January-February 2016 by Colorado Medical Society

January/February 2016

Volume 113, Number 1

From vision to reality

Members shape The New CMS Award-winning publication of the Colorado Medical Society

contents Jan/Feb 2016, Volume 113, Number 1

Features. . .

Cover story The New CMS reform

plan, as deliberated for two previous years and approved by members in September, will empower CMS members and harness the intellectual and political muscle of Colorado physicians in more effective ways than ever before. Following the historic vote, CMS leaders began work immediately, mapping out a comprehensive work plan and recruiting for new work groups. Engagement can take a few minutes to a few hours – however it fits the physician’s schedule and interests. Read more starting on page 8.

2016 public policy priorities–As medical practice evolves into a series of radical realignments, market adaptations will be influenced by shifts in state and federal policy. CMS staff map out the top priorities this year and why they’re important to Colorado physicians.

Insurance-industry-proposed mergers–The Colorado

CPMG Section–The recently appointed governance council for the Colorado Permanente Medical Group Section met to discuss their goals, including how to expand the participation of employed physicians in CMS.

Physician heroes– CMS recognizes Doris C. Gundersen,

9Health Fair–The Colorado Medical Society hosted

Transforming clinical practice–The Transforming

Final Word– Gina Alkes, MD, and Gina Martin, MD, reflect on how CMS brought them together and connected them with resources they need to make a difference, and their hopes for The New CMS.

Inside CMS 5 7 28 30

President's letter Executive office update COPIC Comment Reflections

Departments 32 36

Medical Society has roared into action following the approval by regulators of the Aetna-Humana merger without public notice or input.

MD, for her work with the Colorado Physician Health Program to get physicians back to health and practice. a physician focus group about 9Health Fair to facilitate conversation between primary care doctors and 9Health Fair leaders and improve future fairs.

Clinical Practices Initiative (TCPi) is gearing up in Colorado to assist primary care physicians and specialists in improving how care is delivered by providing practice support to adopt a culture of quality and process improvement.

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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 2016

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

2015/2016 Officers Michael Volz, MD

President

Katie Lozano, MD President-elect J.T. Boyd, 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 Tamaan Osbourne-Roberts, MD Immediate Past President

Board of Directors Charles Breaux Jr., MD Laird Cagan, MD Cory Carroll, MD Sami Diab, MD Joel Dickerman, DO Greg Fliney, MSS Jan Gillespie, MD Kendra Grundman, MSS Curtis Hagedorn, MD Mark B. Johnson, MD Richard Lamb, MD Tamara Lhungay, MSS Lucy Loomis, MD David Markenson, MD Gina Martin, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD David Richman, MD Scott Replogle, MD Floyd Russak, MD Charlie Tharp, MD Andrea Vincent, MSS

Kim Warner, MD Daniel Witten, MD AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Katie Lozano, MD Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD CMS Historian W. Gerald Rainer, 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 Dianna Mellott-Yost, Director, Professional Services, Dianna_Mellott-Yost@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org

Division of Communications and Member Benefits

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

Kate Alfano, Communications Coordinator, Kate_Alfano@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Executive Legal Assistant, adrienne_abatemarco@cms.org

Mike Campo, Staff Support, Mike_Campo@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 D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor. Printed by Spectro Printing, Denver, Colorado

Inside CMS

president’s letter Michael Volz, MD President, Colorado Medical Society

Working together to make sure The New CMS delivers With your input and support, CMS has started the New Year with a groundbreaking – and very busy – start. The New CMS as envisioned after two years of careful study, surveying and planning is coming into focus and I am continually energized by the dedication of the many physician volunteers – including many who are volunteering for the first time – who give their time to ensure The New CMS delivers on its promise to keep Colorado physicians more engaged, informed and empowered than ever before. As you’ll read in this issue’s cover story on page 8, the week after the CMS House of Delegates voted in the most substantial changes to the organization in its history, CMS leadership and staff immediately mapped out an 18-month work plan to implement those changes. We got to work setting up short-term working groups of physician volunteers to inform the development of several aspects of The New CMS, including the virtual grassroots policy forum – a key element for physician engagement and policy development.

mergers and an American Medical Association study indicated particularly harmful effects for physicians and patients in several states, including Colorado. Looking more closely at the Aetna-Humana merger showed its likelihood to enhance market power in certain Colorado metropolitan statistical areas (MSAs) including Boulder, Colorado Springs, Greeley, Pueblo, Grand Junction and Fort Collins-Loveland. Even through a busy holiday season, CMS met with leaders of the Colorado Division of Insurance to urge them to carefully investigate the impact of the mergers and to be accountable in their deliberations to the public and health care providers who care for Coloradans. As the article explains, we have and will continue aggressive advocacy in this area to ensure a transparent and participatory review process can be conducted. We currently have a critical survey in the field on these mergers specifically designed to inform state and federal decision-makers. I urge you to take the time to complete this survey if you haven’t already.

Also in this issue on page 12, you’ll read about our 2016 policy priorities; how CMS is identifying and addressing emergent member concerns like network adequacy, insurance industry mergers and preserving the state’s investment in primary care; and – most important – why each issue matters to you.

The Colorado Medical Society has always been an advocacy organization that stands up for doctors. The New CMS gives us the tools we need to better engage all Colorado physicians and get direction from the grassroots, the boots-on-the-ground physicians caring for patients.

A related article on page 16 about the insurance-industry-proposed mergers demonstrates how CMS is watching out for you and your patients. Four of the five largest commercial insurance companies in America are proposing

I have already heard personally from many members across the state, demonstrating the great range of concerns, passions and ideas of my colleagues. This is what we are harnessing with The New CMS, and coming together

Colorado Medicine for January/February 2016

as a united physician voice will allow us to make great strides in Colorado health care. Each member serves an important role in CMS, and all organizations benefit from renewal and an infusion of new ideas and people. We realize that not

“The New CMS delivers on its promise to keep Colorado physicians more engaged, informed and empowered than ever before.” everyone can or wants to be involved at all times as we travel through cycles in our professional and personal lives and deal with increased workload. But whether you have a few minutes or a few hours, I hope you will consider engaging with The New CMS in some way. This issue of Colorado Medicine is filled with volunteer opportunities. We encourage you to explore the options here and on our website at www.cms. org/the-new-cms. I look forward to the challenge and privilege of leading this organization as we get further into The New CMS plan. We need your help to build The New CMS. Contact me anytime by emailing president@cms.org. n

CMS ORG .ORG CMS CMS CMS.ORG ORG Colorado Medical Society

Colorado Medicine for January/February 2016

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Moving forward with The New CMS The productivity of a medical society, especially state organizations whose primary mission is to advocate for the profession, is a function of its ability to aggregate and deploy its physician-constituencies’ collective wisdom, clinical expertise and homegrown relationships with public officials and other public policy influencers. The fundamentals – the grassroots connections – that organize and weaponize us in the public affairs space are labor intensive and often referred to as “herding cats.” The logistical challenges of bringing a medical society into communities scattered across a wide array of practice settings and professional priorities is difficult, especially given that discretionary time (the physician’s most valuable volunteer resource) is limited. Physicians tell us that regardless of specialty or practice setting, their patient care day has spilled over into the evening hours.

to adapt to the limited bandwidth of medical practice and make policy idea intake and development more horizontal and interactive. Two years ago a task force was created to reinvent how to connect and mobilize our members, and in 2015 that same governing body overwhelmingly voted to re-engineer the process to allow for real-time connections to a smaller board linked to its local constituencies. As a result, we will strive to assure productivity on behalf of Colorado physicians by making it as easy as a keystroke to influence views in Denver and Washington. We are reaching out to you right now with a comprehensive survey on the health plan mega-mergers and will share the results with the United States Department of Justice Antitrust Division and state regulators. We will soon be surveying you on end-of-life decisions in anticipation of

Medicine’s practice productivity is being stressed to a tipping point. Yet physician engagement must drive the politics and process that set health care policy. The laws and supporting regulatory structure directly influence both the clinical and economic components of medical practice and must not be constructed in a void. Even so, despite grassroots-derived, highly relevant annual meeting programming, most CMS physicians have been voting with their feet to not give up personal or professional time to participate as a delegate in our 145-year-old governance process that used to set medicine’s agenda. Evaluations, statewide physician surveys and focus groups praised the program content and criticized the cumbersome governance model. The CMS Board of Directors reaffirmed what they intuitively knew: the problem with physician engagement was not inspirational, but structural. We had Colorado Medicine for January/February 2016

a renewed legislative debate on the role of a physician. We are organizing physician interests and expertise by issue clusters that can be ongoing and readily mobilized in virtual space as those issues heat up. A work group of your colleagues is meeting to reinvent the annual meeting as a family-friendly event that celebrates the community of medicine and deep-dives into the real-world mechanics and innovations of practice support tools and, of course, public policy debates that steer those innovations. This in-person/virtual governance interactive model intends to harness the wisdom, experience and insights of Colorado physicians. It will increase our productivity and influence on your behalf. If you want more information, contact me at alfred_gilchrist@cms.org or, even better, call me on my cell phone at (303) 4750144. I will hear you. n

