July/August 2017 Colorado Medicine by Colorado Medical Society

July/August 2017

Volume 114, Number 4

PROGRESS NOTES: MANAGED CARE REFORMS OF THE 2017 GENERAL ASSEMBLY

Award-winning publication of the Colorado Medical Society

contents July/August 2017, Volume 114, Number 4

Cover story Bipartisanship

and transparency prevailed in the 2017 General Assembly. At the directive of our members and physician leadership, and with the help of legislative champions from both sides of the aisle, the Colorado Medical Society pursued an aggressive platform of managed care reforms and made advancements that will reduce administrative burden, increase transparency in interactions with health plans, and clarify patients’ and providers’ rights. Read more starting on page 8.

Inside CMS

5 President’s Letter 7 Executive Office Update 34 2017 CMS elections/candidate statements 48 2017 Annual Meeting agenda/registration 53 COPIC Comment 54 Reflections 56 Introspections

Features. . . 15

Legislative report–In addition to the extensive managed

Legislative celebration– CMS presented awards to the

Increasing oversight–A bill passed during the 2017

Federal health care reform– CMS leaders met with

AMA Annual Meeting–A delegation of physician leaders,

AMA student engagement–Ten Colorado medical

Addressing antibiotic resistance–A Telligen initiative,

care platform, CMS deployed a series of defensive and offensive maneuvers to protect physicians and patients. legislative champions who worked to advance the society’s health care reform agenda. General Assembly will increase oversight of non-domestic insurance industry mergers. Colorado U.S. Sen. Cory Gardner to urge thoughtfulness in the Senate health reform bill. component staff and CMS staff traveled to Chicago for the AMA Annual Meeting. students attended the AMA Annual Meeting to address health policy and identify top priorities. enrolling Colorado outpatient clinicians through July 31, aims to reduce antibiotic resistance.

30 Maintaining oral health– CMS has partnered with Delta

Dental to encourage patients to care for their oral health in recognition of the link to overall wellness.

Protect patients first– CMS joined the AMA and other

Final Word–Senate Majority Leader Chris Holbert talks

national organizations to urge Congress to protect patients in federal health care reform. about his experience with network adequacy and the motivation to pass Senate Bill 17-088.

Departments 58 60 61

Medical News Letter to the Editor Classified Advertising

Colorado Medicine for July/August 2017

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 STAFF

2017 Officers Katie Lozano, MD, FACR President M. Robert Yakely, MD President-elect Michael Volz, MD

Treasurer

Alfred D. Gilchrist Chief Executive Officer

Board of Directors Kiara Blough, MS Cory Carroll, MD Curtis Hagedorn, MD Mark B. Johnson, MD Richard Lamb, MD David Markenson, MD Gina Martin, MD Patrick Pevoto, MD, RPh, MBA Brandi Ring, MD Charlie Tharp, MD Kim Warner, MD C. Rocky White, MD Kelley D Wear, 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

Michael Volz, MD Immediate Past 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 Fetter, Director, Professional Services, Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org

Division of Health Care Financing Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Program Manager Adrienne_Abatemarco@cms.org

Division of Health Care Policy Chet Seward, Senior Director, Chet_Seward@cms.org JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

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

Colorado Medical Society Foundation Colorado Medical Society Education Foundation 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, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance. COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified. Alfred D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor. Printed by Hampden Press, Aurora, Colo.

Inside CMS

president’s letter Katie Lozano, MD, FACR President, Colorado Medical Society

How we talk and think about our patients We’ve had a tremendously successful year at the state legislature engaging on behalf of our members. We continue to advocate for our members and our patients with our representatives and senators in Washington, D.C., and on critical issues such as the opioid crisis and federal health care reform. You’ll hear more about these topics in this and other issues of Colorado Medicine, Central Line email or text updates, and CMS ASAP e-newsletters. While our health care system is in a state of flux, it’s important to remind ourselves why we do what we do. Our personal experiences as patients, volunteers and with family members often play a role in realizing our calling to practice medicine, and can shape how we fulfill that calling. A nurse entered a patient’s room at a children’s hospital in the Midwest in 1980 and asked, “Where is my little diabetic?” A 7-year-old girl paused, halfway hidden behind the bathroom door, anticipating another injection and wrapping her mind around her new identity – “I am her little diabetic?” Her mother, a petite soft-spoken woman who had shown amazing resilience and strength as she dealt with her daughter’s new diagnosis of insulin dependent diabetes mellitus, promptly rose from her chair to respond to the nurse. In contrast to her usual cheer, genuine but carefully shown almost all the time for her daughter’s benefit, the girl’s mother turned into a stern teacher disciplining a wayward student, grasping the nurse’s wrist and saying in clipped, firm words and with rare fire in her eyes: “She is NOT your Colorado Medicine for July/August 2017

little diabetic. Her name is Katie and she is my daughter. You call her by her name.” All six words in the last sentence were said so emphatically that the nurse dared not cross her again. This was a formative experience for me in many ways. Sometimes mothers are far better teachers than tenured professors, department chairs, administrators or even ethicists. And the lessons they teach us can have much more influence on how we care for and think about patients. A patient is not an illness or a condition. Patients almost always have conditions of some type, either an illness or a health classification. They can suffer from those illnesses or conditions, endure them, overcome them, and even die from them. Patients may feel that they do not have the time or energy to do anything but fight a particular condition, and may think their entire identity is wrapped up in that single disease. Physicians should never reinforce that feeling. However, I see this commonly in medical practice; we routinely characterize someone as an “-ic” of his or her disease. Regardless of our background, training and experiences, and regardless of what we did or did not learn from our mothers, our primary duty is to act in the best interest of our patients. The daily grind of work should not make it acceptable for us to characterize people as a “vasculopath,” “COPD’er,” “schizophrenic,” or “the syncopal episode in 3.” All physicians and allied health professionals – from neurosurgeons, pe-

diatricians, radiologists and physician assistants to advanced practice nurses, registered nurses, nursing aides, dieticians, speech pathologists, ward clerks, hospital and clinic administrators and staff – all of us have a duty to treat patients with respect, as real people rather than just holders or demonstrators of disease states. We’ve often heard that we have a “disease care system” rather than a “health care system.” Referring to patients as demonstrators of disease states reinforces this disease-focused, rather than health-focused, system. My issues with how we classify, characterize and address our patients may seem trivial in the big picture of health reform, but when it comes down to it, all of us will find ourselves at some point as a patient rather than a physician, or at the very least as a family member of a patient. It is humbling to walk through the door of the hospital one day as a confident physician, and the next walk through the same door as an uncomfortable, insecure, scared patient or family member of a patient. I hope we are all lucky enough in these situations to have a physician and caregivers who see and talk about us as people, rather than body parts or disease categories. Our top motivator to pursue medicine was and is to help people. It’s easy to revert to defining a patient by a disease, but to nurture the patient-physician relationship and grow personally and professionally, regardless of our specialty, we have a duty to think of our patients as people rather than disease states. n

Health Policy 101 – – – – –

Managed Care Reform Liability Reform Network Adequacy Scope of Practice Protecting Peer Review

No one can dispute that politics determines our health care policies. If we want our voices heard, we must be involved in who gets elected. Those incumbents and candidates who support our agenda – the ability to provide quality, affordable care to our patients AND keep our business doors open – have to go through the rigorous and expensive process of getting elected and re-elected. They need and deserve our support. Until a better process is invented, it costs money to win and stay in office. COMPAC is the nonpartisan political action committee for the Colorado Medical Society, responsible for approving candidates and campaign donations, coordinating election strategy, and other aspects important to the political strategy of CMS. The CMS Small Donor Committee works to elect candidates who support medicine’s efforts to preserve Colorado’s stable tort environment. Joining the CMS Small Donor Committee is an ideal way to contribute to ONLY those candidates who will protect Colorado’s med mal caps and help us enact comprehensive liability reform.

JOIN TODAY! www.cms.org/contribute Your membership in COMPAC and contribution to the CMS Small Donor Committee will allow medicine to continue to support our champions so we can continue to move forward on medicine’s issues. And you decide your contribution level based on your budget. Please join or renew your contribution to COMPAC and the SDC now so that we can continue to make positive gains for Colorado physicians and patients in the political arena. Voluntary political contributions by individuals to COMPAC/AMPAC should be written on personal checks. Funds from corporations will be used for political education activities and/or state election activities where allowed. Contributions are not limited to suggested amounts. $100 of the suggested contribution amount is transmitted to AMPAC for physicians and $10 for a student or resident. Neither the AMA nor its constituent state associations will favor or disadvantage anyone based on the amounts of or failure to make PAC contributions. Voluntary political contributions are subject to limitations of FEC regulations. COMPAC is a segregated fund established by the Colorado Medical Society. Contributions to COMPAC/AMPAC are not deductible for federal tax purposes. There is a $575.00 limit on COMPAC donations in any two-year election cycle. Call CMS at 720-858-6322 should you have any questions.

Colorado Medicine for July/August 2017

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Managed care reforms of the 2017 General Assembly: Turtles on a fence post The panel of legislative managed care operational fixes covered in detail in this issue of Colorado Medicine, to borrow a barnyard mixed metaphor, are turtles on fence posts: They didn’t climb up there by themselves. They are the result of two years of the blocking-and-tackling fundamentals of grassroots engagement, in-depth policy development, message development and political involvement to ensure on-the-ground support from the bill sponsors and their colleagues on both sides of the aisle. This is what is required to move a complex legislative package in an adversarial process to the governor’s desk.

times, our commitment to political engagement on your behalf has a more visible ROI, an investment that can be measured both in terms of managed care reforms (laws enacted) and the opportunity costs – bad things that could have happened but for our advocacy and the strong alignment of legislators with our views. (Exhibit A: Blocking a push by the plaintiff attorneys to find some means of raising the damage cap or otherwise enhancing the economic return on their investment in a malpractice suit, which will no doubt soon return with the full force of the trial bar’s formidable political muscle.)

Our board of directors, drawing from extensive surveys of CMS members measuring their managed care “pain points,” listening sessions between physicians and practice managers and the Department of Insurance, and the insights drawn from our vigorous opposition to the health plan mega-mergers, set a goal of achieving enhanced patient and provider protections matched to member concerns. Over the two-year period, we worked through the range of time-honored tactics to give us the best possible chance at success, i.e., a failed mediation with Colorado Association of Health Plans, the ongoing work of a multispecialty policy development working group to filter and assess the evolving policy options prior to and during the session, and – just as critical during the 2016 election cycle – a methodical local medical society engagement on behalf of candidates and incumbents generally supportive of our policy choices.

You need not have a single political chromosome in your DNA to see the consequence of politics on health care policy. But, even as we survey our members to assess the possible real-world, exam-room and community-centric consequences of what Congress is considering, our politically and policy-engaged physicians are looking at changes that could profoundly alter the means of federal support of Medicaid, health insurance purchased on the exchange, and a complex shift of funding and operational issues.

Sometimes, and this is one of those Colorado Medicine for July/August 2017

Most physicians are understandably cynical about health care politics. So let us and your more politically inclined colleagues manage that investment. If you lack the appetite or interest in political engagement, join us vicariously by investing in COMPAC, the CMS political action committee. In the 2016 election cycle, COMPAC backed a diverse range of legislators on both sides of the partisan aisle who will now be

challenged by our many adversaries in the 2018 election cycle. At a minimum, these legislators deserve and must be able to count on our unwavering loyalty and support next year. Our adversaries have the guns, the deep pockets; we will always be outspent – but we have the numbers. (Anyone recall the late-60s Doors classic?) We are organized, engaged and we will not be outworked. The medical community, especially in the districts where you live and work, has a locally relevant street credibility when we back a candidate or an incumbent that others don’t. The visible support of the medical community outweighs the sheer weight of the contributions, directly and more so indirectly of those who would oppose us. It is an honor and a privilege to be a medical society advocate, especially during this volatile transition. Thank you for participating in Central Line and for completing our member surveys. Participation in these activities is vital to advancing sound, sustainable health care policy in the tumultuous parallel universe of politics. Now is the time, post-adjournment of the 2017 General Assembly and pre-election cycle, to recharge and recommit. Please consider joining me and “maxout” your support of COMPAC, though any level of contribution will be appreciated and used wisely – which is to say shrewdly – on medicine’s behalf. (See the opposite page for how to join us.) Thank you for your consideration and all that you do for patients. n 7

Kate Alfano, CMS Communications Coordinator

Cover Story In 2015, the Colorado Medical Society and elected leaders from several specialty societies notified health plans and the Division of Insurance (DOI) that if acceptable progress wasn’t forthcoming on mounting problems with narrow networks, CMS would take our case to the Colorado General Assembly. Throughout 2016, CMS urged the Colorado Association of Health Plans to resume discussions on this and other issues after a failed 2015 mediation, and participated in the DOI network adequacy stakeholder process. Going into the 2017 Colorado General Assembly, the CMS Board of Directors recognized that progress had fallen short and they authorized the CMS Council on Legislation (COL) to seek legislation to address the policy gaps. “We knew there was a clear directive from our members to reduce frustrating encounters with health plans that deteriorate the practice environment and place unnecessary hurdles on patients; the only question was whether the General Assembly would respond,” said Mike Volz, MD, CMS immediate past president. While health plans are backed by an army of lobbyists and the financial resources to spot-hire additional help on demand, CMS deployed three all-member surveys conducted in 2015 and 2016 and the insights drawn from our opposition to the health plan mega-mergers to illustrate the urgency of action. Health plans had too much power over physicians, and care access and quality were being negatively affected as a result. Physicians were forced to accept takeit-or-leave-it contracts and were increasingly deselected from networks without a clear explanation or appeal rights. Physicians and practice staff faced difficult prior authorization and payment requirements. And a scant regulatory enforcement was biased in favor of the plans. Now, Volz and other CMS directors have their answer. The 2017 General Assembly responded by passing a package of managed care reforms recommended by a coalition comprising CMS, component and specialty medical sociColorado Medicine for July/August 2017

eties, and the Colorado Medical Group Management Association (CMGMA). “This was a historic session for the medical society,” said Michael Beasley, a highly regarded legislative advocate and president of 5280 Strategies. “In organizing the various medical professions, their leadership was instrumental in passing legislation that had been talked about for many years, and driving the movement to stand up to the abuses of providers and patients by the insurance companies to achieve these reforms.” “Just as important,” he said, “it sent a message to the Division of Insurance that consumer problems can be identified through the concerns expressed by physicians, so I think this is just the beginning of many more reforms we’ll see in the next legislative session or two.” “We are thrilled with the outcomes,” said CMS President Katie Lozano, MD, FACR. “The decision to go to the General Assembly was made two months after I was sworn into office. Naturally I was concerned that our case might not be well received, but it was just the opposite, with bipartisan bill sponsors and overwhelming bipartisan support for all of the reforms. At least in Colorado, the legislative process is working.” “This was a team effort from start to finish,” said Susan Koontz, JD, CMS senior director of government relations and general counsel. “The medical-CMGMA partnership was incredible throughout the journey. Whether participating in our joint policy development process, interviewing candidates in the 2016 election, or advocating locally or at the state capitol, there was this feeling that we were all together and our cause was just. We all understood from physician listening sessions and the survey data that a lot was at stake.” “While there is still work to be done, the ship is turning,” said Lee Morgan, MD, COL chair and past CMS president. “It was a banner session advocating for Colorado physicians and patients, achieving reforms that will surely reduce hassles for physicians and increase transparency in the interactions between plans and practices. These

victories would not have been possible without the legislative champions who took the time to understand these complex issues and work toward solutions.” A longtime participant with the Colorado Medical Society Political Action Committee (COMPAC), Morgan said, “We’ll need to work hard in the 2018 election cycle to support our champions and make new friends.”

