evolved into the bipartisan, broad spectrum 208 Blue Ribbon Commission. Their remarkable, voluminous piece of work preceded by several years the federal reforms embodied in the Affordable Care Act. Its wisdom and recommendations should be of considerable value to legislators and advocates with regard to what works, what might, what won’t and most importantly, the interdependence of the moving parts. We have been doing our homework. As Congress fiercely debated the role of government and commercial markets in care delivery, we pulled together our own Physicians’ Congress for Health System Reform and methodically built a matrix of system components to be

We will press for the operational reforms that are critical to assuring that an expansion will be sustainable. After lengthy discussions, our public policy committees took the point of view that our perspectives will have more credibility if we are at the table, not holding our cards until later in the debate. Our approach will be less political and more practical in nature. For our ideas and knowledge to have consequences at Colorado Medicine for January/February 2013

measured against the congressional models. We have helped build coalitions to champion patient safety, managed care operational innovations, and care coordination initiatives of national

“Our approach will be less political and more practical in nature. For our ideas and knowledge to have consequences at this tipping point in health care delivery, there is no more waiting for things to gel. The pot is boiling.” prominence, just to mention a few of our more prominent efforts. There will inevitably be some tough choices and trade-offs in the coming months. Cost containment won’t be missing from the state package. There will be the usual poison pills to reject, and well-intentioned ideas that we know from experience have a half-life of a few years. But as Yogi says, “When the road forks, take it.” n

Encourage a colleague to join the Colorado Medical Society and your local medical society today!

Visit www.cms.org to learn more about the benefits of becoming a member

For more information and an application to join, call Tim Yanneta 720-858-6306 or e-mail Tim_Yanetta@cms.org

Cover Story

Bridging the gap Chet Seward, CMS Senior Director, Health Care Policy Kim Ross, CMS contributing writer

Structural reforms could help build expanded access to care

Colorado Medicine for January/February 2013

Cover Story The results of the November 6 election all but guaranteed two key proposals for bridging the gap between the uninsured and insured will become reality: health insurance exchanges and – in some states – a substantial Medicaid expansion. The U.S. Supreme Court ruled earlier this year that those key components of the Affordable Care Act (ACA) could stand. The possibility of political pushback remained, however, until Democrats gained ground in both chambers in Washington as well as in the Colorado General Assembly on Election Day. The next day renowned health economist Bob Laszewski PhD, echoed most of the health policy blogosphere when he observed, “The Affordable Care Act (“Obamacare”) is now settled law. It will be implemented. It will also have to be changed but not until after it is implemented and the required changes become obvious and unavoidable.”1 While the final, detailed schematic of the twin bridge to span the uninsured divide is still being constructed, many argue that Colorado is better positioned than most to thoughtfully architect a solution. Colorado is just one of 18 states that elected to run its own health insurance exchange rather than defaulting to a federal exchange in 2014. Passed after a contentious debate in the General Assembly in 2011, the build out of the Colorado health insurance exchange, which is set to go live in October 2013, has been reasoned, stepwise and significant. Some experts hold out the Colorado strategy as a national model for efforts to serve as a new online health insurance marketplace. On the other hand, much more work on Medicaid is necessary, especially given the long-term financial impact on the state and the widely held concerns about the structural flaws within the current program. The expansion of Medicaid to cover all individuals living in families below 133 percent of the federal poverty level ($30,657 for a family of four in 2012) could mean 200,000 or more new participants in Colorado. The state also

could opt to take a different approach – including not expanding at all. Political calculus The lines being drawn in Denver and in other state capitols across the country share common themes. One side argues against increased dependence on federal influence, noting that while the initial offer of federal funding may seem generous, a future Congress could renege on the agreement. Per the ACA the federal government will cover 100 percent of expansion costs from 20142016, and at least 90 percent thereafter. The other side counters that there will likely never be a better deal to cover the uninsured, substantially limit cost shift to private payers, and leverage existing efforts including the Colorado Medicaid Accountable Care Collaborative to assure greater value within the program. The calculus for Governor Hickenlooper and Colorado legislators will be a complex balancing act; evaluating the benefits of a substantial influx of federal dollars against an equally substantial, relative commitment of state revenues to cover their share of the total budget starting in 2017. Colorado Medical Society and physicians across the state have been similarly grappling with this issue since the Supreme Court’s ruling on the ACA this summer. Since then physicians have been engaged in a multi-pronged CMS strategy to determine the potential consequences for Colorado, the medical profession and patients if the state decides to opt-in or declines to participate in the Medicaid expansion. After months of deliberations the CMS Council on Legislation and the Committee on Physician Practice Evolution have forwarded a recommendation to support the expansion in principle. The CMS board of directors will consider this proposal during its January meeting. (See sidebar on page 11 for details on this recommendation.) At press time the political wrangling at the statehouse continues over whether or not to move forward with the expan-

Colorado Medicine for January/February 2013

sion. For many the decision boils down to the resources, or lack thereof, necessary to make the right choice to serve low-income patients. Echoing the sentiments of at least nine other state governors, Alabama Gov. Robert Bentley recently reported that, “Alabama will not expand Medicaid ‘under the current structure that exists’ because Alabama ‘simply cannot afford it.’”2 While Colorado has yet to release a detailed budgetary analysis, many other national think tanks have been churning out studies detailing the pain versus gain trade-offs of Medicaid expansion.

“While the final, detailed schematic of the twin bridge to span the uninsured divide is still being constructed, many argue that Colorado is better positioned than most to thoughtfully architect a solution.” Understanding these projections is critical, especially given the likely “woodwork and crowd out” effects on the final size of the expansion population where people that were previously eligible but not enrolled in Medicaid come out of the woodwork and join once they become aware of the program, or those that may already have insurance drop that private coverage to join Medicaid under a new eligibility category. Experts have noted that states may face other losses if they do not expand, including lower federal matching rates, higher costs for uncompensated care, reduced state income and sales taxes resulting from federal payments to providers, decreased economic activity and continuing costs for insufficient systems to care for underserved populations.3 On the flip side an expansion may reduce the cost of other non-Medicaid state programs such as mental health services, public health and local and state cor-

Cover Story (cont.) rections and public safety. The Robert Wood Johnson Foundation estimates that Colorado could save $361 million over the next decade by reducing those anticipated costs.4 Stakeholder pressure There is a growing urgency to this impending debate, given the bets already placed by both the hospital and health insurance industries on building this twin-span bridge that is now significantly dependent on state governments across the country. Futurist and consultant Jeff Goldsmith, PhD, warns in an article posted on the Health Care Blog: “Hospitals are watching these developments with mounting alarm. National hospital organizations actively supported health reform…(when) they gave up $155 billion in future Medicare payment reductions to gain 30 million new paying patients, and consented to the reduction of disproportionate share

payments (DSH) intended to compensate them for their bad debts and charity care. A cancelled Medicaid expansion would place the safety net hospitals in those states at serious economic risk, who would be forced to continue relying on Robin Hood economics to keep their doors open . . . The only reason health plans agreed to unprecedented federal restrictions on their business practices was the promise of near-universal coverage . . . How can health plans in states which decline the expansion be expected to absorb, through guaranteed issue and guaranteed renewal, the flood of adverse selection, not to mention the above discussed provider cost shifting?”5 Sticker shock For state legislators involved in the appropriations process that has statutory caps, that kind of budget uncertainty is terrifying in an already growing, if not overwhelming, state expenditure category. A recent projection by the Kaiser

Accountable Care Collaborative: Promising Results The Accountable Care Collaborative (ACC) completed its first year of operation this summer and a November 2012 report to the General Assembly shows promising results to date. The collaborative is a central component to the state’s strategy to reform the Medicaid program through the use of local control, changes in payment policies and delivery systems to reward for value versus volume, and providing information technology support to drive informed decision-making. Currently approximately 132,000 patients are served within the collaborative, which the department has stated will be the “predominant program that will lead Colorado Medicaid into the future of better health care.”

Family Foundation put Colorado’s obligations, net savings offsets, at roughly 1.9 percent of the state budget over 10 years, or about $581 million.6 In reacting to that study, the Denver Post summed up the probable sentiment among policy leaders on both sides of this proposal in an editorial entitled, “Sticker shock on Medicaid costs.” The editorial notes: “If you know anything about the state budget, it’s probably that there’s not a bunch of extra money lying around. You might even remember the University of Denver report last year that said lagging revenues meant Colorado would be unable to pay for Medicaid, public schools and prisons by 2025 . . . Which is why a recent Kaiser Family Foundation estimate that expanding Medicaid in Colorado under Obamacare could cost the state as much as $858 million over the next 10 years should give all of us pause. If there was an extra $85.8 million a year available, don’t you think someone would have already claimed it? . . .(B)efore opting in, state officials must diligently review the costs and benefits of such a move – and how it might be paid for.”7 CMS President Jan Kief, MD, says CMS shares the same sentiment. “The practical aspects are obvious to us. We have to find a way to capture these badly needed funds and use them intelligently to retool Medicaid more in the form we are now building with the Accountable Care Collaborative and bridge the coverage gap that is otherwise an economic anvil around our collective necks.” (See sidebar on Accountable Care Collaborative on this page.)

While more work is necessary to realize the full potential of the ACC, the report details some positive quality improvement outcomes to date including reducing inpatient hospital readmissions, emergency room utilization and utilization of high cost imaging services, in addition to lower rates of aggravated chronic health conditions such as asthma and diabetes. The report also shows a $30 million program cost savings from the first year of operations, without full-scale program enrollment and operations.

Déjà vu Even though there wasn’t a national analyst, court watcher, or legal expert who anticipated the Supreme Court’s deft handoff of the Medicaid expansion to the states, one could argue that Colorado policy leaders were already there years ago.

Find more details about the ACC at http://tinyurl.com/b8agryq.