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From vision to reality

Members shape The New CMS

Kate Alfano, CMS Communications Coordinator Colorado Medicine for January/February 2016

Cover Story STORY HIGHLIGHTS • The New CMS will empower CMS members and harness the intellectual and political muscle of Colorado physicians in more effective ways than ever before. • CMS hit the ground running immediately after members approved the sweeping governance and communications reforms in September, mapping out a comprehensive work plan and recruiting for new work groups. • All members are strongly encouraged to engage in whatever fashion fits their schedule, from joining a shortterm work group to completing member surveys on medicine’s most important policy priorities. The Colorado Medical Society is in the midst of a grand metamorphosis following the overwhelming approval in September of a realigned, grassroots-centered governance model developed by physicians and for physicians now and in the future. The reforms, developed through two years of intensive information gathering, promise to empower CMS members and harness the intellectual and political muscle of Colorado physicians in more effective ways than ever before. Member input and support is critical, which is why all members are invited to be involved in every step of the process of the plan in action, in whatever way their interests and schedules allow. The work groups described below are just the beginning of what promises to be a transformative year. Annual Meeting Re-engineering Work Group Because physicians voted to replace the traditional House of Delegates with an ongoing, seamless grassrootscentric series of interactions between a streamlined board of directors and

members, CMS has the opportunity to reinvent the Annual Meeting to assure relevancy and function for a diverse membership with broad interests. CMS President Michael Volz, MD, recruited physicians and students to join a shortterm Annual Meeting Re-engineering Work Group that will meet in the first quarter of 2016 for two or three work sessions and gain insight from meeting planning experts, consultants and other state medical societies who have already re-engineered their annual meetings. They aim to complete their work by the end of March. “A re-engineered Annual Meeting is intended to bring us together as a community of common purpose at a time when powerful influences are threatening to fragment our profession into balkanized interests or, worse, indifference and disengagement from our patients, profession and colleagues,” Volz said. “From this work group we will gain a fresh perspective on how to optimize a collaborative setting for clinical, political and policy education that pulls all ideas and concerns into a highly energized forum.” Virtual Policy Forum Working Group A second working group will guide the development of a key part of the reform proposal: the new virtual grassroots policy forum. The idea behind this communications platform is to give members an unprecedented voice in CMS by enabling members to submit a policy idea 24 hours a day, seven days a week, and to provide input and advice in their areas of interest – all from the convenience of a laptop or smartphone. It replaces the once-a-year call for policy proposals that were considered, debated and approved or rejected by the House of Delegates. The forum promises to greatly increase participation among members as well as increase the agility of the society, as CMS will be able to more quickly respond to the rapidly evolving legislative and regulatory health care landscape. Volz invited both technology-proficient and technology-challenged physicians to participate in the short-term Vir-

Colorado Medicine for January/February 2016

tual Policy Forum Working Group, cochaired by Robert Yakely, MD, and Ray Painter, MD. The group will meet for the first time in January and will meet

“It’s important for all physicians to be engaged in the process, both in the development of the policy through their input, and in implementing the policy through their support, particularly when it involves legislative action.” - Ray Painter, MD Co-chair, Virtual Policy Forum Working Group two or three more times over the next 10 months, working with a computer software company selected from many qualified candidates to help build out the communications platform to ensure its simplicity and ease of use for all members. The target launch for the grassroots policy forum is September 2016. “It’s important for all physicians to be engaged in the process, both in the development of the policy through their input, and in implementing the policy through their support, particularly when it involves legislative action,” Painter said. “I think the new communications platform will be just what the doctor ordered! It will allow us to provide our input electronically, without interfering with our busy work schedule, provide the CMS board and staff with the information they need to develop and support our policies, and streamline the flow of information between physicians, component medical societies and CMS.”

Cover story (cont.)

HOW TO BE HEARD

The virtual grassroots policy forum will make it easy to bring your policy idea to CMS A MEMBER SUBMITS A POLICY OR ACTION IDEA AND RECEIVES A NOTIFICATION FROM THE POLICY FORUM

THE MEMBER RECEIVES A NOTIFICATION FROM THE POLICY FORUM OF THE BOD VOTE AND NEXT STEPS

SHARING YOUR IDEA MAKES A DIFFERENCE!

THE POLICY FORUM NOTIFIES CMS STAFF THAT A NEW SUBMISSION WAS RECEIVED; STAFF CONDUCTS RESEARCH

THE BOD VOTES ON EACH POLICY IDEA

ALMOST IMMEDIATELY FOLLOWING THE VOTE: FOLLOW-UP CROWDSOURCING

Medical Society Management Series A working group comprising past CMS leaders and graduates of the CMS Advanced Physician Leadership Training program will help develop the Medical Society Leadership Training Program, one of the most highly anticipated aspects of The New CMS. A benefit of the traditional House of Delegates was its role as an incubator for the leaders of the future; The New CMS will now aggressively recruit and train leaders for the component and state levels who reflect the evolving demographic and diversity of Colorado physicians. Over the next few months, the working group will select and collaborate with a qualified consultant on the design and marketing of a skills-based curriculum for the explicit purpose of medical society leadership development. The target start date for the first cohort is late 2016 to early 2017. Complementing this effort is the biannual funding and assisted coordination of the Advanced Physician Leadership 10

THE MEMBER RECEIVES A NOTIFICATION FROM THE POLICY FORUM THAT STAFF RESEARCH IS COMPLETE

CROWDSOURCING BEGINS

TWO WEEKS PRIOR TO THE BOD MEETING: ADDITIONAL CROWDSOURCING

AFTER THE DEADLINE: THE MEMBER RECEIVES A NOTIFICATION FROM THE POLICY FORUM

OUTCOMES

THE MEMBER RECEIVES A NOTIFICATION FROM THE POLICY FORUM ABOUT THE BOD ACTION

Program, a yearlong leadership training program that helps physicians attain the tools and skills to effectively lead and transform health care. The program strengthens the ability of physicians to assume leadership roles within the profession and their communities, and empowers them to confidently serve as champions to improve the delivery of cost-effective, high quality and safe care. Planning for the third cohort of the APLP will begin in mid-2016.

to bear in their component societies, specialty societies, practices and hospitals, as well as to develop the future leadership of our Colorado Medical Society,” Lazarus said. “A strong CMS needs strong and even more knowledgeable leadership to be at the center of any changes in our Colorado health care system. I am excited to be a part of developing those initiatives for my physician colleagues and look forward to their leadership in the future.”

“It’s more important than ever for physicians to play an integral role in health care delivery, policy-making and administration,” said Jeremy Lazarus, MD, working group chair and past president of the American Medical Association. “He said these programs represent unique opportunities for physicians to gain skill sets that might not have been part of their traditional medical education.”

Nominating Committee The CMS Board of Directors approved in November the appointment of a seven-member Nominating Committee – six physicians and one medical student – that will be responsible for coordinating all-member elections for the offices of president-elect and CMS delegates and alternate delegates to the AMA. It is chaired by Ted Norman, MD.

“Through these initiatives physicians can master some of the best knowledge to navigate the choppy waters of the future and also bring that expertise

“In an effort to be more inclusive and relevant to our members, the Colorado Medical Society board, with the support of the House of Delegates, voted to change to an all-member election for-

Colorado Medicine for January/February 2016

Cover Story mat,” he said. “We hope that this will stimulate even more discussion within our membership so that more voices can be heard. This new process will require candidates to engage more members of the society than ever before.” All CMS members will now be empowered to choose their own representation for these positions, to run for these offices if they so choose and qualify, and to sponsor and endorse candidates. The nomination period opened in late December and extends through Jan. 31, 2016. An election guide for candidates and members is available on CMS.org that provides more information on the duties, eligibility, terms of office and honorarium for each open position, as well as candidate requirements, campaign guidelines, the election process and more. All members are encouraged to review the guide.

member of the working group and the CEO of the El Paso County Medical Society. He said the relationship between CMS and the component societies is important because each brings unique value to the daily lives of physicians. “CMS excels at policy development and advocacy and can be a unifying force statewide,” Ware said. “Components can each develop their own value at the point of patient care through networking and education, providing practice support services like we do at EPCMS, or many other ways.” “Most members want to practice medicine,” he continued. “They’re not interested in the intricate inner working of their medical societies. By focusing on a strong state/component partnership we ensure medical societies ‘just work.’”