“In organizing the various medical professions, [CMS] was instrumental in passing legislation that had been talked about for many years, and driving the movement to stand up to the abuses of providers and patients by the insurance companies to achieve these reforms.” - Michael Beasley, president, 5280 Strategies Keep reading for the checklist of achievements in the 2017 Colorado General Assembly. ACHIEVED: Transparent selection/de-selection standards and appeal right Effective Jan. 1, 2018 “CMS supports the transparency and clarity of information available to consumers and providers about the selection criteria health plans used to build or tier their networks, and CMS felt that network adequacy regulations issued in 2016 by the DOI did not go far enough to ensure this transparency for consumers or providers,” said John Conklin of Conklin, Cardone and Rutberg, PC. As a result, the General Assembly re-

Cover story (cont.) sponded favorably to recommendations of a CMS-led multispecialty Working Group on Managed Care Reform that addressed the transparency of selection criteria and assured that physicians who were going to be de-selected would have the ability to request a reconsideration before it became effective. SB17-088 requires health plans to communicate selection and tiering standards to participating providers, and to make a description of its standards available to the public. Additionally, health plans cannot terminate or place a participating provider in a more costly tier without providing written notice 60 days in advance with an explanation in sufficient detail to enable the participating provider to challenge the decision. The bill also allows participating providers to request and receive, on a quarterly basis, a list of all network plans and products the health plan offers showing the physician’s participation status for each one. “The Colorado Medical Society set a great example of effective advocacy by getting doctors involved and in touch with state legislators in order to pass Senate Bill 17-088,” said Senate Senate Majority Majority Leader Leader Chris Holbert Chris Holbert, RDouglas County, co-prime bill sponsor. “Well done, CMS!” Sen. Angela Williams, DDenver, said, “I wanted to join the majority leader as the co-prime sponsor of this bill because I am worried about the impact that narrowing netSen. Angela Williams works will have 10

on my constituents – many of whom have had the same doctor treating their family for generations. Losing your doctor is a serious matter!” CMS President-elect M. Robert Yakely, MD, in his testimony in favor of the bill, acknowledged the inescapabilty of narrow networks in today’s health insurance market and explained that the bill allows for reforms to “help our members prepare for narrow networks so that they can qualify to be in-network and care for their patients. … Simply stated, our members cannot prepare if they don’t know the rules of the game.” ACHIEVED: Common-sense clarifications for telehealth Effective immediately In 2015, CMS, with component and specialty medical societies, supported legislation to ensure parity for payment of health care services whether they were provided in-person or via telehealth. That legislation recognized that the physician is the appropriate person to make the determination of when and how telehealth is used. “What was unanticipated in the 2015 bill, however, was that payers would dictate how the care was delivered by restricting payment to telehealth visits provided only through their contracted third-party telehealth vendor,” said Christina Finlayson, MD, professor of surgery, associate medical director and associate dean of clinical affairs at the University of Colorado School of Medicine. The impact of this loophole meant that providers were being forced to work with third-party vendors whose technology may not interface with their electronic medical records, leading to incomplete records and discontinuity of care; a patient of a provider not contracted with the vendor could access telehealth but had to use a provider with whom they may not have had an established relationship; and because payers may contract with various third-party vendors, providers would also have to interface with multiple vendors, complicating operations. The successful passage of HB 17-1094

this year ensures that the determination of when and how to use telehealth falls to the physician rendering the care – not the payer. Health plans are prohibited from requiring physicians to use a specific vendor for telehealth services as a criterion for reimbursement. “It is time we made available and mesh technology with available health care coverage,” said Sen. Larry Crowder, R-Alamosa, Senate co-prime sponsor. “1094 brings Sen. Larry Crowder these vital issues together for the benefit of the patient and opens up future technological advances that does everything to benefit both providers and patients, and reduces health care costs.” “The best way to improve health is to improve access, and this law will increase access to medical professionals,” said Sen. Kerry Donovan, Sen. Kerry Donovan D-Vail, Senate co-prime sponsor. “Particularly in my rural district, it can be difficult to get an appointment or take off time from work to accommodate the travel time. Telehealth is an important tool to address both of these issues, and clarifying that telehealth should be covered by your insurance means more people and more health care professionals can take advantage of the telehealth options. This is good for patients and for professionals.” “I’m very passionate about this bill that will help covered individuals Rep. Donald Valdez in rural Colorado Colorado Medicine for July/August 2017

Cover Story from having to travel distances for inperson care with the use of a computer or laptop,” said Rep. Donald Valdez, DPueblo, co-prime House sponsor. “It is always a goal for a legislator to carry a piece of legislation that can benefit everyone in their state,” said Rep. Perry Buck, R-Windsor, co-prime House sponsor. Rep. Perry Buck “For the state of Colorado, that bill was telehealth. This bill came from doctors who work tirelessly in the field of medicine to help individuals live a better life. I was honored and proud to carry such a significant piece of legislation.” “HB17-1094 allows providers to develop the telehealth platform that works best for their practice and their patients and requires payers to acknowledge and compensate for this work,” Finlayson said. “This puts the provision of patient health services back in the hands of the patient’s provider, who will know best how to use this technology as an important tool in improving their health.” ACHIEVED: Protections for physicians from health plan retaliation Effective July 1, 2017 During the Department of Justice’s investigation into the now-failed merger of Anthem and Cigna, physicians feared retaliation from the health plans if they testified in any hearing. “Legislators agreed that the fear of having a contract terminated can have a chilling effect on a physician’s desire to participate in public policy discussions with legislators or regulators,” Conklin said. HB17-1173, sponsored by Rep. Chris Hansen and Sen. Tim Neville, requires health plans to include a provision in their contracts with participating providers stating that the plan will not take adverse action against the provider for communication with a public official. Colorado Medicine for July/August 2017

“HB17-1173 was a commonsense step in providing protection from retribution for those in the medical field who care about Sen. Tim Neville both patient care and transparency so they can freely voice pertinent concerns,” Neville said. “When a health care provider disagrees with a carrier’s decision they should be able to do so freely, without fear of punitive Rep. Chris Hansen action,” Hansen said. “This bill increases protections for doctors and nurses who advocate for improvements in the health care system and I was honored to see it earn broad bipartisan support in both chambers as well as the governor’s signature.”

ers, in order to have a balanced discussion with p o l i c y m a ke r s and regulators of insurance,” said Alan Kimura, MD, MPH, an ophthalmologist in Denver. “PhysiAlan Kimura, cians cannot fulMD, MPH fill our vital role in the health care ecosystem if we are not free to advocate for patients and our practices – indeed, no improvements are possible if key stakeholders are silenced by the threat of retaliation.” Kimura continued, “The battle to oppose the further concentration of insurer power was hopefully a watershed, beginning to change the power relationship between the mega-insurers and physicians. Thank you and congratulations to the Colorado Medical Society and its lobbying team for garnering bipartisan support of this important protection.”

“Physicians need to speak freely and without fear of retaliation from insur-

Join COMPAC and keep our momentum going COMPAC is the nonpartisan political action committee of the Colorado Medical Society made up of physicians and medical students. Our goal is to support and elect pro-physician, pro-patient candidates on the state level, regardless of party affiliation. On the federal level, COMPAC works in conjunction with AMPAC, the American Medical Association’s Political Action Committee, to represent the interests of physicians and their patients before Congress.

criteria. This process ensures that COMPAC receives input from the physicians who live and work in the candidate’s district.

The COMPAC Candidate Screening Committees comprise local physicians and medical students who interview candidates running for state office. These physicians then recommend a candidate for endorsement by COMPAC using pro-medicine

We need your help to continue our tremendous advocacy on behalf of Colorado physicians and patients. Join COMPAC today at www.cms. org/contribute. And read more about why to join COMPAC in the executive office update on page 7.

Cover story (cont.) ACHIEVED: Transparency and independent investigations in health plan mergers Effective immediately Previously, mergers involving Colorado non-domestic health plans did not require public disclosure of the competitive market analysis or require the DOI commissioner to seek public input. CMS supported SB17-198 to require the commissioner to notify the public of a proposed merger involving a Colorado non-domestic health plan and whether there appears to be a violation of the competitive standard. Additionally, the bill requires the commissioner to seek public input on the impact of the merger. The Colorado DOI had approved the Aetna-Humana merger through inaction and without public notice or hearing despite CMS and consumer groups seeking input. During committee consideration, senators defeated a proposed amendment supported by Anthem that would have weakened the current transparency

requirements for Colorado domestic health plans, said Alfred Gilchrist, CMS CEO. “They had put millions of dollars into the merger and it was on life support. The company was not going to allow the effort to go down without a fight.” At the time the amendment was being run, Anthem was making an effort to persuade a federal appeals court to overturn the trial court decision blocking its merger with Cigna. “The amendment clearly anticipated shielding vital information needed by the public to assess the impact of the merger in Colorado during any DOI investigation,” said David Balto, JD, former policy director of the Federal Trade Commission. Had Anthem prevailed in the appeals court, the DOI would likely have been required to hold hearings, conduct a special investigation, and make a decision on the merger based on Colorado law. Members of the Senate Committee on Business, Labor and Technology, led by Sen. Jack Tate, R-Centennial, however, were not persuaded.

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“With this bill, we closed the policy gap that allowed the DOI to silently approve the merger of Aetna and Humana without any notification to CMS or the public in general,” Balto said. “In the current climate of major health care change and reform, I believe it is important to increase transparency in insurance mergers to ensure that consumers and Sen. Kevin Priola patients are served first and foremost,” said Sen. Kevin Priola, R-Adams County, Senate sponsor. “I was proud to sponsor this bill because it created transparency in a marketplace that has a direct impact on patients and consumers,” said Rep. Alec Garnett, DDenver, House Rep. Alec Garnett sponsor. “The Colorado Medical Society was key to getting this bill to the governor’s desk.” ACHIEVED: Study of providersubmitted complaints to DOI Effective June 20, 2017 Having providers, in addition to patients, be allowed to submit complaints about health plans to the Colorado insurance commissioner was raised in a physician-practice manager listening session hosted by CMS in early 2016. Insurance Commissioner Marguerite Salazar was deeply moved by physician-patient care stories and proactively indicated she would consider the idea of provider complaints. A DOI Physician Advisory Group she subsequently appointed further engaged the DOI on the idea. As the 2017 session was getting underway, the ambulatory surgical society

Colorado Medicine for July/August 2017

Cover story (cont.)

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asked for support of their bill mandating that the DOI accept provider complaints, and the CMS-componentspecialty society coalition signed on in support of SB17-133, by Sen. Jack Tate, R-Centennial, and Rep. Dave Young, D-Greeley. Understanding these dynamics, Joe Neguse, a Hickenlooper cabinet member and DORA executive director, stepped in and supported the idea of a provider complaint pilot project. Shortly thereafter, DOI agreed to the parameters of the pilot. Because it closely mirrored his proposal, Sen. Tate postponed SB17-133 indefinitely.

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Sen. Jack Tate

“Medical providers are small businesses and do not need to be subjected to the unfairness of providing u n re a s on a ble trade credit to large insurance carriers,” Tate said. “Providers

have patients to serve and bills to pay as well. I will be following the pilot project that resulted from my introduced legislation to make sure that the state addresses provider complaints and holds insurance companies accountable for bad commercial behavior.” Tate has indicated he is open to introducing new legislation next session if it is needed. “Providers, particularly practice owners, have unique insight into managed care and can shed light on patient abuses,” Young said. “Imp or t a nt ly, the hassles phyRep. Dave Young sicians experience can be a first indicator of barriers to care and by the DOI hearing these complaints, we can address them early. I look forward to the findings of the pilot.”n

Issue spotlight: Out-of-network (OON) and surprise bills CMS has been working on out-ofnetwork issues and surprise bills for three years. In this legislative session CMS went on offense and introduced a bill, SB17- 206, by Sen. Bob Gardner, R-El Paso County, and Rep. Jonathan Singer, D-Longmont, to provide a solution to the problem that protects the patients and provides the out-of-network physician with a reasonable payment. The solution was based on a recommendation from the CMS multi-specialty Working Group on Managed Care Reform. The bill sponsor, following discussions with health plans and consumers, assessed that the legislation, akin to the previous two sessions, was in need of additional stakeholder dialogue. The major point of contention centered on the use of

billed charges as a benchmark for out-of-network payments. Given the high profile nature of the OON issue and the inability of most legislative bodies to find a solution, CMS and specialty society advocates asked the bill sponsor to postpone the bill rather than risk having the bill amended to set Medicare payment rates as the benchmark.

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Colorado Medicine for July/August 2017

Features

Legislative report Kate Alfano, CMS Communications Coordinator

Colorado physicians achieve outstanding victories in 2017 General Assembly In every session there are issues that arise outside of CMS’ platform that require strategic maneuvering. Continuing our report on achievements in the 2017 Colorado General Assembly from the cover story on page 8 are the issues below. They also required attention and action to educate lawmakers on how bills would help or hurt physicians and patients. CMS recognizes the many physicians who testified in support or opposition to bills and responded to COMPAC “Code Blue” alerts.

House amendments to the registration of n at u ro p at h ic doctors because patients place a lot of trust in professionals whose title includes the word ‘doctor.’ And Sen. Irene Aguilar, MD they see state registration as a sign that the authenticity of the practitioner is verified.”

BLOCKED: NDs scope of practice expansion One defensive maneuver came as a result of a House amendment to SB17106, the bill to extend the regulation of naturopathic doctors (NDs). The legislation was the result of the state’s required sunset review process that mandates periodic study of all state agencies. However, an advocacy group for NDs attempted to use SB17-106 as a vehicle to inappropriately and dangerously expand their scope of practice by giving NDs the prescriptive authority to obtain, administer, dispense, prescribe and treat with intravenous minerals, amino acids and hormones with a collaborative agreement with a physician or APN. Physician advocates responded in force by urging their legislators to strike the amendment. Ultimately, CMS was successful.

BLOCKED: Removal of limits on non-economic damages cap CMS opposed a bill that would have removed all limits for any wrongful death action involving anyone under age 21 against a physician or health care defendant. HB17-1254 would have produced a series of cascading side effects that would have inevitably compromised young patients’ timely access to care, perversely in circumstances where their health is in greatest jeopardy and they require the most skilled kinds of medical care. Physicians would have faced a flood of new litigation; a spike in professional liability premiums; a compression of available settings for general pediatric and highrisk care, especially in rural and underserved regions; and a further compromised recruitment of specialists to those settings and regions.

“There is no scientific evidence of a benefit from infusion of minerals and amino acids. Inappropriately administered hormones can be dangerous,” said Sen. Irene Aguilar, MD, D-Denver. “I thought it was important to block the Colorado Medicine for July/August 2017

“Starting as a medical student I learned from my mentors that you don’t have to do anything wrong to get sued, and you don’t have to do anything wrong to lose that lawsuit,” said CMS Presi-

dent Katie Lozano, MD, FACR, in her testimony against the bill. “This is a sobering realization but one that you have to learn to live with as you provide care for your patients. Uncapping liability for non-economic damages, however, will cause predictable new responses by physicians, which will not benefit the people of this state.” She explained: “New physicians will avoid specialties or settings where they provide care to a very sick child, adolescent or young adult. Physicians will increase the number of diagnostic tests to document their professional decisions and judgment, also known as defensive medicine, which would increase the use of imaging in pediatric care and expose Colorado children to more radiation. And the need to protect and establish medical decisions will force highly trained pediatric subspecialists and emergency physicians to order more tests that they would not currently need to back up diagnoses.” “The death of a child is a terrible, terrible thing,” Lozano said. “No amount of money can possibly replace that unthinkable loss. And that is the point. A lawsuit without limits does not make those who are suffering whole and will demonstrably compromise the availability and cost of pediatric and obstetric care for the people of Colorado.” ACHIEVED: Medicaid pay increase for most providers Entering the 2017 session, it was common knowledge under the golden dome that a $500 million budget gap – the

Legislative report (cont.) difference between required expenditures and available revenues – would constrain legislative asks. However, the CMS coalition persisted in support of a pay increase for physicians who care for Medicaid patients and achieved a 1.4 percent provider rate increase for most physicians. A few services, including primary care evaluation and management codes that received an increase in 2016, were excluded from the 2017 increase. “Starting in August, we were meeting with members of the Legislative Joint Budget Committee to emphasize the importance of community provider rates,” said Ed Bowditch of Bowditch and Cassell Public Affairs, retained by CMS. “Our work continued through the fall and winter, and we worked with our medical lobby colleagues to keep this important issue on the radar of the budget committee members. Our efforts will continue starting in July as the executive branch starts formulating its FY 2018-19 budget request.”

Your

ACHIEVED: Prohibition of “step therapy” for certain patients Many health plans have formularies that require a patient to use the lowest-tier medication before the plan will consider another medication with the same indications. While this may be appropriate in some cases, there are many patients with chronic conditions who have been treated for these conditions under coverage by a different plan and have already tried and failed on several medications. SB17-203 – by Sen. Nancy Todd, D-Aurora; Rep. Chris Kennedy, D-Lakewood; and Rep. Phil Covarrubias, R-Brighton – allows patients to remain on an effective medication they are currently using instead of reverting to an ineffective medication because of lack of coverage. “Requiring step therapy when a patient already has tried and failed the required medication can be unsafe – particularly in conditions that I treat as a neurologist, such as epilepsy, where

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changes in a successful medication regimen may result in increased seizure activity, status epileptics and even death,” said Lynn Parry, MD, CMS past president. “Requiring step therapy in this group of patients is neither costeffective nor safe.” ACHIEVED: Interim study on the opioid epidemic in Colorado Rep. Brittany Pettersen, D-Lakewood, who has a personal connection to the opioid epidemic in Colorado, requested that an interim study be formed to study prevention, intervention, harm reduction, treatment and recovery support strategies for opioid and other substance use disorders in Colorado. The taskforce is expected to produce as many as six bills for consideration in the 2018 legislative session. CMS member Don Stader, MD, an emergency physician with Swedish Medical Center and nationally recognized expert on the opioid epidemic, will represent physicians on the special taskforce that will advise the legislative study. “As part of the interim taskforce on opioid and substance use disorders, I hope to bring a strong physician perspective and evidence-based ideas on how Don Stader, MD Colorado can address our state’s opioid epidemic,” Stader said. “I hope to champion funding for a more accessible and userfriendly Prescription Drug Monitoring Database [PDMP], advocate for improved substance abuse treatment resources, and push for legislative changes that de-stigmatize addiction and advance harm reduction initiatives for our IVD-using patient population.” Colorado is fortunate to be ahead of other states in the fight against the opioid epidemic. The CMS board of

Colorado Medicine for July/August 2017

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Colorado Medicine for July/August 2017

Legislative report (cont.) directors has prioritized this issue since 2013 and has fully cooperated with the governor’s office and the Colorado Consortium for Prescription Drug Abuse Prevention to provide the physicians’ perspective. ACHIEVED: Increased access to direct primary care (DPC) The Colorado Academy of Family Physicians took the lead on a bill to increase patients’ access to direct primary care, or DPC, an increasingly popular payment model in primary care that allows for physicians to directly contract with patients for health care.