“Colorado Medical Society, as early as 2005, was calling for the kinds of re-

Colorado Medicine for January/February 2013

Cover Story forms that were ultimately embodied in the SB 208 Blue Ribbon Commission on Health Care Reform, which we strongly supported from its inception in 2006,” said CMS CEO Alfred Gilchrist. The commission’s final report, which was delivered in 2008, produced an extensive list of recommendations to the Colorado General Assembly that are eerily prescient, based on the premise that costs cannot effectively be managed without first bridging the coverage gap and improving the efficiency of the delivery system. “We must look for ways to stabilize rising costs. For example, if we extend health coverage to more people, we can minimize the cost shift from uncompensated care that represents a ‘hidden tax’ and contributes to escalating health insurance premiums . . . Certain essential building blocks among these recommendations must be put in place before others if those latter elements are to be successful . . . For example, the requirement for all Coloradans to have insurance works only if other measures are enacted to make coverage accessible and affordable, such as expanding public programs, creating subsidies for lower-income people to purchase private insurance and reforming the individual insurance market. Similarly, efforts to expand enrollment in public programs must be preceded by efforts to improve efficiency and increase provider participation in those programs.”8 “The Commission understood, over four years ago, what this bridge building debate in the state capitol will entail,” said Steve ErkenBrack, President and Chief Executive Officer for Rocky Mountain Health Plans. “An opportunity to build a better model which ensures access, not just eligibility, requires a strong underpinning – assuring the delivery system is administratively simple for patients and providers, enhanced patient engagement and care adherence, and reimbursement at rational levels that will sustain physician, hospital, and other providers. Without

Colorado Medicine for January/February 2013

CMS Position on Medicaid Expansion In mid-December the CMS Council Legislation and the Committee on Physician Practice Evolution approved a position statement developed after months of statewide surveys, focus groups and meetings. The statement endorsed the Medicaid expansion in principle, reaffirming a long-standing position that efforts to redesign Medicaid and the larger health care system have to be about more than just improving coverage but rather have to improve care value. “To facilitate successful expansion of access to health care under Medicaid and the ACA, we recommend that the following reforms be addressed urgently,” the statement reads. The recommendation, however, will not become policy until the CMS board of directors votes at its January meeting after considering the statement and its emphasis on the following positions:

• Access to care – Ensure appropriate access to care by enhancing reimbursement rates for all physicians to equitable levels that are at least at parity with Medicare. o Utilize the HB 1281 pilots and other initiatives to test and accelerate the adoption of alternatives to fee-for-service payment, including bundled payments and other methodologies. o Support 12-month continuous eligibility for children in Medicaid, per existing law.

• Preserve and innovate liability protection – Maintain Colorado’s

relatively stable medical liability climate and provide enhanced protections for the use of evidence-based approaches to care management, including, but not limited to, shared decision making models.

• Patient engagement – Maximize clear, shared accountability be-

tween patients and physicians across the spectrum of care. o Explore and promote other options to facilitate patient engagement, health literacy, healthy behaviors and reduce avoidable use of high cost services. o Provide incentives for patients and physicians to use patient decision aids and shared decision-making tools.

• Administrative simplification – Eliminate unnecessary administra-

tive complexity, increase efficiency and standardization of Medicaid administrative processes. o Streamline provider enrollment procedures, standardize use of nationally recognized transaction codes (CAHQ/CORE), maximize efficiency of prior authorization using electronic procedures, improve eligibility determination timeliness and transition to Medicare 1500 electronic claims submission. o Develop and document a well-defined, fair administrative process for cases of suspected fraud and abuse that includes due process for providers.

Cover Story (cont.) that, a health system, even if reformed, is on shaky ground,” said ErkenBrack. n Bob Laszewski, MD. The 2012 Elections and 2013 – We Face a Daunting To-Do List. November 7, 2012. http://healthpolicyandmarket.blogspot.com/2012/11/the-2012-electionsand-2013we-face.html 2 Dana Beyerle. “Bentley: No insurance exchange, Medicaid expansion,” Gadsden Times, 11/13/12. 3 Ray Perryman. The Only Rational Choice: 1

Texas Should Participate in the Medicaid Expansion Under the Affordable Care Act. October 2012. http://www.perrymangroup. com/reports/MedicaidExpansionwithTables12_1003.pdf 4 Colorado Hospital Association. Why CHA Supports Medicaid Expansion in Colorado. September 2012. http://www.cha.com/ pdfs/CHA-Medicaid-Expansion-PositionPaper-9-2012.pdf 5 Jeff Goldsmith, PhD. Roberts “Flying Squirrel” Maneuver Takes Down the Affordable Care Act. The Health Care Blog. July 2012.

John Holohan, et al. The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis. Kaiser Family Foundation. November 2012. 7 Denver Post. “Editorial: Sticker shock on Medicaid costs.” November 29, 2012. 8 Blue Ribbon Commission on Health Care Reform. Final Report to the General Assembly, January 31, 2008. http://www.colorado. gov/208commission/ 6

ANNOUNCING Free website for Colorado physicians offering EHR tools and resources

Your path to meaningful use The Colorado Medical Society and CO-REC are pleased to offer a free online EHR portal that provides the tools, resources and information to help Colorado physicians select, implement and meet “meaningful use” requirements.

• Step-by-step training with tools to track meaningful • • • •

use progress Establish your own free account - quick registration Self-guided and interactive content developed for Colorado physicians and staff Information and links to statewide resources Online forms and downloadable documents to guide you through the meaningful use EHR process

Creating your free account is easy. Sign up today by logging on to

http://www.corhio.org/portal

Funded by a grant from the Physicians Foundation

Colorado Medicine for January/February 2013

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member For more information and an application to join, call Tim Yanetta

720-858-6306 or e-mail

Tim_Yanetta@cms.org

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Colorado Medicine for January/February 2013

Features

Colorado election results

Susan Koontz, CMS Senior Director of Public Affairs, General Counsel

Now what? The post-election significance to medicine From candidate and incumbent screening to endorsements and grassroots support, the initial phase of physician engagement in the political process wrapped up with last month’s election results. We are now in the transitional phase where we sort through plans and priorities, prior to the convening of the Colorado General Assembly in January. There is much to consider given the sweep by the Democrats and the unprecedented health care finance and delivery options tasked by Congress to the Assembly. We’ll face an array of perennial issues, not the least of which will be another well-heeled push by the trial attorneys to expand their reach and ability to sue physicians and hospitals. During this transitional period, our leaders and advocacy team, in coordination with colleagues in your respective communities, will follow up with these legislators from both parties - many of whom we strongly supported - and brief them on our collective policy concerns. In those relatively few circumstances where local physicians endorsed their opponent, we will offer to work with them on many prospective issues of common concern with the hope those legislators will evolve into “friendly incumbents” during their tenure. And during the session, we’ll move forward with our grassroots engagement with those legislators in the halls of the state Capitol. Here is our outlook on Colorado’s po14

litical environment going into the 2013 General Assembly and its implications for health care policy. 1. The re-election of the president, the continued partisan split in Congress, and the fairly definitive ruling by the U.S. Supreme Court on the federal health reform law put to rest attempts at repeal or significant emasculation of the law. The Colorado Legislature will thus have a far wider field of policy options to consider regarding the design, funding alternatives and infrastructure of the optional Medicaid expansion and the Health Insurance Exchange work-in-progress. In that respect, we are fortunate that our state enjoys an enlightened body of health policy leaders among the medical, provider, payer and employer communities, as witnessed by a history of thoughtful collaboration and a considerable range of efforts well underway. We won’t be starting from scratch; we will have a strong sense of what works, is already working, and what might not work. 2. The Democrats will be the ruling majority in both the Colorado House and Senate, a very different political dynamic from our most recent experiences with a split majority between the two chambers. 3. Colorado elected/re-elected a larger pool of legislators who are predisposed to tackle questions of care access and network adequacy, funding streams

that encourage care coordination, and related measures aimed at higher degrees of payer and provider transparency and accountability. While that imposes some risk of enacting suboptimal or adversarial policies, it opens far more doors than it closes. 4. The likelihood of some of these proposals languishing in a committee is significantly decreased. Thus, we will be called upon to engage more frequently in policy discussions as a mostly lay-legislature with a focused interest in the value of state health care resources and finance struggles with the complexities of health policy choices they have not had the luxury to study in any depth. 5. That also means other more antagonistic proposals – especially those brought by the Colorado trial lawyers – are likely to spill over into both chambers, and medicine will be fighting along a 100-member front rather than the confines of a six- or ninemember committee. 6. There will be a spike in legislative activity that we expect will have a disproportionate health care mix. COMPAC and CMS’ extensive investment in grassroots-centric physician activism over the last several months will be regularly deployed during the impending session. It will be a combined fire drill, marathon and Code Blue in one brutal stretch of five-plus months. n

Colorado Medicine for January/February 2013

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Colorado Medicine for January/February 2013