CMS-Component Study Over the next year, a working group chaired by CMS past president Ben Vernon, MD, will study the relationship between CMS and local component societies, and recommend ways to strengthen both levels of organized medicine in supporting the delivery of programs and services to physician members. The first meeting was held in December with two more planned through April 2016. Mike Ware is a

Colorado Medicine for January/February 2016

2016 and beyond Successful implementation of The New CMS will require focused and methodical preparation over the next two years because it will drive policy results, as a matter of design and intent. This redesign is the linchpin to connecting increasingly diverse medical communities into common purposes of advocacy. The New CMS reflects what physicians across Colorado have said matters most to them in terms of relevance and importance, and because the relevance of CMS hinges on how well the organization engages members in this work and on their behalf, CMS requests and welcomes the participation of every physician and student member. Watch for many opportunities to engage with The New CMS over the next year. n

Join Now! Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or e-mail susan_koontz@cms.org

Features

2016 public policy priorities CMS staff report

The involvement of all members is critical The reinvention of how thewriter Colorado Kate Alfano, CMS contributing Medical Society governs, establishes and acts on policy does not alter the society’s scope of work in terms of identifying and addressing emergent member priorities like network adequacy, the impending consolidation of two major health plans doing considerable business in Colorado, and a budget fight in the 2016 legislature to preserve Medicaid primary care code parity with Medicare. CMS’ primary function is now and will continue to be an advocacy organization that stands up for doctors and engages them in the legislative and regulatory process.

funds expired. There are three significant consequences to a proposed 20-percent-or-more rollback of these codes:

At the annual meeting in September, both the CMS Board of Directors and the House of Delegates analyzed and ranked eight areas of exam-roomrelevant, politically-viable public policy priorities, directing staff on resource allocation. These issues and why they’re important to physicians are outlined below. Members will play an even greater role in CMS’ advocacy efforts under The New CMS. The society encourages all members to get involved in these most basic and important issues by visiting www.cms.org/the-new-cms or emailing president@cms.org.

What this issue means to physicians: • After years of stability, now there is resurgent uncertainty about fair rates that could potentially increase unwillingness to participate in the state’s largest health insurance plan. • There will be increased calls to do more care coordination services with less for this important, frequently complex patient population. • There will be pressure to reduce the number of Medicaid patients or stop taking Medicaid altogether.

Repeal of Medicaid E&M code parity with Medicare Limits from the Taxpayer Bill of Rights (TABOR) are once again threatening the ability of the state General Assembly to fund Colorado infrastructure including health care. As such, the repeal of Medicaid evaluation and management (E&M) code parity with Medicare is a 2016 state budget issue and widely regarded to be an “at-risk” item. Colorado is one of few states that extended parity once the federal Affordable Care Act 12

1. Decreased timely access to care for patients. 2. Reduced resources for care coordination within primary care and other practices. 3. A negative backlash on the state’s highly successful Regional Care Collaborative Organization (RCCO) program, leaving the initiative vulnerable to national managed care contracts when the bidding process resumes in 2017.

Colorado has made great gains in the reform of its Medicaid program, namely through the Accountable Care Collaborative (ACC). For three years in a row, the ACC has produced savings and increased patient satisfaction. The program relies on a solid primary care base using the patient-centered medical home (PCMH) model, along with practice analytics and support. The enhanced fees through E&M code parity with Medicare helped strengthen PCMHs, save taxpayer dollars and improve care. Repeal of the enhanced fees threatens these gains.

Members can go to www.cms.org to access a legislative alert on Medicaid payment and send a communication to their state legislators. Network adequacy policy overhaul: protecting consumers from excessive charges and surprise medical bills In 2015, following failed legislation on excessive charges and surprise medical bills in situations where care is rendered by an out-of-network provider in an in-network facility or in an emergency situation, CMS physicians voted to prioritize commercial payer issues for the remainder of the decade. The focus in 2016 is new state policy on network adequacy with a rich mix of examroom-relevant issues. As a first step, CMS and the Colorado Association of Health Plans are already deep into the process of mediation to develop state policy on out-of-network charges and surprise bills, with input from other stakeholders including consumer groups and hospitals. What this issue means to physicians: • Efforts are heating up to ensure that out-of-network physicians are paid fairly for their services and that their patients are protected. • The viability of physician practices will continue to be threatened, including how doctors are paid and how much negotiating power they have in the marketplace. • There will be increased efforts to enhance the transparency of health plan physician network development, including the methods and standards used to narrow their networks. • Health plans can expect increased

Colorado Medicine for January/February 2016

The New CMS

7 Reasons to Engage in Public Policy in 2016

As medical practice evolves (or dissolves) into a series of radical realignments, form will follow function in terms of public policy. Market adaptations will be either influenced or chased by shifts in state and federal policy – how services are authorized and paid for, and how networks include or exclude physicians, to mention a few. Those laws will be set by public officials who for the most part have little or no clinical training. That is where you and the Colorado Medical Society intervene. By engaging in those conversations in the public affairs arena, you bring exam-room-level relevance to the debate.

If you aren’t talking to your legislators, someone else is.

Medicaid reimbursement rates affect access.

Insurance networks matter.

Out-of-network service issues must be managed.

Two huge insurance company mergers are in the works.

6 7

Your legislators should not be talking only among themselves or hearing from others who may have an adversarial point of view. They are eager to talk with you and they rely on their medical communities. They want evidence-based arguments and in the coming months will be overwhelmed with policy choices and contradictory information for which very few have professional or practical experience. Help us explain to your legislators and the governor the consequences of a 22 percent or more cut to Medicaid E&M codes and how it would affect you, your colleagues and your patients. The state budget has once again hit TABOR limits, prompting a range of freezes and cuts, including a proposed rollback in the governor’s proposed state budget of the E&M Medicaid parity payments with Medicare.

Explain to your legislators the practical result of narrowing provider networks. The Colorado General Assembly will debate how health plans develop, maintain and limit their networks.

No patient should be blindsided with a bill that by any rational measure is excessive, nor should physicians find themselves at sea because an insurance company arbitrarily decides to include some magical number of specialists and primary care physicians while throwing the rest overboard. The General Assembly will either debate an agreement between CMS and health plans or take sides if the professional mediation between physicians and health plans currently underway doesn’t find a sweet spot. Just how big does a health plan have to be? The state and federal agencies with antitrust enforcement authority have begun the methodical and mind-numbingly complex task of determining whether the two proposed mega-mergers (Aetna Inc. with Humana Inc., and Anthem Inc. with CIGNA Corporation) are sufficiently anticompetitive to limit or block those deals. You can weigh in now by completing a CMS survey designed specifically to inform state and federal regulatory agencies and by telling us your own story.

Colorado will discuss patients’ end-of-life decisions.

Advocates for physician-assisted suicide have targeted Colorado. CMS is currently evaluating its 15-year-old position statement by engaging physicians and will soon poll its full membership.

Relationships matter.

There are few more valued relationships between a constituency and a legislator than those forged in the heat of a campaign. These homegrown, organic ties carry over into the halls of the capitols in both Denver and Washington and enhance the quality and credibility of those interactions in ways unachievable through a drive-by visit or blast-emails.

FOR MORE INFORMATION: Stay tuned to CMS communications to learn more about these important issues, follow our progress and learn how you can get involved. We want to hear from you and are available to answer your questions. Please contact CMS President Michael Volz, MD, at president@cms.org. Colorado Medical Society | 7351 E. Lowry Boulevard, Suite 110, Denver, CO 80230-6083 | (800) 654-5653

www.cms.org

Policy priorities (cont.) scrutiny to ensure that their provider directories are accurate, timely and contain the information patients need to make decisions about their care. Physician practices can in turn expect increased demands for up-todate information from plans. Aetna-Humana and AnthemCIGNA proposed mergers (see related article on page 16) Colorado Medical Society joined the American Medical Association and the American Hospital Association in urging the United States Department of Justice to thoroughly investigate the proposed mergers of Aetna Inc. and Humana Inc., and Anthem Inc. and CIGNA Corporation. The AMA opposes the mergers, as does the Physician Advocacy Institute. Colorado Medical Society has also asked the state insurance commissioner to investigate both mergers. The effect of these mergers on physician practices and their patients across the state of Colorado is currently being assessed, but CMS experts project the mergers will substantially lessen the competition among insurers by increasing health insurer concentration in the state or by moving toward a monopoly. What this issue means to physicians: • Decreasing competition in Colorado could increase insurer market power, resulting in harm to access and quality care. • Physicians’ ability to negotiate fair and reasonable contracts with insurers may be further threatened. • Physician practices may experience increased pressure to become employed or consolidate with other groups. • Provider networks will increasingly narrow in health plan efforts to decrease costs, and opportunities for physicians to participate in these networks will also shrink. Members can join CMS deliberations that will guide the board of directors on the CMS position before state and federal regulators, or share their stories with CMS on the potential impact of the mergers for submission to the U.S. Department of Justice and state Depart 14

