May-June-13 by Colorado Medical Society

March/April May/June 2013 2013

Volume 110, Number 3 2

Beyond theory

Colorado moves forward on health care payment and delivery redesign

Colorado Medicine for May/June 2013

Award-winning publication of the Colorado Medical Society

Colorado Medicine for May/June 2013

cont n ent nt ns nt May/Jun 2013, Volume 110, Number 3

Features. . . 8

Cover story

Colorado is moving beyond theory into implementation of payment reform and health care delivery redesign. This issue features a series of cover stories on the topic with coverage starting on page 8.

Inside CMS 5

President’s Letter

Executive Office Update

ICD-10 Training Coalition

Maintenance of Licensure

Reflections

COPIC Comment

Departments 40

Medical News

Classified Advertising

Colorado goes beyond theory and moves forward on health care payment and delivery redesign–Colorado Medicine invited six of the largest health plans in the state to write and submit articles sharing Colorado examples of innovative collaboration between health plans and physicians on new approaches to health care payment and/or delivery redesign. Read more: • Rocky Mountain Health Plans . . . . . . . . . . . . . . page 9 • Colorado Access . . . . . . . . . . . . . . . . . . . . . . . . . page 11 • Kaiser Permanente . . . . . . . . . . . . . . . . . . . . . . . page 13 • Cigna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 15 • Anthem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 17 • UnitedHealthcare . . . . . . . . . . . . . . . . . . . . . . . . . page 19

Medicaid Accountable Care Collaborative–Physicians are working to accelerate local innovations as Colorado moves forward on the Medicaid expansion.

Governor's vision for health and wellness–CMS supports the governor's efforts to make Colorado the healthiest state in the nation.

Signs of change–AMA President Jeremy Lazarus, MD, shares recent signs of optimism that point to an SGR fix by Congress in 2013.

Big picture data–Working with CIVHC, CMS physicians are helping develop the specifics of physician performance public reporting by the all payer claims database.

Final Word–Health care consultant and medical director of CIVHC, Jay Want, MD, writes an open letter to Colorado physicians about the changing world of health care .

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

Colorado Medicine for May/June 2013

C OLOR A D O M EDICA L S O CI ET Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 (720) 859-1001 • (800) 654-5653 • fax (720) 859-7509 • www.cms.org

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2012/2013 Officers Jan M. Kief, MD

President

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

Treasurer

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

Board of Directors Susan Bauer, MS Amy Beeson, MS Charles Breaux Jr., MD Robert Brockmann, MD Ellen Burkett, MD Naomi Fieman, MD T. Casey Gallagher, MD Jan Gillespie, MD Ripley Hollister, MD Johnny Johnson, MD Richard Lamb, MD Alisa Lee Sherick, MD Lucy Loomis, MD Donald Luebke, MD Randy Marsh, MD Gary Mohr, MD Jeffrey Moody, MD Edward Norman, MD Tamaan Osbourne-Roberts, MD Bianca Pullen, MS Scott Replogle, MD Ranee Shenoi, MD Stephen Sherick, MD Julia Tanguay, MS

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

COLORADO MEDICAL SOCIETY STAFF Executive Office

Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Mellott-Yost,Director, Professional Services, Dianna_Mellott-Yost@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org Donna Jeakins, Manager, Accounting, Donna_Jeakins@cms.org Janine Hahn, Administrative Assistant, Janine_Hahn@cms.org

Division of Communications and Member Benefits

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

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@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

Division of Government Relations

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

Colorado Medical Society Education Foundation Colorado Medical Society Foundation Mike Campo, Staff Support, Mike_Campo@cms.org Donna Jeakins, Staff Support, Donna_Jeakins@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colorado, and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance. COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified.

Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Brad Pierson, Art Director, Assistant Editor; Chet Seward, Assistant Editor. Printed by Spectro Printing, Denver, Colorado

Colorado Medicine for May/June 2013

Inside CMS

president’s letter Jan Kief, President Colorado Medical Society

CMS board takes action on myriad key issues We’re in the midst of that wonderful time of year when we begin to see the signs of spring. We hear birds singing, see blooms starting to appear on the trees and, between the few remaining bouts of snow, get outside for a jog or a bike ride in the fresh, crisp air. In March, your CMS board of directors met to continue discussion on several key issues from the January meeting and raise others for consideration by the group. If you’ve been paying attention to the headlines, you know that the Colorado legislature recently debated and passed several bills relating to firearm safety. During our last board meeting, we approved a policy that CMS will support the enactment of “reasonable laws” that seek to regulate the sale and distribution of firearms to protect public health and safety. The board asked the Council on Legislation to study these bills in the context of a recent all-member survey and the COL recommended supporting measures to reinstitute universal background checks for firearm buyers and to strengthen mental health checks at the time of purchase. The board agreed and passed the recommendations. Prescription drug abuse We’ve also been working with the governor’s office and other state agencies, nonprofits and patient advocacy groups to address the growing issue of prescription drug abuse. Our top concern is to ensure that our patients who need these prescription pain medications have access to them while also ensuring they use them properly and prevent them from being diverted. The Workers' Compensation and Personal Injury Committee has spearheaded our work and the board approved its report, which sets the following long-term goal. Colorado Medicine for May/June 2013

“CMS will work to assure access to compassionate, evidence-based care for patients who suffer from acute and chronic pain, while significantly reducing the potential for medically inappropriate use or diversion and the resulting range of medical, psychological and social consequences, including addiction, overdose and death.” WCPIC advises CMS to review current evidence about the misuse of opioids and develop strategies to address it, develop and promote new tools and educational materials, develop a public outreach campaign, partner with other stakeholders, and establish monitoring and tracking systems to allow for future evaluation. Several CMS members attended roundtable meetings in early March hosted by the governor’s office and several state agencies, including the Colorado Department of Public Health and the Environment and the Department of Regulatory Agencies, to shape the full state plan on prescription drug abuse. You can read more about the meeting in a feature in this issue. Anticompetitive conduct The board moved forward on the topic of anticompetitive conduct, approving recommendations by a joint CMS-CHA work group that states that when a physician believes a final action taken by the hospital governing board against the physician is a result of anticompetitive conduct, the physician may request mediation or non-binding arbitration to resolve concerns. CMS and CHA will work together to determine what may constitute anticompetitive conduct and what the dispute resolution processes may involve, as well as develop best practices and conduct follow-

up surveys to measure the impact of these recommendations. Retooling annual meeting Though we’re gearing up for Spring Conference, the board approved a format change to the Annual Meeting starting this September. As recommended by the CMS Executive Committee, the board agreed that we should change the consent calendar process to allow more time for deliberation on strategic issues. The CMS Reference Committee will convene before the Annual Meeting to produce a report that will serve as the consent calendar, and make the final report immediately available to component societies and widely available at Friday registration for discussion and action on Saturday morning. With this change, CMS will be able to use the remainder of the Annual Meeting for strategic, interactive programming. Medical society merger For our colleagues in northern Colorado, the board approved a request from the Weld and Larimer county medical societies to merge the two components into a new entity called the Northern Colorado Medical Society. The CMS Council on Ethical and Judicial Affairs has met to prepare a formal recommendation for the board that we’ll consider at our May 3 board meeting. I hope you’re planning to join us for our Spring Conference May 3-5 in Vail to connect with colleagues from around the state, learn the steps practice transformation experts are taking to keep their practices at the forefront, and enjoy the beautiful scenery in one of the gems of the Rocky Mountains. Spring is a wonderful time to get out and about. We’ll see you there! n 5

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

ama-assn.org/go/litigationcenter

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

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

ama-assn.org

cms.org Colorado Medicine for May/June 2013

Inside CMS

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

Governor invests in visionary Colorado wellness plan Governor invests in visionary Colorado wellness plan As this issue of Colorado Medicine goes to press, Governor John Hickenlooper will be rolling out a plan that proposes to make Colorado the healthiest state in the nation. While far too many states are wrapped around the axle of partisan and ideological bickering over health care costs and entitlements, our governor has developed a plan that elevates and accelerates an already solid base of collaboration inspired by the bipartisan 208 Commission. (Preceding the Affordable Care Act by several years, the 208 Commission established a homegrown consensus framework for health care reform in 2008.) The governor’s plan also represents a paradigm shift that physicians and other health care advocates have long argued: the role of government in health care is that of an investor and collaborator, to support an investment infrastructure no less critical to economic health and growth than the same investments the state makes in public and higher education, highways water, and energy. The report makes these obvious and compelling connections over and over: "Healthier Coloradoans mean a more productive workforce, which in turn, supports economic growth, attracting businesses and skilled labor to Colorado. An improved economic outlook means additional resources and improved social and environmental conditions." The plan also formalizes the common sense notion that public health is fundamental to better health: "Research increasingly shows that health care is actually only a small component – about 10 percent – of what shapes the health of individuals. The remainder is due to genetics, individuals' behaviors and lifestyles, and the environmental and soColorado Medicine for May/June 2013

cial conditions where people live, learn, work, and play. " Shovel ready The working models of collaboration and community-centric care delivery have been evolving in Colorado since the earliest efforts that established Rocky Mountain Health Plans in Grand Junction more than 30 years ago. The current private sector care coordination projects featuring medical homes and neighborhoods, the early positive results of the Medicaid Regional Care Collaborative program, the patient engagement work of Patti Skolnik, and the many other innovative experiments now maturing into full-on systems continue the trend. The initiatives in the governor’s plan are daunting but self evident: tackle obesity; improve mental health and reductions in substance abuse; improve oral health; expand public and private health insurance coverage; close gaps in access to primary care; encourage employee wellness; expand patient centered medical homes; support access to state information and services; improve access to community-based long term care; cost containment in Medicaid over the next 10 years (which care coordination can achieve); and invest in health information technologies.