CMS celebrates legislative champions The Colorado Medical Society hosted a party on June 21 in celebration of a successful legislative session and to thank physician members and legislators for their hard work this session advancing the society’s health care reform agenda. Attendees gathered at the Grant-Humphreys Mansion in Denver. Photos by Kate Alfano, CMS communications coordinator.

As proponents attest, DPC offers a model for some physicians to take a different path, emphasize the patientphysician relationship, and reduce the administrative burden from insurance billing. Numerous DPC physicians testified that the model offers a solution to the burnout they were experiencing in a fee-for-service practice. Because DPC is not an insurance product, HB17-1115 clarifies that DPC practices are not subject to insurance company regulations. The bill’s sponsors were Rep. Perry Buck, R-Windsor; Rep. Joann Ginal, D-Fort Collins; Sen. Jack Tate, R-Centennial; and Sen. John Kefalas, D-Fort Collins. Monica Morris, DO, CAFP president and CMS member, said, “This important legislation helps protect greater choice and affordable care Monica Morris, DO for our patients and an interesting and fulfilling practice for physicians.” n Photo captions, top: COMPAC Chair Mark B. Johnson, MD, MPH, left, presents awards to the sponsors of SB17-088. From left: Sen. Angela Williams, Senate Majority Leader Chris Holbert, Rep. Edie Hooten and Rep. Kevin Van Winkle.

Middle left: CMS General Counsel Susan Koontz, JD, left, talks with Rep. Perry Buck. Middle right: Jerry Johnson, CMS contract lobbyist, left, talks with Senate Majority Leader Chris Holbert. Bottom left: CMS CEO Alfred Gilchrist, right,

congratulates Sen. Kevin Priola for his work on SB17-198. Bottom right: Sen. Jack Tate and Rep. Dave Young receive an award for their work to establish the Division of Insurance (DOI) physician complaint pilot program.

Colorado Medicine for July/August 2017

Features

Top: CMS members and component staff discuss the session; left, from left, Brandi Ring, MD; Usha Varma, MD; and Deb Parsons, MD. Right, from left: Denver Medical Society Executive Kathy LindquistKleissler; Nora Morgenstern, MD; and

Colorado Medicine for July/August 2017

COL Chair A. Lee Morgan, MD. Middle left: Rep. Brittany Pettersen speaks about the interim taskforce on opioids and substance use disorders. Middle center: Rep. Leslie Herod receives an award for her support of CMSâ&#x20AC;&#x2122; agenda. Middle right: COM-

PAC Chair Johnson addresses the audience. Bottom left: Sen. Tim Neville receives an award for his work on HB17-1173. Bottom right: From left, Sen. Larry Crowder, Rep. Perry Buck and Rep. Donald Valdez receive an award for their work on HB17-1094.

Features

Increasing oversight David A. Balto, JD

Brief: SB17-198, non-domestic insurance industry mergers Public participation in insurance mergers is instrumental to ensure that insurance commissioners can fulfill their statutory duties and that consumers are protected. At a time when studies show an underenforcement of mergers, the public is becoming more vigilant in protecting themselves from competition-harming mergers.

“SB17-198 is vital for the insurance commissioner’s obligation to protect consumers. It will open the insurance merger process up to beneficial public participation that will aid the Colorado insurance commissioner in properly assessing the competitive impact of proposed mergers.” The recent attempted mergers of Anthem/Cigna and Aetna/Humana show how the public is helping to close the enforcement gap. In states where public participation was encouraged, many consumer groups and representatives filed comments and testified in hearings to raise substantive concerns with the mergers. Public participation based on full access to information was crucial. In states where the proceedings were conducted behind closed doors, the state insurance commissioners approved the 20

mergers with often inadequate analysis. This ended up being at odds with the assessment of the U.S. Department of Justice (DOJ) and many state attorneys general, who challenged the mergers and prevailed in federal district court (nine states participated in the Aetna-Humana challenge and 12 states, including Colorado, participated in the Anthem-Cigna challenge). SB17-198 is vital for the insurance commissioner’s obligation to protect consumers. It will open the insurance merger process up to beneficial public participation that will aid the Colorado insurance commissioner in properly assessing the competitive impact of proposed mergers. SB17-198 will bring greater transparency and public participation to non-domestic mergers Colorado is a highly-concentrated state, which means a small handful of health plans dominate the market. According to the Colorado Health Market Review for 2015, the four largest Colorado insurers, Kaiser Permanente, UnitedHealthcare, Anthem and Humana, have a combined market share of 79.3 percent. This concentration and lack of competition can be costly for consumers. According to data from the Colorado Division of Insurance, individual market premiums increased statewide by 20.4 percent. This may not come as a surprise, as competition in the individual market is decreasing – with UnitedHealthcare and Humana completely exiting the market and Anthem BCBS and Rocky Mountain Health Plans reducing their offerings. These exits will impact about 92,000 Colorado consumers.

Mergers in particular are often a source of consumer harm. According to Erin Trish, health economics expert at the University of Southern California’s Schaeffer Center for Health Policy and Economics, “when insurers merge, there’s almost always an increase in premiums.” Two separate, retrospective economic studies on health insurance mergers found significant premium increases for consumers post-merger. One study found that the 1999 Aetna-Prudential merger resulted in an additional 7 percent premium increase in 139 separate markets throughout the United States. Another study found that the 2008 United-Sierra merger resulted in an additional 13.7 percent premium increase in Nevada. There is also economic evidence that a dominant insurer can push rates 75 percent higher than smaller insurers competing in the same state. In highly concentrated states, non-domestic mergers can have just as much impact on the wellbeing of Colorado residents as domestic mergers. For example, in the recent proposed mergers of Anthem-Cigna and Aetna-Humana the insurers were not domestic insurers in many of the states where the proposed mergers were projected to have substantial impact. Consumers in these states had the same need to be protected by transparency and process as they would if domestic insurers were merging. For these reasons, the bill sponsors – Sen. Kevin Priola, R-Adams County, and Rep. Alec Garnett, D-Denver, the Colorado Association of Health Plans and the Colorado Medical Society – should be applauded for reaching an agreement that permits disclosure and public input on non-domestic mergers. Likewise, the Colorado Medicine for July/August 2017

Features Colorado Division of Insurance (DOI) should be complimented for convening the parties, participating in the discussions and operationalizing the agreement for DOI. Industry-supported efforts to use SB17-198 as a vehicle to overturn current law regarding transparency and public participation on domestic mergers were misguided The Colorado Senate Committee on Business, Labor and Technology defeated – on a 5-2 vote – an industry-led effort to derail SB17-198 with an amendment to remove full transparency for domestic mergers, including the Form E. Form E summarizes important market share information that the public needs to evaluate the impact of a merger. The recent mega-mergers of AetnaHumana (blocked in federal court) and Anthem-Cigna (previously under appeal in federal court) highlight the need for greater transparency and public oversight. DOI approved the Aetna-Humana merger without public notice or hearing, despite pleas for participation by providers and consumers, and there are examples from other states of failures in the state insurance regulatory review process. It is vitally important, especially in light of studies that show an under-enforcement of anticompetitive mergers, that a robust state review of mergers be transparent, rigorous and inviting of public participation. Such a process improves the ability of the insurance commissioner to gather useful information and helps avoid the appearance of impropriety. This can be seen in states like California, where an open process with public hearings was held on both the proposed Anthem-Cigna and Aetna-Humana mergers. These hearings were televised and included panels composed of providers and consumer representatives. Colorado law requiring an independent investigation of mergers in certain circumstances, such as was conducted recently in United’s acquisition of Rocky Mountain Health Plans, is unique in the country and once again demonstrates Colorado Medicine for July/August 2017

the sensitivity of past General Assemblies to the need for public participation in mergers and acquisitions in Colorado. Mergers conducted after the state district court’s ruling affirming Colorado’s transparency rules show the usefulness of transparency The recent state district court ruling in Marguerite Salazar v. Colorado Medical Society affirmed that the General Assembly intended to shine a brighter light on domestic mergers. In this case, Judge Morris Hoffman found that the Form E is not confidential when the merger is domestic, but that under current statute it is confidential when the merger is nondomestic. SB17-198 responds to this ruling by closing the transparency gap and extending basic consumer protections to all insurance mergers in the state of Colorado. Judge Hoffman’s ruling should be applauded for confirming the transparency intent of the General Assembly, and not reversed by industry-sponsored legislative action through SB17-198 that sought to make all Form Es confidential. Instead, through the law, this important process allowing public oversight has been extended to non-domestic mergers that can have just as much of an impact on the wellbeing of Colorado residents as domestic mergers. UnitedHealth Group’s recent, successful acquisition of Rocky Mountain Health Plans, which was conducted following the district court ruling, shows how the transparency provided by SB17-198 will promote consumer interests without being harmful to the companies. In that merger, UnitedHealth provided the Form E and other documents to provider and consumer organizations. In turn, these organizations examined the materials, participated in the public hearing process, and collaborated with UnitedHealth and Rocky throughout the Colorado DOI process. This collaboration between stakeholders and the merging parties led to better results and consumer protections than could have otherwise been achieved. The UnitedHealthRocky Mountain Health Plans merger can serve as a model for future mergers and acquisitions that, with the passage

of SB17-198, will serve consumer needs without unduly burdening the parties. The passage of SB17-198 continues Colorado’s strong record of putting consumers first, bringing vital transparency to the mergers of non-domestic health insurance companies in Colorado. Transparency benefits the process by allowing consumers, providers and their advocates to judge whether and how a merger might harm them and to participate so that their interests are represented. n About the author David Balto has more than 30 years of experience as a consumer advocate, serving as policy director of the Federal Trade Commission and attorney advisor to Chairman Robert Pitofsky. He litigated nine merger cases in federal court and testified before 14 state insurance commissioners on health insurance mergers. He has represented consumer groups, health plans, unions, employers and providers on various regulatory and competitive issues with respect to the practices of health insurance. He led the consumer opposition to the blocked AetnaHumana and Anthem-Cigna mergers, in which they testified before 12 state insurance commissioners and the National Association of Insurance Commissioners, and advocated for state departments of insurance to hold public hearings on the mergers.

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Features

Federal health care reform Kate Alfano, CMS Communications Coordinator

CMS leaders meet with Sen. Cory Gardner to urge thoughtful health care reform During the American Medical Association Annual Meeting in mid-June, a subsection of the Colorado delegation to the AMA traveled to Washington, D.C. to meet with U.S. Sen. Cory Gardner. Gardner is a member of the group in charge of crafting the senate version of the American Health Care Act (ACHA). AHCA passed the U.S. House of Representatives in May and received strong opposition from the AMA for the large number projected to lose their insur-

ance, 23 million by the Congressional Budget Office’s estimation; for cuts to Medicaid of $830 billion, for the elimination of the Prevention and Public Health Fund that supports about 12 percent of Centers for Disease Control and Prevention Programs, and for the ban on Planned Parenthood funding.

“The meeting with Sen. Gardner and his legislative aide went really well,” said CMS President Katie Lozano, MD, FACR. “They listened, asked for more information (articles from CMS magazine including survey results), and understand our concerns about maintaining and increasing coverage.”

Gardner has already expressed concerns about cuts to Medicaid and how it crucially lacked “stability and certainty” for those in the Medicaid expansion.

CMS Immediate Past President Michael Volz, MD, while discussing maintaining the Medicaid expansion coverage, was asked about the “fundamental difference” in how different political parties view Medicaid. He said, “Actually there isn’t a fundamental difference. We all want the same thing: better, affordable coverage for the people of Colorado.” CMS and AMA will continue to follow the federal health care reform debate as it unfolds. n

Plug in to your reinvented medical society! Log on today to choose Interest Areas, submit policy proposals, and more. www.cms.org/central-line 22

Colorado Medicine for July/August 2017

Features

AMA Annual Meeting Kate Alfano, CMS Communications Coordinator

Delegates discuss, act on federal health care reform The Colorado delegation to the American Medical Association traveled to Chicago in mid-June for the AMA Annual Meeting of the House of Delegates where much of the focus was on federal health care reform. In line with this focus, a subsection of the CMS delegation traveled to Washington, D.C. to meet with U.S. Sen. Cory Gardner. (See related article on page 22.) “Bottom line: 23 million people lose coverage,” said AMA Senior Vice President of Advocacy Richard Deem during an educational session, referring to the Congressional Budget Office’s estimate of the bill passed by the U.S. House of Representatives in May. Now that the Senate is debating its version of the bill, the AMA is urging senators to preserve the Medicaid expansion, support continued coverage of pre-existing conditions, and fund cost-sharing reductions (CSRs) to help those with low-incomes afford insurance. “We are at a crossroads here,” Deem said. “Are we going to move forward and fix some of the problems with the ACA [Affordable Care Act], or are we going to retreat on some of the goals we set for improving health care for the nation?” The threat to health care coverage in the current environment seemed to unite the AMA House of Delegates in a common purpose, said AMA Delegate Lynn Parry, MD, and there was practically no partisan bickering – a “sea change” from past years. “The AMA HOD was solidly behind a re 24

Top: Delegate Jan Kief, MD, testifies before the AMA House of Delegates. Bottom: Between business, the Colorado delegation took time to explore Chicago, including Millennium Park and the Cloud Gate sculpture, more commonly known as the Bean. sounding ‘no’ to caps on Medicaid,” she said. “For the first time that I can recall, a discussion of health care as a right was accepted as a legitimate mat-

ter for referral and report, and there was a proposal for a public option brought forward by our Pac West coalition with a better awareness that a Colorado Medicine for July/August 2017

Features public option is not the same as single payer.” “Over all, the discussions were well informed and reflected a recognition that the profession needs to move forward with changes that can accommodate shifting landscapes in health care,” Parry continued. “Of course, I like to think that these changes are the result of the influence of our small but mighty Colorado delegation as well as the passion of the medical students – the ones who will inherit the system – across the country.” This marked the first official meeting with Colorado as part of Pac West, a coalition that merged Pacific Rim (five states plus Guam; 42 delegates) and Western Mountain States (six states; 24 delegates). The new coalition succeeded in electing New Mexico candidate Barbara L. McAneny, MD, to the position of AMA president-elect. In other election news, Luke Selby, MD, MS, a surgical resident at the University of Colorado, was elected delegate of the Resident and Fellow Section (RFS), and will represent the interests of resident and fellow physicians in the AMA HOD. Sohayla Rostami, a third-year medical student at Rocky Vista University, was elected to the position of Region 1 vice chair to the AMA Medical Student Section (see sidebar). And Brandi Ring, MD, began her term as chair of the AMA Young Physician Section (see sidebar). Ten CMS student members from both Colorado medical schools participated in the meeting under the guidance of medical student advisor Brandi Ring, MD (see related articles on page 26). “I haven’t seen this many Colorado medical students with such a high level of engagement in years – although we clearly had a superlative medical student crew in attendance,” said Tamaan Osbourne-Roberts, MD, CMS alternate delegate to the AMA. “Much credit to Lynn Parry in particular, for helping to create the environment in which such happened.” n

Colorado Medicine for July/August 2017

Brandi Ring, MD, begins term as chair of AMA Young Physician Section At the conclusion of the AMAYoung Physician Section Meeting in Chicago on June 13, 2017, Brandi Ring, MD, began her term as chair of the American Medical Association-Young Physician Section (AMA-YPS). Ring has spent the last year as chair-elect preparing to launch her initiatives for change within the AMA-YPS. Her focus will be on leadership, collaboration and managing member transitions within AMA sections.

• Increase collaboration between the AMA-YPS and the specialty societies that many members represent to effectively work together to fight the major health care crises in this county. • Establish and maintain ways to help keep people involved in the AMA as young leaders transition from the medical student and resident sections and as youngcareer physicians transition between career settings.

Her goals are: • To improve the visibility and development of young leaders within the AMA and to establish training and mentoring sessions that allow for the development of future leaders.