ment of Insurance by emailing them to president@cms.org or by completing our all-member survey currently in the field (see an email from president@cms.org in your inbox regarding the health plan merger survey). Colorado end-of-life options Rep. Joann Ginal (D-Fort Collins) and Rep. Lois Court (D-Denver) have already made known plans to bring the issue of physician-assisted suicide to the 2016 Colorado General Assembly following a failed attempt in 2015. According to some public opinion polls, patients favor expanded options when it comes to end-of-life care. The last CMS policy on physician-assisted suicide was approved in 2000 and confirmed with limited debate in 2014 during a sunset review of the CMS policy manual. CMS policy is being re-evaluated through a series of focus groups on the topic, an all-member survey and in-person deliberations. What this issue means to physicians: • There is a range of passionate views among Colorado physicians on both sides of the physician-assisted suicide issue. CMS has already held focus groups to gain insight into these opinions and will continue to solicit member feedback as the issue and the legislation evolves. • There is a great opportunity to expand the conversation with policymakers to the palliative care needs of patients in Colorado communities. Members can participate by: 1. Completing an online survey to be launched in mid-January. 2. Emailing views to president@cms.org that will be shared with the Council on Judicial and Ethical Affairs (CJEA) responsible for re-evaluating the CMS policy. 3. Joining an online discussion hosted by University of Denver Law School Dean Emeritus Ed Dauer, LLB, MPH, that will be launched simultaneously with the all-member survey. ColoradoCare ballot initiative ColoradoCare is a universal health care proposal that the Secretary of State cer-

tified in November 2015 for the November 2016 general election ballot. It will be listed on the ballot as amendment 69 and would create a single-payer government-run health care plan through a new $25 billion annual tax taken out of paychecks, similar to how Medicare is funded. Funds would go to an elected board of trustees, which would act as an insurance company and reimburse doctors. Medicare and Tricare would remain intact but co-payments and deductibles would go away. Colorado Care proponents are organizing an aggressive ground game and the Denver Metro Chamber has announced a full-on effort to defeat the measure. What this issue means to physicians: • This ballot proposal ups the game in the ongoing debate on how to expand health care coverage. The question of coverage always turns on three points: how to pay for it, how to assure that it is affordable, and how to assure that care is accessible and delivered at the right time, place and value. • Whether the proposal can pass or not, this will be a healthy debate because it will raise the awareness of Colorado leaders and voters on health care choices. Colorado will have a larger pool of informed and engaged patients who are willing to make those choices. CMS will appoint a special select advisory committee to advise the board of directors, selected from a presidential call for volunteers. Members selected to serve will need, at a minimum, experience in public policy, health economics and nonprofit board governance. The second regular session of the 70th General Assembly convened on Jan. 13, 2016. Watch for more on these issues and ways to stay involved with CMS during the session and beyond. n

CMS ORG CMS..ORG CMS CMS ORG ORG Colorado Medical Society

Colorado Medicine for January/February 2016

Features

Insurance-industryproposed mergers Alfred Gilchrist, CMS CEO

Colorado regulators okay Aetna-Humana merger without public notice or input CMS vigorously objects; considering all options The Colorado Division of Insurance (DOI) has green-lighted Aetna’s acquisition of Humana despite a steady stream of Colorado Medical Society requests for a hearing or other opportunities to provide analyses, commentary and raise anticompetitive concerns. “We are very disappointed that the Division of Insurance appears to have done little more than a paper review of Aetna’s request, summarily rejecting our repeated requests, and has forfeited the state’s considerable authority and leverage over these two health plan giants,” said CMS President Mike Volz, MD. “Given the national controversy the mergers have provoked and the potential risks they pose to physicians and their patients, we expected a more methodical approach that at a minimum allowed for public hearings in those communities where the two combined companies could dominate a market.” The state insurance commissioner has wide discretion to approve or reject an application, notwithstanding the importance of federal antitrust authorities, explained David Balto, a Washington, D.C.-based attorney and former policy director of the Federal Trade Commission, during a presentation to the National Association of Insurance Commissioners (NAIC) late last year. He noted that along with the Department of Justice Antitrust Division and the states’ attorneys general, the states’ insurance commissioners serve a critical role in investigating and reviewing mergers between health insurers. 16

Balto stressed that unlike the other regulators, the insurance commissioners’ powers allow them to analyze the health insurance market within their state fully, both broadening the scope of the investigation into potential competition issues and considering additional factors outside of typical antitrust jurisprudence. Most important he argued that a commissioner’s review is independent of those done by other regulators and therefore not beholden to the competitive analysis done by others. He further noted that insurance commissioners derive their health insurance merger review powers from state statutes modeled on the NAIC Model Insurance Holding Company System Regulatory Act; and while there are variations among states, all states have adopted some version of the model act. Upon hearing about the proposed AetnaHumana and Anthem-CIGNA mergers, CMS has taken a number of steps on behalf of physicians including: • Joining the American Medical Association and the American Hospital Association in urging the U.S. Department of Justice to investigate the proposed mergers thoroughly. • Notifying the Colorado Congressional delegation and state legislative branch leadership about CMS concerns and the CMS recommendation for the Colorado Attorney General and the DOI to investigate the merger. • Sharing these concerns in writing and in person on several occasions with the DOI commissioner and her staff.

• Highlighting for the DOI, prior to their Aetna-Humana decision, the

DOI creates public notification system for merger info in response to CMS action The Division of Insurance established an electronic notification system through which the public can sign up to receive information about filings, notices, documents, etc. associated with acquisitions or mergers of insurance companies in Colorado. To sign up to receive these notifications, go to www.dora.colorado. gov/insurance and click on the blue “Get DOI Alerts” button. On that page, find the “Division of Insurance – Merger Information Notification,” enter your email address and click “submit.” This will register you to automatically receive a notification when items are posted to the division’s website pertaining to insurance company mergers or acquisitions. This announcement was made on Jan. 4, in response to a meeting between CMS and DOI leaders on Dec. 31. An email from DOI thanked CMS for initiating the meeting and stated DOI’s commitment to using the notification mechanism, as well as their website, to post the public information about mergers and other acquisitions, including the fact and date of the filing of documents and information.

Colorado Medicine for January/February 2016

Features AMA’s 2015 report on competition in U.S. health insurance markets that concluded that an Aetna-Humana merger would be presumed likely to enhance market power in certain Colorado metropolitan statistical areas (MSAs) including Boulder, Colorado Springs, Greeley, Pueblo, Grand Junction and Fort Collins-Loveland. (The agency has told CMS that they did not consider MSA-level data in making their decision about the merger.) • Repeatedly asking to be involved and to be notified of any of the company’s filings given that they trigger timelines for the DOI review and investigation should the commissioner decide to use her statutory authority. CMS was satisfied from these meetings with the DOI that the society would be timely notified and given an opportunity to provide information at a minimum, even though a full investigation of the merger was requested. As if to emphasize the irrelevance of public comment, CMS learned that DOI had permitted the Aetna-Humana merger to proceed through an article in a Florida newspaper. DOI classified the merger as involving “non-domestic” insurers and therefore concluded (apparently with input from Aetna alone) not to conduct an independent investigation, public hearings or to otherwise request stakeholder input. CMS attorneys strongly dispute this merger classification as a legal technicality.

Update on the proposed Anthem-CIGNA merger Anthem-CIGNA made their initial filing, Notice of Acquisition of Control or Merger under CRS 10-3-803(1)(a), on Nov. 24, 2015. The Division of Insurance made this document available on their website on Dec. 2, 2015. The application is not complete. DOI has stated its intention to notify the public through the new electronic notification system when the insurance commissioner determines it is complete. DOI will also conduct an independent investigation of the Anthem-CIGNA merger application and hold a public hearing. The commissioner will make the investigation report public as well as all data and reports used in the investigation, with the exception of what she deems is proprietary information, again information is based on publicly available data and argue that such data used by insurance companies to justify a merger should be transparent, open to public debate and subject to rebuttal.

using the electronic notification system to notify the public of its availability. The precedent of the discoverability of Form E as determined in the Aetna-Humana merger will apply in the Anthem-CIGNA merger. Finally, DOI will provide notice regarding the public’s ability to participate in the review of the application. CMS is actively engaged in advocacy and research efforts on the Anthem-CIGNA merger, similar to the Aetna-Humana merger. Watch for future communications and outreach on this merger and be sure to complete the online CMS membership survey on health plan mergers that you should have received via email. CMS is also considering other actions to overturn the DOI decision permitting the merger to proceed so that a transparent and participatory process review process can be conducted. n