Features

Cerebral Palsy Care Project

Initiative aims to provide immediate assistance to children born with cerebral palsy Families who have children born with Cerebral Palsy (CP) often pursue lawsuits to identify financial resources to help them address the unimaginable challenges they face in caring for their child. Unfortunately, the tort system is fraught with uncertainty, takes years of drawn-out legal proceedings, carries high emotional costs, and requires huge investments of time and energy. After all of this, the family still receives no guarantee that they will be given the financial support they need. The challenge, as anyone familiar with the medical liability system knows, is that families typically only can become eligible for significant compensation if they claim that medical providers are at fault for their child’s condition. But research has demonstrated that, in the vast majority of cases, CP is not the result of provider negligence. Does the absence of negligence eliminate the families’ needs? Of course not. And even when families go to court and prove negligence, they receive only a fraction of the amount spent on the case, with opposing counsels’ legal fees consuming much of the total. All too often, the physician-patient relationship and the physician end up as collateral damage. Physicians named in lawsuits endure the glare of negative publicity and the stress of litigation even when they are blameless. An effective medical liability system should meet three goals: 1. Fairly compensate injured patients and their families. 2. Improve safety by ensuring that phy16

sicians and other healthcare providers learn from errors. 3. Hold physicians and other providers accountable for the quality of the care they offer. The current medical malpractice system falls far short in all three areas: 1. Compensation is unpredictable and inequitable. Many patients cannot afford to access the judicial system. Those who can access it may get nothing if they cannot legally prove negligence – regardless of their needs. Even if they win a settlement or verdict, it may take years and they typically get less than half of the money spent on their cases. 2. Errors don’t necessarily lead to improvements. Just the threat of lawsuits creates a bunker mentality that makes physicians and other health care providers less likely to report and address emerging safety issues before they result in more harm. 3. Litigation does a poor job of identifying medical errors. Only about 2-3 percent of errors result in claims yet research shows there is no negligence in as many as five out of six medical malpractice claims. “It’s about the child. It’s about that family. We have a wonderful opportunity in this state to be on the cutting edge in solving this problem,” says Judith Ham, president and CEO of United Cerebral Palsy of Colorado. Piloting a system that doesn’t make support for patients contingent on assigning blame could give immediate relief to the families of neurologically impaired

children while pointing the way to better health care for all Coloradans. While this initiative is new, encouraging precedents are offered by the National Vaccine Injury Compensation Program, among other time-tested programs that don’t tie compensation to a finding of fault. The Cerebral Palsy Care Project has drafted a legislative proposal that, if enacted, would create a five-year project to: • Provide care coordination and resources to certain families of children with birth-related CP. • Demonstrate that such a program can be more effective for these families and more financially efficient than the current lawsuit-based system. Children and families meeting the proposal’s guidelines would receive benefits without having to prove that a provider was at fault or even that their condition is connected to the medical care they received before or during birth. Participating families would not be able to pursue other legal options for additional benefits. The demonstration project, which would exclude premature babies or those with CP that was the result of other childhood causes, could be renewed after five years. Even if it were not renewed, participating families in the initial five-year stage would be covered for the life of the child. It would be administered by a not-forprofit organization accountable to the

Colorado Medicine for January/February 2013

Features Colorado insurance commissioner and governed by a board, which will include members appointed by the governor. Funding for the program would come from insurers like COPIC that currently bear the financial burden of birth-related CP lawsuits. Under the program, all monies that have traditionally gone toward defense expenses and compensation would then go into a fund to benefit eligible families. COPIC supports the initiative, which would need to be enacted by the Colorado Legislature. Leaders of the initiative are meeting now with families, groups that advocate for people with disabilities, physicians, nurses, health provider organizations, hospitals and health plans, among others. n

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Features

AMA President Jeremy Lazarus, MD Amy Farouk, MA, AMA Staff Assistant IV

AMA gives doctors powerful voice in post-election issues Colorado’s own Jeremy A. Lazarus, MD, AMA President, spends about 200 days per year criss-crossing the United States, talking with folks about the AMA’s efforts to make an impact on the issues that matter most to America’s physicians and patients. This article was originally published as part of the series, ON THE ROAD WITH DR. LAZARUS, a blog that can be accessed on the American Medical Association home page at www.ama-assn. org. With November’s contentious elections behind us, Congress has weighty issues to act upon – many before the end of the year. I am asked frequently how the AMA is proceeding during this critical period. Rest assured that the AMA is giving physicians a powerful voice in our nation’s capital on issues that are vital to the future of medicine.

deficit reduction and entitlement reform legislation that is anticipated in 2013. As I wrote a few weeks ago, we have asked Congress to use our principles as the basis of a new, high-performing Medicare program. We’re also focusing our efforts to preserve graduate medical education funding. Like Medicare physician payments, this funding faces a 2 percent cut under the Budget Control Act of 2011. Proposals for additional substantive cuts also have been placed on the table as lawmakers search for ways to reduce spending. With a predicted physician shortage on the horizon, any cuts to already limited funding would be a great disservice to our nation’s patients. Visit the AMA Legislative Action Center to write to your members of Congress about this important issue.

Among the most pressing of these issues is the Medicare physician payment system. Continually shaken and disrupted by the faulty sustainable growth rate (SGR) formula on which it is based, the instability of this system continues to threaten the financial viability of physicians’ practices and Medicare patients’ access to care. A recent survey confirmed that this instability also is preventing physicians from pursuing more innovative models of delivering care, which could both improve health outcomes and reduce overall health care costs. Beyond ensuring the 26.5 percent payment cut required by the SGR formula does not take place, we are urging Congress to fully reform the Medicare physician payment system as part of the larger Colorado Medicine for January/February 2013

In addition to these legislative pursuits, we will continue our work to reduce physicians’ regulatory burden. For instance, we are advocating for a more reasonable approach and greater flexibility in the Medicare meaningful use requirements for electronic health records to accommodate the clinical needs of physicians across specialties and practice settings. Another priority is easing the burden of Medicare’s numerous audit programs, which I wrote about earlier this year. There’s much to be done, so I encourage you to join the AMA’s Physicians Grassroots Network to stay up-to-date on the latest legislative developments. By doing so, you can add your voice in calling on Congress to address the critical issues for America’s physicians and the patients for whom they care. n

The Jane Nugent Cochems Trust Financial help for physicians in need The Colorado Medical Society administers all grants with the average amount ranging from $5,000 to $10,000. The application process is simple and the review processes are completely confidential. For more information or to obtain an application form, please call Tom Wilson at the Colorado Medical Society, 720-858-6316. Visit http://www.cms.org/about-cms/cochems-trust/ to download an application form.

Features

AMA Interim Meeting report

CMS AMA Delegation

Colorado Delegation accomplishes ambitious meeting agenda When the AMA Interim Meeting convened in Hawaii on Nov. 9, the Colorado delegation arrived with a threepart strategy – to pass two resolutions; increase the visibility of Brigitta Robinson, MD, candidate for the prestigious AMA Council on Medical Education; and to enhance relationships with the delegations from state medical and specialty societies across the country. Mission accomplished. The two resolutions – Resolution 812 and Resolution 811 – both successfully passed and direct the AMA to step up its efforts on administrative simplification and patient engagement. The Colorado Medical Society delegation crafted these two important resolutions in September, with a deep concern over Colorado physician burnout tied to the administrative complexities of the practice environment and the recognition that patients need to be more engaged in their own care. Both tie directly to initiatives already underway in Colorado. Resolution 812 Patient engagement through shared decision making Shared Decision Making (SDM) is a more robust form of informed consent and is actualized through the use of evidence-based tools called patient decision aides (PDA). PDAs make the options, benefits and risks of medical decisions clearer to the patient. These tools provide patients with unbiased, complete, accurate and understandable information about care choices. The concept was included in the federal Affordable Care Act, including grant making for SDM pilots, but Congress has yet to fund the pilots. Colorado Res20

olution 812 directs the AMA to lobby Congress to secure the funding. Funding for SDM pilots is significant for numerous reasons. First, there are recent studies demonstrating that patients have chosen to avoid many elective surgeries, saving dollars in the system. Second, an SDM pilot is already underway for employees of the San Luis Valley Regional Medical Center, with an evaluation in progress and publication of results anticipated. Third, the Washington State Legislature passed an SDM statute in 2007 providing physicians with additional liability protections when approved tools are utilized. Bottom line, SDM represents an innovation that engages patients in their own care, potentially reduces cost, is evidence-based and provides an opportunity for enhanced liability protections for physicians. The CMS Workgroup on Patient Safety and Professional Accountability will take action on a recommendation that CMS immediately promote liability protections for physicians who use SDM if the Colorado pilot proves successful. CMS alternate delegate and past president Dave Downs, MD, led our association’s efforts to pass the resolution. A practicing physician with the Colorado Permanente Medical Group, Dr. Downs is leading the clinical side of Colorado’s SDM pilot, which is funded by grants from the state department of Health Care Policy and Finance and the Robert Wood Johnson Foundation. Resolution 811 Administrative simplification: The hard work of reform Colorado senior delegate M. Ray Painter, MD, testified on Colorado Resolu-

tion 811 on administrative simplification, using a poignant metaphor to illustrate that addressing the administrative complexities are both daunting and ubiquitous. The rationale behind Resolution 811 is evidence-based and urgently needed. Studies show that: • U.S. physicians spend 66 percent more than other benchmark countries on administrative-related costs. • A minimum of $55 billion is wasted annually in unnecessary administrative costs. • Physicians in Colorado and across the country measure alarming levels of career-threatening burnout as a consequence of pervasive “hassle factors” in their practice environment. • There is a direct link between excessive administrative burdens with increased care redundancy and preventable errors. • Administratively-simple and transparent care delivery systems enhance care efficiency, value and outcomes. CMS has already approved numerous initiatives to address administrative complexities supported by the AMA, such as a national effort to standardize claims edits and prior authorization, among others. CMS strongly believes that the pervasive nature of hassle factors must be addressed across the spectrum and in a manner coordinated throughout organized medicine. Resolution 811 directs the AMA to: • Continue its strong leadership role in automating, standardizing and simplifying all administrative actions required for transactions between payers and providers. • Continue its strong leadership role in automating, standardizing and

Colorado Medicine for January/February 2013

Features simplifying the claims revenue cycle for physicians in all specialties and modes of practice with all their trading partners including, but not limited to, public and private payers, vendors and clearing houses. • Prioritize efforts to automate, standardize and simplify the process for physicians to estimate patient and payer financial responsibility before the service is provided, and determine patient and payer financial responsibility at the point of care. • Continue to use its strong leadership role to support state initiatives to simplify administrative functions, such as the Colorado Clean Claims Taskforce. • Expand the AMA Heal the Claims process campaign as necessary to ensure that physicians are aware of the value of automating their claims cycle. AMA Delegates demand elimination of ICD-10 During the AMA Interim Meeting, delegates insisted that the Centers for Medicare & Medicaid Services should stop its planned use of the new diagnosis coding set ICD-10, delegates said. A

policy adopted at the meeting instructs the AMA to immediately reiterate to the Centers for Medicare & Medicaid Services that the physician reporting burdens imposed by ICD-10 will force many small practices out of business. This message will be sent to everyone in Congress and displayed prominently on the AMA website. The Centers for Medicare & Medicaid Services requires that ICD-10 be the new standard to use for billing Medicare physician services starting Oct. 1, 2014. The coding set contains 68,000 codes; the current standard ICD-9 has roughly 13,000. The AMA must continue to communicate to the Centers for Medicare & Medicaid Services about the burdens that ICD-10 implementation places on doctors, said W. Jeff Terry, MD, a delegate for the Medical Association of the State of Alabama and a urologist in Mobile.