She has served in leadership roles within the AMA and with her specialty society, the American College of Obstetricians and Gynecologists (ACOG), as well as community health initiatives with the Department of Health in Pennsylvania.

Ring is a private-practice OB/GYN in Denver at Mile High OB/GYN Associates.

Sohayla Rostami elected Region 1 vice chair Sohayla Rostami, a third-year medical student at Rocky Vista University, was elected to the position of Region 1 vice chair to the AMA Medical Student Section (MSS). MSS consists of seven regions, each governed by a chair, vice chair and additional leaders elected to accomplishing the goals of the region. Together, the region’s executive board provides the medical students a basis for communication, collaboration and guidance in the policy efforts presented by the MSS. Region 1 represents the following states: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming.

As Region 1 vice chair, Rostami’s role is to support the executive board and students in bringing forth health policies pertinent to the region and ultimately the nation, serve as the region chair in case of her absence, and coordinate all region efforts during the annual Medical Student Advocacy and Region Conference (MARC). MARC, held in Washington, D.C., is an opportunity for students to have direct interface with state representatives to request action on major issues concerning the AMA. Past topics of discussion have included graduate medical education, safety provisions for medical students protected under Deferred Action for Childhood Arrivals, and preserving vital sections of the Affordable Care Act. She will work closely with vice chairs in other regions to coordinate MARC in 2018.

Features

AMA student engagement

Medical students report on a successful meeting Kiara Blough, Rocky Vista University College of Osteopathic Medicine With the generous support of the Colorado Medical Society, the Medical Student Section (MSS) from Rocky Vista University was able to send four medical students to the American Medical Association’s Annual House of Delegates (HOD) meeting in Chicago. During this meeting, physicians and medical students from across the country gathered to address health policy. Working intimately alongside our colleagues from the University of Colorado School of Medicine, the Colorado MSS played an active role in both the MSS and main HOD meetings, including authoring and reviewing resolutions, serving as delegates and alternate delegates to the House, and giving testimony on the floor. Rachel Landin and I served as delegate and alternate delegate, respectively, to the MSS. I also served as alternate delegate to the main HOD. Sohayla Rostami worked diligently in prior weeks to co-author a resolution, “Recognizing Poverty-level Wages as a Social Determinant of Health,” which was adopted as MSS Policy. We are especially proud of Rostami for being elected vice chair of Region 1, which leads and organizes 15 states from across the country. While the conference itself was a valuable learning experience for all, RVU and CU medical students invested countless hours during late-night meetings and conference calls reviewing resolutions. These meetings allowed us to discuss our stance early, propose amendments, anticipate opposition, and strategize and prepare for debate in the House. Thanks to the leadership of CMS advisor Brandi Ring, MD, the 26

Colorado MSS was well prepared and poised to create and pass important and timely resolutions. RVU students left with a shared sense of inspiration. When asked about their experience, here’s what our classmates had to say: “It was and continues to be absolutely inspirational to see all students, from myriad backgrounds, various geographic locations, and different years of medical training, come together and find a single, strong voice on difficult issues. We see, in real time, representatives and delegates set aside their personal beliefs and advocate for their patients and the medical field. Especially with the AMA Annual Meeting this year, there was a clear resounding stance on major issues plaguing our politics and one that the students decided to take ownership of as we will be the future of medicine. The students were initiating proactive measures in an otherwise very reactive political landscape. The compassion and care of the students transcend the classroom and clinic walls and reach a level where thousands of lives across the nation can be positively affected.” – Sohayla Rostami, MS4 RVUCOM “I left the AMA-MSS Annual Meeting feeling incredibly inspired by the brilliance of our fellow medical students. The event had such an enormous impact on my view of medicine and policy, and I am thrilled to know that the next generation of practitioners is so passionate to push the current boundaries of medical policy to advocate for their patients in the strongest way possible. The three greatest accomplishments the AMA-MSS achieved

included the following: passing support for the future development of singlepayer health care with the allowance of intermediate steps such as a public option; supporting the creation of supervised injection facilities, which not only passed through the MSS House but also through the main AMA HOD; and requiring religiously affiliated medical institutions to fully disclose all reproductive health service options. I cannot emphasize enough the excitement I have for the future of medicine and medical policy, and I look forward to seeing more policy that will benefit the diverse range of our patients.” – Rachel Landin, MS2 RVUCOM “I attended the Women Physician Section breakout mentoring session. As medical students, we heard advice from multiple female physicians on leadership, contract negotiation, patient advocacy, landing that residency, and how to not only survive but also thrive in often male-dominant areas of medicine. I can truly say that I will keep with me the personal stories and advice shared during this session for the remainder of my career in medicine.” – Krista Allen, MS2 RVUCOM When speaking about the interim meeting in November, Allen says, “I’m inspired and ready to work with my Colorado peers and students across the nation. We already have resolution ideas in mind and I’ve applied to the Bioethics and Humanities standing committee of the MSS governing council!” In addition to working hard at the meeting, we made sure to find time to explore the beautiful Millennium Park, listen to blues music, dance the night Colorado Medicine for July/August 2017

Features

Right: Colorado medical students practice procedures. Left: The medical student delegation poses before the House of Delegates. away at the Presidential Inaugural Ball, and connect with new and old friends and colleagues from across the country. We are proud of the work accomplished by the Medical Student Section and look forward to bringing progressive resolutions to the AMA Interim Meeting in November. Halea Meese, University of Colorado School of Medicine University of Colorado School of Medicine Delegate Allee Torres and Alternate Delegate Eric Lakey saw the resolution they co-authored, “Air Ambulance Regulations and Reimbursements,” pass the AMA-MSS with minor amendments. Lakey also served on the AMA-MSS reference committee that reviewed resolutions from colleagues from across the nation. Laylaa Ramos-Arriaza and I provided live testimony on the floor of the MSS on topics such as divestment from fossil fuels and full disclosure of all reproductive health service options at religiously affiliated medical institutions. Kiara Blough (RVU) and I also served as alternate delegates in the main House of Delegates. In addition to our time in the MSS and AMA House of Delegates meetings, we visited the very first Nutella café in Colorado Medicine for July/August 2017

the U.S., went on an architectural boat tour of the river, ate delicious deep-dish pizza at Giordano’s (with the rest of the CMS delegation; thank you!), explored the Magnificent Mile at night and danced at the AMA inaugural ball. CUSOM students left feeling energized and engaged. When asked what impacted them most from their time at the meeting, here’s what our classmates had to say: “Sitting in the Region 1 policy meetings had the biggest impact on me. It was fascinating seeing just how much of the strategizing, writing and discussion on policies happened beforehand to help the AMA-MSS meeting go smoothly and ensure everyone’s voice was heard in the shortest amount of time.” – Eric Lakey, MS2 CUSOM “My favorite part of the AMA meeting was seeing the amount of knowledge students and physicians had about policy and how passionate they felt about patient advocacy.” – Laylaa Ramos-Arriaza, MS2 CUSOM “I left the AMA-MSS meeting feeling overwhelmed with everything I had experienced, yet incredibly energized to act. Learning that the AMA is

the third highest spender for lobbying in Washington and that the resolutions that medical students wrote have turned into U.S. laws made me realize what a powerful platform I have to enact change. I am energized to write new resolutions and am highly interested in being part of various committees as I see a tangible way to advocate for my patients through AMA.” Subada Soti, MS2 CUSOM “After spending the last few months reviewing policies with Region 1 and with CMS, it was amazing to see them go through debate, to see how passionate students were about them, and to see the best policies become adopted by AMA-MSS.” – Allee Torres, MS2 CUSOM “I left the AMA meeting in Chicago feeling more energized and hopeful than I have in a long time. I slept less and learned more in one week than I ever have before about health policy. It was awe-inspiring to see my Colorado colleagues and other students from across the nation work with physicians to get their ideas to become the official policies of our AMA. This meeting showed me that the impact of student advocacy is truly limitless. I’m hooked.” Halea Meese, MS2 CUSOM n 27

Features

Addressing antibiotic resistance Lyndsay Fluharty, MA, Senior Marketing and Communications Consultant, Telligen

New Telligen initiative enrolling Colorado outpatient clinicians through July 31 Clinicians agree that antibiotic resistance is a public health crisis. Yet for those who care for patients in outpatient settings – such as physician offices, urgent care clinics, emergency departments and pharmacies – many

From patient education materials to suggested scripts to help prepare for talks with patients and families about appropriate antibiotic use, Telligen can offer tools and resources that will help you maintain patient satisfaction while practicing good antibiotic stewardship. aren’t sure what they can do to make a difference. A new Telligen antibiotic stewardship initiative tailored to outpatient health care providers offers a stepwise approach to antibiotic stewardship to help prevent clinicians and staff members from feeling overwhelmed. Antibiotic stewardship is a coordinated plan that promotes appropriate antibiotic use to help reduce microbial resistance and improve patient outcomes. Telligen works with health care providers throughout the state as Colorado’s Quality Innovation Network-Quality

Improvement Organization (QINQIO) for the Centers for Medicare and Medicaid Services (federal CMS). The organization’s new outpatient antibiotic stewardship initiative is helping clinicians, practices and clinics adopt the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship with no-cost consulting services and technical assistance.

Action: Implement at least one policy or practice to improve antibiotic prescribing The use of evidence-based diagnostic criteria and treatment recommendations can help improve prescribing practices. Clinicians may recognize opportunities for improvement for conditions such as bronchitis, pharyngitis and sinusitis.

Colorado clinicians have until July 31 to sign up for the project, which will help participating clinicians incorporate the CDC core elements into their practices by the end of 2018. Here’s an outline of the CDC core elements and some common-sense examples to show how you or your practice can get started.

LaRocca also emphasizes that reducing antibiotic underuse, overuse and misuse should be approached as “a team sport – from appointment-setting and reception to triage, diagnosis, discharge and pharmacy.” Research has shown that unnecessary antibiotic prescribing for respiratory illnesses rises as the day progresses, demonstrating the effects of “decision fatigue” among stressed clinicians. Telligen staff offer training using evidence-based systems like Team Strategies and Tools to Support Performance and Patient Safety (TeamSTEPPS®) to improve communication and collaboration among your health care team.

Commitment: Demonstrate dedication and accountability to optimize antibiotic prescribing Telligen QIN-QIO Medical Director Christine LaRocca, MD, cites research that shows how simply displaying commitment letters in examination rooms can decrease inappropriate antibiotic prescribing for acute respiratory infections. As part of Telligen’s no-cost services, practices and clinics that partner with Telligen receive an antibiotic stewardship “start-up kit” of commitment posters, patient educational posters, brochures and an adult treatment recommendation resource. “These kits allow your practice or clinic to meet three out of the four CDC core elements immediately,” LaRocca says.

Tracking and reporting: Monitor at least one aspect of antibiotic prescribing Tracking and reporting allows clinicians to assess progress. “You could start by tracking appropriate use of a single antibiotic, such as levofloxacin, for which the FDA added an updated warning in 2016,” LaRocca says. For those practices with an electronic health record (EHR), this information can often be generated with existing

Colorado Medicine for July/August 2017

Features EHR reports, or Telligen can help your staff get started with this process. Other practices have considered tracking antibiotic use for a defined duration, such as the traditional flu season of Oct. 1 to March 1. “There’s no requirement for participants to share their practice data with Telligen,” LaRocca says. “Clinicians need only keep us informed in their journey to complete all four CDC core elements.”

ity and will help you avoid a downward payment adjustment in 2019.”

Education and expertise: Provide resources to clinicians and patients on evidence-based antibiotic prescribing Patient and clinician education cannot be overlooked, as real and perceived patient demand is an important factor in antibiotic overuse. From patient education materials to suggested scripts to help prepare for talks with patients and families about appropriate antibiotic use, Telligen can offer tools and resources that will help you maintain patient satisfaction while practicing good antibiotic stewardship.

Telligen is accepting applications for

“The Telligen program supports an urgent need recognized by the federal CMS and the CDC among community health care providers. Clinicians who join us by July 31 can get no-cost help from Telligen to implement antibiotic stewardship in outpatient settings. It’s a win-win for patients and providers.”

its outpatient antibiotic stewardship initiative from Colorado physician offices, emergency rooms, urgent care centers, rural health clinics, federally qualified health centers and pharmacies through July 31, 2017. To learn more or to sign on, visit https://telligenqinqio. com/our-work/antibiotic-stewardship/ or contact Andrea Campbell at andrea.campbell@area-d.hcqis.org or Christine LaRocca at christine. larocca@area-d.hcqis.org. n

A win-win: The MIPS connection With the May release of Merit-Based Incentive Payment System (MIPS) clinician participation letters, outpatient clinicians who care for Medicare Part B patients may be looking for ways to successfully participate this year. The federal CMS has included implementation of an antibiotic stewardship program as one of the MIPS improvement activities. So activities that you or your practices take on in 2017 to help decrease the spread of antibiotic resistance can also help you avoid negative payment adjustments of up to 4 percent in 2019. “Antibiotic stewardship is important to patient safety,” LaRocca says, “and we know that no action during the 2017 MIPS performance year means a 4-percent negative payment adjustment in 2019 for health care providers participating in MIPS. If done right, implementing antibiotic stewardship in 2017 counts as a MIPS improvement activ-

Colorado Medicine for July/August 2017

Features

Maintaining oral health Kathy Jacoby, Marketing Director, Delta Dental of Colorado

CMS partnership with Delta Dental encourages patients to take care of their oral health to improve overall health Before starting her current role as CEO of Delta Dental of Colorado, Helen Drexler learned first-hand how closely tied oral health is to one’s overall health. Her son Gary, who is 26 years old and lives in Denver, had gone to a doctor complaining of stomach issues following a family vacation last summer. Within days, after a blood test, he ended up in the hospital diagnosed with a potentially life-threatening kidney disease called IgA nephropathy, also known as “Berger’s disease.” His kidneys were shutting down, and a transplant was the only course of action. “I remember walking up to the hospital bed, holding his hand and looking at him and telling him, ‘We’re going find you a kidney by your birthday,’” Helen Drexler said. The hospital visit took place in August. Gary’s birthday was a few months away, on Nov. 21. It was an ambitious goal. Finding a willing and qualified kidney donor is difficult, particularly for families like the Drexlers in which no immediate family member qualifies due to blood type or other issues. There are 3,000 people in Colorado on a waiting list for a kidney donation. About 120 Coloradans die every year waiting for a kidney donation. By September, Drexler had decided to quit her job as an executive of a large health care company in Atlanta to become, as she jokingly puts it, “CEO of

find my kid a kidney.” Since he was little, Gary said, he has always shared a special relationship with his mom. The pair went to every “Harry Potter” movie premier – all eight movies – throughout his childhood. He recalls Helen and her mother taking him out of elementary school in Louisville, Colo., for the first in the series. Just this past summer, during a wedding celebration in San Diego, the family went to a local bookstore release of the latest of J.K. Rowling’s books. Gary describes his mom as an activator, someone who makes a plan and sees it through to the end. And that’s exactly what she did. “I said in my letter to all my friends and family when I was trying to find people to donate that there’s nothing like the power of the mother of a sick child,” Helen Drexler said. “Mothers of sick children are not to be reckoned with. They will move mountains to help their children.” After contacting more than 150 friends, family members, co-workers and anyone else who would listen, Drexler said, the University of Colorado received a flood of calls from volunteers asking to be tested to see if they were a match for Gary. By Gary’s birthday, the family had their donor. The donor, Brian Boose, had worked with Helen in Atlanta years earlier. He

Helen Drexler, CEO of Delta Dental of Colorado, and her son Gary, who underwent a successful kidney transplant this year, thanks in part to taking good care of his oral health. had been one of the first to call CU to get tested. Brian flew out to Denver to meet Gary. A lifelong Ohio State University fan, Brian suggested he name the donated kidney “I-O.” Brian’s remaining kidney would be “O-H.” Put them together, and you get the fan chant song that fills the Ohio State football stadium every game, “O-H-I-O!” The next step was preparing Gary for surgery. This is when the Drexler family got a first-hand lesson in the importance of oral health. “You have to have a very healthy sys-

Colorado Medicine for July/August 2017

Features tem, because you’re about to go through a very taxing surgery and will be on immune suppressants, so your body can’t fight infection,” Gary Drexler said. “You want to make sure your entire body is clear of infection. Your mouth and gums are one of the easiest ways for infection to attack your body. So you need to have a very clean mouth.” Fortunately for Gary, he had been vigilant about twice yearly dental visits throughout his life, even in college, and had no complications. If he had a cavity or inflammation in his mouth from some other oral health issue, it could have delayed his surgery until the issue was addressed. In January, Gary and Brian underwent surgeries in rooms across the hall from each other. After some initial early complications, which can be common, Gary had a well-functioning new kidney and a new lifelong friend with a special bond.

Gary Drexler (second from right) and his kidney donor Brian Boose, with their wives Sharon and Kristin, form “OHIO” with their arms, a cheer of fans of Ohio State University.