CMS subsequently filed a Colorado Open Records Act request to obtain paperwork filed by Aetna with DOI to determine the basis of the agency’s decision. The agency will ask a Colorado state district court to determine whether the information should be produced. The AMA Litigation Center was notified of the situation in late December and subsequently voted to financially support CMS legal advocacy at the district court now that the attorney general’s office filed a petition for review. CMS attorneys interpret the statute as permitting release of Aetna’s market analysis. Aetna has taken a vigorous position opposing CMS’ request, stating that the information is proprietary. CMS attorneys contend that market analysis Colorado Medicine for January/February 2016

Features

CPMG Section CMS staff report

CPMG Governing Council meets, shares goals for involvement in Colorado Medical Society A new representative member section comprising employed physicians from Colorado Permanente Medical Group

“It was clearly time for the two organizations to align. We have strengths and learnings that can complement each other around education, health, wellness and advocacy, which will make each organization stronger, and benefit the physicians and patients of Colorado.” - Kim Warner, MD CPMG representative to the CMS Board of Directors

(CPMG) was created last year and approved by the CMS Board of Directors and House of Delegates in September. As an organized section, CPMG will have a voice on the board and aims to expand the participation of employed physicians in the Colorado Medical Society. The section’s recently appointed governing council held its first meeting on Dec. 2 to conduct a review of the section bylaws, give an overview of The New CMS reform plan, discuss the outcomes of the July 14 inaugural CPMG section meeting, and give thoughts on their focus and objectives. Each physician leader on the council also went around the table and told why they look forward to the engagement opportunities through The New CMS and why they decided to volunteer their time to the CPMG Governing Council. Oscar Sanchez, MD, who specializes in physical medicine and rehab, told the group about his passion for treating pa-

The CPMG Section Governing Council gathered for their first official meeting on Dec. 2. From left to right: Oscar Sanchez, MD; Cyrus Mirshab, MD; Alison Sandberg, MD; Kim Warner, MD; Ashley Wheeler, MD; Nora Resnikova, MD; and Chris Fellenz, MD. 18

tients with pain and his desire to bring education to physicians on new thinking and evidence in treating pain patients. Chris Fellenz, MD, a family medicine physician, expressed his passion for serving the underserved and helping patients in safety net programs, and his desire to connect more specialists with this patient population. Alison Sandberg, MD, who specializes in diagnostic radiology, sees a need to control radiologic costs – though thoughtfully – through stewardship and education around the cost of overused and unneeded imaging, ensuring the health care system continues to cover appropriate imaging. Cyrus Mirshab, MD, an anesthesiologist, expressed his passion for physician wellness and desire to bring what he and colleagues have learned at CPMG to CMS. Nora Reznickova, MD, an internal medicine physician, expressed her aim to educate the community and physicians about geriatric care, dementia and elder abuse. And Ashley Wheeler, MD, a psychiatrist, is passionate about advocacy and education regarding mental health, access to mental health and physician burnout. “CPMG and CMS share common visions for the State of Colorado,” said Kim Warner, MD, an obstetriciangynecologist and CMS board member for CPMG. “It was clearly time for the two organizations to align. We have strengths and learnings that can complement each other around education, health, wellness and advocacy, which will make each organization stronger, and benefit the physicians and patients of Colorado.” n

Colorado Medicine for January/February 2016

CMS Education Foundation

Help send a student through school About the CMS Education Foundation Founded in 1982, the Colorado Medical Society Education Foundation (CMS EF) is a non-profit, tax-exempt charitable foundation established primarily to support educational and charitable programs in Colorado. Since 1993 the Foundation has dedicated itself almost exclusively to the funding of scholarships to incoming first-year medical students at the University of Colorado School of Medicine. Scholarships are awarded to students who come from underserved areas, have high academic credentials, demonstrate a financial need, and anticipate practicing in a rural or underserved area.

Call 720-858-6310 for more information and to donate Colorado Medicine for January/February 2016

Features

Physician hero Healing the healers Kate Alfano, CMS Communications Coordinator

Doris C. Gundersen, MD, helps get physicians back to health and practice when their emotional, mental or physical health suffers – the Colorado Physician Health Program (CPHP). And this issue’s Physician Hero honoree, CPHP Medical Director Doris C. Gundersen, MD, is enthusiastically committed to promoting the health and wellbeing of physicians and physician assistants through evaluation, treatment referral, support, education and research.

Doris C. Gundersen, MD New statistics on physician burnout are grim. A December 2015 study from the Mayo Clinic shows that physician burnout rates in the United States increased from 2011 to 2014 and the gap between physician burnout rates and burnout rates in the normal population widened. In 2014, 54.4 percent of physicians admitted to at least one symptom of burnout, up from 45.5 percent in 2011, with emotional exhaustion being the most common symptom. Thirty-nine percent of physicians screened positive for depression and the rate of suicidal ideation jumped from 4 percent to 7.2 percent from 2011 to 2014. Nearly half of physicians, 44.5 percent, reported their work schedule does not leave enough time for personal or family life. Fortunately, Colorado physicians have a tremendous resource to help them 20

Gundersen has worked with CPHP since 2000 and became their medical director in 2009. Board-certified in psychiatry and neurology and trained in forensics and addiction, she works within CPHP’s clinical team environment to lead, listen, direct and maintain focus on returning physicians – the healers themselves – to health. “The challenges of caring for those who care for others are vast and often go unobserved,” her nominator wrote. “Without any need for recognition, Dr. Gundersen continues to persist in this challenging pursuit, and gives her time, energy and extensive knowledge to physicians in need.” Gundersen evaluates and monitors physician-clients who contact CPHP for support and supervises a clinical team of experts comprised of five other psychiatrists and five master-level clinicians. Together they serve all physicians, residents and medical students by providing comprehensive health evaluations, directing participants to treatment providers with the requisite expertise and supporting physician participants as they recover from illness or stressful circumstances. “CPHP is important because healthy physicians provide better patient care,”

Gundersen said. “Our research has demonstrated that healthy physicians have lower malpractice risk. CPHP provides a safe haven for physicians. Specifically, if physicians come to us for help, they do not need to disclose their medical problems to the regulatory agency. We provide strict confidentiality.” It was her work in private practice treating physicians that drew her to the organization, as she recognized the unique demands medical professionals face. “I understood that CPHP was committed to improving the lives of those physicians who were struggling with stress, burnout, addiction or other downstream consequences of overwork and poor self-care,” Gundersen said. “It could not have been a better match for me.” Since its inception, CPHP has helped more than 4,600 physicians and each physician Gundersen has worked with has inspired her with his or her courage, resilience and determination. She recalled one physician who sustained a serious head injury while bike riding in the mountains. “Her rehabilitation, both physically and cognitively, was hard, painful and protracted,” Gundersen said. “She was unable to practice for a year. Despite this loss, she always maintained a sense of humor and confidence that she would return to practice, and she did. After almost losing the privilege to practice medicine due to illness, she developed this amazing gratitude for her recovery and is one of the happiest doctors I know.” Gundersen recognizes how intimidating it can be for physicians to seek help. They’re taught to be healers, educators

Colorado Medicine for January/February 2016

Features or caretakers – not patients. “Where the joy for me comes in is watching these terrified, depressed physicians get empowered, love their work again and be healthy,” Gundersen said. “There’s not a greater reward than to see my colleagues get back into action and be happy with their choices.” She continues to maintain a private adult psychiatry practice and a forensic practice specializing in independent medical evaluations and threat assessment. She was also appointed to the Attorney Regulation Committee of the Colorado Supreme Court where she provides clinical input concerning attorneys who may have health problems and are potentially facing discipline; she helps the courts and juries understand psychiatric illness and how it may impact the behavior, choices and judgment of citizens on trial; and she advocates for mental health care in the prison system. Gundersen chairs the CMS Committee on Physician Wellness and helped develop CMS’ physician wellness toolkit that was launched in September 2014. The toolkit addresses the eight dimensions of wellness with a focus on stress and burnout. Go to www.cms.org/ articles/category/physician-wellness to download the toolkit. Learn more about CPHP at www.cphp.org. n Editor’s note: The Colorado Medical Society recognizes the prevalence of burnout among physicians, particularly in this time of great change in health care. To help our members reflect on the meaningful difference they’re making in the lives of their patients and community and to recognize extraordinary actions, Colorado Medicine launched the Physician Heroes series. We will profile as many different members as we can who have gone above and beyond in the profession to help their colleagues or community. We hope you’ll see your own values reflected in these stories and be reminded of the joy of medicine. Members are invited to nominate themselves or a colleague by contacting Dean Holzkamp at dean_holzkamp@cms. org or 303-748-6113 or Kate Alfano at kate_alfano@cms.org. Colorado Medicine for January/February 2016

Features

Physician focus group Jim Goddard, 9Health Fair president/CEO, and Sherri Laubach, MD, chair of the 9Health Fair Medical Advisory Committee

