May-June 2014 by Colorado Medical Society

May/June 2014

Volume 111, Number 3

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Award-winning publication of the Colorado Medical Society

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Colorado Medicine for May/June 2014

contents May/June 2014, Volume 111, Number 3

Features. . .

Cover story

Michele Lueck, President and CEO of the Colorado Health Institute, continues our series on health care costs with a data-driven look at how increasing consumer engagement and financial responsibility in health care affects costs. Read about these new health care consumers and whether their empowerment will actually bend the cost curve. Coverage starts on page 8.

What if Colorado ranked No. 1?–The 2014 Colorado Health Report Card explores where and how Colorado can improve our health care system.

Consumer cost-sharing–Colorado Health Institute report examines the effect of consumer cost-sharing on health care costs.

Legislative update–CMS leadership and the advocacy team have been hard at work this legislative session. Read an update on their progress.

Colorado physicians support 133,000 jobs–A new study reveals that physicians bring extraordinary economic benefits to their communities.

What has the government made public?–Catherine Hanson presents action steps for physicians now that the federal CMS has released extensive information on what it paid doctors to treat Medicare patients in 2012.

Roadmap to reentry–CPEP presents a free resource that provides guidance for clinicians returning to practice and the entities that employ them.

Physician heroes: Stories of service–John Ogle, MD, MPH, presents his anti-burnout strategy: Deploying on humanitarian and combat missions around the world with military and civilian organizations.

CMS president wins coveted award–The Colorado Academy of Family Physicians has named CMS President John L. Bender, MD, its Physician of the Year.

Final Word–Sen. Irene Aguilar, MD, and Sen. Ellen Roberts discuss their proposed Colorado Commission on Affordable Health Care Costs, which strives to bring stakeholders together to control costs.

Inside CMS 5 7 32 36 37 38 40 42 44

President's Letter Executive Office Update Legal Update Board of Directors Prescription Drug Abuse Update ICD–10 Update Clean Claims Task Force Reflections COPIC Comment

Departments 45 52

Medical News Classified Advertising

Colorado Medicine for May/June 2014

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

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

2013/2014 Officers John L. Bender, MD, FAAFP President Tamaan Osbourne-Roberts, MD 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 Jan M. Kief, MD Immediate Past President

Board of Directors Charles Breaux Jr., MD Laird Cagan, MD Leslie Capin, MD Cory Carroll, MD Joel Dickerman, DO Naomi Fieman, MD Carolyn Francavilla, MD Jan Gillespie, MD Johnny Johnson, MD Richard Lamb, MD Lucy Loomis, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD Daniel Perlman, MD Scott Replogle, MD Floyd Russak, MD Ranee Shenoi, MD Stephen Sherick, MD Joshua Tartakoff, MS Theodore Timothy, MS Michael Welch, DO

Jennifer Wiler, MD Allison Wood, MS Harold “Hap” Young, MD Lena Young, MS AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Immediate Past 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

Division of Communications and Member Benefits

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

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

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Angie Baker, Program Manager, Angie_Baker@cms.org

Mike Campo, Staff Support, Mike_Campo@cms.org

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

Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Brad Pierson, Art Director, Assistant Editor; Chet Seward, Assistant Editor. Colorado Medicine for May/June 2014 Printed by Spectro Printing, Denver, Colorado

Inside CMS

president's letter John Lumir Bender, MD, FAAFP President, Colorado Medical Society

The scoop on scope Dear Physician, As the 2014 Colorado Legislative session winds up, it is clear that scope battles are becoming more frequent, and harder to fight. Here are just a few of the recent discussions down at the Capitol: Should acupuncturists give injections (they have been doing so for 15 years in Colorado without incident)? Should the Colorado Department of Health Care Policy and Financing reduce or remove the 3,600-hour training requirement for nurse practitioner’s desiring independent prescriptive authority?

What is important at this point in the discussion is not whether this development is fair, but more importantly asking how are we as physicians going to adapt? Recall that Darwin promises survival not to the smartest or the strongest, but to the most adaptable. Physicians must start focusing more on our own restraints in the free market, and how best to overcome those, rather than spending all of our time keeping others from practicing or expanding their trade. The destiny of ancillary and complimentary service

providers is to provide more and more services that look like primary care. Primary care in turn must evolve by disrupting specialty care, and specialists must focus on how to reduce or replace hospital-based services. Anything less becomes a distraction, a further loss of credibility in the public square, and the road to extinction. Sincerely, John L. Bender, MD, FAAFP n

Should pharmacists be paid by insurance companies to conduct medication reconciliations (a task that even physicians are not really paid directly to do)? What is becoming evident is that the physician perspective of serving as the consumer advocate in the name of patient safety is no longer nearly the credible argument in the Capitol that it was years ago. The legislators are focused on access, outcomes, costs and restraint of trade. This is not a phenomenon only in Colorado, but happening around the nation. Gone are the days when the Colorado Medical Society can march into the governor’s office and opine, “Practitioner X cannot perform procedure Y because of safety issue Z.” The argument is seen as turf protection, because the public only sees practitioner X doing procedure Y for less money and generally the data showing the harm is nonexistent.