At a time of great uncertainty, we are fortunate to have a large reservoir of leaders in the public and private sectors coming together to fix problems, not blame. These are more than platitudes

While far too many states are wrapped around the axle of partisan and ideological bickering over health care costs and entitlements, our governor has developed a plan that elevates and accelerates an already solid base of collaboration inspired by the bipartisan 208 Commission. and noble ideas. The plan is grounded in the practical aspects of what works, and what could work through an inclusive approach – a very healthy start to this righteous mission. n

Join COMPAC Now! Colorado Medical Political Action Committee Call 720-858-6326 or 800-654-5653, ext. 6326 or e-mail chris_mcgowne@cms.org

Cover Series

Beyond theory

Colorado moves forward on health care payment and delivery redesign

Colorado Medicine for May/June 2013

Cover Series

Practice transformation Kevin R. Fitzgerald MD, Patrick Gordon, MPA and Lori Stephenson, RN, Rocky Mountain Health Plans

Rocky Mountain Health Plans collaborates with Western Slope physicians to promote service integration Editor's note: This issue of Colorado Medicine features a suite of cover stories written and submitted by six of Colorado's largest private health plans that were invited to share Colorado exampes of innovative collaboration between health plans and physicians on new approaches to health care payment and/or delivery redesign. For nearly 40 years, Rocky Mountain Health Plans (RMHP) has collaborated with physicians and community organizations on the Western Slope to create access, quality and health equity for commercial, Medicaid and Medicare patients – as well as for the uninsured. Built by physicians in the early 1970s to address issues associated with government programs, RMHP is one of very few health plans to enroll Medicaid members in Colorado. Changes ahead with the pending Medicaid expansion and subsidized coverage through the Colorado health insurance exchange will necessitate even greater health services integration if we hope to maintain a high level of quality and social equity in access to care. Fortunately, this change is already well underway on the Western Slope, and is taking shape in collaboration between RMHP and physician practices and networks to accelerate transformation of the system. RMHP’s work in this area began more than 10 years ago, when the health plan in collaboration with local physician organizations implemented its first program to comprehensively address chronic disease and create useful patient regColorado Medicine for May/June 2013

istry functionality. One of the first of its kind in Colorado, this program received national recognition and served as a model for other programs in this state. Beacon Two years ago Rocky collaborated with a local IPA (Mesa County Physician’s Independent Practice Association), a regional medical center (St. Mary’s), a business and civic leadership association (Club 20), and a nationally recognized regional health information network (Quality Health Network) to obtain a $12 million federal investment for an initiative called Beacon. These funds were utilized to expand the development of health information technologies and to improve the coordination of services and population health management at the point of care. By learning new skills and adopting new tools, several participants achieved success in validating performance baselines and making rapid, longitudinal improvements within their patient panels. More importantly, the lessons learned and shared through large-scale, collaboration enabled participants to create closer connections with their patients, and position themselves for more complex activities such as comprehensive care management. The experience was so valuable that RMHP and several of the participants moved forward to create broader opportunities for practice transformation, collaborative learning and payment reform. For instance, RMHP aggressively pursued participation in the Centers for Medicare and Medicaid Innovation

Centers Comprehensive Primary Care initiative (CPCi). CPCi enabled western Colorado providers to capitalize on the Beacon work, by leveraging substantial new funding from RMHP, other private payers, and Medicare and Medicaid to invest in the infrastructure required to create a new system of care and to begin to study the move away from the volume-driven fee-for-service payment. RMHP was also designated technical assistance contractor for CPCi on the Western Slope (the only health plan in the nation to receive this designation), and extended its commitment to employ personnel for practice transformation and EHR data extraction and reporting specialists to more effectively support practices as they take on the difficult work of advanced transformation. Foundations program In addition to the practices with which we are collaborating within the CPC effort, we have also developed an expanded system to create an “on ramp” to transformation through a new program called Foundations (the former Beacon program). Foundations is a program curriculum designed to provide practices with foundational knowledge and experience with quality improvement principles. Graduate practices of the Foundations curriculum can continue their work in our Masters 2013 program. This program focuses on the transformation techniques established in the Foundations program but incorporates more rigorous objectives regarding management of patients that are high risk with

RMHP (cont.) a care team approach. Both of these programs are supported with Rocky staff and include some financial incentives from Rocky to accelerate learning and off set the cost of transformation within the practices. RMHP sponsors ongoing quarterly learning collaboratives that enable participants to share experiences, problemsolve and form the relationships necessary to create a sustainable medical neighborhood. The geographic outlay of these programs has expanded from the initial seven counties in which the Beacon program operated to include practices throughout the entire Western Slope. “Participation in the Beacon program provided additional resources to our practice in terms of quality improvement coaching and health information technology training,” said Gregory C. Reicks, D.O., F.A.A.F.P., family physician at Foresight Family Physicians in Grand Junction and president of the Mesa County Physicians IPA. “The

quality improvement coaching helped transform our practice into a continuous quality improvement organization using proven strategies for implementing and sustaining change. The health information technology resources helped us to better understand the full capabilities of our electronic health record and develop an interface with our health information exchange to allow better sharing of data across our community.” “The end result is better quality of care for patients and greater satisfaction of our staff and providers. The additional funding coming into our practice through CPCi will allow us to expand our resources further in terms of care coordination, health coaching, patient engagement and activation tools, which we believe will improve outcomes in our patient population.” Global payment models RMHP recognizes that behavior is the key driver in both health and future costs. As such, we are investing in new

global payment models to accelerate the integration of behavioral health services in primary care and community settings, in partnership with academic and policy partners at the University of Colorado, Collaborative Family Health Care Association and various physician practices. Lessons learned in this effort and the transformation underway throughout our system will soon enable us to expand a truly complete and sustainable model of comprehensive care. RMHP’s overall goal is to actively support the development of the skills, technologies, workforce, and professional relationships necessary to create an accountable care community, in which all local organizations work independently – well outside their own walls and platforms (and the realm of health care itself) – to achieve a healthier and more economically-competitive community. We remain committed to effectively supporting our physician partners and being an open, active, collaborative part of the solution in health care. n

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

720-858-6306 or e-mail

tim_yanetta@cms.org

Colorado Medicine for May/June 2013

Cover Series

Managing care Palwasha Khan Marketing Communication Coordinator, Colorado Access

Colorado Access provides innovative patient-centered care through collaboration Colorado Access is a local safety net health plan that aims to provide high quality and innovative care for its members. Plan administrators understand that the best way to deliver care is though collaboration with members, providers and other organizations, as these groups are an integral part of the health engagement process Community education is key, and Colorado Access is focused on bringing care management delivery as close to the medical home as possible. The organization delegates its care management to practices that can participate within the Regional Care Collaborative Organization (RCCO). Practices that are able to partake in care management delegation receive an additional payment and expand the services they can offer to patients within their practice.

sion for support of health and wellness for Colorado’s Medicaid members. Colorado Access also works to engage directly with practices in many different ways. The organization collaborates with Sister Joanna Bruner Family Medicine Center, a patient-centered medical home. The Colorado Access RCCO teamed with the clinic to analyze data, create action plans, measure outcomes, effectively use care management, coordinate care through transitions, integrate behavioral health and participate in collaboration.

“Involvement with Colorado Access RCCO has been a great opportunity for us,” said Aaron Gale, executive director of Sister Joanna Bruner Family Medicine Center. “We strive for certain benchmarks of health care, like continuity of care and reduction of emergency room utilization. Collaboration with a health plan like Colorado Access can bring us closer to achieving these benchmarks. The goal is to target patients who are ER super utilizers and connect them to a medical home through a care manage-

The RCCO model allows Colorado Access to offer unique opportunities for healthcare professionals to engage with one another. One such opportunity is through its Best Practices & Clinical Transformation meetings. These quarterly meetings bring together a wide array of health care professionals to participate in conversations about transforming care based on best practices and available data. The organization has also developed the Virtual Community for Collaborative Care, or VC3. This web-based interactive platform provides an opportunity to continue the collaboration between the meetings in a virtual format to increase awareness, promote best practices, share resources and ideas, and showcase a viColorado Medicine for May/June 2013

Colorado Access (cont.) ment program. Our efforts are working. We are seeing a decrease in unnecessary ER use and high-cost imaging. ” Colorado Access has been active in facilitating the bidirectional integrated care partnership with Sister Joanna Bruner Family Medicine Center as well as the Mental Health Center of Denver (MHCD). Mid-sized organizations can successfully work together to improve the healthcare of patients who are a part of the behavioral health system.

Through this collaboration, the organizations are able to track improvements by finding high-risk patients and intervening for better patient outcomes. Colorado Access also provides additional services to all practices that participate in the RCCO. In 2009 Colorado Access developed a Transition Access Program (TAP) specifically for practices that are not yet ready to take on delegated care management. TAP is a patientcentered intervention that is designed

to improve continuity of care from inpatient hospital to medical home, improve member outcomes and decrease avoidable hospital readmissions, which result in lowering the cost of healthcare. Through TAP, care managers work oneon-one with members who were recently discharged from an inpatient hospital and also work with their providers. Care managers intervene by helping members better understand their diagnosis and encourage members to play an active role in self-care. The program has been successful throughout all of Colorado Access’ lines of business, including Access Advantage, Access Behavioral Care, RCCO and CHP+. “Because of our TAP program, we have seen a real decrease in the number of hospital admissions and readmissions. We want to get patients connected to a medical home because we know that is where patients will get comprehensive care,” said Laura Coleman, director of coordinated clinical services at Colorado Access. “We want our members to understand the value of a medical home relationship.”

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The overall goal is to improve quality of care while reducing costs. By aligning patients with effective care management and a medical home, they can begin to receive care that is more tailored to their needs. With this, we can begin to see a trend for better care, healthier communities and reduced cost of care, Coleman said. Health plans and practices can symbiotically work together to promote effective coordination of care, ensure Coloradans have access to a medical home and support the most effective prevention treatments. n

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Colorado Medicine for May/June 2013

Cover Series

First things first Michael Chase, Associate Medical Director of Quality and Infomatics, Kaiser Permanente Colorado

Kaiser Permanente physicians making members a priority At Kaiser Permanente, our patients are our members and we put them first. With patients/members at the center of our care, Kaiser Permanente’s integrated system supports an innovative use of teams backed by technology so physicians can focus on members’ total health.

• Highest in member satisfaction in the JD Powers and Associates Member Health Insurance Plan Study for six years in a row. • The only Medicare Five Star Health Insurance Plan for three years in a row in the country, based on quality performance.

In partnership with our members, our integrated system makes it easier for physicians to coordinate care and achieve superior outcomes. Physicians consistently look to balance quality, service and affordability to provide value to our members. The integrated system means a member’s physician and health care team, including pharmacists, and laboratory and radiology technologists, are linked electronically 24/7/365.

The awards are gratifying. They let people know we’re delivering high-quality health care. But the real reward is seeing our members get and stay healthy. One example that highlights the effectiveness of care is our approach to hypertension.

Supporting our integrated system is the electronic health record (EHR). Through the EHR, physicians communicate with each other and members, and proactively care for our members by using our information systems, including clinical registries. This coordinated approach has the added benefit of lowering health care costs. We’ve achieved some worthy recognition in our quest for total health: • 2012 Million Hearts Hypertension Control Champion from the U.S. Department of Health and Human Services • National Committee for Quality Assurance Accreditation o #1 Commercial Health Plan and #1 Medicare Health Plan in Colorado o #6 Commercial Health Plan and #2 Medicare Health Plan in the nation (out of 395) Colorado Medicine for May/June 2013

Last fall, U.S. Department of Health and Human Services Secretary Kathleen Sebelius recognized Kaiser Permanente’s Colorado region as a 2012 Hypertension Control Champion by Million Hearts™, a national publicprivate initiative of the Department of Health and Human Services. Kaiser Permanente Colorado is one of just two health care providers in the country to be recognized as a 2012 Hypertension Control Champion. What does it mean to be a Hypertension Control Champion? The designation signifies Kaiser Permanente Colorado as having had remarkable success controlling hypertension across its entire patient population, supported by verifiable data documenting the improvement. The result is fewer heart attacks and strokes for members. “The recognition of Kaiser Permanente Colorado’s hypertension control work reflects Kaiser Permanente’s dedication in engaging patients proactively and focusing on their total health,” said Bill

Wright, executive medical director, Kaiser Permanente. Measuring results Since 2008, Kaiser Permanente Colorado’s focus on managing hypertension has resulted in an improvement from an initial member control rate of 61 percent to its current control rate of 82.6 percent. Nationally, hypertension control rates hover around 50 percent. There are five central components of Kaiser Permanente’s hypertension control strategy: • Managing blood pressure in the office: Primary care physicians, nurses and clinical pharmacy staff develop long-term medication management programs for members with hypertension. • Eliminating barriers: Members with hypertension are able to receive free blood pressure checks on a walk-in or appointment basis. • Registries: Through data housed within the Kaiser Permanente HealthConnect® electronic medical record, registries are created to identify members with hypertension. • Identification of care gaps: Through the use of clinical registries, members are identified who have care gaps, such as uncontrolled hypertension that needs additional attention. • Patient outreach: Members with care gaps are proactively engaged through multiple channels, such as phone calls, mail, secure messaging and face-to-face visits. Prevention. Proactive care. Putting the member first. Physicians at Kaiser Permanente, believe this is a better way to build a healthy future. n 13

Colorado Medicine for May/June 2013

Cover Series

From volume to value Mark Slitt, Communications Manager, Cigna

Cigna's Collaborative Accountable Care program transforming physician groups across the country In 2008, well before “Obamacare,” global health service company Cigna embarked on a journey to transform the U.S. health care delivery system from one that paid for volume to one that pays for value. Cigna’s Collaborative Accountable Care (CAC) program started as a single pilot program in New Hampshire with Dartmouth-Hitchcock based on the principles of the patient-centered medical home. Since then, the CAC program has grown to involve nearly 60 physician groups in 24 states - including four groups in Colorado - reaching more than 650,000 Cigna customers throughout the U.S. who receive primary and specialty care from more than 23,000 participating doctors. The four Colorado physician practices currently participating in CAC are Colorado Springs Health Partners, Integrated Physician Network (iPN), MedSouth and New West Physicians. Cigna continues to look for additional medical groups that would be good candidates to join the program. CAC is Cigna’s approach to accountable care organizations, or ACOs. The CAC program shares the same population health goals as ACOs – the “triple aim” of better quality, affordability and patient satisfaction. “What sets Cigna's program apart from other accountable care programs is the high degree of coordination and collaboration between Cigna and the physician groups, which is why we call it collaborative accountable care,” said Mark Colorado Medicine for May/June 2013

Laitos, MD, Cigna's medical executive for Colorado.

chronic condition and lifestyle management programs if appropriate.