“Brian is my greatest hero in life,” Helen Drexler said. “I will always be grateful for the gift he gave my son.”

#TeethMatter: Raising the volume on oral health

Gary is enjoying life free of pain and kidney complications. His doctors have told him to remain vigilant about his oral health. Having completed her mission to find a donor for her son, Helen Drexler began her new role as CEO of Delta Dental of Colorado in December. She is now strong advocate for oral health issues, spreading the word about the importance of oral health everywhere she goes. Instead of regular phone calls, mother and son now see each other regularly. They eagerly await the release of J.K. Rowling’s next book. n

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

Colorado Medicine for July/August 2017

Did you know that a dentist or dental hygienist can spot early signs of 120 diseases, including heart disease, diabetes and several forms of cancer? Or that 90 percent of systemic diseases have symptoms in and around the mouth?

ous chronic health conditions, including heart and liver disease and diabetes. And you can increase your chances of living a long, healthy and productive life.

The Colorado Medical Society is partnering with Delta Dental of Colorado and others across the state to better inform businesses, health professionals and the public about how closely connected oral health is to overall health.

Through our oral health communications campaign, #TeethMatter, we hope to encourage Coloradans to make regular visits to their dentist or dental hygienist and to raise awareness and understanding of the importance of oral health to us as individuals and as a society.

By taking care of your oral health, you can help prevent or better manage many seri-

For more information, visit w w w.deltadentalco.com/ wellness.

Features

Protect patients first Kate Alfano, CMS Communications Coordinator

CMS joins national groups to urge Congress to “protect patients first” in federal health care reform debate The Colorado Medical Society joined several leading national organizations, including the American Medical Association, AARP, American Heart Association, and American Cancer Society, among others, to urge lawmakers to “Protect Patients First” in the federal health care debate. In a media event at the Colorado state capitol on June 27, the groups highlighted shortcomings in four main areas: affordability of insurance, access to essential care, protection for those on Medicaid, and protections for those with employer-sponsored health insurance. CMS President Katie Lozano, MD, FACR, moderated the event. In her opening remarks, she suggested, “At a minimum, Congress should first do no harm. The Senate bill needs to be methodically thought through, not hurried.” She also summarized the highlights of a CMS-member poll conducted June 23-26, noting that “79 percent of CMS members disapprove of the approach U.S. Senate and House leaders are taking with the nation’s health delivery system. Should this legislation pass as written, many doctors could be forced into early retirement, stop investments in practice infrastructure, and be left unable to spend enough time with patients to deliver proper care.” Read a summary of the survey results on CMS.org. Brian Eades, MD, an OB/GYN in Delta County, also spoke at the media event and at Fox 31 Denver. “In our hospital, 85 percent of the patients are on Medicaid or Medicare. This bill could force rural hospitals to close, forcing Delta 32

CMS President Katie Lozano, MD, FACR, moderates a press conference at the Capitol. County residents to drive 40-60 miles to see a doctor, which means they will delay needed care or won’t see a doctor at all…. Ultimately this bill could end up closing facilities up and down the Western Slope, leaving Coloradans without the care they need.” Also on June 27, the AMA released poll data of registered voters in Colorado that shows strong disapproval of policies currently under consideration – particularly Medicaid cuts and narrowed coverage plans. A vote on the Senate health reform bill has been delayed until after the July 4 congressional recess. The AMA poll found that nearly half of Coloradans polled (47 percent) believe the ACA is a good idea; 36 percent be-

lieve it is a bad idea. A majority of voters (58 percent) believe the House health care legislation is a bad idea; 17 percent believe it is a good idea. On June 26, the AMA sent a letter to Senate leaders outlining its opposition to the bill. Throughout the federal health care reform debate, the AMA has urged that reforms not result in individuals with health insurance losing access to affordable, quality coverage; that Medicaid, CHIP and other safety net programs be adequately funded; and that key market reforms, such as pre-existing conditions, be maintained. After analysis of the Senate draft, the AMA asserts that it violates many of those principles. Read more on the AMA’s federal health reform website, www.patientsbeforepolitics.org. n Colorado Medicine for July/August 2017

Colorado Medicine for July/August 2017

Inside CMS

2017 CMS elections Kate Alfano, CMS Communications Coordinator

Cast your vote in August for CMS president-elect and delegates/alternate delegates to the AMA On Tuesday, Aug. 1, you will receive an invitation to vote for a slate of Colorado Medical Society officers from Survey & Ballot Systems (SBS). To assure your election ballot email arrives safely in your inbox, please add “noreply@directvote. net” as an approved sender (directions below). Each ballot is individualized to the voting member and includes your member number and passcode to cast your ballot. If CMS does not have your email address, email membership@ cms.org or call 720-858-6306. The

following physicians have announced their candidacy. Read their candidate statements starting on page 36. President-elect Debra Parsons, MD AMA Delegates/Alternate Delegates (eight positions open, listed in alpha order) David Downs, MD, FACP Henrique Fernandez, MD, FACP Carolynn Francavilla Brown, MD

Jan Kief, MD Rachelle M. Klammer, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSC, MD Patrick Pevoto, MD, RPh, MBA Brigitta Robinson, MD, FACS Michael Volz, MD Matthew Wynia, MD, MPH This is the second all-member election and, like last year, all ballots will be cast electronically. All CMS members are encouraged to use this opportunity to vote, affirming the significant repurposing of our organization that aims to engage all members in the governance process. We also ask you to consider seeking a leadership position next year. More details on the 2018 nomination period will be available in September. Thank you for your participation in our medical society. What does it mean to add an address to a safe senders list? Email newsletters can be blocked or filtered into the bulk folder especially now that email filters are focusing more strongly on “grey mail” or commercial mail. As a result, you may miss important announcements or alerts, like this one for the all-member election. To avoid these situations, add “noreply@ directvote.net” to your Safe Senders List. Constant Contact, the email blast company CMS uses to send membership emails, has compiled a list of the most commonly used email programs with easy-to-follow instructions on how to add email addresses to your Safe Senders List. Access the instructions at http://tinyurl. com/constant-contact-safe-sender. n

Colorado Medicine for July/August 2017

Inside CMS

CMS elections

Sample ballot, instructions on how to vote for candidates of your choice and explanation of how election will be run

In order for candidates to be elected to a Colorado Medical Society office each candidate is required to receive a majority vote of the membership. This year's election has an uncontested race for president-elect and has 11 AMA delegate /alternate delegate candidates running for eight positions. The vote for president-elect will feature a simple yes or no choice made by checking the box next to the name that will result in a majority vote for the president-elect. The AMA delegate/alternate delegate election will use a preferential voting ballot to elect the top eight candidates with a majority vote. Here’s how it will work. All CMS members with an email address will be emailed a link to a ballot with instructions from Survey & Ballot Systems. Candidates will appear on the ballot in alphabetical order and voters will be instructed to rank the entire 11-person field in order of preference with 1 being the first choice, 2 the second and so on. In the accurately filled out ballot example below, all 11 candidates have been checked in preferred order by the person voting. Once the ballot closes at midnight Sept. 1, the computer will tabulate the results to see if one candidate receives a majority vote. The program will then drop the person with the lowest votes and reallocate that candidate’s votes to the rest of the field, continuing the process of dropping the next lowest candidate until one candidate has received a majority vote. Once the first person is elected, that person will be removed from the next tabulation with their votes being reallocated to the rest of the field, including the candidates dropped in round one. The computer will then re-tabulate votes for the second open position following the same procedure of dropping the lowest candidate(s) and reallocating those votes until a second person receives a majority vote. The computer will repeat this procedure with all remaining candidates until the top eight candidates are elected.

2017will Election TheCMS election company certify the results of the election and provide CMS with the results on Sept. 1. Colorado Medical Society CEO Alfred Gilchrist will first share the results withTothecast candidates and then inform the entire membership via email. The AMA Delegation as a whole will then meet to determine which candidates will serve as delegates and a vote: Check the box next on toexperience a candidate name. which asalternate delegates depending and specific needs of the position. n    

To change your vote, click the box again, and the mark will be removed. To review candidate information, click the "View Bio" button next to each candidate. 2017 Election - Sample Ballot (final versionbutton. may vary in design but not function) To review CMS your selections, click the "Proceed to Ballot Confirmation" You may save your ballot and return later by clicking the "Logout" link.

General Instructions for Casting a Ballot:

Preferential Voting Instructions for AMA Delegate Positions:

• You may save your ballot and return later by clicking the “Logout” link.

• The electronic ballot will not allow any number to be used more than once.

Preferential Voting Instructions • Check the box next to a candidate's name. for CMS National Board of Directors • Please indicate the order in which you prefer ALL the candidates within each office; 1  Please indicate the order in which you prefer ALL the candidates within each office; 1 being your first choice, 2 your • To changesecond your vote,choice, click the box again, and the mark will be removed. being your first choice, 2 your second choice, etc. etc. • To review information, thecheck “View Bio” next totoeach • It is important that for you check a box nextwish to theto name of each candidate for whom you  Itcandidate is important thatclick you a button box next thecandidate. name of each candidate whom you vote.  Do choose number more than once. • To review yournot selections, click any the “Proceed to Ballot Confirmation” button. wish to vote. You must fill out all 11 preferences or your ballot will NOT be counted.

President-Elect (1 Position PositionOpen) Open) President-elect (1 Select one.

Logout

View All Candidate Biographies Candidate A View Bio

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Proceed to Ballot Confirmation AMA Delegates/Alternate AMA Delegates/Alternate Delegates Delegates (8 Positions Open) Preferential Voting. Rank each candidate once. View All Candidate Biographies 1

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Colorado Medicine for July/August 2017

Inside CMS

CMS elections

Be an informed voter, visit: www.cms.org/ articles/2017-cms-all-member-election

Candidate statement: Debra Parsons, MD, FACP, CMS President-elect biases and preconceived notions requires that all assertions be supported by data when available. Applying best evidence to our 21st century medical society policy development will help us build consensus.

Debra Parsons, MD, FACP Candidate for CMS president-elect The voice of the members of CMS was heard loudly in a recent member survey. Members described the ideal medical society as one that puts members first and promotes our profession through advocacy, effective communication and member education. To this end, CMS physician and executive leaders came together to transition CMS into a 21st century medical society. The new CMS will communicate with members in unprecedented ways, maximize member engagement, invest in members as health care leaders and create well-vetted policies that consider members’ diverse perspectives. As a candidate for CMS presidentelect, I want to carry on this innovative work. My skills and experiences from over two decades in clinical practice, graduate medical education, serving as a medical staff president and in Medicaid reform, will bring value to this role. I’d be honored to have your support. The commitment to evidence-based practices runs strong in the culture of graduate medical education. Moving resident-physicians from anecdotes, 36

I served as president of the medical staff and chair of the medical executive committee at Saint Joseph Hospital during the launch of system-wide quality improvement projects ranging from sepsis bundles to pressure ulcer prevention. Our success at improving clinical outcomes was attributable to unparalleled partnerships between medical staff, hospital administrators, nurses and IT personnel. Patient quality issues were analyzed using problemsolving tools that define the current state of the problem being addressed and then define the ideal state we all desire. The solutions to move from the current to ideal state were grounded in both relational and operational solutions. This applies to solving problems we face as physicians and as an organization. My involvement in health care reform intensified as a medical director for the Medicaid Accountable Care Collaborative, created by Colorado’s legislature, and evolved into my current role as medical director for eQHealth Solutions, a nonprofit population health management and technology solutions company. This work immersed me in the tenets of clinical practice transformation designed to strengthen the quality of patient care and spend health care dollars more wisely. Yet, physicians need to know where we are going and what we can expect when we get there before we engage. Far too often, multiple initiatives drain our practices and leave us on the road to burnout. As a member of CMS’ Physician Wellness Committee, we are exploring real solutions to increase resiliency in medical professionals and

decrease burnout. The AMA adopted our resolution of using the provider experience as an important metric for determining overall performance in proposed alternate payment models. The balance of power in the 2017 Colorado General Assembly with a Republican majority in the Senate and a Democrat majority in the House, means that only legislation with bipartisan support will pass. Since physicians are the most credible messengers on health care issues and solutions, opportunities to educate and inform state legislators will rise in frequency and importance. When we organize issues using best evidence, and leverage trusting relationships, we can execute excellent processes and policies that lead to a better future for physicians and patients. I am convinced that the communication and advocacy strategies of the new CMS will uniquely engage our members in those issues that matter most to medicine. As the practice of medicine and the business of medicine rapidly evolve, every physician voice is needed to inform and build the future we all desire. Let’s talk or meet in person. Please contact me at debparsonsmd@gmail.com. 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 July/August 2017

Inside CMS Be an informed voter, visit: www.cms.org/ articles/2017-cms-all-member-election

CMS elections

Candidate statement: David Downs, MD, FACP, AMA Delegate regarding the basic elements needed for the foundation of a robust health care delivery system and principles for its financing. This was quite an accomplishment for a body selected by an equal number of Republicans and Democrats in the state legislature and two governors.

David Downs, MD, FACP Candidate for AMA delegate As co-chair of the CMS Health Leadership Committee, I helped conceive and co-found the Physiciansâ&#x20AC;&#x2122; Congress on Health Care Reform. The Congress is largely responsible for development of current CMS policy on health care reform, which has served well as a template for advice to policymakers on how doctors think and feel about best practices in the financing and structure of the systems we work in. I served as a commissioner on Coloradoâ&#x20AC;&#x2122;s Blue Ribbon Commission For Health Care Reform (208 Commission). This forum, over the course of a little more than a year, was able to come to a nearly unanimous consensus

I have now served on the Colorado delegation to the American Medical Association for several years. I began as somewhat of a skeptic, having had several disagreements with AMA policy over the years. I found the organization to have arcane, sometimes byzantine, processes and politics. At the same time, it is one of the most democratic institutions Iâ&#x20AC;&#x2122;ve worked in and it offers a venue in which ideas, presented properly, are given a full vetting. As the country begins to evaluate massive changes in how health care is structured and financed, the voice of the AMA will become important and influential in the evolution of the environment in which we practice. Our delegation is your avenue to express your concerns, aspirations and doubts into the process of policy development within the single, largest physician organization in our country. While physicians, like the greater population, see different paths to a better practice environment and alternative strategies to make safe, affordable,

high quality care available to everyone, I feel strongly that a consensus that respects differing points of view can be developed and that the AMA is a great place to begin the process of achieving that. Given our current political environment, the building of consensus in the development of health care policy will be sorely needed. I ask that you support me in bringing the voice of Colorado physicians to the AMA to promote the best policy options and to move them forward in national health policy development. I have practiced primary care internal medicine for 33 years in Colorado and continue to do so. I understand the challenges we face from payers and the support needed for us to practice high quality, evidence-based medicine. Perhaps most importantly, I understand the need to sustain the intimate relationships we have with our patients. I have seen the benefits and the pain caused by well-meaning policy makers that often make decisions without an understanding of the complex world we all work in. I would be privileged to continue serving in the role of alternate delegate and ask for your vote. Please feel free to communicate with me at davedowns1@icloud.com. n

All friends of medicine are eligible to participate. Email susan_koontz@cms.org or call 720-858-6327 or 800-654-5653, ext. 6327 Colorado Medicine for July/August 2017

Inside CMS

CMS elections

Be an informed voter, visit: www.cms.org/ articles/2017-cms-all-member-election

Candidate statement: Henrique Jose Fernandez, MD, FACP, AMA Delegate University of Connecticut, I was elected to serve as chief medical resident; this experience taught me the importance to lead and teach by example. After my graduation, I went to the University of Miami, Fla. to pursue my gastroenterology fellowship.