9Health Fair seeks input about new directions in balancing public health with individual health STORY HIGHLIGHTS • The Colorado Medical Society hosted a focus group about 9Health Fair (9HF) to facilitate conversation between primary care doctors and 9HF leaders. • Participants said 9Health Fair plays an active role in connecting their uninsured participants with enrollment resources and with a medical home. • 9Health Fair’s leadership will use input from this focus group to implement changes to future 9HF seasons. These leaders consider it a great advantage to be able to facilitate conversations with CMS members and help the organization continue engaging patients in their own health. The Colorado Medical Society has endorsed 9Health Fair (9HF) for many years, recognizing its role in giving individuals the tools they need to take responsibility for their own health. So when 9Health Fair needed input from primary care physicians, CMS immediately offered to help. In 2012 CMS surveyed members to get feedback about how physicians utilize the screening results that are brought by their patients from a 9Health Fair. The feedback received from that survey was encouraging for the nonprofit screening organization, showing the vast majority were supportive of, or 22

had actively utilized, those results. There were also many very helpful comments that spurred further conversation between our two organizations. In October 2015 CMS gathered a group of primary care doctors and facilitated a conversation to give more specific input about 9HF’s mission and selection of specific screening tests and to gain more insight into the organization’s future direction. CMS President Michael Volz, MD, welcomed the group and CMS CEO Alfred Gilchrist facilitated the discussion. We gave an overview of the operation of 9Health Fair; the focus group was pleased to learn more about our mission and also how helpful the health fair website is in describing offerings and the model of the fairs. There were also some pleasant surprises that the group reported: 9Health Fair plays an active role in connecting their uninsured participants with enrollment resources (both Medicaid and Connect For Health Colorado) and with a medical home, and all the data collected at 9Health Fair via blood screening is stored with CORHIO and is ready to be downloaded to electronic medical records, upon permission from the patient. Several questions were posed to the group about the current array of screenings. Overall the focus group participants were supportive of the 9HF concept and several had volunteered in the past. Two participants expressed interest in volunteering to

serve on the 9HF Medical Advisory Committee (MAC). There were differing thoughts within the group about the helpfulness of the results that 9HF participants bring to them and some members of the group expressed their opinion that the screenings need to be more evidence-based and updated to reflect current thinking about population health. They advised 9Health Fair to be mindful of the influence vendors might have on the selection of screenings or tests. They expressed the need for 9Health Fair to help reduce the fragmentation of health care (the connectivity to CORHIO was lauded as a good step in this direction). And the group supported the refocusing of screenings and health education toward those interventions that are known to make the most difference, especially in underserved populations (diabetes, hypertension, metabolic syndrome, stroke, heart disease, obesity, alcohol, smoking, etc.), and to continue to reach out to sections of the population where certain conditions are most prevalent. Much of the discussion pertained to the selection of screenings, and there were many questions about how they were selected and whether they were aligned with the recommendations of the U.S. Preventive Services Task Force. With this movement, it was recommended that good educational support tools and patient decisionmaking aids be used to help partic-

Colorado Medicine for January/February 2016

9Health Fair (cont.) ipant-patients understand the risks/ benefits of each screening to prepare them for shared decision-making discussions with their doctor. The group also recommended a number of things for the MAC to consider. • Support the ongoing opportunity that 9Health Fair offers for medical and allied health profession students. • Educate participants more about appropriate medications. • Continue to offer health insurance enrollment resources. • Promote further the CORHIO connection for providers to access results. • Create a direct connection to the Medicaid RCCO and ACO programs for results, enrollment and connection to providers. • Expand screenings that support the aging population. • Provide leadership to help improve health outcomes. Additionally the focus group noted

that 9HF’s mission of patient responsibility aligns with the greater mission of patient engagement and is commendable. They felt that the MAC should consider using more quality improvement review processes to get at best practices and the best evidence for screening selections, and that a discussion should be initiated to consider adding more aspects of public health to the focus on personal health within the mission of 9Health Fair. The next meeting of the 9Health Fair Medical Advisory Committee will be in January, just before the implementation of the spring 2016 health fair season. We appreciate the input from our partners at CMS to help us further refine our array of educational and screening options for 9HF participants. The goal of 9Health Fair has always been individual choice, with consultation between providers and patients. 9Health Fair’s leadership will recommend that input from this focus group

be used to implement changes to future 9HF seasons. It is a huge advantage to us to engage CMS members to help us continue engaging patients in their own health, and to facilitate conversations with these doctors. Thanks to the CMS members who gave their valuable input as a part of this focus group. • • • • • • • • • • • •

Samuel G. Cloud, MD David A. Downs, MD Shannon E. Jantz, MD Mark Mathews, MD Debra J. Parsons, MD H. Manning Pickett, MD Genie Pritchett, MD Christopher J. Unrein, DO Simi Varanasi, MD Michael A. Volz, MD Erik Wallace, MD Prosper L. Wang, MD

There is no substitute for the experience of practicing physicians when evaluating how to maximize the effectiveness of community health programs. n

Colorado Medicine for January/February 2016

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Features

Transforming clinical practice Kyle Knierim, MD, family physician and associate director, Colorado Health Extension System and Barbara J. Martin, RN, MSN, ACNP-BC, MPH, program manager, Transforming Clinical Practices Initiative

TCPi model will assist clinicians with practice support on quality and process improvement Much has been written about the Triple Aim since Don Berwick first introduced it in 2007. The Triple Aim – enhancing patient experience, improving population health, and reducing costs – is widely accepted as both a guidepost and a measure of success in transforming our broken health care system. In the past year we have heard more and more about the quadruple aim, recognizing that quality health care needs to involve the well-being of the health care team. In order to truly evolve into a system of quality and value, we must develop the infrastructure and support that will empower providers to be the leaders in delivery system redesign. The good news is there is widespread agreement. At the Centers for Medicare and Medicaid Services National Quality Conference: Building Partnerships, Delivering Results in Baltimore earlier

Five phases of transformation to achieve TCPi aims and goals: • Setting aims and developing basic capabilities • Reporting and using data to generate improvements • Achieving aim of lower cost, better care, better health • Getting to benchmark status • Capacity to generate better care, better health at lower cost 26

this month, more than 2,000 individuals came together to celebrate the successes we have achieved and lay out a road map for the future of health care redesign; the care team was at the front and center of the conversation. This conference served as the kickoff for the Transforming Clinical Practices Initiative (TCPi) funding opportunity, a four-year grant from the Centers for Medicare and Medicaid Services. As reported in the November/December issue of Colorado Medicine, the TCPi model will assist clinicians in improving how care is delivered by providing practice support to adopt a culture of quality and process improvement. TCPi will build on and spread proven change management methodologies and practice redesign tools to ensure health systems and providers can be successful in value-based payment models. TCPi has the following aims. • Support more than 140,000 clinicians. • Improve health outcomes for millions of patients. • Reduce unnecessary hospitalization for 5 million patients. • Generate $1 billion to $4 billion in savings. • Sustain efficient care by reducing unnecessary tests and procedures. • Build an evidence base for transformation. To achieve these aims, TCPi funds two types of collaborative networks – Practice Transformation Networks and Support and Alignment Networks.

Support and alignment networks • American College of Emergency Physicians • American College of Physicians, Inc. • HCD International, Inc. • Patient Centered Primary Care Foundation • The American Board of Family Medicine, Inc. • Network for Regional Healthcare Improvement • American College of Radiology • American Psychiatric Association • American Medical Association • National Nursing Centers Consortium

Through a collaborative partnership among many local and regional organizations across the state, Colorado was selected as one of 29 Practice Transformation Networks (PTNs). The Colorado PTN will coordinate peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies specific to practice redesign. This approach allows clinicians and practices to become actively engaged in the transformation and ensures collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system. The 10 Support and Alignment Networks (SANs), which include organizations such as the American Medical

Colorado Medicine for January/February 2016

Features Association and the American College of Radiology, will provide a system for workforce development utilizing national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts. Utilizing existing and emerging tools (e.g., continuing medical education, maintenance of certification, core competency development, data and HIT assistance) these networks will help ensure the sustainability of these efforts. These will especially support the needs of practices serving small, rural and medically underserved communities. While at first glance this may look like just another case of acronym soup, the Colorado PTN has been developed to add value to and support delivery system redesign that is already underway and to do so with a lens of supporting the care team â&#x20AC;&#x201C; ensuring that the infrastructure and tools and resources are in place for providers and staff to not only survive but also thrive with a sense of professional wellbeing in the midst of the ever-changing health care landscape.