Cigna shares patient-specific data that physicians can use to improve care, such as lists of hospitalized patients who might be at risk for readmission; diabetic patients who may be overdue for an A1c; or patients who may have skipped a prescription refill.

Integrated Physician Network is pleased to participate in CIGNA’s CAC program as an important step toward value-based payment reform,” said David Ehrenberger, MD, chief medical officer of Avista Adventist Hospital and Integrated Physician Network. “For eight years, our 200 providers have worked successfully to drive superior quality outcomes for our patient populations. The CIGNA CAC initiative helps support our care coordination services and strengthens our population health services. Beyond better health and health care, this innovative program helps us complete the third goal of the triple aim: superior quality at lower cost.”

“Our claims data contain information that can help the physician groups identify which patients are not coming to their office but might need follow-up care or outreach, information doctors can’t get through the patient’s chart,” Dr. Laitos said. Care coordinators employed by the practices and supported by Cigna – typically registered nurses – contact these individuals to help them get the followup care or screenings they need, identify any issues related to medications and help prevent chronic conditions from worsening. Cigna also helps physician groups identify practice-specific issues, such as high emergency room use or an above-average rate of referrals to higher-cost specialists. Another important aspect of the program is clinical coordination between the physician groups and Cigna. Care coordinators work in the physician’s office and use tools that work best in that office to help their doctors reach out to patients missing opportunities for care. They can also augment doctors’ instructions by referring patients to Cigna's

“Our goal is to align incentives for doctors to expand access to care and clinical support programs, so that Cigna customers get the right care and support at the right place at the right time,” Dr. Laitos said. “We aim to improve quality, which means better health for Cigna customers and lower total medical costs. When a CAC physician group meets its annual targets for improving quality and lowering cost, they’re rewarded through shared savings. Aligning physician incentives to results is key.” Early returns on investment But does it work? Results from some early adopters indicate that it does. For example, in 2011 Medical Clinic of North Texas improved total medical cost trend by 4.4 percent while main-

Cigna (cont.) taining quality (as measured by following evidence-based medical guidelines) at 4 percent better than the Dallas/Fort Worth market. During the same period, Holston Medical Group had an overall emergency room visit rate that was 12 percent lower than its eastern Tennessee market, while avoidable emergency room visits for Cigna Medical Group were 24 percent lower than the Phoenix market. While it’s still too early to measure results for the Colorado CACs (as none of them have been in place for a full year), Dr. Laitos said Cigna expects them to perform well. “The physician groups we’re working with in Colorado all have a strong patient-centered culture and a firm commit-

ment to achieving the Triple Aim,” Dr. Laitos said. “We expect they will be able to achieve results similar to what we’ve seen in other successful practices, such as reduced emergency room use, better medical cost trend and improved health for patients with chronic conditions.” While Collaborative Accountable Care continues to grow, it’s not the only approach that Cigna is taking in an effort to move from volume to value. “Not all Cigna customers go to a doctor who is part of a large practice,” Dr. Laitos noted, “so we’re developing other programs targeted to small and solo practices.” Cigna is participating in the Centers for Medicare and Medicaid Services’ Comprehensive Primary Care program. “Cigna supports this program for our fully insured clients, when Cigna's dol-

lars are at risk. With our self-insured clients, it’s their own dollars that are at risk, so we let the client make the decision to participate,” Dr. Laitos said. n

Serving the CME needs of Colorado physicians Your bridge to quality improvement in health care Today’s CME is new and improved. It is based on practice gaps, thoughtfully designed formats and collaboration with other stakeholders, to address and overcome barriers to improved care. The new model of CME can serve as a bridge to quality health care. Colorado Medical Society accredits CME that addresses physician core competencies, ensures evidence-based content developed independently from commercial interests, and evaluates change in competence, performance or patient outcomes.

Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720.858.6309

Colorado Medicine for May/June 2013

Cover Series

Transforming reimbursements Elizabeth Kraft, MD, Medical Director, Anthem BCBS in Colorado

Anthem's new program aims to impact quality and cost of primary care Amidst all the changes in health care reform and health information technology, one key understanding has remained true: primary care is fundamental to a highly effective health care delivery system. Research tells us that primary care providers (PCPs) are in the best position to improve health outcomes and affordability for healthy patients and those with chronic conditions. Yet many PCPs are in an untenable position due to a shortage of time to deliver the care they want to provide and a shortage of resources that would allow them to get off the treadmill created by fee-for-service payment arrangements. Anthem Blue Cross and Blue Shield in Colorado is transforming the way we reimburse providers. We’re starting with primary care, because we know that empowered PCPs can make a dramatic, positive difference in the cost and quality of care. Patient-centered primary care Last year, we adopted patient-centered primary care as our new way of doing business in Colorado. Our three-year patient-centered medical home pilot demonstrated measurable progress in improving patient care and controlling costs. We saw a 1.3 percent increase in persistent medication usage, suggesting improved member compliance; better results in nearly all diabetes compliance measures; an 18 percent drop in acute inpatient admissions per thousand; and Colorado Medicine for May/June 2013

a 15 percent drop in the number of ER cases per thousand. The patient-centered primary care program design is based on the most successful parts of our early payment innovation pilot programs: • We compensate primary care physicians for care they deliver outside of face-to-face patient visits, like spending time on care planning or responding to member emails. • We give physicians access to tools and resources that can help them redesign their practices around patient-centered principles. We encourage them to adopt a true collaborative care model, using a team of caregivers to support the health and well-being of each patient. • We reward providers who succeed in delivering high-quality care and controlling costs. If actual costs are less than the projected expected costs AND the provider meets a quality threshold, then the provider group becomes eligible to receive a portion of any savings. By the end of 2016 we want to have 75 percent of our primary care doctors across the country contracted through

Anthem’s patient-centered primary care program. Today, about 380 primary care doctors in Colorado who care for more than 46,000 Anthem members are working with us under this innovative payment arrangement. Blue Priority Anthem launched Blue Priority in late 2012 as the first commercial health insurance product in Colorado designed to support the patient-centered primary care program. There are six Denver area and Colorado Springs practices participating in Blue Priority: • Colorado Pediatric Collaborative • Colorado Springs Health Partners • Mountain View Medical Group • Primary Physician Partners • South Metro Primary Care • New West Physicians Blue Priority primary care physicians and specialists will work together as a team. Blue Priority members will also have increased access to their primary care physicians, with extended hours to help reduce emergency room visits. The first PCPs Anthem enrolled in An-

Have an idea you want to share? Do you like something CMS is doing? Are we heading on the right or wrong track with our strategic plan?

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Anthem (cont.) them’s patient-centered primary care program were part of Blue Priority, but this isn’t a requirement going forward. Comprehensive Primary Care Initiative The Centers for Medicare & Medicaid Services (CMS) last year announced that 75 Anthem practices had been selected to participate in a groundbreaking multi-payer partnership known as the Comprehensive Primary Care (CPC) initiative. Under this program,

CMS will pay primary care practices a care coordination fee to support enhanced, coordinated services on behalf of Medicare fee-for-service beneficiaries. Simultaneously, participating commercial, state and other federal insurance plans are also offering enhanced payment to primary care practices designed to support high-quality primary care. The CPC initiative aligns with Anthem’s patient-centered primary care program. Both aim to significantly

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strengthen the role of primary care through financial incentives and rewards. Through both programs, Anthem is committed to offering a much more comprehensive approach to cost and quality improvement than pay-forperformance programs of the past. With financial rewards, practice support and sharing of meaningful information, Anthem’s approach aims to provide PCPs a way forward – off the treadmill and with the time and tools to deliver the kind of care every patient deserves. n

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

Call 720-858-6310 for more information and to donate 18

Colorado Medicine for May/June 2013

Cover Series

Cost control Bill Mandell, DO, JD, Medical Director, UnitedHealthcare, Colorado

UnitedHealthcare employs incentive-based models to achieve better outcomes and save money In the wake of escalating health care costs, health care reimbursement is moving away from fee-for-service and toward value-based reimbursement designs with an expectation of better care and outcomes at reduced costs. While the scope and pace of this activity will fluctuate, movement in this direction is inevitable. The reason? Health care consumers – companies, government and individuals -- are unable to afford further cost escalation and expect quality and value for their health care dollar. In this new model, physicians, hospitals, payers and consumers must work together to achieve the level of quality and value that companies, consumers and our government demand. UnitedHealthcare is taking a disciplined approach to address this issue with incentive-based contracting models. Through the expansion of existing programs and the creation of new ones, we are able to offer financial recognition to physicians who deliver quality results based on evidence-based guidelines. Medical home pilot One of the first value-based programs UnitedHealthcare was involved with was the patient-centered medical home, a pilot project started nearly four years ago. UnitedHealthcare was one of seven payers involved in the project, and we paid a per-member-per-month (PMPM) management fee on top of the fee for service. The intention of the fee was to put the patient in a position of shared decision-making, provide 24/7 access, and improve communication and transitions of care for the patient. During the three-year program, we saw a cost trend Colorado Medicine for May/June 2013

reduction of 4.8 percent, a decrease in emergency room visits by 4.5 percent (15 percent for all payers), and an 18 percent decrease in hospital admissions for all payers. Due to the success of this pilot program, UnitedHealthcare is considering the continuation and expansion of this project. Collaborative efforts We have also focused on collaborations like the Colorado Clinical Quality Improvement Project and the Comprehensive Primary Care Initiative (CPCi). The Colorado Clinical Quality Improvement Project was a joint effort between UnitedHealthcare, the American Medical Association and the Colorado Medical Society to decrease variations in care. Working together with physicians from multiple specialties (ENT, GI and general surgeons) we developed a contract with the general surgeons to provide shared savings for changing the site of service for cholecystectomies. The contracts were effective as of Sept. 1, 2012, and will run for one year. CPCi is a Centers for Medicare and Medicaid Services (CMS) initiative to foster collaboration between public and private health care payers. Primary care offices will receive a PMPM management fee in addition to the fee for service. The goal of this initiative is to strengthen primary care by offering bonus payments to primary care doctors who better coordinate care for their patients. There are additional payments available for achieving milestones in practice enhancement, which UnitedHealthcare will pay in the form of shared savings.