AMA adopts principles for physician employment During the Interim Meeting, AMA also adopted new principles for physicians entering into employment and contractual arrangements, acknowledging the “unique challenges to professionalism” arising from the trend toward physician employment. An AMA press release reports that one-third of final-year residents list hospital employment as their first choice of practice setting. The principles address six potentially problematic aspects of the employer-employee relationship: conflicts of interest, advocacy, contracting, hospital-medical staff relations, peer review and performance evaluations, and payment agreement. n

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“If we lose this fight, the doctors need to know we went to battle for them,” he added.

Ensuring faster physician payment

The American Medical Association is proud to work with the Colorado Medical Society to educate physician practices on how to streamline their claims process. Getting billing information quicker—and paid faster—is a prescription for efficiency. The AMA and the CMS support physicians in your practice, in the state house and in the courthouse. Working together with the CMS, the AMA will continue to make a difference.

Be a part of it. ama-assn.org/go/memberadvocate

Colorado Medicine for January/February 2013

Features

Acute and chronic pain management: Responsible opioid prescribing Patricia L. VanDevander, MD, MBA Over the past decade, prescription drug abuse has experienced a significant increase across the United States with deleterious consequences to our public’s health and safety, bringing this issue to the attention of national and state stakeholders. According to the National Office for Drug Control and Prevention (ONDCP): “Prescription drug abuse is the nation’s fastest-growing drug problem, and the Centers for Disease Control and Prevention has classified prescription drug abuse as an epidemic.” In response to this crisis, the ONDCP in 2011 put forth the Prescription Drug Abuse Prevention Plan, which includes a strategy covering four areas: education, monitoring, proper medication disposal and enforcement. Every provider with prescriptive authority in Colorado is encouraged to look at the evidence currently available for our state and to adopt the recommendations to avoid increased regulations on our prescribing privileges. Here are just a few of the disheartening statistics for Colorado: 1. According to Peer Assistance Services, Inc., deaths related to the most commonly abused prescription drugs nearly doubled from 228 in 2000 to 414 in 2010, while deaths related to the abuse of prescription opioids more than doubled from 180 in 2000 to 343 in 2010. 2. In 2010, more than twice as many people in Colorado died from prescription drug abuse (414) than from drunk -driving-related crashes (127). 3. A 2009 Youth at Risk survey conducted in a Denver-metro community revealed that more than 33 percent of high school students had abused pre22

scription medication. This is significantly higher than the national data of 1 in 5 teens (20.9 percent) reporting the abuse of prescription drugs in 2009. On a positive note, Colorado actively engaged in three of the ONDCP strategic areas prior to 2011. Our Prescription Drug Monitoring Program (PDMP), an electronic database of all Schedule 2-5 drugs dispensed by non-federal outpatient pharmacies licensed in Colorado, went live on February 4, 2008 and contains information from July 2007 to present. Helen Kaupang, diversion group supervisor for DEA, has organized in cooperation with local law enforcement three Take Back programs across Colorado since 2010. The last program in September 2012 netted 12,260 pounds of unused drugs and 244 tons nationwide. There are also several organizations within Colorado working on public education. Taking steps to solve the problem Colorado provider awareness and education about prescription drug abuse and its threat to public health and safety is crucial. We must be part of the solution; not a contributing factor. To address this, The Colorado Prescription Drug Abuse Task Force organized a dynamic group of Colorado physician experts to present related topics. On November 15, approximately 200 providers from across Colorado attended a 3.5-hour educational program, either in person or via live webinar, titled “Acute and Chronic Pain Management: Responsible Opioid Prescribing.” This free program was held at the CU Skaggs School of Pharmacy

on the Anschutz Medical Campus and made possible by generous donations from The Colorado Division of Behavioral Health, CU Skaggs School of Pharmacy and Occasions Catering. In addition to the webinar, participants received dinner, 3.5 CME credits by Colorado Medical Society and two ERS points by COPIC. The program was led by Kelly Perez, health services advisor for Gov. Hickenlooper’s office, and Chris Urbina, MD, executive director, Colorado Department of Public Health and Environment. Both emphasized that top stakeholders in our state are aware and interested in curbing this crisis. Ms. Perez noted that Gov. Hickenlooper has placed mental health and drug abuse on his list of “winnable” health issues and has dedicated his efforts to co-chair the National Governors Association’s yearlong initiative on prescription drug abuse. To learn more about this go to www.nga.org/cms/rx. Dr. Urbina then put into perspective the tremendous number of prescriptions written in 2011 across the country (3.8 billion = 12.1/capita), in comparison to in Colorado (49.8 million = 9.7 per capita) and the estimation of 1.5 million prescriptions wasted each year. This translates into many of the unused drugs being disposed of in the trash (33.8 percent) or flushed (14.7 percent). One result of this epidemic has been a feminization of our fish, highlighting the fact that not only are we facing a prescription drug abuse crisis but also water contamination. Steven Wright, MD, who divides his

Colorado Medicine for January/February 2013

Features clinical practice into primary care, addiction medicine and medical pain management, addressed the definitions of acute and chronic pain, emphasized the necessity of appropriately treating acute pain and gave a stepwise approach to the evaluation of the patient with chronic pain. He stressed the importance of clarifying upfront the patient’s goals and function (which are documented at each visit) and then communicating a willingness to provide treatment with clear expectations, such as prescription management, informed consent for medications and urine drug testing. In addition, he spoke of non-medication treatment choices, drug selection and opioid adverse events. His approach to patients with pain was clear and compassionate. A new software vendor was contracted for the PDMP, and a new requirement in the statute was added. Jason Hoppe, MD, a toxicologist at the Rocky Mountain Poison and Drug Center and assistant professor in the Department of Emergency Medicine at the University of Colorado School of Medicine, and Tia Johnson, PDMP administrator on the Colorado State Board of Pharmacy, gave a live demonstration on navigating the new Website and answered audience questions. Dr. Hoppe emphasized the importance for all providers with prescriptive authority to register on the site (www.coloradopdmp.org) and to access it regularly for patients whom they are considering prescribing Schedule 2-5 drugs. Currently only 18 percent of physicians licensed in Colorado are registered to use the PDMP. He also reminded everyone that the Website is not real-time; therefore it may take up to 25 days to see a dispensed prescription in the system. The PDMP must be accessed only by a provider obtaining information about a patient he/she is treating, and a new part of the statute specifies that the prescriber must inform patients that their information will be entered into the database. Kathryn Mueller, MD, medical director for the Colorado Division of Workers Compensation, is board certified in occupational medicine and professor in

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Colorado Medicine for January/February 2013

Pain management (cont.) the Department of Emergency Medicine and School of Public Health at the University of Colorado School of Medicine. She gave an informative presentation on management of the patient with chronic non-cancer pain, which stressed the importance of having a multidisciplinary approach that may include a variety of medications, cognitive behavioral therapy, physical movement/exercise and patient education for better self-management. Dr. Mueller suggested the patient’s focus should not be on “eliminating pain, but managing pain to restore physical and mental function and quality of life,” adding that this expectation tends to be more successful and lead to improved patient satisfaction. Just as Dr. Wright emphasized the importance of a patient’s “functional status,” Dr. Mueller endorsed the same to gauge the benefit of, or lack thereof, the treatment plan. In addition, she covered the recommendations for opioid use (one long-acting with one short acting, for break through) and warned of the combination of opiates

with benzodiazepines due to a greater risk of adverse events. She suggested looking at the Washington state guidelines for chronic non-cancer pain management at www.agencymeddirectors.wa.gov.

tients in the appropriate management of their pain, while doing our best to avoid the diversion of prescription medications. Let’s advocate for education, rather than regulation.

A final presenter, Alan Lembitz, MD, vice president, COPIC Patient Safety and Risk Management, presented the importance of documenting your hx, PE, appropriate data, meds Rx, medical decision making and plan for all patients. “Your actions must match the documentation,” he said. Dr. Lembitz reported that the issues that cause providers the most problems with regard to medications are more likely to get them involved with the Colorado Board of Medical Examiners rather than with their liability carrier. As a last note, Dr. Lembitz showed a few slides about the profitability on the black market of prescription drugs, where oxycodone sells for $5-$10 per pill.