Change is coming, most notably in the form of payment reform as laid out in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. As we await the final rule that will guide MACRA, slated to come out this spring, take note that the Centers for Medicare and Medicaid Services and the Colorado community do not want practices to go it alone. The Colorado PTN, in alignment with the other opportunities for practice transformation in the state, are committed to this support. Stay tuned as we continue to highlight TCPi in the months to come, and particularly the partnerships with many of the SANs (see the complete list in the sidebar on the previous page). Notably, the American Medical Association is partnering with the Colorado PTN and the Colorado Medical Society to host a learning and network event on Jan. 29 to present the Colorado PTN model. More details will be available in the coming weeks. In the meantime, for more information or to get involved please contact the Colorado PTN

Colorado Medicine for January/February 2016

Jan. 29, 2016 Colorado TCPi kickoff learning and network event featuring: Carol Greenlee, MD, FACE, FACP, an endocrinologist and national leader on building the medical neighborhood through coordination and high-value referrals. Christine Sinsky, MD, vice president of professional satisfaction, American Medical Association, national leader on practice redesign and physician satisfaction and a board-certified internist practicing at Medical Associates Clinic and Health Plans in Dubuque, Iowa. Program Manager at barbara.martin@ state.co.us or visit https://innovation. cms.gov/initiatives/Transfor mingClinical-Practices. n

Inside CMS

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

Addressing the issue of diagnostic errors Diagnostic errors were pushed to the forefront last year when the National Academy of Medicine (formerly known as the Institute of Medicine) released its Improving Diagnosis in Health Care report. The report highlights key factors that contribute to these errors and establishes a solid foundation of data to draw upon. It also illuminates the scope of this issue, estimating that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error. An important observation from the report is that diagnostic errors are not always due to human errors, but, rather, often occur because of errors in the health care system. “The complexity of health and disease and the increasing complexity of health care demands collaboration and teamwork among and between health care professionals, as well as with patients and their families,” said John R. Ball, chair of the Committee on Diagnostic Error in Health Care, in the report’s preface. Several of the recommendations outlined reflect efforts that COPIC has engaged in for years. For example, the report calls for the adoption of communication and resolution programs to enhance the disclosure process with patients. Our 3Rs Program, launched in 2000, is considered an industry benchmark and continues to support resolutions between patients and physicians while attempting to preserve these relationships. The report also highlights the need to enhance education and training in the diagnostic process for health care professionals. During the last decade, COPIC has developed courses and seminars that specifically examine diagnostic errors to support learning that leads to improved outcomes. COPIC’s Practice Quality (PQ) Review is another valuable resource that helps medical practices address diagnostic errors. These on-site reviews are conducted by specially trained nurses who use Level One Guidelines developed by COPIC. The guidelines are determined by actual medical liability claims and incident reports in order to recognize high-risk areas. Through these thorough and objective reviews, medical professionals work closely with COPIC to identify areas for improvement, address challenges unique to a particular practice and integrate best practices. The report notes that “because the diagnostic process is a complex, team-based, iterative process that occurs over varying time spans, there are numerous opportunities for failures.” 28

To better understand why these failures happen, we need to look at the diagnostic process and examine why certain steps never occur or are being done incompletely or incorrectly (accuracy), as well as what may be causing meaningful delays in taking a step (timeliness). PQ Reviews serve as an audit to help medical practices evaluate steps in their own internal systems. We know that ordering tests and communicating results to the medical team and patients is an area where problems can arise. Therefore, the guidelines used during a review include a list of “best practices” and “things to avoid” so there are standardized systems in place for the following. • • • •

Patient follow-up and consultation tracking. Test tracking. Reviewing/signing of incoming reports and correspondence. Patient notification of test results.

PQ Reviews also focus on medical records and documentation. An accurate clinical history and gathering appropriate patient information is crucial in the diagnostic process. The reviews provide guidance on what patient details to collect, how to include these in the record, and documentation standards that ensure others interpret information correctly. This includes the following areas. • • • •

Allergies and adverse drug reactions. Current problem list/medical history. Current medication list. Vital sign documentation in acute illness.

While diagnostic errors are an issue that the health care community was aware of, this report tackles the subject from a fresh, comprehensive perspective that adds clarity as to why they occur. It provides informative data, raises new questions and promotes discussions on how to improve patient safety. And for COPIC, it reminds us of the role we can play in offering resources and guidance that help medical professionals learn from past events and improve their future diagnoses. n A copy of the Improving Diagnosis in Health Care report can be downloaded at www.nap.edu/catalog/21794/improving-diagnosisin-health-care. Colorado Medicine for January/February 2016

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.

AUTOMOBILE PURCHASE/LEASE Rocky Mountain Fleet Associates 303-753-0440 or visit www.rmfainc.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit www.copicfsg.com * CMS Member Benefit Partner Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com Sharkey, Howes & Javer 303-639-5100 or visit www.shwj.com * CMS Member Benefit Partner 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 Colorado Drug Card 720-539-1424 or visit www.coloradodrugcard.com *CMS Member Benefit Partner CO-POWER 720-858-6179 or www.groupsourceinc.com *CMS Member Benefit Partner MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, www.medjet.com/cms *CMS Member Benefit Partner RXAssurance Visit www.rxassurance.com or www.opisafe.com Colorado Medicine for January/February 2016

University of Colorado Hospital/CeDAR 877-999-0538 or visit www.CeDARColorado.org PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit www.alnmm.com Carr Healthcare Realty 303-817-6654 or visit www.carrhr.com First Healthcare ComplianceTM 888-54-FIRST or visit www.1sthcc.com *CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit www.medteleco.com * CMS Member Benefit Partner The Health Law Firm 407-331-6620 or visit www.TheHealthLawFirm.com The Legacy Group at Re/MAX Professionals 720-440-9095 or visit www.legacygroupestates.com/physicians TransFirst 800-613-0148 or visit www.transfirstassociation.com/cms *CMS Member Benefit Partner Transcription Outsourcing 720-287-3710 or visit www.transcriptionoutsourcing.net Transworld Systems 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner 29

Inside CMS

Reflections Reflective writing is an important component 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 School of Medicine faculty members Steven Lowenstein, MD, MPH, and Henry Claman, MD.

Kristin Schmid University of Colorado School of Medicine

Kristin Schmid is a third-year medical student at University of Colorado School of Medicine. She is a Colorado native and graduated from the University of Denver in 2012 with a bachelor’s degree in biological sciences. Before medical school, Kristin worked as an EMT in San José, Costa Rica, and continues to participate in research in pre-hospital medicine in San José. She plans to specialize in emergency medicine and pursue her passions in EMS and global health.

The Game The trauma pager goes off; the ED fills with anticipation. Everyone assumes the position for the game we are about to play. **33-year-old male with multiple gunshot wounds to the chest and abdomen** Our team arrives at the ambulance bay. The paramedics are doing CPR. “He’s dead,” I think. “He’s dead,” the surgeon says. But we decide to engage in the game. The paramedics want to play, too; “CPR underway 5 minutes.” The players assemble. 40 30

The buzz of shared sinus tach is almost audible; Except for the dead guy. I wonder if no one is looking at his unseeing eyes. But maybe that’s part of the game. Someone cuts open the chest. Hands are shoved inside. “Are we still doing this?” I think. A nurse calls out “BP 80 over palp.” “I guess so,” I think. She’s made her move; Enough to prolong the game. In the OR, lungs and guts are pulled out of their homes. Lots of holes. Even the heart has one. But it’s still beating. Not in the usual fashion. “Are we done yet?” I think. “We’re done here,” the surgeon declares. The game is over. The dead guy is still dead. I’m entrusted to close the chest. “Gloves, gloves, gloves, what size gloves, what size, what size?” yells the scrub nurse. “Six-and-a-half.” I say. The heart is still fibrillating. Strangely ineffective, Yet unrelenting. Tenacious? I touch it. Not unlike a bag of worms. I feel I’m encroaching on some strange truth; The secret to our humanness. The interconnectivity. Colorado Medicine for July/August 2015 Colorado Medicine for January/February 2016

A heart that has done nothing but beat. A hallowed union of electricity and anatomy. A symbol of love for some. A sign of life for others. I wonder what twist of fate brought me to its last pulsations. I acknowledge my own. “Hurry up! And don’t waste suture,” barks the scrub nurse. She’s seen hearts before, probably. I’m woken from my reverie. I shouldn’t think these things, When dead chests are meant to be closed. Quickly, Objectively, With minimal suture, And a steady hand. I gently tuck in the vibrating heart with its lung blanket; He’ll sleep soon. “Yes ma’am,” I say. The coroner must be in a rush today; We have to prepare the field for the next game. I close the chest of the dead guy, With a 00 CT suture, And no further frivolities. The nurse bequeaths me with the unused sutures, To practice my knots. 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, call Tim at 720-858-6306 or e-mail tim_yanetta@cms.org

Colorado Medicine for January/February 2016

Departments

medical news CMS, component leaders gather for dialogue CMS announces call

for nominations for all-member elections CMS President Mike Volz, MD, officially opened the nomination period for the new Colorado Medical Society member-wide elections in an email blast on Dec. 21. Member-wide elections are an important part of The New CMS reform package. They are yet another step toward creating optimum balance between member involvement and board decisions and accountability.