physician organization in Colorado, New West Physicians, starting an Accountable Care Organization with UnitedHealthcare on April 1, 2013. These collaborative efforts between consumers, employers and care providers are essential to achieving the Triple Aim of improved individual experience, improved population health and decreased per-capita costs. Our accountable care platform and outcome-based payment models reward providers for improvements in quality and cost-efficiency, while aiming to transform the delivery system to be more accountable for cost, quality and experience outcomes - making health care more affordable and helping people live healthier lives. Ken Cohen, MD, chief medical officer of New West Physicians, says their organization is part of four ACO pilots total. “This model has to do with balancing quality and efficiency to achieve maximal results on both of those. In the past, we have always done it because it was the right thing to do. This was the first opportunity we have had where we can actually begin to see some revenue generated out of those efforts as well as seeing some revenue flow back to the employer.” “We are very pleased that these models have finally come to fruition. We’ve taken what we hope will be the revenue generated by these ACO projects and have funneled them back into efforts that will allow us to push the quality envelope even higher.” n

Additionally, we are pleased to have a 19

TO MAKE A POSITIVE CHANGE PERSONAL HEALTH RECORDS

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PATIENT ELIGIBILITY AND BENEFITS INFORMATION

REAL-TIME ADJUDICATION FOR CLAIMS PROCESSING

UnitedHealthcare supports the physicians of the Colorado Medical Society. People count on you every day, even your staff. We understand that you are the one who takes care and takes charge – but you’re not alone. UnitedHealthcare offers you the support and resources you need so that you can focus on what’s most important – your patients. We can help you, your staff and your patients navigate the health care system with greater efficiency and quality of care.

To learn how UnitedHealthcare can better serve you and your patients, visit UnitedHealthcareOnline.com.

uhc.com ©2013 United HealthCare Services, Inc. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of Colorado, Inc.

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Colorado Medicine for May/June 2013

Features

Medicaid Accountable Care Collaborative Chet Seward, Senior Director, Health Care Policy

Physicians work to accelerate local innovations The Medicaid expansion in Colorado under the Affordable Care Act is moving forward, and Governor Hickenlooper just pledged his support for not only maintaining but also growing the Accountable Care Collaborative (ACC) in Medicaid.

Carolyn Shepherd, MD, details the importance of actionable data to improve care. Colorado Medicaid will soon become the second largest payer in the state because of the ACA expansion and the program is in the midst of a serious upgrade thanks to the ACC using local care innovations through Regional Care Collaboratives (RCCOs), sophisticated data analytics, alternative payment models to encourage patientcentered care, and perhaps most importantly physician engagement. Governor Hickenlooper has laid out an ambitious plan to help make Colorado the healthiest state in the nation and a central component to his strategy focuses on expanding and enhancing the ACC. The governor’s State of Health report notes, “The ACC infrastructure, with its focus on client-centered care and regional solutions, is the foundation of the Medicaid program in Colorado and will be the vehicle for delivery and payment reforms in Colorado Medicaid. Through a number of programs, including the ACC, we will reduce the number of individuals in unmanaged, Colorado Medicine for May/June 2013

fee-for-service care to less than 30 percent by 2018.” All in on the ACC Anticipating the growing importance of the ACC, the Colorado Medical Society convened a professionally facilitated retreat for RCCO medical directors and other ACC leadership in February. The meeting focused on utilizing the expertise of the RCCO medical directors, practicing physicians and operational leaders to identify what’s working, what’s not and what’s missing in the RCCO program. “We may not see another opportunity in our lifetimes to close the coverage gap, and to reinvent Medicaid in innovative ways that guarantee a meaningful return on this substantial investment by the federal and state government,” said CMS President Jan Kief, MD, emphasizing the importance of the ACC and its RCCO components. Nearly 20 medical directors, practicing physicians and operation staff attended the day and a half long meeting. The group leveraged the excellent work done by physicians, health plans, the state and many others over the past few years as the ACC was conceptualized and is now being operationalized. Importantly, the meeting focused physician leadership from across the state on fleshing out the “exam-room view” of the program. The group raised a number of topics and then prioritized nine key issues that can and should be addressed to accelerate the progress being made by the ACC. Top priorities include: 1. Attribution of patients

2. Behavioral health integration with physical health and social services 3. Data analytics 4. Access to specialty care 5. Payment reform/gainsharing 6. Continuous eligibility 7. Care coordination/flexibility in models and regions 8. Resident training 9. Colorado Client Assessment Record Next steps More work remains to flesh out these priorities and develop and implement proposed solutions. Results of the facilitation will be compiled into a white paper that CMS will publish and use in a concerted and collaborative push to help state officials get this historic opportunity right for taxpayers, patients and providers. RCCO medical directors will reconvene at the CMS spring conference in May to prioritize and synchronize next steps. Watch for more information on this important initiative in the future.

(l to r) Gretchen McGinnis, Kevin Fitzgerald, MD, Susan Pharo, MD, and Michael Welch, DO, address care coordination issues. “Local is the way to go,” Kief said. “We support the ACC because it represents a real partnership with the state, that focuses on local empowerment, innovation, data sharing, patient-centered care and coordination across medical specialties and through the system. This is health care reform – locally operated, locally led and locally delivered.” n 21

Features

Blueprint

for success Kate Alfano, CMS contributing writer

CMS supports governor's vision for health and wellness In the March/April issue of Colorado Medicine, Colorado Gov. John Hickenlooper offered a glimpse into his vision to make Colorado the healthiest state in America. Through the promotion of prevention and wellness, expansion of health care access and capacity, improvement of system integration and quality, and enhancing value and strengthening sustainability, he hopes a collaboration of individuals and public and private partners can improve health outcomes for every Coloradan and improve the quality of life in Colorado communities at the best value – a variation of the “Triple Aim.” Organizations from around the state, including CMS, were given a first look at the draft plan, “The State of Health: Colorado’s Commitment to Become the Healthiest State,” and an opportunity to provide feedback. CMS CEO Alfred Gilchrist hailed the blueprint as “fertile ground for collaboration among stakeholders” as it reaches beyond the medical aspects of health to include physical, behavioral, oral and environmental health. Now final, the plan states: “Achieving this vision demands innovation that will reshape our current health care delivery and payment mechanisms to bend the health care cost curve, improve efficiency, achieve higher quality, and drive more value out of the health care dollars we spend. … Addressing social and environmental factors that influence our health is also essential to Colorado becoming the healthiest state.” 22

Next steps On March 29, Gilchrist and CMS leaders John Bender, MD, and Dennis Waite, MD, attended the first of a series of meetings with representatives from the governor’s office, major state agencies and hospital systems to discuss the plan and identify each organization’s role going forward. “The governor’s office has earmarked $19 million to be spent in a continuing manner, not just a one-time payout but an increase in the budget, to provide more services and meaningfully coordinate care,” Dr. Bender said.

the administration is championing, he said, but he also noted that there are areas that must be addressed in regard to specialty care such as payment for telemedicine in a way to allow access to mental health for at-risk populations in rural areas who may not normally have access.

“If you look at all the things that the governor proposes – administrative simplification, continuity of care in Medicaid, working with the RCCOs (regional care collaborative organizations), understanding the barriers – as an organization we could support those efforts,” Dr. Waite said. “Their points of view are like everyone else’s: we have a problem, we need to have better integration, we need to have better communication.”

Leading by example As care providers, physicians inherently play a role in encouraging wellness and healthy lifestyles but a group of CMS members said this often does not extend to physicians caring for themselves.

“Much of the discussion fell on mental health and the disconnect between public health, behavioral health organizations and primary care, Dr. Waite said. “The concept of supporting behavorial health advancement and modification while integrating it into the patientcentered medical home model supports the mission and values of the Colorado Medical Society.” Dr. Bender agreed. “I feel like there are some opportunities for change with primary care and behavioral health that

“The feeling is definitely genuine; $19 million is real money and depending on how it’s leveraged in the budget between the agencies, it has the potential to do some good things,” he added.

Back in April 2011, CMS conducted an all-member morale survey that revealed only one-half of physician members are able to live a healthy lifestyle in regards to exercise and diet; fewer are satisfied they’re able to find time to relax through activities like yoga or reading. Following the survey, then-CMS President Brent Keeler, MD, appointed an expert panel on physician wellness to advise the board of directors. The panel finalized its recommendations this past February and the board will consider its report for approval in May. The wellness panel recommends strongly supporting and actively participating in the governor’s vision for health and wellness. Colorado Medicine for May/June 2013

Features Internally, CMS should: • Educate members on the governor’s plan and encourage its support by all elements of organized medicine; • Encourage individual physicians to lead by example, promoting prevention and wellness to their patients and the public by living a healthy lifestyle; • Provide resources on healthy living and ways physicians can participate in public and patient education, specifically through a specialized section of the CMS website that will be continually shaped by the wellness panel; and • Partner with other stakeholders. Now that we have the final plan, “we would do well to circulate this and get some discussion among ourselves because I think this hits on a lot of the tenets of what we put forth in all of our meetings in regard to wellness of the state, how to work at prevention, how to better integrate care, and better methods of communication like health IT,” said Dr. Waite. “These are all things that are on the horizon.” n

Colorado’s commitment to become the healthiest state

Governor Hickenlooper’s vision is to make Colorado the healthiest state through four focus areas where “we can have the greatest impact” and includes targets to track progress over time. Promoting prevention and wellness • Tackle obesity among youth and adults • Support improved mental health • Support reductions in substance abuse • Improve oral health of Coloradans • Encourage wellness among state employees Expanding coverage, access and capacity • Expand public and private health insurance coverage • Strengthen Colorado’s health workforce • Close gaps in access to primary care and other health services Improving health system integration and quality • Expand use of patient-centered medical homes • Support access to state information and services • Support better behavioral health through integration • Improve access to community-based long-term services and supports Enhancing value and strengthening sustainability • Achieve cost containment in Medicaid • Advance payment reform in the public and private sectors • Invest in health information technology Read the full report at www.colorado.gov/stateofhealth

Ensuring faster physician payment

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

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

Colorado Medicine for May/June 2013

Features

Signs of change Jeremy Lazarus, MD, President, American Medical Association

Several recent steps point to SGR fix in 2013 care patients just to keep their offices open. Over the years, the AMA has led public a campaign to get Washington’s attention. We have testified before Congressional committees and worked behind the scenes. Last October we wrote to Congress outlining transitional principles that should replace SGR. The Colorado Medical Society was one of more than 100 medical organizations that signed that letter.