The webinar from this program will be available online until January 15, 2013 at mms://essvideo.ucdenver.edu/ public/Prescriber_Opioid_Training_ NOV_15_2012.asf

In summary, I would like to make a plea for all providers to take an active approach to this public health crisis. Let’s engage and communicate with our pa-

The slides are available at www.peerassistanceservices.org on the right side of the home page via the link next to “access presentations.” A special thanks to the Colorado Division of Behavioral Health, Peer Assistance Services, Colorado Prescription Drug Abuse Task Force, Colorado Medical Society CME unit, COPIC, CU Skaggs School of Pharmacy and Pharmaceutical Science (Rob Valuck), Colorado Pain Initiative, Occasions Catering, Laurie Lovedale, Helen Kaupang and all the volunteers who joined together to make this event a success. n

Colorado Medicine for January/February 2013

Features

Patient Safety Congress Kate Alfano, CMS contributing writer

Invest in collaboration and communication to move patient safety forward When he was a second-year resident training at Boston Children’s Hospital, Don Berwick, MD, almost killed a baby. This was 1974, decades before his service as administrator of the Centers for Medicare and Medicaid Services, and he was on overnight duty at a neighboring hospital for his secondever neonatal intensive care unit rotation. At 3 a.m., a nurse called Dr. Berwick to the baby’s bedside for an exchange transfusion, a procedure now outdated because of better prenatal screening. She handed him a bag of blood, and he hung it on the IV holder and connected the stopcock. Syringe in hand, he began the transfusion. But something wasn’t right; the syringe felt sticky and

he was pushing really hard. He just kept going. And things got worse. Within a few minutes, the baby was grey, mottled and squirming, and his heart rate was rising. Dr. Berwick paged the neonatal fellow on call and he arrived 20 minutes later, just as the lab results came back with the bad news: the baby’s hematocrit was 92. Dr. Berwick looked to the blood bag and followed a tube to the floor that was connected to a second bag filled with pure, clear plasma. “I remember that moment; this flash of horror and tension seared in me,” Dr. Berwick says. He was transfusing with

packed cells and the baby was going into acute renal failure. The neonatal fellow sprang into action and worked to reverse the damage. Once the baby was stabilized, the fellow pulled Dr. Berwick aside and told him not to feel bad, that this could happen to anybody. But he had been taught to take ownership in his patients, and racked with guilt the young doctor went back to his on-call room and cried. For 30 years, Dr. Berwick stayed silent on this story. He shared it on October 17 to set the stage for a summit of more than 300 thought leaders from physician practices and hospitals around the state as they participated in the second annual Patient Safety Congress hosted by the Colorado Medical Society and the Colorado Hospital Association. Dr. Berwick reflected on that experience, telling attendees that he didn’t go to the blood bank to report on himself. He didn’t go to the head of the training program to tell them he had moved between two different hospitals that used different banking procedures. And he didn’t sit down with his fellow residents, tell them the story, and warn them about how it could happen to any one of them, too.

Attendees of the Patient Safety Congress, from left to right, Ben Vernon, MD, CMS Past President; Allen Nissenson, MD, DaVita CMO; Jan Kief, MD, CMS President; and Don Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services 26

“We have a problem here,” Dr. Berwick told the audience. “The problem is ethical. Something went wrong that was highly preventable and we did nothing except fix the baby. There’s a bet-

Colorado Medicine for January/February 2013

Features ter way to do this. We’re going to show you [today] that this isn’t just a matter of science or diligence; it’s a matter of ethics. To allow a person to be hurt in our hands without action is unethical.” To achieve real success in-patient safety initiatives, Dr. Berwick explained, each health care professional on every level of the system must actively support a culture of safety. Physicians and nurses don’t intend to make errors. Errors inherently exist in the system because of the “human factor,” which is multiplied by the shear number of exposures over a patient’s entire care episode. When errors occur, the key is not to inflict punishment, regulation or blame, but to create systems of reporting and communication by which processes can be enhanced and improved. “Every system is perfectly designed to get the results it gets,” he says. “The trick in safety, accuracy and reliability is to build a new system with new properties. … The concept that we can eliminate error is impossible. What we can do is build fortifications around it and construct robust systems.” Vinod K. Sahney, Ph.D., another speaker at the Patient Safety Congress, told the audience that the current health care system is unreliable because “we rely on vigilance and hard work, we focus on outcomes rather than process, we fail to design and implement standard work, we do not learn from human factors, and we value individual freedom over reliable design.” Sahney served for 25 years as senior vice president at the Henry Ford Health System, which has become a leader in the patient safety movement because of its “No Harm Campaign” and the system-wide results it has achieved in harm reduction. “We need to shift from a care delivery process dependent on autonomy to one centered on standardization,” Sahney says. “When we think about fixing errors, we think about not making mistakes. We have to design the systems that catch mistakes. You have to have

checks and balances that catch them before they happen.” To get physicians on board, you must frame the quality challenge in terms that are important to physicians. “Focus on improving the process to improve quality. Take wasteful things out…. Measure and display the results on important things and show [physicians] that together you’re making things better. Then they become champions in quality improvement,” Sahney says. Leading into the congress, CMS surveyed physicians who work in a hospital setting on patient safety. CHA conducted a similar survey with a group of hospital executives. Results show that overall; physicians and hospital leaders feel that current patient safety efforts are effective. However, physician respondents expressed the need to build systems of communication that emphasize evidence-based approaches and improvements to specific initiatives, a non-punitive culture that emphasizes education and communication of misses and near misses, and visible physician leadership guiding patient safety initiatives. CMS has been on the forefront of the movement to retool patient safety systems for years; patient safety and professional accountability is one of the association’s five strategic priorities. Guiding the effort is the CMS Ad Hoc Workgroup on Patient Safety and Professional Accountability, formed four years ago to make policy recommendations and shape legislative strategies. It comprises physicians from around the state, legal experts, patient safety advocates and hospital representatives. CMS past president Ben Vernon, MD, a transplant surgeon in Denver, is the current co-chair of the group and attended the Patient Safety Congress. He says conferences like this present a great opportunity. “Today we had in the room a great mixture of hospital

Colorado Medicine for January/February 2013

executives, patient safety officers and physicians listening to world experts on patient safety and the coming transformation in American medicine. We [physicians] are not going to get this accomplished by ourselves. Physicians are not the sole standard bearers for patient safety, nor are hospitals, nor are nurses. We’ve got to do this together. “So sitting everybody in the room to hear this information together, to laugh, to think and then to be challenged is really a big first step in the right direction and I’m looking forward to the results of this.” CMS CEO Alfred Gilchrist agrees, and adds that the partnership with CHA to host this conference demonstrates the will of physician leaders and hospital executives to move forward. “We have to find a way to build on the energy from this meeting. We need more physician leadership and we need to put a greater focus on this collaboration. We’re anticipating a lot of great dialogue as we chart our future course, and I look forward to improved collaborations on patient safety.” “One of the things I respect most in the medical profession is the culture of learning and sharing and we can use this culture to make Colorado the safest state in the country to receive care,” Gilchrist says. Multiple times throughout the day, Dr. Berwick praised the efforts of physicians and hospital executives in Colorado, recognizing the state as being far ahead of other states on patient safety initiatives. He encouraged stakeholders to keep pushing forward. “Though you are focusing on safety, I think you’re building to address the other dimensions of quality. There are players in Colorado that are ahead of the game. You’re doing something terrific in your ability to improve, not just in safety.” “Bravo safety; it’s a great way to start, but it’s not the end. Colorado can cut its teeth and go to total excellence through the window of safety.” n

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Colorado Medicine for January/February 2013

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Joint CMS/CHA flash survey measures progress on patient safety programs CMS staff report

Physicians and hospital management generally optimistic about patient safety initiatives underway Colorado physicians and hospital executives have generally positive attitudes about patient safety initiatives underway at the hospitals where they work, though it’s clear doctors have concerns, according to a poll conducted earlier this year. The poll found hospital execs shared many of physicians’ concerns. Among them: issues of communication between management and physicians; doctors’ comfort level about participating in peer review and reporting misses and near-misses; and having technology that is effective in helping reduce events. The questions about patient safety were posed to Colorado Medical Society members during a 2012 CMS flash survey conducted last summer by pollster Benjamin Kupersmit of Kupersmit Research. The poll of 378 CMS members working in a hospital setting has a margin of error of plus or minus 5 percent at the 95 percent confidence level. The same questions were also asked of 26 hospital administrators who are Colorado

Hospital Association members, with the results being used to help identify strategies at an October patient safety summit (see story on page 26) and to support ongoing efforts by CMS. Because of the number of responses, they may only be used to draw general conclusions and trend. The findings are not statistically representative, Kupersmit said. Of the physicians polled, 29 percent said patient safety initiatives are “very” effective, while 45 percent said “somewhat” effective. Three percent said “not at all,” while 9 percent said “not that” effective. The remainder said “vary too much” or are unsure. Among the hospital executives who responded, 13 said “very” effective, while 11 said “somewhat” and 2 said “not that” effective. A majority of both physicians and administrators said physicians in hospitals are engaged in patient safety efforts but not “totally” engaged. Differences are seen on the issue of communication. One-half of physicians said

they were satisfied and one-quarter said they were unsatisfied with “management being willing to listen” to improve patient safety. Among the administrators, 23 of 26 said they were satisfied with this. Slightly more than half of physicians (55 percent) said they were satisfied with “physicians being willing to listen,” while relatively fewer hospital execs (17 out of 26) said they were satisfied with this. Four said they were unsatisfied. Kupersmit said the research suggests there are opportunities for physicians and hospital executives to work together to ensure that specific tasks, technology and EMR systems and communication channels are aligned with the overarching objective of improving patient safety. “It is clear that in those cases where there is evidence and data that actions and tasks make an impact, participation and willingness to be involved is very high,” he said. “The challenge lies is opening and ensuring lines of communication that are two-way, and serve to continually check and improve systems at all levels.” n

Combined Flash Survey Results – Communications CMS members

Very satisfied

Pretty satisfied

Neither

Pretty unsatisfied

Very unsatisified

Colorado Medicine for January/February 2013

CHA members

Inside CMS

CMS Corporate Supporters and Member Benefit Partners While CMS analyzes the quality and viability of our member benefit partners and their offerings, we do not guarantee any product or service will be right for you. Before you make a purchase, we recommend you perform your own due diligence.