CMS President Mike Volz, MD, and President-elect Katie Lozano, MD, co-hosted an informal dinner with component society leaders on Dec. 17 for the purpose of relationship-building and sharing information. From left to right: Steve Sherick, MD, Denver; Simon Oh, MD, Aurora-Adams; David Markenson, MD, Arapahoe-Douglas-Elbert; Kevin Fitzgerald, MD, Mesa County; J.T. Boyd, MD, Clear Creek Valley; Volz; Leto Quarles, MD, Boulder County; Cory Carroll, MD, Northern Colorado; and Lozano. n

All members now have the ability to: • Vote to elect the president-elect (1 position open), AMA delegates (1 position open in 2016) and alternate delegates (1 position open in 2016); • Run for these offices if they so choose and qualify; and, • Sponsor and endorse candidates of their choice. Access the election guide on CMS.org. It provides important information on the duties, eligibility, terms of office and honorarium for each open position, as well as candidate requirements, campaign guidelines, election process and more. Please note that the nomination period extends through Jan. 31, 2016. CMS looks forward to all members’ participation in this new process. All nominees should review the position descriptions and qualifications for office starting on page three of the election guide and the candidate requirements on page five of the guide. Please email CMS CEO Alfred Gilchrist at alfred_gilchrist@cms.org if you have additional questions or would like to submit a nomination for office. n

CMS .ORG ORG CMS CMS CMS.ORG ORG Colorado Medical Society 32

Colorado Medicine for January/February 2016

Departments

medical news Bill gives blanket approval for meaningful use exemptions Prior to adjourning for the holidays, Congress adopted legislation that will allow any physician who applies for a hardship exemption from the 2015 electronic health record (EHR) meaningful use program to be exempted from the penalties that would have been levied in 2017. This blanket exemption will alleviate burdensome administrative issues for both physicians and the agency. Addressing the regulatory problem The Patient Access and Medicare Protection Act (S. 2425) is intended to address the issues created by the delay of the Stage 2 modifications rule issued in October. The modifications rule revised meaningful use requirements to make them more realistic but did little to help

physicians because it was finalized so late in the year. Under the Stage 2 modifications, physicians could avoid a financial penalty if they attested to meeting the Stage 2 requirements for 90 consecutive days during 2015. But the modifications rule wasnâ&#x20AC;&#x2122;t published until Oct. 16, leaving fewer than the 90 minimum days left in the calendar year. The Centers for Medicare and Medicaid Services (federal CMS) previously stated that it would grant hardship exemptions for 2015 if eligible physicians were unable to attest as a result of the lateness of the rule. But the agency was legally only permitted to grant such exemptions on a case-by-case basis. That

meant that many physicians would have been required to apply for exemptions, and the federal CMS would have had to act on each application individually. Alleviating this burden The meaningful use provision in the new legislation, for which the American Medical Association was instrumental in securing support, will grant the federal CMS the authority to process requests for hardship exemptions to physicians through a streamlined process. Physicians will have until March 15 to apply for an exemption from the 2015 meaningful use program year. As of press time, the agency had not yet posted instructions on applying for the hardship exemption. n

Colorado Medicine for January/February 2016

Departments

HCPF calls for applications for Accountable Care Collaborative The Department of Health Care Policy and Financing (HCPF) has announced the opening of the second cohort of the Accountable Care Collaborative (ACC) Chronic Pain Disease Management Program and invites any interested primary care practice to apply. The program is modeled after New Mexico’s Project ECHO (Extension for Community Healthcare Outcomes). The first cohort engaged 84 providers from 42 practice sites from every region across the state. The Chronic Pain Management Program leverages cuttingedge telehealth technologies to connect providers to specialists. Providers consult directly with specialists regarding client cases and learn best practices for treating clients with a variety of chronic pain conditions. HCPF will sponsor approximately 40 practice sites to serve as telehealth pioneers for Colorado in 2016. To learn more and to sign up for the pain management program e-mail Ági Erickson at ericksa@chc1.com or call 860-347-6971 ext. 3741. Or go to www. colorado.gov/hcpf/provider-training and click on “Accountable Care Collaborative (ACC) Chronic Pain Disease Management Program” to learn more. n

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CMS member appointed to SIM advisory board Gov. John Hickenlooper appointed CMS member Cara Beatty, MD, of Boulder, to the State Innovation Model Advisory Board representing a health plan. Her term expires June 1, 2019. The SIM board provides advice, oversight and guidance over the operation of the Office of State Innovation Model and the management of grant funds. n Colorado Medicine for January/February 2016

Medical news (cont.)

Complete the CMS CME Needs Assessment Survey The Colorado Medical Society’s CME program requests all members complete the CME Needs Assessment Survey. The electronic survey takes less than five minutes to complete and all responses will be kept confidential. CMS’ CME program is committed to its primary goal of disseminating current and new information concerning public health concerns, practice management, health care systems transformation, patient communication and safety, and other needs as determined by health environmental changes. This survey aims to identify professional development needs of physicians and their practice teams and will allow us to focus our efforts toward those areas that will be most beneficial to physicians, practices and patients. Go to www.surveymonkey.com/r/ CMENeedsAssessment2016 to complete the survey. n

Support the Colorado Medical Society Foundation The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans.

Consider giving a taxdeductible donation of $25, $50, or more to help CMSF continue its mission. Questions? Call 720-858-6310. 36

classified advertising Publication of any advertisement in Colorado Medicine is not an endorsement by the Colorado Medical Society of the product or service. Colorado Medicine magazine is the official journal of the Colorado Medical Society and is authorized to carry general advertising.

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Features

the final word Gina Alkes, MD

Gina Martin, MD

The New CMS opens up new avenues for engagement 2016 represents a year of tremendous change at the Colorado Medical Society. You’re already well aware of the extensive governance reforms voted in by Colorado physicians at the annual meeting in September. This issue of Colorado Medicine outlines a few of the actions CMS leaders and staff have taken to jump start these changes. In many ways we, Gina Martin and Gina Alkes, represent The New CMS. We’re both physicians of a younger generation who are new to practice (“early career,” you might say), having completed our family medicine residencies in Grand Junction in 2014 and 2015, respectively. We are passionate and motivated to help our patients navigate the health care system and live healthier lives, and we both followed our hearts to work where we’re most needed, in rural Colorado. But our story begins before residency; we met at a meeting of the American Medical Association. Gina Martin was the lone student representing the Oregon Medical Association and Gina Alkes was part of the large Colorado medical student delegation. We fortuitously sat next to each other at the student social that first night; we were kindred spirits and best friends from the beginning. We went to Lynn Parry’s famous wine and cheese party and Gina Martin was wholly embraced by the Colorado physician and medical student delegation. She was amazed at their overwhelming support of medical students’ involvement at the state and national level. Even then we saw CMS as an 38

inviting, progressive, engaged society that would support us in our desire to be involved in the political arena and learn more about health care policy. For both of us the choice to pursue a residency in Colorado was solidified that evening. We wanted to be involved and stay involved, together, in the Colorado Medical Society. By design we matched at St. Mary’s Family Medicine Residency Program and immediately connected with our local component, the Mesa County Medical Society. This allowed us to become involved in another progressive medical community and we were actively involved as executive board members throughout our residencies. Gina Martin served as president during her third year. Now as full-scope rural family physicians we recognize even more so the importance of being a part of the Colorado Medical Society. The constant change of health care reform does not make it easy to do our jobs. Complaints about the drags of the system are common; however we still don’t see the participation in organized medicine in the numbers that were common in the days of our predecessors. We need more physicians to be engaged in affecting change within the health care system. Physicians are extremely powerful when dedicated and motivated but in the current state have given the impression of being passive by not becoming more directly involved in the policy-making process. Through the recent CMS governance reform we

all have an opportunity to help shape the new system that’s coming into play because the vote is now at the individual level. Additionally, The New CMS provides new and novel ways to become more active in policy from the ground up: from the public policy course that is being designed to the virtual policy forum and Medical Society Management Series, there are so many exciting ways to become involved. As doctors our No. 1 priority is our patients, but we need to make sure that they’re protected as new regulations come through and that we, as physicians, are protecting our profession and livelihood. The hardest thing for physicians right now is the pull in every direction to do more and be more involved. Our workload goes up and up as we see more patients and deal with administration, insurance contracts, the business of medicine, etc. On top of that, local, state and national organizations that we care about need volunteers, too. We urge you to find your limits and make sure your valuable time isn’t stretched too thin, but at the same time please push to find small ways to be involved so that we can unify as a group of physicians, make our voices heard and take back the power of what we want to do as physicians – take care of individuals and make our community a healthier place. We are committed to help shape the changes that are happening in the health care system for the better. The New CMS will get the grassroots engaged to help us accomplish this; we invite you to be a part of the process. n

Colorado Medicine for January/February 2016

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