Jeremy Lazarus, MD, AMA President SGR may be on the way out. As I write this, there is emerging agreement among health policy experts and policymakers that the time has come for Congress to truly reform the Sustainable Growth Rate Medicare payment system. SGR’s history is dismal: in the past dozen years, SGR payments to physicians for Medicare Services have remained static while the cost of care has risen 22 percent. As a result, many physicians have been forced to limit or deny Medi-

And while it is never a sure thing to predict the future, least of all in Washington, the signs are positive. • Recently the Medicare Payment Advisory Commission, a key congressional advisory panel, once again urged Congress to put an immediate end to SGR. Other private sector groups like the Bipartisan Policy Center are also calling for repealing the SGR. • The president’s 2014 budget also rec-

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ognizes the need to eliminate the broken Medicare physician payment formula and move toward new ways of delivering and paying for care that reward quality and reduce costs. The president's proposals align with many of the principles developed by the AMA and other physician organizations on transitioning Medicare, including that there be an array of accountable payment models and a period of stability for physicians where they have the flexibility to choose options that will help them lower costs and improve the quality of care for their patients. • In March, a bipartisan bill to repeal SGR was reintroduced in the House by Rep. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV). • At the AMA’s National Advocacy Conference in February, House Energy and Commerce Committee chair Fred Upton (R-MI) affirmed his intention to complete his committee’s work on legislation to repeal the SGR and reform the Medicare physician payment system by August. • The House Ways and Means Committee and the Energy and Commerce Committee’s majority (Republican) staff has also circulated a draft of a joint framework for repealing SGR. The committees’ proposal is generally consistent with the principles we sent to Congress last fall. It would immediately repeal the SGR, promote a diversity of new payment and delivery reform models, modify but still preserve fee-for-service, and maintain the medical profession’s Colorado Medicine for May/June 2013

Features leadership role in developing quality measures and data reporting systems. We view these as very positive developments. It is encouraging to see this focused attention on the Medicare physician payment system so early in the year combined with the effort by committees with jurisdiction over Medicare to solicit comments directly from physician groups. The AMA will remain in close touch with committee members and staff and will be working to shape the missing details into policies that are consistent with our principles. Sequester cuts challenge progress In the meantime, the outlook for the sequester cuts are not so positive. The Budget Control Act of 2011 called for $1.2 trillion in federal spending cuts over ten years. Unless Congress changes the law, federal spending will be subject to sequestration until 2022. We all know that payment rate cuts and freezes are not enhancing value in the Medicare program. In fact, inadequate Medicare payment rates work to stifle physicians’ ability to invest in new technology and staff – key moves in adopting new systems of well-coordinated, cost effective care. The future of the sequester likely will depend on whether Congress and the White House can reach a new budget agreement to address deficit and spending concerns. The AMA is working to educate members of Congress about the negative consequences of sequestration. We also cosponsored a study with the American Hospital Association and American Nurses Association detailing the impact the cuts will have on health sector employment. During the coming months the AMA will continue to work with CMS and all of organized medicine in urging Congress and the Obama Administration to move from discussion to action and deliver on long overdue reforms. n

Colorado Medicine for May/June 2013

All Medical Answering Service Owned and operated by the Arapahoe-Douglas-Elbert Medical Society (ADEMS) and backed by an all-physician Board of Directors, MTC is uniquely focused on the needs of its clients. Serving medical professionals is all we do. MTC’s management team has over 50 years of experience in medical answering services. Our operators are professional, friendly and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule. MTC proudly received the prestigious 2009 Award of Excellence for the fourth year from ATSI (Association of TeleServices, Intl.), a service-quality award based on test calls placed over a six-month period. MTC is a member of the Denver/Boulder Better Business Bureau, ATSI and Telescan Users Network (TUNe). MTC participates in the Colorado Medical Society’s Disaster Preparedness Program by contacting volunteer providers in the event of a large scale disaster. In addition we collaborate with CMS every six months in testing the response time of the volunteer providers.

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Physicians’ Billing 720-236-1280 or visit www.physicians-billing.com IC System www.icmemberbenefits.com Line Pressure 303-742-0202 Physicians’ Billing 720-236-1280 or visit www.physicians-billing.com Medical Telecommunications 866-345-0251 or 303-761-6594 or visit www.medteleco.com * CMS Member Benefit Partner Solve IT 303-800-9300 or visit www.solveit.us TransFirst 800-613-0148 or visit www.transfirstassociation.com/cms *CMS Member Benefit Partner

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

Features

Big picture data Chet Seward, Senior Director, Health Care Policy

All payer initiative on physician performance reports advances The drive to enhance the transparency and meaningfulness of health care cost and quality data in Colorado is advancing, and physicians from around the state are working to ensure that itâ&#x20AC;&#x2122;s done right. Colorado Medical Society (CMS) is collaborating with the Center for Improving Value in Health Care (CIVHC) to help develop the processes, methodologies and specifics of physician performance public reporting by the all-payer claims database (APCD). As administrator of the APCD, CIVHC has committed to report comparative cost and utilization data publicly on a named payer, facility and provider group basis by the end of this year. The APCD has appealed for help from CMS in identifying quality and cost-effectiveness measures for certain chronic and pre-

Colorado Medicine for May/June 2013

ventive diseases and common medical procedures to support consumer-focused reporting. Overview The prospect of practice specific cost and quality reports available on the web for all to see elicits mixed responses from physicians ranging from gritted teeth to rolled eyes. Perhaps part of this perceived or real lack of value stems from prior experience with individual commercial health plan physician designation programs. Physicians are understandably wary about these programs given their opaque, complex and frequently flawed nature that has served to only heighten physician skepticism about the usefulness of these data. Colorado physicians have long struggled with these programs, even after CMS championed the passage of the first in

the nation law in 2008 to mandate that these programs use both cost and quality measures and that they ensure appropriate appeals mechanisms. Thatâ&#x20AC;&#x2122;s why the APCD work is important because it captures data from multiple payers and enables more comprehensive reporting. In effect, the APCD provides an opportunity to utilize a big picture view to create more meaningful and actionable data reports. Importantly, the looming, detailed APCD reports are a response to strident demands from consumers, employers and policymakers for better information about the cost and quality of Colorado health care. Start with the end in mind The CMS Committee on Physician

APCD (cont.) Practice Evolution has been meeting about this project with CIVHC leaders since January. The ultimate goal of this initiative is to use and share data to improve care delivery and demonstrate physicians’ ability to provide high-quality, cost-effective care. To date much work has been accomplished and more remains before these reports go live at the end of this year. The group has used the following criteria to begin the process of selecting a small, meaningful and manageable set of physician performance measures for public reporting. Physician performance measures should be: • Based on solid clinical evidence that is not controversial – wherever possible they should be based on nationally recognized standards; • Reasonably easy and accurately collected from claims data; • Meaningful and actionable by pa-

tients and physicians and able to guide quality movement • Transparent; and • Standardized between the groups/ payers who are measuring physicians. A handful of chronic and preventive measures have been identified as a draft starter set for consideration, and work to identify simple and strong measures for common procedures is also progressing. Measures and conditions under consideration include hemoglobin A1C testing for diabetes, mammography screening, osteoporosis management, total knee and hip replacements, cardiac catheterization and coronary artery bypass grafts. Future work will focus on vetting potential measures with physicians across the state, and then understanding and gaining consensus on attribution and risk

adjustment methodologies that will be used in APCD reporting. The committee recognizes that this type of public reporting will happen with or without CMS collaboration and being involved provides more opportunities to shape the process. While members are quick to note the flawed nature of claims data, they also emphasize that this is a start and a piece of a larger strategy by CMS to help physician members to develop and use data to improve the value of care. Physician feedback critical The roll out of more detailed physician performance reports by the all-payer claims database holds both promise and peril. If done correctly it can shed light on what is and isn’t working well in Colorado health care. And if done incorrectly it can further muddy an already cloudy atmosphere surrounding cost and quality transparency programs or even worse imperil physician reputations and practices. CMS is committed to seeking physician feedback on this initiative. Outreach has begun with component and specialty societies and other physician driven organizations around the state. CMS believes that raising awareness and educating physicians around the state about the initiative will be as important as determining what will ultimately be measured and reported. Contact Chet Seward in the CMS offices (chet_seward@cms.org) if you’d like to schedule a meeting with your local colleagues to discuss the APCD initiative and in turn prepare for future, larger transparency and quality improvement programs. n

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Colorado Medicine for May/June 2013

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WHAT’S YOUR PATH TO MEANINGFUL USE? Find out with the free tool: www.corhio.org/portal CORHIO and the Colorado Medical Society, with grant funding the Physician’s Foundation, developed this self-guided tool to assist Colorado medical practices with many of the tools and resources needed to help make the Path to Meaningful Use a success.

The new and improved tool includes: Information for your specific stage of EHR adoption A Practice Readiness Tool, with self-guided questions on five capacity areas: management, finance/budget, operational, technology and organizational A Meaningful Use Gap Analysis to assess your practice’s knowledge of meaningful use and direct you to the right post-launch tools Helpful information on EHR tools and resources in the Document Library Self-guided training in different modules Information and links to Colorado-specific resources Online forms and downloadable documents to guide you through the meaningful use EHR process

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Colorado Medicine for May/June 2013

Inside CMS

Prescription drug abuse roundtable Kate Alfano, CMS contributing writer

CMS joins coalition to combat prescription drug abuse On March 8, nearly 90 stakeholders from around the state met at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora to pose strategies for reducing prescription drug misuse in Colorado. These experts included a dozen CMS leaders and members, many from the CMS Workers Compensation and Personal Injury Committee, who provided the physicians’ perspective.

that our critics will say you can’t successfully fight drug abuse from a law enforcement context,” he continued. “We know we can’t be successful with law enforcement efforts alone, but I can tell you that we have seen dramatic examples of success in reducing drug abuse when prevention, treatment and law enforcement work together. That’s what we need to do now. Together we can turn this around.”

The day started in a large group session as several top state officials described their agencies’ work on prescription drug misuse. The key message from each speaker was collaboration: that all participants in the meeting, and others invested in the issue not attending that day, must work together to meet a lofty goal of reducing the number of Coloradans who misuse these medications.

Barbara Gabella, MSPH, epidemiologist for the Colorado Department of Public Health and Environment, said the state’s focus falls on opioids because in 2011 36 percent of the state’s drug poisoning deaths in Colorado and 6.4 percent of admissions to substance abuse centers involved these drugs, the highest rate in 10 years. Opioid misuse disproportionately affects younger people; 61.5 percent of clients admitted in 2011 to substance abuse centers for these drugs were between the ages of 18 and 34.

Colorado Attorney General John Suthers framed the issue by talking about the huge direct and indirect costs of prescription drug misuse that translate to increased health care costs, law enforcement costs, social services and loss of workplace productivity. He then described his role and explained how a successful collaboration between law enforcement and pharmacists brought down an oxycodone trafficking ring in January. “The fact is partnership is key in combating this measure and that’s why we’ll work closely with all our law enforcement partners and with our key partners in this room,” Suthers said. “Those of us in law enforcement know Colorado Medicine for May/June 2013

“We have an interest in Colorado for setting a prevention goal for opioid misuse,” Gabella told the audience, standing before a presentation slide illustrating the goal for 2016. “If currently 6 percent of Coloradans are misusing prescription pain relievers, that represents about 255,000 people. If we set our goal to reduce misuse to 3.5 percent, that means that we want no more than 163,000 Coloradans age 12 and older misusing opioids. We would need to prevent 92,000 Coloradans age 12 and older from misusing.”