Henrique Jose Fernandez, MD, FACP Candidate for AMA delegate To be a successful academic gastroenterologist requires not only the skills of a surgeon but also the knowledge of an internist, the constancy of a researcher and the patience and willingness to give of an educator. Through my medical training, clinical and work experiences in the United States I have worked hard to develop those skills and to improve them. During my entire career I have also demonstrated leadership, exceptional teamwork and the constant willingness to improve wherever I work. After my residency program at the

After the completion of my fellowship in 2010, Parkview Medical Center gave me the honor to practice my career; the hospital has been honoring me with different opportunities to grow as physician-gastroenterologist and in the medical administrationleadership field. In the year 2010, I started as board member of the CME and GME committees. In the year 2011, I was elected as board member of the Medical Executive Committee and since then I have been re-elected for that position. In 2010, there was an opportunity to start a Gastroenterology Fellowship Program; during that process I was a very active member collecting, writing and submitting all the necessary paperwork for the approval of this training program. After its approval in 2011, I worked initially as associate program director and since 2013 I have been working as its program director. Also, at the institution, I have been an attending for the residency program. Since 2012, I have had the honor to be an associate professor of medicine for Rocky Vista University

in Colorado. In 2016, I was elected by the entire Parkview Medical Centerâ&#x20AC;&#x2122;s medical staff to be chief of medicine of the institution. My leadership and vocational time has not only been at my institution; since I came to Colorado, I have also been actively involved at the Pueblo County Medical Society, initially as board member and since 2016, I have been its president. In my role as president, I have been working hard to represent the society at state, regional and national levels. Something very important to me is that throughout my career, my patients and coworkers have honored me with different awards: Fellow of the American College of Physicians, American Top Physician Awards (2011, 2013, 2014, 2015, 2016), Pueblo County Health Foundation Outstanding Medical Services and Commitment (2011), University of Connecticut Excellence in Ambulatory Care (2006), and Universidad Central of Venezuela Jose Izquierdo Award (1993). My family and mentors have taught me the value of hard work, honesty and the importance of developing a set of ethical standards in order to improve the quality of life for all people. My strongest desire now is to apply my values and what I have learned during my career and in different leadership positions to further pursue the duties of a delegate at the American Medical Association-Colorado Medical Society. This honor will give me the opportunity to grow as a physician, and also help me to represent my patients and colleagues at your prestigious institution. During my tenure as AMA delegate, I will work hard to give everything for the institution, to be an efficient member of your team and to help in the continuous improvement of all patientsâ&#x20AC;&#x2122; health. n Colorado Medicine for July/August 2017

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Candidate statement: Carolynn Francavilla Brown, MD, AMA Delegate and resident, as well as being on the the Executive Committee. I have also served on three different delegations to the AMA, representing the Medical Student Section, the Resident and Fellow Section and, currently, the Obesity Medicine Association. I have a decade of experience within the AMA and CMS that I would bring to the Colorado delegation. Throughout all these roles I have participated with the Colorado delegation to the AMA, allowing me to become familiar with how they represent CMS – and let me tell you, they do a stellar job!

Carolynn Francavilla Brown, MD Candidate for AMA delegate I became an active member of the Colorado Medical Society almost from the day I joined medical school and participated in a White Coat Lobby day at the Colorado Capitol, before I even took my first exam. I was immediately drawn to this organization that championed for the care of our patients and the betterment of our profession. I have always been a big picture person and immediately identified organized medicine as the way to improve many of the issues in health care. My organized medicine involvement includes sitting on the CMS Board as a student

I have been so encouraged by the changes we have made in health care. At the same time, the day-to-day work of being a physician continues to become more burdensome, more and more physicians are employed by large medical groups, and physician burn-out is a serious problem. And of course, more health care changes are around the corner. The AMA is a powerful voice in shaping health care change and I believe I have the experience to help move that change forward. We need to protect access to care while at the same time improving quality and reducing the cost of care.

with a partner. I have a small private practice in Lakewood that is a traditional insurance-based clinic with a mix of private insurance, Medicaid and Medicare. While many of my friends are already burned out and disenchanted with the medical field, I love what I do and truly feel I get to help my patients every day. Starting a new practice has been very educational and there have, of course, been many challenges along the way. For the Colorado delegation, I would bring a “boots-on-the-ground” perspective to the daily struggles of practicing medicine in a small practice. I am passionate about ensuring that physicians can still go into business for themselves. An important aspect of the role of AMA Delegate is public speaking, including testifying at reference committees, caucuses and in front of the House of Delegates. You know how some kids in college get scholarships for football or tennis? Well, I got one for policy debate. So let’s just say I can confidently get in front of an audience and convince them of what I need to. I have the passion, I have the experience and I have the skills to represent Colorado physicians to the AMA. n

One year after residency, I decided to start my own practice, from scratch,

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All-member electronic election open Aug. 1 - Aug. 31, 2017 Colorado Medicine for July/August 2017

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Candidate statement: Jan Kief, MD, AMA Delegate to become leaders and advocates for our profession and patients. I feel that my experience in many settings in organized medicine, and now with students, gives me the depth and breadth of insight to make a real difference at the AMA. I can effectively look at proposed policies through this lens of experience.

Jan Kief, MD, Candidate for AMA delegate It has been a pleasure serving as an AMA alternate delegate in the highlyrespected Colorado delegation. I have been a member of the AMA since I finished medical school and I was just accepted as a member of the Academic Physician Section at the AMA. My current position as adjunct faculty at Rocky Vista Medical School has given me great insights into what medical students need to receive a great education and meet the needs of being a modern physician as well as

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Although I had a lot of experience as a recent CMS past president, a House of Delegates Speaker for over a decade and CMS board member for 14 years, the AMA is a uniquely challenging place where it is necessary to be active over time and build relationships, be well prepared, collaborate and know the issues your colleagues face. While at the AMA and its other venues, I actively engage with colleagues from other states and really get to know their issues so that I can make a difference there. I finished four years as vice speaker of the 10-state Western Mountain States Conference. I also chaired the Governance Reform Task Force for the Western Mountain States Conference, which has now merged with the Pacific Rim Caucus to become the Pac West Conference. From my attendance at the Western Leadership Conference and more, I know most of the California delegation to the AMA and

am excited to get active in committees in the new caucus. It was an honor to be one of only a few physicians other than the AMA Board of Directors invited to attend and participate in the AMA/AHA Summit on Health Care Delivery Systems. Twice I was asked to be a speaker at OSMAP (Organization of State Medical Association Presidents) to speak about Coloradoâ&#x20AC;&#x2122;s Medicaid opt-in and share our experience on the health care exchange. I was honored to be asked to chair the Constitution and Bylaws Reference Committee during the June 2016 AMA Annual Meeting in Chicago. Two years ago I ran a vigorous campaign for a seat on the AMA Council on Constitution and Bylaws, an area that I am passionate about. Although unsuccessful in that campaign, I gained valuable experience and forged important relationships for the future and our work at AMA. I humbly ask for your support for reelection to continue to represent YOU in this important national work for our profession. n

About the CMS Education Foundation Founded in 1982, the Colorado Medical Society Education Foundation (CMS EF) is a nonprofit, tax-exempt charitable foundation established primarily to support educational and charitable programs in Colorado. The Foundation has dedicated itself almost exclusively to the funding of scholarships to incoming students at the University of Colorado School of Medicine and Rocky Vista University. 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. Colorado Medicine for July/August 2017

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Candidate statement: Rachelle M. Klammer, MD, AMA Delegate in Chicago. My most memorable experience from that first House of Delegates (HOD) meeting was working with other medical student members desperately trying to win support for a Medical Student Section resolution establishing comprehensive health system reform as the top priority the AMA. While it did not pass as initially brought to the HOD, the resolution was successful and within a few years the AMA had a major public relations campaign regarding coverage for the uninsured that largely stemmed from this resolution. Rachelle M. Klammer, MD Candidate for AMA delegate The Colorado Medical Society (CMS) and the American Medical Association (AMA) have been an important part of my medical career since I was a first-year medical student at the University of Colorado. I was lucky to become a part of the CMS delegation to the AMA at my first Annual Meeting

As a medical student, I had the privilege to serve for two years on the AMA’s Council on Medical Service. This experience was one of the most formative of my health policy career – advancing my knowledge of health affairs, how government policies affect physician practices, and further broadening my understanding of how the AMA functions. Serving on the council also increased my network within the AMA itself; I had access

and exposure to members outside of my region and designated section. Despite leaving Colorado for residency, the delegation was always welcoming when I returned to AMA meetings as a member of the Louisiana delegation. Working within organized medicine in another state and a different region was very educational and has broadened my perspective about issues facing physicians throughout the country. My residency program was fully supportive of my involvement in organized medicine, which allowed me to serve on the Resident and Fellow Section’s Governing Council twice. Since returning to Colorado, I have been a part of CMS’ delegation as one of our YPS delegates. This role has been a wonderful way to stay involved with both CMS and the AMA, but I would be honored to take a larger role on the delegation to the House of Delegates of the AMA. n

2018 CALL FOR NOMINATIONS

INTERESTED IN RUNNING FOR OFFICE? Any member who meets the qualifications can run for the positions of president-elect, AMA delegate or AMA alternate delegate, or participate by sponsoring or endorsing candidates. Gotowww.cms.org/uploads/2017_Election_Manual.pdfformoreinformation.Thisguideprovides 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. The deadline for candidates to announce their intention to run for office in 2018 is Jan. 31, 2018. Colorado Medical Society looks forward to all members’ participation in this process. Colorado Medicine for July/August 2017

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Candidate statement: Tamaan Osbourne-Roberts, MD, AMA Delegate proving systems of care, ensuring the continued viability of independent practice at the same time as protecting the growing numbers of physicians who choose employment. But even with so much at stake, physicians, more and more, find ourselves separated from each other.

Tamaan Osbourne-Roberts, MD Candidate for AMA delegate “A house divided against itself cannot stand.” – Abraham Lincoln, 16th President of the United States Sadly, right now, much of the country finds itself divided, and the House of Medicine is no different. There is much for us to tackle as a profession: navigating new payment systems, im-

Against this backdrop, the AMA has become a critical voice of physician unity, a place where all voices within the profession can come together to seek agreement and move forward. It has been my privilege to serve as one of the hands steering that ship, as a member of Colorado’s delegation to the AMA, and I once again ask for your vote to continue in this role. Indeed, my life experiences have prepared me well for the task. As a first-generation American of Caribbean parentage, and as an Air Force brat born in the Pacific and raised in multiple states throughout the U.S., I learned to appreciate the values of unity, diversity and tolerance from an early age. My father’s career in the U.S. armed forces taught me much

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All-member electronic election open Aug. 1-31, 2017 42

about duty and service, while my mother’s profession as a teacher reinforced in me not only these values, but also a love for problem solving and for working with people. My medical career, serving the underserved in both outpatient and inpatient settings throughout urban and rural Colorado, has given me an on-the-ground appreciation for the work of practicing physicians in multiple settings, while honing my skills in finding creative solutions to the often difficult and intractable problems physicians face in the current business environment. My policy experience, serving as president of CMS, president of CAFP, alternate delegate to the AAFP Congress of Delegates, a trustee of the Colorado Hospital Association board, and in multiple other roles, has given me a deep well of policy experience to draw from in working with the many complex parts of America’s health care ecosystem. And most recently, my work as a health system transformation change agent, helping to build Accountable Care Organizations for independent primary care practices across the country at the same time as I continue to practice as a physician here in Colorado, has allowed me to put these many lessons to use working to reshape America’s health care system from the ground up, with a view to keeping physicians at the center of it. It has been my privilege to serve as a member of Colorado’s AMA delegation over the past six years; it is my hope that you will allow me the privilege of continuing to serve you, and our entire House of Medicine, during such a critical time in our nation’s history. I ask for your support, and your vote. Thank you. n Colorado Medicine for July/August 2017

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Candidate statement: Lynn Parry, MSc, MD, AMA Delegate to champion the rights of women, minorities and the LBGTQ community â&#x20AC;&#x201C; rights for both physicians and patients. The AMA, understandably, evokes strong responses from physician members and nonmembers alike. Many physicians dropped their membership when the AMA refused to oppose the Affordable Care Act and now, members are leaving because of the AMA support of Dr. Price as head of HHS. It is important to remember that the policy of the AMA is determined by its House of Delegates.

Lynn Parry, MSc, MD Candidate for AMA delegate Physicians have had a long and ambivalent relationship with the American Medical Association. As your Colorado delegate to the AMA House of Delegates, I have been active and vocal in support of the AMA policies that expand coverage for patients and decrease regulatory burdens on physicians. As an AMA member and an AMA delegate, I work with coalitions

Colorado Medicine for July/August 2017

You can influence the advocacy of the AMA by selecting Lynn Parry as your Delegate to the AMA. The voice of Colorado physicians is recognized in the AMA because we are dedicated, have integrity and have developed close relationships with members of the HOD on all philosophical sides. In our present health care climate, physicians are struggling to balance the duties and joys of the physicianpatient relationship with keeping their doors open. Physician wellness is plum-

meting. We need health care reform, payment reform and greater leverage in an industry driven by corporate and government agendas. We need to protect our most vulnerable patients and our most vulnerable physicians. With the new CMS, you can vote directly. A direct vote is both an increased opportunity and an increased responsibility. I am asking that you look at my CV to know that I have been active in formulating the CMS policy on health care systems and that I advocate for patients. I ask that you reconsider joining the AMA since we need your commitment to influence the future of medicine. I am asking you to contact me if you have questions, concerns or, even better, ideas that will make me a better delegate. And, I am asking for your vote as Colorado delegate to the AMA. n

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Candidate statement: Patrick Pevoto, MD, RPh, MBA, AMA Delegate grew up. He was my hero and guide, setting the example for me of excellence in medical practice. I have been involved in organized medicine since medical school, including membership in the AMA. I was mentored by many fine physicians in Texas and owe much to them for showing me that getting involved in organized medicine was truly an honor and special calling.

Patrick Scott Pevoto, MD, RPh, MBA Candidate for AMA delegate I am relatively new to Colorado medicine, having moved to the Western Slope to practice in a rural setting after 25 years of practice in Austin, Texas. I am the son of a physician and pharmacist; medicine has been in my lifeblood since childhood. My father, who was a pediatrician and emergency medicine specialist, gave me many opportunities to shadow him while I

My practice in obstetrics and gynecology has involved being in solo practice for 18 years, then multispecialty, single specialty, and most recently as an employed physician in a rural setting. I know the challenges of trying to run a business, which include trying to cover overhead when insurance companies stall and delay payment repeatedly; many times, I barely made payroll though I had at least four months of revenue in receivables. It was during those moments that the networks with other physicians available to me through involvement in organized medicine became priceless and kept me afloat during times of great adversity.

The practice of rural medicine has become my newest, greatest and most fulfilling challenge. One who practices in a setting of limited resources must approach patient care from many different angles. I truly respect the men and women in rural areas who have dedicated themselves to a lifetime of such medical practices. I am grateful to the physician leaders in Colorado for giving me opportunities to serve in many capacities since I relocated here. I feel that I am well qualified to serve as your delegate to the AMA. Recent events, including the acquisition of Rocky Mountain Health Plans by United, have brought the Western Slope and issues that pertain to rural medicine to the forefront. I believe it is time for representation at the AMA level from the Western Slope once again. I would be honored to fill this role as delegate to the AMA and I respectfully ask for your support. You can reach me via my email: pspevoto@utexas.edu. n

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Candidate statement: Brigitta Robinson, MD, FACS, AMA Delegate held many positions in the states in which I resided. I was president of the Indiana State Medical School Section delegation, regional delegate from Ohio in the Resident and Fellow Section while doing my surgery residency at the Cleveland Clinic, and chaired the Young Physician Section at the AMA level once I moved to Colorado to practice. I was fortunate to be elected to be part of the Colorado Delegation to the AMA, when it became apparent I was no longer a “young physician” five years ago! Brigitta Robinson, MD, FACS Candidate for AMA delegate I have been active in organized medicine since I was a first-year medical student. Over the last 26 years, I have

I continue to enjoy debating the pros and cons of resolutions that are brought to the AMA House of Delegates and making good policy that will benefit all physicians. I am not too shy to speak out and will happily bring

any issues we have and that should be shared at the AMA. I am also quick to point out the benefits of being an AMA member and wish all Colorado physicians would join. I am currently serving as the co-chair of the Election Committee in our newly formed PacWest conference at the AMA and also serve as the “man on the ground” on the Physician Satisfaction Committee to the AMA. I am hopeful that I can continue to serve as your AMA delegate as it has been a pleasure to do so, and I feel that I have helped make practicing medicine better for all physicians. n

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Candidate statement: Michael Volz, MD, AMA Delegate welfare of the medical profession and the patients it serves).