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COPIC Financial Service Group 720-858-6280 or visit www.copicfsg.com * CMS Member Benefit Partner Sharkey, Howes & Javer 303-639-5100 or visit www.shwj.com. * CMS Member Benefit Partner Wells Fargo 303-863-6014 or visit www.wellsfargo.com INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit www.callcopic.com *CMS Member Benefit Partner UnitedHealthcare 877-842-3210 or visit www.UnitedhealthcareOnline.com MEDICAL PRACTICE SUPPLIES AND RESOURCES CO-POWER 720-858-6179 or www.groupsourceinc.com *CMS Member Benefit Partner

Healthcare Management 866-986-3587 or visit www.hcmcolorado.com HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner KKB, P.C. 303-815-1100 or visit www.kkb-cpa.com Line Pressure 303-742-0202 Physiciansâ&#x20AC;&#x2122; Billing 720-236-1280 or visit www.physicians-billing.com Medical Telecommunications 866-345-0251 or 303-761-6594 or visit www.medteleco.com * CMS Member Benefit Partner Solve IT 303-800-9300 or visit www.solveit.us

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Solveras: A Division of TransFirst 800-613-0148 or visit www.solveras.com *CMS Member Benefit Partner

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TMS Center of Colorado 303-884-3867 or www.tmscenterofcolorado.com

Alphapage 303-698-1111 or visit www.aplha-mail.com

Transcription Outsourcing 720-287-3710 or visit www.transcriptionoutsourcing.net

athenahealth 888-402-6942 or visit www.athenahealth.com/cms. *CMS Member Benefit Partner

Transworld Systems 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner Colorado Medicine for January/February 2013

Inside CMS

Reflections Reflective writing is now a regular portion of the CU School of Medicine curriculum, beginning in the first semester. All medical students participate by writing essays or poems that reflect what they have seen, heard and felt. This column is selected and edited by Henry N. Claman, MD and Steven R. Lowenstein, MD, MPH, from the new Medical Humanities Program

Questions Unanswered Victoria Collins

delicate outside paper skin acquiesces to the blade so easily I am not careful enough. strong inside sturdy muscle holds to the bone so tightly I am not reckless enough.

Victoria Collins is a second-year medical student at the first I am worried about the cutting University of Colorado. She grew up in South Dakota then repulsed by the ripping and studied biology and neuroscience at Arizona State University and the University of South Dakota. Victoria and disgusted by the smell is looking forward to a career in women’s health.

Save the Date! 2013 CMS Spring Conference May 3 through May 5, 2013 Sonnenalp Resort, Vail

Colorado Medicine for January/February 2013

but then I am enthralled by the muscles and curious about the tendons and slightly vexed by the veins some pieces are slopped in a bucket some are cradled with reverence until everything is peeled and each piece is clean and each part is named and the questions are answered except all of them. I’ve met the ligaments and the ganglia but we have never been introduced what was your name? how was your leg injured? who are your children? why this last gift to us? and if it’s not too forward of me to ask I’d love to know where your inferior medial genicular artery is hiding. n 31

Inside CMS

Ted J. Clarke, MD Chairman & CEO COPIC Insurance Company

2012 – A year of changes, challenges and achievements As I look back on 2012, I think about the future of health care in the wake of big moments like the Supreme Court decision on the Affordable Care Act. Then there were the little moments – priceless one-on-one interactions with physicians and patients that remind me why I chose medicine as my path in life. Every year, I feel fortunate that COPIC is in a position to play an important role where all these moments intersect. From learning from medical errors in order to prevent future ones to developing new solutions that address evolving medical liability needs, it all connects to our mission to improve medicine in the communities we serve. Expanded education This year we introduced our “Inside COPIC” program as an intensive, two-day session that provides direct contact with COPIC’s leadership team and a comprehensive overview on key medical liability issues. We expanded our offering of on-demand courses to include interactive case studies that provide a learning opportunity mirroring what physicians face in real-life situations. COPIC also added video versions of popular in-person seminars that can be viewed through our website. And we continue to invest in educational resources that integrate new technology, highlight topics that are timely and relevant, and provide more ways to gain valuable knowledge. Besides offering education to physicians and health care professionals, COPIC also increased its focus on providing resources for office staff that support medical teams. We launched new on-demand courses focused on topics such as assessing patient safety in the office and we hosted a seminar that dealt with legal issues in managing employees. Innovative programs In a partnership with Poudre Valley Health System, COPIC launched a pilot program known as Seven Pillars. The program’s comprehensive approach reinforces key principles of patient safety among members of health care teams. Seven Pillars was developed by recognized medical leaders at University of Illinois Medical Center at Chicago and uses system improvements, data tracking, performance evaluation

and staff education to create a culture that fosters improved patient care. Protecting professional review The Colorado Professional Review Act (CPRA) was set to expire in 2012, so COPIC and other organizations, including the Colorado Medical Society and the Colorado Hospital Association, made it a top priority to work with legislators to continue the privileges and processes established in CPRA. Not only was CPRA extended for another seven years, but it was also expanded to include legal protections for the review of physician assistants and advanced practice nurses in Colorado. Strengthening our team A key factor in COPIC’s success and stability is the involvement of physician leaders who are part of our Board of Directors and serve as faculty consultants. They provide valuable perspectives, trusted insight, and a level of leadership that is crucial in developing a vision for the future of health care. In 2012, Matthew Fleishman, MD, joined COPIC’s Board of Directors and our team of faculty consultants was expanded to 20 physicians. Personal commitment to our insureds In addition, our leadership team stayed connected with practice administrators through meetings designed to keep them informed on issues relevant to their roles and responsibilities. We also conducted our biennial customer insight survey to gather feedback and our Policyholder Service department continued to reach out and work closely with insureds to provide the direct, personal attention that is part of COPIC’s commitment. 2012 statistics of which we are proud: • Approximately 165 residents participated in our training program. • We declared a $12 million distribution for eligible Colorado physicians. • More than 12,000 health care team members participated in our patient safety and risk management programs. n

Colorado Medicine for January/February 2013

Departments

New Members Arapahoe-DouglasElbert Medical Society Mark S Dacey, MD Michelle Draznin, MD Adam K Graham, MD Felipe Hernandez, MD Emily M Lampe, MD Jessica W McCullough, MD Patricia M Meyer, DO David B O’Keefe, MD Evan L Stepp, MD Boulder County Medical Society Jennifer M Blattner, MD Stephen E Brown, MD, FACS Joshua B Di Carlo, MD Christopher L Dunkin, MD Patrick J Grathwohl, MD Stephen T Huang, MD Nancy P Kelley, MD Michael C Lahm, MD Khoshal Latifzai, MD Joanna M Plonska, MD Leto Quarles, MD Michael A Zona, MD Chaffee County Medical Society Meggan J Grant-Nierman, DO Bradford L Moss, MD Clear Creek Valley Medical Society Gregory T Hirons, MD Angie N Martinez, MD Curecanti Medical Society Kerstin S May, MD Teal S Warthen, DO Denver Medical Society Bryan S Ahlgren, DO Blaze J Cook, MD Bradley S Duhon, MD Jessica E Essary, MD Stacy L Fairbanks, MD Shira G Fishman, MD Anthony P Khalifah, MD Rudy Kovachevich, MD

Bryan C Kramer, MD Molly A Uhlenhake, DO Karin D Van Baak, MD Marc A Voelkel, MD Mary Jo Young, MD El Paso County Medical Society Toby J Genrich, MD Gregg Martyak, MD Michael O’Neill, MD La Plata County Medical Society Michelle Hemingway, MD Larimer County Medical Society Bret R Baack, MD Melissa M Grunloh, MD Kathleen A Hannifan, MD Kathrin E Harrington, MD Kaitlin W Heisel, MD Qinghua Liang, MD Michael D Osborn, DO Eugene J Reinersman, MD Sandhya Tadikonda, MD Montezuma County Medical Society David S Letbetter, MD Mt. Sopris Medical Society Brett M Hesse, MD Rebecca E Laird, MD Kelly B Thomas, MD Pueblo County Medical Society Raj A Jain, MD Medical Student Component Maria Abernethy Gilbert M Accredo Joseph Adewumi Ibukun J Akinboyewa Oluwatoyin M Akintujoye Sarah S Allexan Tyler J Anderson Lydia L Archuleta Brittany L Badesch

Colorado Medicine for January/February 2013

Tyler D Barr Susan Baver Kristen E Beck Amy M Beeson Paige E Bennett Sean Bergsten Marcus Bethurem Matthew L Bezzant Luke Bidikov Megan Bonney Peter Boulos Claire A Bovet Amelia L Bowman William E Brandenburg Brooke C Bredbeck Lindsy Brickell Alyssa Broker Mitchel Brown Zachary Brown Ashton Brunn Quan M Bui Natasha A Cabrera Ryan A Caldwell Thomas A Califf Julian E Cameron Maureen M Canellas Sean Caskey Sarah K Cebron Vivek P Chadayammuri Christine J Cliatt Brown Brittany Cody Nathan E Coffman Chelsey Coles Anastesia Collins Jack F Conner Catherine G Cooper Laura Coppola Varea Costello Brittany A Cowfer Ryan S D’souza Ben Dahlberg Leslie K Dalacious-Helgeson Brian P Davis Rachel De Andrade Pereira Kelly Dea Abby Dekle

Francis J Del Rosario Jose Diego Jim M Do Andrea Dore Morgan Dreesen Charlie Echeverria Stephen Edwards Andrew P Eitel Daniel Enriquizz Justin Evans Brittany A Farniok Ashley Fejleh Wendy Fick Kathryn Fischer Emily Fitch Robert J Flick Brendan Fowler Nicholas Frane Christopher S Frederick Melissa Genter Alexander R Ghincea Christian V Ghincea Chelsea C Giagni Michael Gleason Danielle N Gonzales Tudor Gradinariu Jordan Greenberg Rachel Griffith Laura E Grigereit Jason S Hafer Saba G Halaby Hajerah Hameeduddin Markus C Hannan Philipp L Hannan Joshua Hansen Ashley Harmening Kristin Harmon Nicholas Hasandras Audrey Hemmings Erin E Hickey Kelly C Higa Ben Hirshberg Amanda Holmes Kylie Holway

Departments Medical Student Component (continued) Mark R Hopkins Netana Hotimsky Allison R Howard JiaHao Hu Andi C Hudler Caleb Hudspath Kathryn Huff David T Hughes Meghan M Hurley Sandy Huynh Matthew C Iacovetto Michael I Jarrett Justin Johnsen Emily J Johnson Daniel Jones Joshua Kalb Halinganji T Kanani Ilan Y Kaye Graham Kehner Zachary Keller Zoeherg Kelly Charles B Kemmler Ryan Kostka

Kyle Kubes Elizabeth Kubota Regina Kwon Jennifer A LaBudde Kyle Larson Lindsay Lawrence Adam B Lawson Peter Layman Paul A Leccese Justin Y Lee Cecilia B Levandowski Erin R Lindsay Josh Linton Megan Lippad Brian W Locke Seth J Lofgreen Steven Long Reed Z Louderback Kevin Loudermille Alexandra Loza Kelsey A Luoma Alexandra R Ly Brittney A Macdonald Shannon Mackay Jessica K Mackey