She continued: “Studies show that if we prevent opioid misuse, we’ll prevent misuse of other drugs like anti-depressants and benzodiazepines. We all have a role in creating this future and we’re starting today.” Chris Urbina, MD, CDPHE executive director, presented his agency’s strategies. He said they will look closely at the prescription drug monitoring program and use it to continue to identify and monitor trends, work with partners to implement a permanent drug disposal program, encourage open dialogue about mental health and substance abuse, and encourage the continued effort to educate physicians and other providers. “Those are our four key strategies going forward,” he said. “I hope you’ll believe this is truly a winnable battle and we can really make a difference.” Participants then moved into roundtable discussion groups focusing on five topics: the Prescription Drug Monitoring Program (PDMP), safe disposal of prescription drugs, data and analysis, public awareness, and provider and prescriber education. Attendees discussed current action in these areas as it pertained to their specific expertise, and each group worked together to develop prevention strategies. By the end of the day, each roundtable submitted at least one recommendation.

Drug abuse (cont.) Highlights include: • The PDMP group recommended requiring education about the existence and utilization of the PDMP as part of the licensing process for prescribers and pharmacists, and they recommended improving the usability of the PDMP system through the use of information technology and increased access. • The disposal group recommended expanding the existing prescription drug reclamation program and establishing permanent dropoff locations. • The data and analysis group recommended mapping out all sources of data related to prescription drug use, misuse, and overdose in Colorado, then standardizing data collection tools across agencies for continued analysis. • The public awareness group recommended multiple education campaigns that target different

audiences and address common misperceptions. • The provider and prescriber education group recommended requiring all DORA-licensed prescribers (with exemptions) to undergo education that reflects best practices in controlled substance prescribing and addresses pain management and patient safety. These recommendations have been forwarded on to be further developed at the Governor’s Prescription Drug Abuse Reduction Policy Academy meeting and will influence Colorado’s full strategic plan and timeline on the prevention of prescription drug misuse, which will be presented at the National Governors Association meeting in May. Over the past few months, the CMS Workers Compensation and Personal Injury Committee has studied this issue and the Colorado Medical Society’s role

in it. The group drafted a report containing their proposed long-term goal and strategies for CMS in preventing prescription drug abuse, and the CMS Board of Directors approved the report at its March 15 meeting. Look for action on this issue as CMS works to fulfill this goal: “To assure access to compassionate, evidence-based care for patients who suffer from acute and chronic pain, while significantly reducing the potential for medically inappropriate use or diversion and the resulting range of medical, psychological and social consequences, including addiction, overdose and death.” n

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Colorado Medicine for May/June 2013

Inside CMS

Marilyn Rissmiller, Senior Director, Health Care Finance

CMS coalition creates tools to assist physicians and staff address more than 55,000 code changes

The ICD-10 pathway involves seven stages: • Build awareness and engage with physicians and staff • Assess the impact Colorado Medicine for May/June 2013

The ICD-10 Training Coalition is open to any organization or individual who shares the goal of providing an organized, affordable approach to statewide ICD-10 training for physicians and their staff.

Join those who have already pledged their commitment to readiness through the ICD-10 pledge on the new coalition website, www.cms.org/icd-10/pledges. Be sure to explore and share the website with your colleagues and staff as new information is added. Stay up to date on training coalition events and resources by signing up for our mailing list at www.cms.org/news/livewire. n

Which one are you using? Their’s

Our’s

NITROGEN

Colorado Medical Society coordinated the formation of this statewide training coalition comprised of educators, consultants, physician practices, the Denver Regional Office of the Centers for Medicare and Medicaid Services and others, uniting all partners under the goal of ensuring physicians and their staff are prepared for ICD-10. The switch to the new code set adds more than 55,000 codes to the previous version and will require changes to how health care information is collected, documented and used in physician practices, both internally and externally. Physicians and their staff must begin preparing now.

Create your timeline Develop your project plan Begin your preparations Train staff and physicians Test ICD-10 readiness Implement your transition plan Follow up post-transition

LN177201

These resources and training materials include live seminars and a free monthly webinar series. The first two webinars were held on March 19 and April 16 of this year. Archived recordings and slide presentations are available on the website.

• • • • • • •

The Colorado Medical Society’s ICD-10 Training Coalition has launched a website at www.cms.org/icd-10 to provide physicians with resources to navigate new requirements of the International Classification of Diseases, 10th Revision (ICD-10) code sets and tailor an implementation plan to fit their practices’ needs in time for the Oct. 1, 2014 implementation deadline.

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Inside CMS

JoAnne Wojak, Director, Continuing Medical Education

Process taking shape under direction of CMS A blueprint for the maintenance of licensure process has been in development for several years, but Colorado physicians will soon begin to see the foundation take shape, as pilot projects kick off this summer. Under the maintenance of licensure process, which will go into effect as early as 2019, licensed physicians will periodically provide evidence that they are participating in continuing professional development relevant to their area of practice. Board-certified physicians participating in a maintenance of certification program or an osteopathic continuous certification program will likely satisfy MOL requirements without additional action, and physicians working in non-clinical positions will have specialized pathways that account for their situation. The Colorado Medical Society has partnered with the Colorado Society of Osteopathic Medicine, the Colorado Medical Board, the Federation of State Medical Boards, the National Board of Medical Examiners and the American Board of Medical Specialties to ensure the MOL process meets the needs of Colorado patients and physicians. Throughout its development, all organizations have sought input from physicians on these new requirements and will continue to do so. Physicians who hold a license to practice medicine in Colorado should have received information in March about a survey on maintenance of licensure with their license renewal notification from the Department of Regulatory Agencies. CMS strongly encourages all members to complete the

survey, as it will influence the various types of activities that could fulfill future MOL requirements. To access this important survey, go to www.nbme.org/ PhysicianSurvey. The organizers understand that physicians will have many questions moving forward. To help address initial questions, CMS has provided the following information. Why is CMS leading the MOL effort? As the primary organization speaking on behalf of Colorado physicians, CMS became involved to ensure the physician’s voice is heard. By leading the effort from the beginning, we hope to greatly influence the outcome. Why pursue an MOL process? The MOL initiative is part of a larger, widespread movement in health care aimed at increasing patient safety, quality outcomes and overall system improvement. MOL is an administratively simple and economical means to assure physicians can show their continuous development and meet increasing reporting demands and scrutiny. Is MOL proven to increase patient safety and quality? While CME research and data are limited, they do show that CME can be effective for improving physician knowledge, skills, behaviors and patient outcomes when it includes interactive formats and is relevant to the participant’s practice (AHRQ Effectiveness of CME 2007). Other studies and articles strongly support the need for a continuous life-long learning process that includes practice-

based learning in order to be effective for patient outcomes. Physicians involved in practice-based learning review their own practice data, compare it to best evidence of care and then develop an improvement plan. A bibliography of extensive research on MOL can be found at www.fsmb.org/mol. How will the MOL process work? Physicians will report and periodically demonstrate compliance of practicebased learning, including current lifelong learning activities. There are three components: reflective self-assessment, assessment of knowledge and skills, and performance in practice. Unlike maintenance of certification, MOL will not culminate in a “high-stakes” examination. How will MOL affect me? The majority of Colorado physicians, specifically those already involved in maintenance of certification or osteopathic continuous certification, will not experience a significant increased burden of cost or time. Physicians who choose not to participate in the MOC or OCC continuous certification process will have to participate in the MOL process. Who can I contact if I have more questions? You may contact the Colorado Medical Society CME/MOL staff office, where many of your questions can most likely be answered. CMS has a subcommittee on MOL that meets periodically, and any member is welcome to attend those meetings. The office can provide information about the MOL meetings. Please feel free to call (720) 858-6309. n

Colorado Medicine for May/June 2013

Inside CMS

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

challenge of taking care of a unique individual every day rather than merely following rules or formulae.

Brian Cristiano

Brian is a third-year medical student at the University of Colorado and past treasurer of the CMS Medical Student Section. He is an alumni of the University of Colorado at Boulder and is a member of the Colorado Research Track where he has presented original research in pediatric neuro-oncology. He hopes to pursue a career in neurosurgery after graduation.

The observer She lay still beneath sterile blue drapes and hot white lights, only a small area of scalp and her right hand visible. A 40-year-old woman, a complete stranger with metastatic colorectal cancer and her skull open under an operative microscope. All I know about her I read in a hastily composed H&P filed away neatly in the electronic medical record, and all that really talked about was her disease, which was both extensive and deadly. And unfair. A 40year old woman isn’t supposed to die from colorectal cancer. We don’t even screen for the disease before age 50. Little consolation that piece of medical knowledge would be to her or her family now. “Patients don’t read the books,” I’ve been told – a cliché because it’s true. Sometimes the cliché seems more accurate than the books themselves, like the textbook case is the exception not the rule. But isn’t that one of the reasons I chose this field, I remind myself; for the novelty, the 36

I somewhat esoterically wonder if she might have a familial colorectal cancer syndrome and imagine the alphabet soup of genes – APC, MSH-1, WNT, K-RAS, p53, et alia ad nauseum – that I have learned are affected in such diseases. Translucent ghosts of arbiters floating in an ultramicroscopic world within countless nuclei of countless cells deep within our tissues, somehow determining our fate. Unlikely, I concede. These are the exceptions not the rules. Simple, cruel, random fate is far more likely. The surgeon dissects shiny blue dura away to reveal pristine white cortex marked with a stippled area of neovascularization suspended beneath a barely perceptible layer of translucent arachnoid and cerebrospinal fluid. I correlate what I’m seeing with the radiographic images I studied before entering the operating room, a greytone portrayal of a killer. Scrolling through the flipbook of magnetic resonance generated images, the tumor seems to manifest from nothing. It emerges from temporal cortex and white matter first with edema then to reveal a nest of malignancy in her left mid temporal lobe. Wernicke’s area, I think to myself. Who is she? I wonder. What did she care about? There were other tumors – in her cerebellum, liver, lungs and adrenal glands. Why this one? Why did she want this operation, that won’t cure her disease or extend her life? She has something she wants to say, I deduce. Something important that she hasn’t said that she doesn’t want to die without saying. And communicating that, or perhaps just communicating, was not only worth the risk of this operation for her; it was more important than walking (or Colorado Medicine for May/June 2013

Inside CMS else we’d be operating on her cerebellum). But that’s just speculation, an impression of my own values on the facts. Neurosurgery, perhaps, is a field for those who enjoy irony. Me watching my resident operate on my patient’s brain while I wonder what she was thinking. And perhaps, a field for those who desire an almost metaphysical connection with their patients. For my part anyway, I can think of no more personal connection than to operate on the substance that is the physical representation of oneself on this Earth. And to be trusted to do so safely must be a supreme privilege. The surgeon delicately dissects through layers of cortex. A tissue composed of tiny wisps of jelly that are somehow configured to append language to our internal cognitive processes. A tissue without which we would be prisoners in our own minds unable to communicate effectively with the outside world. Bayonets, irrigation, bipolar. His hands move imperceptibly but produce fine and precise gestures under the microscope. The ugly, brown, lobulated tissue of the cancer stands in stark contrast to the surrounding white matter. It leaves her brain and the operating room at the point of his instruments, off for further scrutiny under a pathologist’s microscope. I wish I could have met this patient, understood her, learned her story. But today I’m just an observer. And all

Colorado Medicine for May/June 2013

I can see of her is a hand, a reminder that there’s a human being underneath these sterile blue drapes and hot white lights. A human being with a need to communicate and a desire to be understood. Hopes and desires that we all share. Hopes and desires that in part make us human. I hope her operation was a success – that she will be able to speak what she needed to say. Surgeons have a stereotype of being cold and impersonal but I think that, on the contrary, surgeons have the opportunity for the most poignant of patient relationships. When you operate on someone – and especially when you operate on that person’s brain – you’re somehow permanently linked to that individual because for the rest of their life they will have to live with what you have done, and so will you. The best surgeons remind themselves of this before every case. They don’t forget the privilege they have been given or the purpose of their training. Someday, that’s the kind of surgeon I hope to be. n