Michael Volz, MD Candidate for AMA delegate As physicians, we share the same goals, mission and purpose as the American Medical Association (to promote the art and science of medicine and the betterment of public health) and the Colorado Medical Society (to promote the science and art of medicine, the betterment of public health, and the

We’ve trained hard, work hard and pursue what is in the best interest of our patients. Today, there are more challenges and complexities in achieving these results than ever before, and they’re coming at us from many directions. Single voices simply are not as well positioned, able or effective as organized groups of physicians to hear, understand and make changes in our efforts to overcome or mitigate these barriers. Connecting with our colleagues to best define areas and opportunities to unify and work to make improvements has been and will continue to be at the core of being successful in these efforts. What is at stake is just too important to Colorado for us to not be fully involved, engaged and active in all aspects of health care in an organized manner. Throughout my career, my love and passion for medicine has always been strong and has been strengthened by

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caring for patients and being involved in other ways to promote the science and art of medicine, the betterment of public health, and the welfare of our medical profession and our patients. Over the past 25+ years my efforts have been put to work through many organized groups. I have had the honor to serve as CMS president and in the many levels and activities of this position, as well as in many other capacities at CMS. I have also served my component society both nationally and locally in my subspecialty of allergy and asthma. Not only has my solo practice provided me with a rich source of many experiences, perspectives and lessons on managing my practice and interacting with many stakeholders critical to the day-to-day realities of providing medical care in the Denver metropolitan area, but I have also gained these experiences through my outreach clinic, which I’ve attended twice per month for more than 22 years. My training and experience as a physician, as well as my leadership roles, have taught me that engagement, reaching out and learning processes and methods to have impact in all aspects of what we do is how we will achieve these goals. We must never give up, but we must work hard to be organized and involve all of our colleagues. One of the key lessons learned during my year as CMS president is the importance of defining and improving the value proposition to CMS members and all colleagues. I believe my qualifications will provide the effective voice and mechanisms that Colorado physicians want and need to give to the AMA. I pledge that as a delegate/alternate delegate to the AMA I will strive to be one of those voices and to understand what is of value to all of you in medicine. n

Colorado Medicine for July/August 2017

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Candidate statement: Matthew Wynia, MD, MPH, AMA Delegate ance on some of the thorniest issues facing medicine. From there, I went on to found the AMA Center for Patient Safety, providing facts and tools to improve safety in ambulatory care settings. And in the four years before moving to Colorado, I served as director for physician and patient engagement for the AMA’s Improving Health Outcomes initiatives, working with physician practices to develop, test and implement practice improvement tools. Serving in these unique roles over the last 20 years, I’ve worked with and spoken to physicians in more than 30 states. Matthew Wynia, MD, MPH Candidate for AMA delegate I am native to the west, growing up in both rural and urban areas in Oregon and attending medical school in Portland before moving first to Boston and then to Chicago. My wife and I fulfilled our dream of moving back to the west when I was recruited to Colorado in 2014 to lead the University of Colorado’s Center for Bioethics and Humanities, and she is the new chief research officer for Denver Health. My center is working on all four university campuses – and reaching out across the state to support health professionals and the patients and communities we serve – grappling with challenging ethical issues. My involvement in state society and AMA leadership extends back more than 25 years, beginning as a resident, with service on the Massachusetts Medical Society Board and as an AMA delegate to the Resident and Fellow Section. I went on to serve on a number of local and national committees before being hired in 1997 to lead the AMA Institute for Ethics in Chicago, charged with understanding ethical dilemmas physicians face in practice and providing data and guidColorado Medicine for July/August 2017

In my roles as a researcher, speaker, negotiator and advocate for patients and physicians, I have also led projects with the National Academy of Medicine and many other private sector, state and federal government agencies and organizations, seeking changes in health care to help our patients and our profession. In sum, my career has led me to gain a working knowledge of American med-

icine, and the AMA in particular, that is both deep and broad. Success in these various roles has always required that I work effectively with local and national leaders, sometimes across seemingly-cavernous ideological divides. While it may seem that today we are more divided in our nation and profession than ever before, I’ve been on the front lines for the failed Clinton health reform efforts, the Sunbeam scandal, and bitter rhetoric around issues from malpractice reform to the “org of orgs” debate, to the regulation of foreign medical graduates in the U.S., to the use of military physicians in the “enhanced” interrogation program. In navigating each of these situations, as today, I’ve known there is much more that unites us as physicians than stands between us. I will continue to seek common ground and practical solutions to the challenges we face; I would be honored to do so as a delegate from Colorado to the AMA. n

Now scheduling Regional Forums across the state! Colorado Medical Society leaders are ready to travel to your community for a homegrown meeting open to all physicians. CMS will work with you or your component society to plan and execute the event. Email president@cms.org or call 720-858-6321

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2017 CMS Annual Meeting Sept. 15-17 Beaver Run Resort, Breckenridge, Colo.

Kate Alfano, CMS Communications Coordinator

Sail away to fun, socializing, education and more at the 2017 CMS Annual Meeting in Breckenridge Fun, collegial and informative. These three words summarized last year’s reengineered CMS Annual Meeting and our 2017 annual meeting workgroup is already hard at work to build on its successful format that emphasized social events and professional development sessions. The 2017 meeting will be held Sept. 15-17 at Beaver Run Resort in Breckenridge, and we hope you and your family will make plans to join us. As always, there is no registration fee for members and we have secured discounted group pricing on lodging at the resort. Once again, our annual meeting will be entirely devoted to celebrating the community of medicine, bringing Colorado physicians together for social, clinical and intellectual stimulation. Attendees will experience informative panel discussions and worthwhile workshops on the hottest topics in medicine, led by an impressive slate of state and national speakers, including: • End-of-life care, • Compassion fatigue with live actors, • Cyber security • Telehealth, • Practice transformation, • Alternative practice models, 48

Hotel accommodations: Reserve your room online at tinyurl.com/2017-lodging Register: www.cms.org/ register Bring your kids for the Children’s Activity Center! Plan to bring your kids and register them for fun-filled activities Friday evening, Saturday morning/afternoon • Prescription drug abuse/opioids, • Federal health care reform, and more! We’ll also have special public policy training for medical students with Joe Gagen, JD. Plus, you’ll get to explore beautiful Breckenridge, a top mountain destination, in its gorgeous fall colors. Families can join the fun, too! Childcare will be provided with advanced registration. Breckenridge offers activities for all ages: spa time, history, guided hikes, a saloon tour, ghost tours, gold mine hikes and panning, the Mountain Top Children’s Museum, the Edwin Carter Discovery Center…the list goes on and on!

and evening, and/or Sunday morning while you are enjoying the conference. Snacks and lunch will be provided. Parents/ guardians can attend and participate, but are not required. Children will be grouped by age and will participate in ageappropriate activities. More information available at www.cms.org/events/annualmeeting You won’t want to miss the CMS signature events: a sailing-themed exhibitor reception Friday evening with great food, live music and fun catching up with your colleagues; the COMPAC Luncheon midday Saturday for insightful political commentary; and the black-tie Presidential Gala and COPIC dessert buffet Saturday evening to kick off the presidency of M. Robert Yakely, MD. We can’t wait to welcome you and your family to the 2017 CMS Annual Meeting Sept. 15-17 at the Beaver Run Resort in Breckenridge. Find more information and to register online at www. cms.org. n Colorado Medicine for July/August 2017

CMS ANNUAL MEETING AGENDA: DAYS 1 & 2 FRIDAY, SEPTEMBER 15 12:00 p.m. - 12:45 p.m. 12:00 p.m. - 1:00 p.m. 1:00 p.m. - 5:00 p.m. 3:00 p.m. - 3:30 p.m. 3:00 p.m. 5:30 p.m. - 9:30 p.m. 5:30 p.m. - 7:30 p.m. 7:45 p.m. - 9:30 p.m.

Finance Committee BOD Lunch Board of Directors (open to all CMS members to attend) BOD exhibitor break and refreshments Registration opens for all members and guests Children’s Activity Center (child care) Exhibitor reception, including appetizers and cash bar What the Heck Just Happened? Health Policy Beyond 2017 (We WILL Get Through This!) Len Nichols, PhD

SATURDAY, SEPTEMBER 16 7:00 a.m. - 8:00 a.m. 7:00 a.m. 7:00 a.m. 8:00 a.m. - 3:45 p.m. 8:00 a.m. - 9:00 a.m.

Healthy Choice Breakfast Early-riser Yoga Early-riser Hike with Dr. Osbourne-Roberts Children’s Activity Center (child care) Should Health Care Institutions be the Epicenter for Health? Patricia Gabow, MD

9:00 a.m. - 10:00 a.m.

Increasing Compassion in the Patient-Physician Relationship Care Equity Project

10:00 a.m. - 11:00 a.m. 11:15 a.m. - 12:15 p.m.

Exhibitor Break and Giveaways Workshops Cyber Security: Cyber Extortion (Ransomware), Practical Protective Measures and How to Survive an Attack Eliot Payson Telehealth Update Elizabeth A. Krupinski, PhD PLSS programming – Creating Civil Teams: Awareness to Action Deborah Center, MSN, RN, CNS, CTA-CC PLSS programming – Physician Engagement: Autonomy, Mastery and Meaning Kathy Kennedy, DrPH, MA Compassion Fatigue and Physician Burnout: A Care Equity Project Module Betty Hart What’s REALLY Happening with the Colorado End of Life Options Act? An Ethical and Operational Reality Check Jennifer Moore Ballentine, MA

12:30 p.m. - 1:45 p.m. 1:45 p.m. - 2:30 p.m. 1:45 p.m. - 4:00 p.m.

Student Track: Public Policy Joe Gagen, JD COMPAC Luncheon: What’s Next? State-view Update of Federal Health Care Reform – Michele Lueck Student Track: Public Policy (cont.) – Joe Gagen, JD

2:45 p.m. - 3:45 p.m. 3:45 p.m. - 5:30 p.m. 5:30 p.m. - 9:30 p.m. 5:30 p.m. - 6:00 p.m. 6:00 p.m. - 11:00 p.m.

Workshops (repeated) Free time Children’s Activity Center (child care) Inaugural Gala Reception Inaugural Gala

10:00 a.m. - 12:30 p.m.

• Roundtable Discussions • BOD Q&A • Who are CMS/AMA?

• COPIC Dessert Reception

Colorado Medicine for July/August 2017

CMS ANNUAL MEETING AGENDA: DAY 3 SUNDAY, SEPTEMBER 17 7:00 a.m. - 9:00 a.m.

Healthy Choice Breakfast

7:00 a.m. - 8:00 a.m.

Top Ten: What’s New in the World of Safety and Liability Lee Morgan, MD (CME and COPIC Points available)

8:00 a.m. - 11:00 a.m.

Children’s Activity Center (child care)

8:00 a.m. - 9:00 a.m.

Breakfast with the BOD

8:00 a.m. - 9:00 a.m.

Alumni Breakfast

8:00 a.m. - 9:00 a.m.

Hot Legal Topics in Health Care Mark Fogg, JD (CME and COPIC Points available)

8:00 a.m. - 10:45 a.m.

Student Track: Public Policy (cont.) Joe Gagen, JD • MSS Annual Meeting wrap-up

9:15 a.m. - 9:30 a.m.

COPIC Update and General Session Mark Fogg, JD • Science fair winner presentation

9:30 a.m. - 10:45 a.m. 10:45 a.m.

The Opioid Crisis: Latest Developments in the U.S. and Colorado Robert Valuck, PhD Closing comments M. Robert Yakely, MD

CMS 2017 Annual Meeting Sept. 15-17 • Beaver Run Resort • Breckenridge CMS thanks the following sponsors and exhibitors for their support of this year’s annual meeting

Presenting Level Sponsor

COPIC Gold Level Sponsors Colorado Drug Card UnitedHealthcare

Exhibitors

Center for Personalized Education for Physicians CIGNA HealthCare Colorado Physician Health Program CORHIO Dynamic Physician Billing Solutions First Healthcare Compliance Medical Telecommunications National Healthcare Realty Radiology Imaging Associates Tysys

Colorado Medicine for July/August 2017

Annual Meeting Registration Now Open

Colorado Medical Society Annual Meeting • Beaver Run Resort • Sept. 15-17, 2017 Visit www.cms.org/events/annual-meeting to register online. It’s quick, simple and secure. Registration is required for the Children’s Activity Center; go to the meeting webpage for details and to register your kids.

Name (please print) Component Society Name of Spouse/Guest(s) CMS Connection Member q Yes q No Registration deadline is September 5, 2016. Registrations accepted on a first-come, first-served basis (may be limited for some

programs). For purposes of registration, Connection members and staff of county medical societies are considered members. You must indicate the number of attendees for each function so that we may be cost efficient with food/beverage orders.

Friday, September 15 member spouse/guest 5:30 p.m.

Exhibitor Reception

Saturday, September 16 (Complimentary for member and one guest only) 7 a.m. 12:15 p.m. 5:30 p.m. 6 p.m.

Breakfast Buffet COMPAC Lunch Inaugural Gala Reception Inaugural Gala Meat dinner Vegetarian dinner Vegan dinner Gluten-free dinner

charges for additional guests

q #_______ @ $35/each_________

q #_______ @ $105/each_________

8 a.m.

Breakfast Buffet

#_______ @ $35/each_________

#_______ @ $105/each_________

Sunday, September 17 member spouse/guest

TOTAL amount enclosed for non-members and additional guests.

#_______ @ $35/each_________

Please make check payable to: Colorado Medical Society, or charge ❑ Visa ❑ MasterCard ❑ Discover ❑ Am. Express

#exp. date

Signature

or e-mail this form to dianna_mellott-yost@cms.org; mail it to PO Box 17550, Denver, CO 80217-0550; or fax it to 720-859-7509

Hotel Reservations Reservations must be received by Monday, August 14, 2017, to be eligible for the group rate. Visit www.cms.org/events/annual-meeting or tinyurl.com/CMS-2017-hotel to reserve your room today. ROOM TYPE RATE Hotel Room (2 double or queen beds) $147 Studio (1 queen bed, 1 queen sofa bed in open floor plan) $162 Breckenridge Studio (1 queen bed, 1 queen sofa bed in expanded layout) $167 Colorado Suite (1 queen bed, 1 queen sofa bed in open floor plan) $177 Summit Suite (1 queen bed, 1 queen sofa bed in expanded layout) $182 One Bedroom Suite (1 queen bed in private bedroom, 1 queen sofa bed) $182 Building 4 One Bedroom (1 queen bed in private bedroom, 1 queen sofa bed) $197 Two Bedroom Suite (1 queen bed in first bedroom, 2 queen beds in second bedroom, 1 queen sofa bed) $245 Building 4 Two Bedroom (2 queen beds - 1 in each bedroom, 1 queen sofa bed) $245 Colorado Medicine for July/August 2017

Colorado Medicine for July/August 2017

Inside CMS

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

Back to the basics: Cyber risks Tips to prepare your organization for emerging digital threats In May, we were reminded of the cyber vulnerabilities that exist when a worldwide ransomware attack – referred to as WannaCry – infected more than 230,000 computers in over 150 countries. Hackers used a security flaw in Microsoft Windows to gain access to systems, and then they encrypted data files and demanded a “ransom” from users in bitcoins (a digital currency system). Security experts were able to address WannaCry quickly, but these types of attacks are becoming more common and health care remains a key target. BakerHostetler, a national law firm that focuses on cyber legal issues, recently published its Third Annual Data Security Incident Response Report. The following are highlights from the report’s “Basics to Minimize Risk,” a set of best practices on how to prepare and respond to cyber risks. Increase awareness of cyber security issues Employees should be aware of cyber risks and threats so they are informed on how to prevent and mitigate an incident. Organizations should proactively train employees on phishing and other social engineering threats. COPIC offers seminars and other resources to help educate insureds on this topic, and another great source of information is www.healthit.gov, a website overseen by the Office of the National Coordinator for Health Information Technology that provides EHR and mobile device security tips, training modules and videos, and a security risk assessment tool. Identify and implement basic security measures The following are top preventative measures a company can take to address vulnerabilities: • Use multi-factor authentication for remote access to any part of the company’s network or data (i.e., email platforms like Outlook). • Maintain a patch management system to ensure critical software patches are installed promptly. • Remove admin rights from normal users and limit the number of admin accounts. • Install a web proxy to block access to untrusted websites. • Conduct periodic vulnerability scans and penetration tests to help improve the security of your network and systems. Colorado Medicine for July/August 2017

Build business continuity into your incident response plan Having data and systems unavailable can shut down an organization’s primary operations (i.e., patient information systems) and key questions the BakerHostetler report suggests to consider are: • Have you conducted a business impact analysis to identify the most critical systems and downtime impact? • What are the systems backup procedures? • How often are the full systems backed up? • Where are the backups stored, and for how long? • What are the procedures for restoring systems and testing them to ensure functionality? Manage your vendors Many vendors have some type of access to an organization’s systems and networks, and the vendor’s cybersecurity practices might not be up to snuff. Take these into consideration when engaging vendors who access, process or store sensitive information: • Do they have an incident response plan and will they share it? • Do both parties understand the information (and level of sensitivity) being given? • Are the business associate agreements compliant under HIPAA? (if applicable) • How are you monitoring your vendors during the relationship? • Do you have a questionnaire or checklist to gauge the vendor’s information security practices and controls? • Are there notification provisions in the agreement in the event of an incident to address required notice and who bears the financial responsibility? Cyber risks have created a new area of focus for medical professionals that requires ongoing education and heightened awareness. Managing these risks is challenging and not an easy task for medical practices. Therefore, COPIC continues to look at resources to help our insureds implement best practices and adequately prepare. It’s another way we are dedicated to providing trusted guidance and support as technology influences the ways health care evolves. n 53

Inside CMS

Reflective writing is an important component of the CU School of Medicine curriculum. Beginning in the first semester, medical students write essays, stories or poetry that reflect what they have seen, heard and felt. Reflections is edited by Steven Lowenstein, MD, MPH, and Tess Jones, PhD. It is dedicated to the memory of Henry Claman, MD, Distinguished Professor of the University of Colorado, founder of the Arts and Humanities in Healthcare Program, and original co-editor of this column.