Owori B Mang’eni Cory D Manly Kyle Markel Natasha K Marvi Jim McAleer Zach McBeth Brett M McGettigan Sterling J McLaren Alexander J Metoxen Margaret Meyer Kevin Middlemist Logan T Mims Bradley Mohar Sara Monahan Emily M Moreno Gabriel F Morgione Bethany L Morris Jarod Murdoch Amanda J Neidermyer Timothy P Newton June H Ng Dan D Nguyen Quoe Nguyen Thanh Huong L Nguyen Thienan Nguyen

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Tom Nguyen Jessica C Nicholas Phillip J Nickerson Claudia Nieuwoudt Abigail M Nimz Jaimie Nuckolls Oluwafunmilayo Ogunremi Michael Palash Hamza Pasha Warren W Pettine Travis S Peveto John V Pham Ryan H Phan Samuel Plesner Seerat K Poonia Jayce Porter Daniel E Portillo Kelly Powell Lauren Powell Bianca Pullen Shamita Punjabi Stephen Quach Kyle Quillin Victor Ranga Saned Raouf Anireddy R Reddy Romany M Redman Madgdalena C Reinsvold Jessica L Rice Joshua Roach Doug Robinson David Rodriguez Alejandro D Rodriguez Prieto Santiago Rodriquez Stacy L Romero Madeline L Rovira Tyler Runde Brian Russ Rae L Russell Kaitlin Ryan Michelle Rybka Robert Sand Renee Sanders Elaine M Scholpp Anna F Schubert Tina Scoggins Megan Seamon Eric Seger Joshua A Shapiro Kate Shelp Ramy M Sidhom Codie Simoneaux Samuel R Skovgaard Ryan Slattery Colton Smith Jordan Snell Jesse Snider Taylor K Soderberg

Colorado Medicine for January/February 2013

Departments Mee Na Song Kyle Sonnabend Jacquelyn Stanton Kara Stuhr Luke Ta Myles R Tamsen Julia Tanguay Samantha Tarshis Anne C Taylor Richard Tennant Matt Terhark Lane Thaut Lauren J Thomas Sara Thomatis Lauren Thorp Sarah E Tietz Juel L Tourfeliotte Dong-Kha Tran Nhat-Tuan Q Tran Paul N Tran Rebecca B Tran Tuong-Vi Tran Elizabeth Tu Brandon Valentine Daniel VanLenven Nico Vassel Denise Veloria Thad W Vickery Thomas O Vogler Jackie Vroman Danielle Walsh Joshua R Wheeler Rick White Gabrielle T Whitmore Gabriel K Williams Jason D Williams Andrew B Wolf Elizabeth L Wood Katharina Wyns Andrew Xu Elise S Yerelian John Yurek Marc Zafferani Chelsey Zahler

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Telephone: 720-858-6318 or 800-654-5653

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MEMBER BENEFITS

Spotlight Todd Balsley, GL Advisor

Considerations as you navigate medical school debt Due to the rising cost of higher education, student loan debt for medical school graduates has more than tripled in the last 15 years, with the average debt now exceeding $174,000.1 Needless to say, these debt levels, in conjunction with low starting salaries, can result in an undue financial hardship on residents. Concern regarding cash flow often leads residents to postpone student loan payments and attain the liquidity necessary to pay for living expenses such as rent and groceries. While this forbearance offers payment relief, it can be at a considerable cost, as interest continues to accrue and can substantially increase an already significant medical school debt burden. This article provides an overview of the student loan repayment options that medical school graduates can utilize to help minimize the cost of their debt. Utilize federal student debt relief programs Federal student debt relief programs are available to help recent graduates obtain payment relief and savings on their federal student debt. The nuances of these programs must be fully understood in order to ensure eligibility and the maximization of potential benefits. Income-based Repayment or ICR-A Income-based Repayment (IBR) or ICRA, commonly known as “Pay As You Earn,” are viable options for residents, as they were specifically designed for borrowers with high debt levels and propor36

tionally low incomes. These programs ask borrowers to make payments based on what they earned in the prior year, not on what they owe. Monthly payments under ICR-A are reduced to 10 percent of a borrower’s discretionary income versus 15 percent under IBR. The ICR-A regulations are still being finalized, but borrowers must have no outstanding loans disbursed prior to October 2007 and at least one loan disbursed after October 2011 in order to qualify for the program. It is extremely important to utilize the most accurate income documentation when applying for these programs in order to ensure the lowest possible monthly loan payment. Public Service Loan Forgiveness Public Service Loan Forgiveness (PSLF) allows for tax-free loan forgiveness to federal loan borrowers who make 120 qualifying payments while working for a non-profit entity. The majority of hospitals are classified as non-profit and therefore, many medical school graduates can begin working toward forgiveness during the first year of residency. Only Direct Loans are eligible for PSLF, so many borrowers interested in pursuing PSLF will need to transfer federal loans issued through the Family Educational Loan Program (FELP) to the Direct Loan Program via the Federal Direct Loan Consolidation program. Federal Direct Loan Consolidation Program As referenced above, federal consolida-

tion with the Direct Loan program may be necessary to position loans for Public Service Loan Forgiveness. Consolidation can take months to complete, so timing is an important consideration. Additionally, structuring consolidations by grouping like interest rate loans together will preserve the ability to target higher rate debt if necessary in the future. Understanding your options Student loans and related federal programs can be overwhelming. Taking full advantage of available benefits requires an in-depth understanding of each program’s details. To begin formulating your optimal repayment strategy, you can sign up for a free personalized student debt assessment from GL Advisor. GL Advisor offers a unique service designed to help medical professionals lower the cost of their debt, obtain payment relief as needed, and save time so they can focus on their careers. After receiving a free assessment, CMS members can retain GL Advisor’s service at a discounted fee for their first 12 months of service. To learn more or to sign up for an assessment, please visit www.glAdvisor. com/CMS or contact by phone at 877552-9907. n GL Advisor is a division of Graduate Leverage, LLC. GL Advisor does not offer all services to residents of North Dakota at this time. Based on data collected by the AAMC, AMA and GL internal student database.

Colorado Medicine for January/February 2013

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medical news Colorado Medicaid receives $42.9 million performance bonus The Department of Health Care Policy and Financing announced December 19 that Colorado Medicaid has received a $42.9 million Children’s Health Insurance Program Reauthorization Act (CHIPRA) Performance Bonus from the Centers for Medicare and Medicaid Services (CMS). This bonus was the largest awarded in the country and marks the third consecutive year Colorado Medicaid has earned CMS recognition for its ongoing efforts to identify and enroll eligible children in Medicaid and Child Health Plan Plus (CHP+). The award today brings the total CHIPRA Performance Bonus for 2012, which included a supplemental payment of $7 million, to $49,674,898. Total amounts awarded in 2011 and 2010 were $30,673,282 and $13,671,043 respectively. To qualify for the CHIPRA Performance Bonus, states must have in place at least five of eight Medicaid and CHIP program features known to promote enrollment and retention in health coverage for children and demonstrate a significant increase in Medicaid enrollment among children during the course of the federal fiscal year.

Colorado met seven of the eight required program features: 1. The removal of the asset test for Medicaid eligibility; 2. The elimination of in-person interview requirements; 3. The use of one application for applying and renewing Medicaid and CHP+; 4. Presumptive Eligibility – the ability for applicants who appear to be eligible to receive health care services while waiting for final eligibility determination; 5. Health Insurance Buy-In – A premium assistance program allowing families to receive subsidies for eligible Medicaid clients to purchase employer insurance; 6. Administrative Renewal – the use of a pre-populated renewal form that is sent to families asking for household changes but is not required to be returned to renew eligibility; and 7. Express Lane Eligibility, which allows families to opt to allow information on the school lunch program application to be used to start a joint Medicaid/ CHP+ application. “The Department has continued to make

ACA Medicaid primary care payment increase: Attestation required Changes to Medicaid primary care reimbursement were enacted as part of the Affordable Care Act (ACA). Eligible physicians will receive supplemental payments for services rendered between January 1, 2013, and December 31, 2014, that raise the Medicaid reimbursement to Medicare rates. To be eligible for the supplemental payment, physicians must self-attest as having a specialty in family medicine, general internal medicine, and/or pediatric medicine. Only physi-

cians can complete this form (staff or other representatives are not allowed). Make sure that you are eligible for these increased payments by visiting the Colorado Department of Health Care Policy and Financing attestation page at www.surveymonkey.com/s/CO-DR-Attestation. Learn more about ACA enhanced payments for Medicaid primary care physicians at www.colorado.gov/cs/ Satellite/HCPF/HCPF/1197364127336. n

Colorado Medicine for January/February 2013

progress on increasing the number of insured children in Colorado,” says Susan E. Birch, executive director. “Colorado is a leader in health care and we were thrilled to receive the highest performance bonus in the country. This bonus demonstrates how we are modernizing our eligibility processes and is recognition of the hard work our local county and community partners continue to do in reaching eligible but not enrolled kids.” Colorado will need to continue to implement at least five of eight program features and demonstrate an increase in Medicaid enrollment compared to a baseline in order to qualify for the performance bonus next year. n

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medical news Over 175 primary care physicians join Health Information Exchange Primary Physician Partners (PPP), the largest primary care independent practice association in the Denver metro area, along with their medical management company, Physician Health Partners (PHP), has connected their first of many practices to the CORHIO health information exchange (HIE). PHP is one of 32 Pioneer Accountable Care Organizations (ACOs) chosen to provide high-quality, coordinated care to more than 24,000 Medicare beneficiaries in the Denver area. CORHIO’s secure HIE allows providers to receive vital patient information in a quicker and easier way, improving the level of care they are able to provide to patients.