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Inside CMS

COPIC’s Volunteer Physician Program

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

No-cost coverage for those who provide uncompensated care COPIC’s Volunteer Physician Program is a successful, ongoing initiative that exemplifies our mission to improve medicine in the communities we serve. The program offers medical professional liability insurance at no charge to eligible Colorado physicians who provide only uncompensated medical care. Requirements Physicians who wish to take advantage of the program must complete an application to be approved for coverage. The requirements for coverage eligibility include the following: 1. The physician must have a valid, current and unrestricted medical license. 2. The physician must be providing services on a volunteer basis without any remuneration (monetary or otherwise) and wholly within the state of Colorado. 3. The physician may not perform any obstetrical, prenatal, invasive or surgical procedures. 4. The physician may maintain only consultation or courtesy privileges at a hospital with no admitting privileges. 5. The physician may not maintain professional liability insurance coverage with any other carrier.* * Physicians actively insured with COPIC who would like to provide volunteer services should contact their COPIC underwriter for details. Volunteer physician testimonials Name: John Cletcher, MD Background: Orthopaedic surgeon “To this day, I still enjoy the patient interaction and making a difference in people’s lives. It’s so much a part of me that I can’t give it up,” said Dr. John Cletcher, a retired orthopaedic surgeon. Dr. Cletcher’s connection to medicine continues through volunteer work he performs for Longmont Salud Family Health Center, a clinic that provides integrated primary health care services focused on the low-income, medically underserved population. Dr. Cletcher’s relationship with Salud began more than a decade ago when he and two other orthopaedic surgeons at his former practice started volunteering with the clinic. Since retiring, he has taken on a mentor role at Salud, working closely with medical staff. Volunteering two to three days a month is not an overwhelming commitment, but rather, an important and rewarding experience, Dr. Cletcher said. “What I bring to the clinic is a significant amount of experience and valuable insight. This would be completely lost if I didn’t 38

use it. The clinical judgment I can offer helps us accomplish a lot in a way that conserves health care resources,” he said, citing an example of a patient whose torn meniscus was treated conservatively at first, instead of rushing to order an MRI. “I would not be able to do this work if the (no-cost) medical liability coverage wasn’t available from COPIC. It makes volunteer physician programs in Colorado feasible,” Dr. Cletcher said. “This is rewarding for me to help treat people that really need care, and I can do it without the duress of fearing a lawsuit.” Name: Dianne Leeb, MD Background: Plastic surgery Since 2008, Dr. Dianne Leeb has been a volunteer physician with Summit Community Care Clinic, the only safety-net health care provider in Summit County. “Doctors in private practice in the mountains could have a continuous stream of patients rolling in who are under-insured or uninsured, but they have to pay rent,” she said. “People’s health exists on a spectrum that extends from being perfectly well to having a life-threatening issue. But, there are a lot of things in between that need attention and my volunteer role helps to address them.” Dr. Leeb’s role as a volunteer physician is crucial in delivering care on several levels, said Christine Hoppe, Summit Community Care Clinic’s medical director. “She is able to perform routine procedures, like removing moles and performing biopsies, as well as provide expert consultation based on her skills as a plastic surgeon. Because of her expertise, it allows us to effectively manage our finances, our time and our services to provide the best patient care possible.” In addition to her work at Summit Community Care Clinic, Dr. Leeb also utilizes her no-cost volunteer physician coverage from COPIC to serve as an on-call physician at Roundup River Ranch, a camp for kids with chronic and life-threatening illnesses.” I really wouldn’t be able to do this if I had to buy my own insurance. It frees up the concern of making sure you have adequate coverage and allows you to focus on practicing medicine,” she said. For more information regarding COPIC’s Volunteer Physician Program, please contact our Underwriting and Policyholder Service department at (720) 858-6000 or (800) 421-1834. n

Colorado Medicine for May/June 2013

Inside CMS

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Colorado Medicine for May/June 2013

Departments

medical news Physicians urged to complete survey on what activities should satisfy maintenance of licensure requirements The Department of Regulatory Agencies has released an maintenance of licensure survey about your participation in and opinion of various types of continuous professional development

activities that may be approved for fulfilling future MOL requirements. CMS strongly encourages all members to complete the survey. It should take no more than 10 minutes. To access this

Participate in AMA's monthly check-up series to evaluate practice health One of CMS’ strategic priorities is to ensure physician wellbeing and success both personally and professionally. When it comes to providing resources in support of the wellbeing of the physician’s practice, the American Medical Association's work directly aligns with CMS. We invite you to take advantage of their 2013 monthly check-up series, “Prescription for a Healthier Practice.” Launched in January, the AMA Practice Management Center’s series helps physician practices examine everyday administrative processes in areas that include practice automation, fair contracting, ensuring accurate payment, physician efficiency and clinical quality issues. Each brief, delivered by e-mail, contains a tip and a link to a resource on the AMA webpage. AMA has featured information on simplifying the claim audit and appeals

process, including a step-by-step course of action to address underpaid or inappropriately denied claims and how to utilize the National Managed Care Contract Database in an appeal letter, plus a guide on contract negotiation, resources on preparing for retrospective audits, and an analysis of the return on investment for e-billing. Stay current on these check-ups by signing up for practice management alerts emails at www.ama-assn.org/go/pmalerts or watch for them in CMS’ e-newsletters. n

important survey, go www.nbme.org/ PhysicianSurvey. Maintenance of licensure, or MOL, is a process in development by which licensed physicians will periodically provide, as a condition of license renewal, evidence that they are actively participating in a program of continuous professional development that is relevant to their area of practice. The Colorado Medical Society has partnered with the Colorado Society of Osteopathic Medicine, the Colorado Medical Board, the Federation of State Medical Boards, the National Board of Medical Examiners, and the American Board of Medical Specialties to help develop the new process and ensure it meets the needs of Colorado patients and physicians. n

Complete CMS education survey and be entered to win a $150 gift certificate Physicians: We need your help to develop the best CME for your needs. Simply complete a very brief survey about your continuing medical education needs and we will enter your name into a drawing for a $150 gift certificate

to a restaurant of your choice. Please let us help you achieve your continuing professional development goals and requirements through accredited CME. To fill out the survey, go to www.surveymonkey.com/s/CMENeeds2013.

2013 CMS Annual Meeting September 20 through 22 Vail Marriott 40

Colorado Medicine for May/June 2013

Departments

medical news Young science fair award winners show great promise for the future

Janet Seeley, MD, PhD (l) congratulates CMS Colorado State Science Fair Junior Division winner Ellie Mackintosh. Ellie Mackintosh and Jenna Hartley won the Colorado Medical Society Award for Excellence in the Health and Behavior Sciences in the junior and senior division of the 2013 Colorado State Science Fair held on April 11 on the Colorado State University campus in Fort Collins. A longtime supporter of the science fair, each year the CMS Education Foundation presents an award to one student from the junior high division and one student from the senior high division. These students receive $100 and an invitation to the CMS Annual Meeting to display their project and receive recognition before the CMS House of Delegates. Colorado Medical Society member Janet Seeley, MD, PhD, served as the official CMS judge at this year’s fair. The junior division winner, Ellie Mackintosh, presented her project, “Simply Mouthwatering – Development of a Mouthwash to Increase Saliva.” “Ellie demonstrated a straightforward design and solid questions forming her hypothesis, variables and controls,” Dr. Colorado Medicine for May/June 2013

Janet Seeley, MD, PhD, (l) congratulates CMS Colorado State Science Fair Senior Division winner Jenna Hartley.

Seeley said. “She also showed critical thinking about alternative explanations of her results and how to continue to test in the future. I see that she enjoys applying science to critical problems and see great promise for a career in science.” The senior division winner, Jenna Hartley, presented “Pseudomonas a. Infections in the CF lung: Inhibition of Bio-encapsulated Pathogens – Effects of Herbal Extracts Compared to Tetracycline on Pseudomonas Biofilm Formation in Presence and Absence of Mucus Analogue.” Jenna was the 2012 junior division winner, winning for her in vitro model of Pseudomonas biofilm that tested antimicrobial effects of several agents. She discovered a flaw in her experiment, though, suspecting that the most effective agent last year was due to its ethanol content. That led her to this year’s project, for which she tested her hypothesis, found it true, and tested antimicrobial effects of several aqueous agents. She also strived to more closely mimic the lung environment of her test system with the addition of a viscous agent.

“Jenna was very articulate,” Dr. Seeley said. “I probed her rationale, knowledge of the system and potential pitfalls, and she answered each question with clarity and poise. Her project was well designed, documented, displayed and discussed. She shows persistence and creativity, and the ability to analyze and learn from her result experiments.” n My confessional instead is intended to illustrate an important principle I've seen unfold in the careers of many successful scientists. It is quite simple: put passion ahead of training. Feel out in any way you can what you most want to do in science, or technology, or some other science-related profession. Obey that passion as long as it lasts. Feed it with the knowledge the mind needs to grow. Sample other subjects, acquire a general education in science, and be smart enough to switch to a greater love if one appears. But don't just drift through courses in science hoping that love will come to you. Maybe it will but don't take the chance. As in other big choices in your life, there is too much at stake. Decision and hard work based on enduring passion will never fail you. – E.O. Wilson, from Letters to a Young Scientist, 2013. 41

Departments

medical news Aiming for Stage 2 meaningful use? Connecting to HIE can help Physicians in the process of implementing or improving electronic health record systems and participating the Medicare or Medicaid EHR Incentive Programs may be able to satisfy some Stage 2 meaningful use requirements by connecting to Colorado’s health information exchange, CORHIO. Stage 2 requires physicians to do a variety of tasks electronically, including e-prescribing, using computerized pro-

vider order entry (CPOE), and submitting electronic data to immunization registries, among others. The number of physicians signing up to connect to CORHIO has steadily increased and their staff reports that they are “at capacity” for implementations required to connect physicians’ EHRs to the HIE. That means that physicians who are planning to do Meaningful Use stage 2 need to schedule their

implementation with CORHIO now to be able to be connected within the next three to six months. They caution that if physicians delay, they won’t be able to get connected in time and they may miss out on their incentive payment that year, which could impact the practice’s bottom line. For more information, go to www.corhio.org/for-providers/physicians.aspx. n

Medicaid rule clarification expands eligibility for bonus All Medicaid providers should check to see if they are eligible to complete an attestation to receive a Medicaid bonus. Changes to Medicaid reimbursement were enacted as part of the Affordable Care Act (ACA). Eligible physicians will receive supplemental payments for services rendered between Jan. 1, 2013, and Dec. 31, 2014, that raise Medicaid reimbursement to Medicare rates. A recent study shows that for many Colorado physicians this change would rep-

resent an estimated 32 percent fee increase on average. The statute specifies that higher payment applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine or pediatric medicine. It also specifies that specialists and subspecialists within those designations as recognized by the American Board of Medical Specialties (ABMS), the American Osteopathic Association

MCCTF task force to release first set of "clean claims" rules for public review and comment The Colorado Medical Clean Claims Task Force (MCCTF) has announced the pending release of rules that will ultimately establish a standardized set of health care claim edits and payment criteria to process medical claims. The task force members, which include national representatives from many health plans, software vendors and providers, will release the first set of rules for public comment in the second quarter of 2013. Once available, they will be posted on the task force website for public review and comment. The task force has deliberated on this 42

issue since its establishment in 2010 through the Medical Clean Claims Transparency and Uniformity Act. Under the act, the task force must submit to the General Assembly and Department of Health Care Policy and Financing a report and recommendations for a uniform, standardized set of payment rules and claim edits to be used by all payers and providers in Colorado.