Sally Peach University of Colorado School of Medicine

Sally Peach is a fourth-year medical student with big plans to become a pediatric emergency physician. She grew up in Gastonia, N.C., and completed her undergraduate degree at the Massachusetts Institute of Technology. Sally is part of the Medical Scientist Training Program (MSTP) and received her PhD in Molecular Biology. She enjoys hiking fourteeners, bicycling long distances, teaching the youth, and traveling all over the world.

To be human stevie always reminded me to be human, so when VA afternoons end early, i grab cheesman park dirt and get earth grit in my palm creases. yet you never had even a moment to feel this morning sun. now We choose: before constellations dim, before frost thaws, We gather. 54

your last breath gone, your metronome broken; We hold your hand. or We are prerounding. “Code Blue” comes through the intercom. We run down 6 flights. you are naked, your genitalia is on display. We thrust hands on your chest, force blood through your body. We stick a tube down your throat; blood and secretions splatter Our glasses. We shoot medicines into your veins. We keep pumping; We know this is futile. We continue until your brother runs into the room, weeping-screaming for Us to stop. As We linger until our turn to file out, We hear his anguish howl through halls. then We round on the other patients. We write lengthy notes that will not be read, and the day goes too long for park dirt. so we didn’t have the chance to be human. 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 tax-deductible donation of $25, $50 or more to help CMSF continue its mission. Questions? Call 720-858-6310. Colorado Medicine for July/August 2017

Colorado Medicine for July/August 2017

Departments Inside CMS

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

Benjamin Horn Rocky Vista University College of Osteopathic Medicine Benjamin Joseph Michael Horn, OMS I, grew up in Phoenix, Ariz., and attended The University of Arizona for a Bachelor of Science in Organismal Biology and a Bachelor of Arts in German Studies; thereafter he obtained a masterâ&#x20AC;&#x2122;s degree in Bioethics at KCUMB in Kansas City, Mo. Benjamin has a strong passion for end-oflife care, specifically with pediatric patients. When Benjamin manages to put the books down and get out of lab, he enjoys hiking, backpacking, ultimate Frisbee, board games, puzzling and shark diving in the summer months.

Sharing in suffering On March 23, 2014, my definition of the doctor-patient relationship changed. It was at this time that a resident approached the foot of my bed to inform me that imaging results showed I had thyroid cancer. As the words left his lips, I felt time slow to a halt. Cancer. The word rang through my ears and cut through me like glass. I felt myself losing touch with reality. However, in one uncontrollable instant, I was brought back; the resident wanted to know if I had further questions before he left to attend to his other patients. As I looked in disbelief at the news, my body resorted to the only primal action that it could remember: crying. As the tears rushed down my cheeks, I saw a look of apprehension and confusion from the resident. No standardized patient in the course of his schooling could have prepared him for this moment, but yet, here we were sharing in the 56

moment. Sensing the urgency of the situation, the physician withdrew from my room in haste to grab the attending; this was no task for one individual to handle alone. I sat in my hospital room crying, lost within the confines of my mind. This was a difficult time and place to be as I began to realize that it was no longer possible to go back to the way life was. I was no longer just an aspiring medical student or middle child; I was now a cancer patient. Nothing could turn the clock back to change the previous five minutes with the resident. Instead, I needed to focus to consciously make informed decisions, and I had to redefine my very sense of being; I had to find that which I found meaningful and important within my existence to move forward. Unfortunately, it is easier said than done. Luckily for me, my quest for guidance was answered with a reverbing knock at the door as the attending oncologist entered my room. The physician sat down at my bedside and gently placed his hand upon my shoulder. No words were exchanged between us at first, but when he looked at me, I felt like we connected on a more personal level; I was more than just another one of his patients. It seemed as though the weight of my concerns were being shared with him. During my two weeks in the hospital, the oncologist sat with me each day for two hours to discuss findings, develop a plan and learn who I was. Whereas the burden of treatment felt insurmountable beforehand, it now seemed as though it would be possible to tackle. With the oncologist standing by my side, I knew that I had found someone who was actively willing to participate as a direct subject within my suffering. He was someone that I knew I could depend on for my voice to be heard, as well as for him to take the appropriate action to ensure that my needs were met. But the story does not end there. To this day, my oncologist and I have retained a strong interpersonal relationship. Despite being nearly 900 miles away from one anothColorado Medicine for July/August 2017

Inside CMS er, my oncologist still takes the effort and time to check on me annually. We go over recent scans and imaging results, but then we discuss how other matters of life and school are going. When we talk, I still feel like he is as dedicated to my health and wellbeing as he was that first day when we met. I never would have imagined that I would leave that hospital room with a physician who is not only interested in my physical health but is genuinely invested in me as a human being. Illness, and the suffering that comes with being ill, is articulated through the dialogue of the physician-patient interaction. The experiences that the patient generates through their symptoms and treatment is, in turn, interpreted by the physician. Our experiences of suffering are part of a bigger picture that beg to be shared and experienced with others. These narratives of suffering have no definable beginning or end. My medical suffering is but one chapter that will define not only my own future career within medicine, but that will also impact the lives of others who hear my story and take active roles in it. It is crucial as I continue to share my own narrative that I explore by myself, and with others, interpretations of my story. When I reach my clinical years at RVU, I hope that I will be able to reach my patients in the same way as my oncologist reached me. I want to afford my patients the same time that my physician invested in me by taking the time to sit down and truly understand my patients: who they are, what they desire, what makes them unique. These goals will provide me the opportunity to grow, experience different perspectives and beliefs from others, and offer a healing role in my patientsâ&#x20AC;&#x2122; illness narratives. n

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

Colorado Medicine for July/August 2017

Departments

medical news Primary care payment for Medicaid providers is changing Primary care payment for Medicaid providers is changing. The Department of Health Care Policy and Financing (HCPF) will be implementing an alternative payment methodology (APM) for primary care beginning in December 2017. The goal of the APM is to: • Provide a long-term sustainable investment strategy in primary care. • Reward performance while maintaining flexibility, transparency and accountability for both providers and the department. • Create alignment across the delivery system and across other payment reforms. The APM is essentially a transformation of the 1202 bump. The Affordable Care Act provided federal funding for a temporary increase in primary care

rates starting in 2013. When the federal funding expired on Dec. 31, 2014, the state chose to continue the 1202 bump with general fund dollars. The department’s budget request for fiscal year 2017-2018 asked for a continuation of the 1202 bump with the addition of a value proposition. The APM is that value proposition. HCPF developed the APM collaboratively with physicians and others. The department convened six workgroups with representation from primary care physicians, Regional Care Collaborative Organizations (RCCOs) and primary care practice coordinators. The groups met consistently over six months and had input in almost every aspect of the APM. The model is a point-based system.

Practices will choose quality measures they want to focus on. Those measures are assigned a point value and if practices achieve their goal for the measures and earn enough points they will receive enhanced payment on a defined set of primary care codes, what we are calling the APM codes. The department recorded a webinar on the APM. To access this webinar and other materials, visit the department website at www.colorado.gov/hcpf. Click on “For Our Stakeholders,” then “Committees, Boards and Collaboration.” Scroll down to “Primary Care Payment Reform.” The department will conduct another webinar in August. Look for information soon with date, time and how to register. n

Carriers file to offer health insurance plans in Colorado in 2018 On June 19, 12 health insurance carriers submitted their 2018 Affordable Care Act (ACA) plans and premiums for the individual and small group markets to the Colorado Division of Insurance (DOI) for review. DOI will begin an initial review of the proposed plans and premiums and will make them available for viewing and public comment on July 14. “Based on the plans filed, there is at least one insurance carrier planning to offer plans in every county in the state,” said Colorado Insurance Commissioner Marguerite Salazar in a news release. “That is great news for Colorado. However, it remains pivotal that the Trump administration commits to funding the cost-sharing reduction (CSR) subsidy payments in 2018. As I said in a letter to the Colorado Con 58

gressional delegation in April of this year: ‘Using the CSRs as a bargaining chip is tantamount to gambling with Coloradans’ access to health care.’” The following carriers filed plans in both the individual and small group markets: Anthem (both HMO Colorado and Rocky Mountain Hospital and Medical), Bright Health, Cigna, Colorado Choice, Denver Health Medical Plan, Freedom Life, Kaiser Permanente, and Rocky Mountain HMO. The following additional carriers filed plans in the small group market: Aetna, Humana, Rocky Mountain Health Care Options, and UnitedHealthcare. By July 14, DOI staff will complete an initial review of the information to

make sure the filings are complete and in the correct format. It also provides time for the insurance companies to adjust their plans and premiums depending on the information the insurers receive from the federal government on June 30 regarding the risk adjustment program of the ACA. Throughout the summer, DOI staff will examine the plans to ensure they meet ACA requirements and that the premiums satisfy statutory and regulatory requirements. As part of that process, public comment will be taken until Aug. 4, 2017. In late September/early October, the division will release the final list of approved plans and premiums for 2018, along with analysis and summary information. n Colorado Medicine for July/August 2017

Departments

CMS supports petition to limit damages in medical malpractice cases

medical news Medical students meet to discuss updating bylaws, upcoming events

Susan Koontz, JD, CMS General Counsel, and Mark Fogg, JD, COPIC General Counsel CMS partnered with several other health care advocacy groups, including COPIC, to file an amicus (friend of the court) brief to support a petition filed by Children’s Hospital with the Colorado Supreme Court to review the issues in an approximately $14 million verdict against Children’s Hospital. The case involved allegations of mismanagement by hospital staff and physicians surrounding a surgical procedure to repair an aortic coarctation in a four-day-old child and resuscitation attempts following cardiopulmonary arrest resulting in hypoxic-ischemic brain injury. Following the verdict, the trial court considered evidence of whether “good cause” existed to exceed the Health Care Availability Act (HCAA) damage cap of $1 million. Children’s Hospital argued that the trial court should consider the totality of the circumstances by considering the significant resources available to the child and determining a more precise measure of damages pursuant to the legislative policies set forth in the HCAA. Children’s also argued that the trial court should eliminate any areas of potential double recovery. The trial court did not agree with the position taken by Children’s Hospital. The Colorado Court of Appeals affirmed the trial court’s ruling. CMS, along with the other health care advocacy groups, respectfully believed that the rulings were not consistent with the policies of the HCAA and participated in funding the preparation of an amicus brief in support of the petition to the Colorado Supreme Court to reverse the prior trial court ruling and Court of Appeals opinion. n Colorado Medicine for July/August 2017

The CMS Medical Student Council (CMS-MSC) held their final business meeting for this academic year on May 11. The business meeting focused on continued evaluation of current bylaws for each school and formation of an MSC Bylaw Review Working group to begin the task of updating the CMS-MSC bylaws. Other items of discussion included new member event planning for the fall, student track planning for the CMS annual meeting, and updates on a successful opioid overdose prevention session held by the students. n

Cost commission issues third and final report on addressing health care costs The Colorado Commission on Affordable Health Care issued its third report to state policymakers on June 30. The report details recommendations to address rising health care costs, including studying the effect freestanding emergency rooms have on health costs, provider utilization rates in rural Colorado, substance use disorders, and confronting aggressive and opportunistic drug pricing. “Addressing the rising cost of health care is a complex matter, but the Colorado Commission on Affordable Health Care has made tremendous progress identifying key steps the state can take to confront this monumental challenge,” said Bill Lindsay, the commission’s chairman. “This

third report is the result of years of work – but more needs to be done. In addition to its recommendations, the commission also has highlighted a series of area for further study. Colorado’s elected leaders should build on these recommendations and continue to strive to confront the primary drivers of rising health care costs.” Their recommendations include training physicians on how to effectively present options to patients about end-oflife care and developing licensing standards for freestanding emergency rooms. The commission, created through Senate Bill 14-187, previously issued reports to lawmakers and the governor’s office in 2015 and 2016. n 59

Departments

letter to the editor Take lesson from description of New Zealand health care system Was it irony that appearing in the May/ June 2017 Colorado Medicine, “Back in the spotlight - How will federal health care reform work for Colorado?,” was Dr. Genie Pritchett’s delightful article about practicing in New Zealand? This colorful piece was nestled betwixt the countless articles about the challenging health care issues facing CMS, our state and our nation. Can you imagine practicing where you don’t need to hire a coder or someone to deal with insurance denials or to collect the bills? Those of us who favor a single payer system, such as New Zealand’s, believe that a Medicare for All program in the U.S. would reduce costs, improve access and put the focus on quality of care. Most World Health Organization

measurements of health statistics show better rankings than the U.S. in countries like New Zealand, Canada, France, Spain, Japan and the United Kingdom, to name but a few. Citizens in those countries do not go bankrupt because of inability to pay medical bills. Citizens in those countries have a right to health care, hence no reason to delay access for financial reasons. Doctors rarely face malpractice suits in nations that offer universal coverage. Further, there is no impetus to do more procedures or surgery than necessary, since income is unrelated to fee for service.

pharmaceutical companies. Yet, most Americans do support an “expansion of Medicare to provide health insurance to every American,” according to an April 2017 poll by the Economist/YouGov.

To undertake such a huge shift in our system would require major campaign finance reform and saying goodbye to lobbyists from health insurance and

Respectfully, Howie Wolf, MD n

When organized medicine leaders and the politicians we elect to represent our views finally acknowledge the social injustices in our for-profit health care system – especially how the poor and many people of color are marginalized – perhaps an article such as Dr. Pritchett’s would be regarded as serendipitous rather than ironic.

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Departments

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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Colorado Medicine for July/August 2017

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Features

the final word Sen. Chris Holbert, Senate Majority Leader

Senate Bill 17-088: Colorado General Assembly addresses network adequacy My experience with network adequacy or, more accurately, inadequacy, began in October 2016. At age 55, I had not yet received my first colonoscopy and my wife made it clear that I would get one – prior to the opening of the 2017 legislative session on Wednesday, Jan. 11, 2017. Because I am in reasonably good health, rarely see a doctor and take no prescriptions, I needed a primary care physician. I had never visited the doctor whose name was listed on my insurance card and I discovered that he no longer practiced at the clinic listed on my card. So I explored my insurance company’s website to find a primary care physician, schedule a physical examination and obtain a colonoscopy referral. The website listed dozens of doctors in my network who were located in the Parker and Lone Tree area where I live. Many were listed as accepting new patients…so far, so good! However, after calling several offices to inquire about the dozens of doctors listed, I discovered that the earliest available appointment for a physical was in late January 2017: four months out. That seemed more an indication of the inadequacy of my network. That judgment was not about doctors – but against the insurance company. Its promotion described a large number of excellent providers who were willing and ready to see me – all within a predetermined network that would offer quality, convenience and pre-negotiated pricing. What I found was limited availability. With no appointments available, the cost exposure of my insurance company was zero – at least for that four-month 62

period prior to the first available appointment with a doctor. Such limited access might be more common in rural communities where few doctors are located. However, in north central Douglas County between Sky Ridge Medical Center and Parker Adventist Hospital, we have a thriving and growing medical community. My own experience came on the heels of meetings with the Colorado Medical Society during the summer and fall of 2016. I listened to the growing frustration with network adequacy decisions. Some of those very doctors with whom I met have offices within a mile of my home. I heard from many doctors who had been deselected from one or more networks with no explanation as to why, but were left having to explain to their patients that they could no longer treat them due to an unexplained decision by an insurance company. Knowing that there were doctors near my home who were not only seeking new patients but who were literally having patients taken away while I could not find a physician was frustrating. In the end (no pun intended), I was able to schedule an appointment with a physician’s assistant within a few weeks and received a referral for a colonoscopy before the start of the legislative session. PA, yes; doctor, no. My experience proved that the perspectives shared by many doctors were accurate: Insurance companies and doctors may agree on prices and services, which play a role in controlling costs. But insurance companies also control costs by limiting the supply of doctors in relation to patient demand. When that occurs,

the value of insurance to the policyholder plummets. It was a pleasure to work with the Colorado Medical Society – particularly Susan Koontz, JD, CMS general counsel and senior director of government relations; Marilyn Rissmiller, CMS senior director, division of health care financing; and Jerry Johnson, contract lobbyist for CMS – to craft Senate Bill 17-088, which I carried in the Senate with my friend, Sen. Angela Williams. Most important, the bill requires health insurance companies to develop and use standards for selecting and tiering participating providers. Insurers are now required to make their standards publicly available. Insurers must also provide written notice to a provider at least 60 days in advance of a deselection or tiering action, and allow providers to request reconsideration of such a decision. Read more about what the bill does on pages 9-10 of this issue. After much discussion and negotiation with insurers, SB 17-088 passed the state Senate on a vote of 30 Yes and 5 No, with 14 co-sponsors. It then passed the House with strong bipartisan support and was signed into law by Gov. Hickenlooper on Tuesday, April 18. Thank you to all the doctors who took the time to meet and brief legislators and candidates last year, sharing both your frustration and personal experience with network adequacy. Thank you for taking the time to contact legislators to advocate for the bill. Thank you to all the CMS members and staff who testified in committee and worked on amendments. Congratulations, CMS. It is an honor and privilege to work with you. n Colorado Medicine for July/August 2017

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