Connecting to the HIE will allow the more than 175 primary care physicians in PPP to quickly and securely access their patients’ information from hospitals, other provider offices and public health departments, such as lab results, X-ray, MRI and other imaging reports, physician transcripts, referral information, hospital discharge reports and newborn screening results. Having access to this information will help PPP physicians efficiently and accurately assess, diagnose and provide treatment to their patients. “PPP is a longtime innovator in health care and being one of the first groups

to connect to CORHIO’s HIE further proves our dedication to moving health care forward,” said Michael Archer, MD, PPP, board president and physician at Complete Family Medicine. “We made the decision as a group to invest in this technology, but ultimately it’s an investment in our patients and their health.” The data provided through the CORHIO HIE helps the PPP providers with care coordination initiatives that are imperative to their goals of accountable and patient-centered care. The HIE makes it easier for providers to proactively follow up with their patients after hospital or specialist visits, which helps prevent medical complications and avoidable hospital readmissions. For individuals with chronic conditions, such as heart disease, asthma or diabetes, well-managed care coordination is essential to avoid unnecessary complications. “CORHIO is thrilled that thousands of people in the Denver metro area will benefit from improved care coordination as a result of PPP’s providers joining the HIE,” said Larry Wolk, MD, CORHIO’s chief executive officer. “We’re also pleased to be supporting PHP with their clinical data needs as a Pioneer ACO.” On a state level, there are currently 27 hospitals, 348 office-based providers, 28 long-term and post-acute care facilities, two behavioral health centers and two large medical laboratories connected to the CORHIO HIE. CORHIO is also in the process of expanding its network of health care providers and is actively working to connect two additional hospitals, more than 1,000 additional office-based providers, eight additional long-term and post-acute care providers and three behavioral health centers. n

Colorado Medicine for January/February 2013

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medical news Jan. 31 dealine set to file for 2013 Medicare ePrescribing hardship If physicians believe they meet one of the Medicare electronic prescribing (ePrescribing) hardship exemptions but did not file by the June 30, 2012 deadline, they will have another opportunity to apply. Pursuant to AMA advocacy, the Centers for Medicare and Medicaid Services (CMS) has reopened the Communications Support webpage to give physicians more time to file for a hardship, allowing more physicians to avoid the ePrescribing penalty. Available hardship exemptions include physicians: 1) unable to ePrescribe due to state, federal or local law/regulation; 2) with fewer than 100 prescriptions between Jan. 1 and June 30, 2012; 3) in rural areas without sufficient high-speed Internet

access; or 4) in areas without enough pharmacies available for ePrescribing. Many of the ePrescribing penalties received in 2012 by physicians who filed for a hardship exemption were due to filing errors. Therefore, it is important to know that hardships should be filed using the physician’s individual Type I NPI. That is, the rendering Provider NPI used for box 24(J) of CMS 1500 form, or the NPI used in the Rendering Provider Name loop or the Billing Provider Name loop, if the billing provider and rendering provider are the same on the 837 (electronic claim) and the Tax ID number (TIN) they use to bill. Physicians who bill using their Employer Identifier number (EIN) they should use their EIN for filing a hardship and those

who bill using their Social Security Number (SSN) should use their SSN for filing hardship. Please visit www.CMS.gov/ERxIncentive for additional information and resources. If you have questions regarding the ePrescribing Program or need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk via qnetsupport@sdps. org or at 1-866-288-8912 (TTY 1-877715-6222). They are available Monday through Friday from 7 a.m.–7 p.m. CST. Physicians who are Mac users may still experience trouble filing for a hardship; if this occurs they should contact the Help Desk as well since CMS is still working to resolve these issues. n

Tell Congress: Crippling cuts to Medicare program are inexcusable! A letter the AMA sent Dec. 19 to both chambers of Congress calls for immediate action to stop the crippling Medicare pay cut scheduled for Jan. 1 and stabilize the Medicare program. Congress has yet to work toward stopping the 26.5 percent cut in Medicare physician payments required under the sustainable growth rate (SGR) formula. “This continuing game of political chicken is unacceptable and dangerous to the future of the Medicare program,” the letter states. Meanwhile, the Centers for Medicare & Medicaid Services has announced it will not delay processing Medicare claims. Medicare carriers will process payments for physician services provided after Dec. 31 under the normal 14-day cycle required by law. That means physicians who care for Medicare patients will see an immediate reduction of 26.5 percent

in payment for their services beginning Jan. 1. “With no sign of action from Congress, physicians must prepare themselves and their patients for an impending Medicare crisis,” AMA President Jeremy A. Lazarus, MD, said in a statement. “With a full year to stop this drastic cut, it is absolutely inexcusable that Congress has failed to act, leaving Medicare patients and physicians to deal with the consequences.” While the AMA continues to urge Congress to avert this crisis, physicians should make plans for how they will mitigate disruptions and meet their financial obligations, should the cut take effect Jan. 1.

practices also should notify their patients promptly so they can explore other options for their health care and medical treatment. Tell Congress it’s time to stop partisan games and address Medicare physician payment. Email your members of Congress through the AMA Physician Grassroots Network today, or call using the AMA grassroots hotline at (800) 833-6354. Patients also can contact Congress through the AMA’s Patients’ Action Network. If you or your patients are interested in helping the AMA better illustrate how Medicare instability is affecting individual Americans, you can send the AMA an email with your story. Please include your name, specialty and city. n

Physicians who are forced to restrict their involvement with Medicare because it threatens the viability of their

Colorado Medicine for January/February 2013

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Final Word (cont.) (Continued from page 42) ment for hip and knee arthritis, patients chose to have hip replacements 28 percent less frequently and knee replacements 38 percent less frequently. In another study, similar unbiased information was provided to patients with a herniated spinal disc. The number choosing surgery dropped by 30 percent. Not only were patients spared unwanted surgery through this shared decision-making process, but many dollars were also saved that could then be used to pay for other needed care. In Colorado, a new method is underway to address patient needs and make care more affordable using a smarter approach to insurance benefits. Called Engaged Benefit Design, this new method changes insurance in three important ways: 1. Patient cost in the form of copayments is eliminated for many kinds of care that is high in value, so that care is easier to access for things such as preventative care, as well as good care for chronic diseases like diabetes and others. 2. Selected forms of preference-sensitive care (as described above) cost a little more in the form of higher copayments to alert consumers that there are alternatives and that it is worth learning more before making a decision. 3. Patient decision aids provide unbiased, complete, accurate and understandable information about choices.

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In this way, insurance benefits can be redesigned to produce smarter consumers making better decisions about their own care. Better-engaged patients make choices that lead to better care, frequently at lower cost. Visit www.engagedbenefitdesign.org for more information. n

Colorado Medicine for January/February 2013

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Features

the final word David Downs, MD, FACP CMS Past President

Can insurance benefits improve care and reduce cost? Medical science has moved forward at a remarkable pace. We can now replace worn joints and diseased heart valves, open clogged arteries and identify cancers before they become untreatable. We can see into the center of the body with remarkable detail using CT scanners, MRI machines and other technologies – all without pain or discomfort. These and many other modern medical miracles are generally viewed as a great benefit to the health of those for whom they are available. And in the American spirit of newer, better and faster, we have taken to these services avidly. It is one reason we spend more money on health care in the United States than any other country – by a lot! But questions have arisen as to whether more and newer is always better treatment. Researchers have looked carefully at use of new and old high-tech medical care across the United States, and have identified wide variations in the degree to which it is provided from one region to another. You would think that in areas of the country where high-tech services are provided to more people, that health would be better than in areas where they are provided less frequently. Surprisingly, that is not the case. In fact, areas that use more high-end medical technology often have worse health outcomes. How can this be? Let’s look at coronary angioplasty, a common procedure that involves inserting a tiny balloon into an artery supplying blood to the heart muscle that has become narrowed. By inflating the balloon, the narrowing can be lessened and a small metal tube called a stent can be inserted to keep the narrowing from 42

coming back. If you are in the middle of a heart attack, this procedure can save heart muscle and your life. But what if you have a narrowed artery causing chest discomfort when you exert yourself that is not immediately threatening to cause a heart attack (stable angina)? Opening the artery can relieve your symptoms, but will it keep you from having a heart attack down the line? Can it help you to live longer? Does it help relieve symptoms better than medications? These are important questions if you are considering an invasive procedure that is generally safe but can occasionally result in a stroke, heart attack or even death. The answers are surprising; people who have coronary angioplasty for an isolated narrowing of a coronary artery do not have fewer heart attacks than those who don’t have the procedure. They do not live longer and they do not avoid having to take medication. In fact, in some instances they may have to take more medication. Even though we know angioplasties have little net benefit for many people who have coronary artery disease, they are still done frequently. In addition, those who receive the procedure usually believe they will prevent heart attacks and death (in one study 88 percent and 76 percent respectively). And these people were given “informed consent” by their cardiologist before the procedure. The end result is a proliferation of very expensive, somewhat risky interventions that drive up insurance premiums and make health care less affordable, but produce very little, if any, improvement in health.

So what can be done to improve the decisions we make with our doctors about our treatments? For many health problems, there is more than one option for treatment that is supported by medical evidence. In those cases, a person’s values, goals, health , and a number of other individual factors should influence the decisions they make. But in order for those personal factors to become part of the decision, the person who is affected must understand all the alternatives for care and the risks and benefits each one carries. Additionally, their health care provider must understand the patient’s own values, goals, needs and fears to be effective in jointly making choices about what care is right for that individual. This process is referred to as shared decision-making. There are many examples of what is called preference-sensitive care – care for problems when more than one alternative is available and supported by medical evidence. In addition to angioplasty for stable angina, the list includes replacement of knees and hips, treatments for breast and prostate cancer, surgery for spine problems, and many others. A growing body of evidence shows that current decision-making is frequently undertaken with an accurate medical diagnosis but a misdiagnosis of the patient’s preferences for care. It is likely that some care is given to people who wouldn’t want it if they understood all the facts. In a recently-published study in which patients were given detailed, unbiased and complete information about treat(Continued on page 41)

Colorado Medicine for January/February 2013