(AOA) or the American Board of Physician Specialties (ABPS) also qualify for the enhanced payment. Under the regulation, “general internal medicine” encompasses internal medicine and all subspecialties recognized by the ABMS, ABPS and AOA. To be eligible for the supplemental payment, physicians must self-attest as having a specialty in family medicine, general internal medicine, and/or pediatric medicine, or as having a subspecialty within those specialties recognized by ABMS, ABPS and AOA. Only physicians can complete this form (staff or other representatives are not allowed). Make sure that you are eligible for these increased payments by visiting the Colorado Department of Health Care Policy and Financing attestation page at http://tinyurl.com/cdhcpf-attestation. Learn more about ACA enhanced payments for Medicaid primary care physicians at http://tinyurl.com/colorado-govattestation. n

Find more information on the task force and legislation in the previous issue of Colorado Medicine, pg. 23, March/April 2013. n Colorado Medicine for May/June 2013

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medical news Colorado Beacon Consortium recognized for work connecting physicians Vitation et labo. Voluptatus esequis diatior rem si quos aut recaessum eaquas The Colorado Beacon Consortium is one of six organizations nationwide to be named a 2013 Healthcare Informatics Innovator by Healthcare Informatics magazine. The award recognizes leadership teams from hospitals, medical groups, integrated health systems and other health care organizations that have effectively deployed information technology to improve clinical, administrative, financial or organizational performance. CBC, a not-for-profit collaborative of four health care organizations (the

Quality Health Network, Mesa County IPA, St. Mary’s Hospital & Regional Medical Center, and Rocky Mountain Health Plans), was recognized for its work to leverage analytics and health information exchange tools to connect office-based physicians across a 17,500 square mile region of western Colorado. CBC operates with a cooperative agreement from the Department of Health and Human Services’ Office of the National Coordinator for Health IT. CBC uses an advanced regional health data architecture through the Quality Health Network to deploy a decisionsupport tool called Archimedes IndiGO

Respect – Empowerment – Team – Safety - Stewardship We are Agape Healthcare.

Agape Healthcare is a locally-owned, premier provider of Hospice & Palliative Care Services. Our professional & compassionate staff is dedicated to providing exceptional quality care.

Hospice Team Physician

We are looking for a Doctor of Medicine or Osteopathy licensed to practice in the State of Colorado who is passionate about serving our patients with quality care to meet their end of life goals and objectives. Our interdisciplinary team of highly trained board certified medical professionals is best in class in their ability to expertly and compassionately support patient and families in their end of life journey. The Hospice Team Physician will build upon this with knowledge of symptom management and pain control, pharmacology, and psychology of loss, grief and bereavement. Prior hospice and/or palliative care experience is not required, but the desire to learn and grow in this field of medical care is. If you’re interested in discussing this opportunity and the philosophy of Agape Healthcare, please visit us online at www.agape-healthcare.com or call (720) 482-1988. The Agape Healthcare Philosophy We believe every person is entitled to participate fully in the last phase of his or her life in order to prepare for death in a way that is personally meaningful and fulfilling. We believe we are all dependent on one another; therefore it is crucial in the last few months of life to help develop a caring community that can provide comprehensive services to patients and their families. Our main goal is to enhance the quality of life for patients with life limiting illness through expert palliative care so that patients experience optimum comfort and support.

across multiple, independent primary care sites with different EHRs throughout the seven-county region. Leaders estimate their analytics span a base of more than 55,000 patients. “We are honored to receive this award; it recognizes the value of bringing clinical and administrative data together in one place — at the point of care — to more closely correlate quality with outcomes and value,” said CBC Executive Director Patrick Gordon in a press release. The consortium members hope CBC will serve as a model for other communities with independent providers. “We can collaborate across multiple independent organizations and still achieve community goals and population-level impact,” Gordon said. “This isn’t corporate health care integration; rather, we are working to show what integration can look like when it is created on a community basis.” A profile of CBC’s efforts appeared in the February issue of Healthcare Informatics, and the winning teams were honored during the annual HIMSS Conference in March in New Orleans. n

Join COMPAC Now! Colorado Medical Political Action Committee

Call 720-858-6326 or 800-654-5653, ext. 6326

or e-mail chris_mcgowne@cms.org Colorado Medicine for May/June 2013

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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.

➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES ➤ MISCELLANEOUS ROCKY MOUNTAIN FAMILY MEDICINE - is seeking Board-eligible/ Board-certified family medicine and pediatric physician providers. Join a vibrant group of primary care providers with 8 locations in the Denver metro area. Full scope of out-patient practice with no OB. Less than 2 weeks call/ yr. Pay and benefits are competitive. Fax c.v. to 303-872-1856 or e-mail to nmoore@rm-uc.com. Physicians and Psychiatrists - Several positions are currently available for your specialty providing medical exams. As an independent contractor, you will set your own schedule. A good supplemental income can be expected. Great for simi retire Docs. Please forward a letter of introduction and a convenient time to call. Fax: (720) 285-1955.

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HEALTHMARK CENTER seeks board certified Internist to join 3 well-established Internists in a multi-specialty setting. Clinic provides chronic and acute adult care plus cardiology, podiatry, gynecology, dermatology, osteopathy, and alternative care. No hospital care. Partnership opportunities possible. Competitive salary, CME allowance, health insurance, matching 401K, great EMR, light call, and wonderful support staff. Please email CV to erin@healthmark.org COLORADO MD OR DO - needed for easy, part-time work. Any specialty welcome – we will train. Evaluation exams, no procedures. Great extra income for semi-retired doctor or new doctor with active DEA cert. Denver/Boulder area primarily with some day-travel to ski areas. Email CV to healthchoiceco@ gmail.com or call Martha 303-618-1774.

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ASSOCIATES IN FAMILY MEDICINE, the largest primary care provider in Fort Collins, Colorado with 29 physicians, has an immediate opening for a full-time BC/BE Family Physician for our South location. Our practice was established in 1979 and remains an independent medical group that works closely with University of Colorado Health. Responsibilities of the position include the full spectrum of primary care including OB. Inpatient care is limited to pediatric care and OB. In-house hospitalists are utilized for adult medical and surgical admissions. Call responsibilities are approximately 1/10. Frequently ranked as one of the most desirable communities in the United States, Fort Collins has an exceptional public school system, unlimited recreational opportunities in town and in the nearby Rocky Mountains, in addition to the diverse cultural offerings. Fort Collins is blessed with a stable employer base with Colorado State University as the largest employer along with many technology companies like Hewlett Packard and Intel. Competitive first year salary guarantee with production incentive with partnership opportunity after one year of employment along with real estate investment opportunities. Excellent benefit package also included. Please contact Dr. James Sprowell, (Executive Director) at 970-495-6202 to learn more about our practice or send CV to jsprowell@afmfc.com. Additional practice information available at www.afmfc.com 45

Features

the final word

Jay Want, MD Principal, Want Healthcare LLC Chief Medical Officer Center for Improving Value in Health Care

Dear Colorado physician . . . Hi. It’s Jay, the guy from down the hall. I am writing to you today to talk to you about how our world is changing, and why I think it is doing so. First, none of this is going to make any sense until we face up to the fact that what we have viewed as “the normal course of business” in medicine is anything but normal. In the history of the world, never have so many spent so much of other people’s money with so little accountability for how it was spent. Never. It’s been the biggest bonanza of unsupervised money in the history of the planet. You and I, hospitals, drug companies, insurance companies, and many others have made incredible livings based on this lack of adult supervision of our spending patterns. While we like to excuse ourselves from that list, as Walt Kelly said in Pogo, “We have met the enemy, and they is us.” At least, partly us. How did this happen? Well, remember that in 1950, the sum total of the data about our practice patterns could fit into a cocktail party conversation. With loud music on. In the absence of the ability to judge who was doing better and who was doing worse at our gig, society did a number of things to try to help itself sleep at night. First, they invented the malpractice suit. By more or less randomly punishing anecdotally bad behavior, they sent the message, “We can’t tell if you’re doing a good job, but we’ll rely on your fear and guilt to regulate your behavior. Sorry to resort to that, but it’s the best we can do right now.” We learned to fear and loath trial attorneys. To try to regulate our spending, the spending with no natural brake on it, they invented prospective review in insurance companies. This was to send the message, “We can’t tell if you’re doing a good job, 46

but we’ll rely on you giving in to the hassle factor for things you don’t really want all that much, to distinguish what’s medically necessary from what’s not. Sorry to resort to that, but it’s the best we can do right now.” We learned to fear and loath insurance companies. To try to regulate our quality, the quality no one could define with any specificity, they created hospital peer review and credentialing. Good, we thought, because we control those, and so while we do punish egregious error, for the most part we go through the motions and excuse anything we can imagine having done ourselves on a bad day. We do no root cause analysis, no systems improvement, and we wait for the same thing to happen again. We shake our heads when it does, and wonder why so many of our peers are having bad days. But in 2013, we are learning to tell who does a good job. In 1965, Gordon Moore working at Fairchild Semiconductor observed that the number of transistors on a chip was doubling every 18 months, and the cost was halving at the same time. This meant that computing power, and therefore information, was getting cheaper at an exponential rate. Today in 2013, Moore’s Law is still true, and information is cheaper than zero. The cheapness of information fundamentally changes the properties of modern society. It means that everybody’s performance can be measured, including yours, with increasing precision and accuracy. It means data will be increasingly available to do systems analysis, and improve the safety, reliability, and efficacy of treatments and procedures. It means that very complicated things will be modeled predictively, including things that are way more complicated than a hip replace-

ment. So what are the chances this computing power isn’t being applied to your performance as a doc? Zero. All the major health plans have already invested a lot of money to do exactly that. So we have a couple of options here. We could try to ignore this trend, and hope everyone who pays for our stuff will, too. We can spend our time and effort trying to discredit the data that’s being used, even though similar techniques are being used to send coupons to women who are pregnant before they’ve told anyone, through their buying patterns. “Big Data” is here, and it cannot be lobbied or wished away. Or, we can use the information that health plans and others can provide to get better, and to accelerate our quest for error-free, high value care. We can humbly accept that the smartest doc alone has no chance to do his or her best work without the data and analysis enabled by Moore’s Law. And we can begin to use these data to get better at what we do at a rate unimaginable in the days before powerful computing. I’m not here to make that choice for you, even if that were possible. I’m here to tell you that whether you voted for this or not, it’s where we are. The profession will never be the same, and like all loss, that is sad. But we should recognize that the old system and its imperfect quid pro quo were driven by society’s inability to judge what it was buying from us; its need to feel safe through fear and guilt-based mechanisms; and comforting delusions about our infallibility that we secretly wanted to believe ourselves. Today in 2013, I am confident that none of those things produced what is best for us, our patients, and our society at large. What will you choose? You won’t have to tell anyone. They’ll know from the data. n Colorado Medicine for May/June 2013

While you’re taking care of patients, we’ll be taking care of you. COPIC Financial Service Group www.copicfsg.com•(720) 858-6280/(800) 421-1834 Colorado Medicine for May/June 2013

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Colorado Medicine for May/June 2013