Colorado Medicine for May/June 2014

Please help support CMSF In March 1997, Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization. The foundation’s mission is to administer and financially manage programs that seek to improve access to health care and health services, with the potential to improve the health of Coloradans. The Board of Trustees of CMSF is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. The spirit of Colorado is alive in the many ways that we help our neighbors. Call 720-858-6310 for more information and to donate.

Colorado Medicine for May/June 2014

Inside CMS

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

Commission on Health Care Costs passes Senate In mid-April the Senate Health and Human Services Committee held the first hearing and favorably reported on a 5-to-2 bipartisan vote for legislation to create a Commission on Health Care Costs in Colorado. The bill subsequently passed the full Senate and as of this printing is awaiting action in the House. In the Final Word column in this issue, the Senate authors outline the compelling public policy motives for a commission. They understand what a growing consensus of legislators and policy advocates have been warning. Expanding coverage will accelerate the cost spiral if the delivery system doesn’t produce consistently greater value. This is not an abstract concern that plagues other states. Here in our backyard Coloradans were surprised when a national analysis recently ranked our mountain resort counties as the highest priced health insurance exchange products in the United States. As I reported in my last column, the Colorado Department of Insurance, initiated by Governor Hickenlooper, has already appointed a study group directly tied to a public backlash over the cost of health insurance sold on the Exchange in the resort region of Summit, Garfield, Eagle and Pitkin counties, and at least one county has threatened to sue the state. In our testimony to the Senate committee, we emphasized what members of the 69th Colorado General Assembly already know: Health care spending trends point to anticipated cost increases that will risk compromising health care spending and investment, and crowd out funding for highways, education and clean water, among Colorado Medicine for May/June 2014

other vital infrastructure needs. We also commended the methodical, empirical approach proposed by the authors. Good data analytics are vital to producing sustainable, functional state policies for managing health care costs without compromising optimal patient outcomes. When the massive Medicare physician payment dump recently hit the media fan, we witnessed a raft of predictable media reports, some fair and some sensational. We can be reasonably certain that the cost commission as contemplated under the current legislation won’t indulge in similar tactics. Unlike other states, Colorado thought-leaders and influencers had already come together through the 208 Commission to create the Center for Improving Value in Health Care and the All Payer Claims Database, one of only a handful in the country. Because the authors’ predecessors showed patience and foresight, we have the expertise on the ground that can convert unfiltered payer data into useful information for consumers and physicians alike. The Health Care Cost Commission legislation, like the 208 Commission before it, is not without controversy. It has reignited the perennial debate over market-based versus public sector approaches. Comparisons to the federal reforms in the Affordable Care Act have already surfaced. These approaches are not mutually exclusive, and the methodology in the legislation to establish the commission points to market-based approaches.

policy challenges methodically and collaboratively, you tend to get faithbased positions – laws based on beliefs rather than empirical evidence, making leaps of faith that often seek to fix the problem by declaring the symptoms illegal. Fee freezes, eligibility, coverage

Health care spending trends point to anticipated cost increases that will risk compromising health care spending and investment, and crowd out funding for highways, education and clean water, among other vital infrastructure needs. caps and other barriers to care are a couple of time-honored responses that come to mind. Colorado has a long history of consensus building through interim work groups and blue ribbon commissions. Interim studies minimize the risk of end-of-session fire drills because they bring diverse views and expertise together to fix problems rather than blame and to lay the groundwork for legislators on a solid foundation of what works, and what should be avoided. n

We expressed strong support for a commission model. When legislators and advocates fail to approach complex 7

Cover Story

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$1.0 Michele Lueck, President and CEO, Colorado Health Institute

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Colorado Medicine for May/June 2014

Cover Story One of eight Coloradans has reported not getting medical care that they needed because it cost too much, according to the 2013 Colorado Health Access Survey (CHAS). You might be tempted to think that most of the people going without care do not have health insurance. You would be about half right. Of the Coloradans who said they didn’t get needed care from a doctor in the 12 months before the survey because they couldn’t afford it, about 44 percent were uninsured. A nearly identical percentage, however, had commercial insurance, most through an employer. The other 13 percent who didn’t get medical attention because of the cost were covered by public insurance, primarily Medicaid, Medicare and Child Health Plan Plus (CHP+). Bottom line: An insurance card doesn’t guarantee access to affordable health care in Colorado. (Table 1). At the Colorado Health Institute, we spend a lot of time thinking about the affordability of health care. The CHAS, which is funded by The Colorado Trust and which we field, analyze and disseminate, provides a wealth of data that allow us to delve into this crucial issue from a number of angles. The Colorado Health Institute’s mission is to provide health care research and analysis that supports better-informed health policy discussions and decisions. But we go beyond the numbers to offer context and insight as well. It is clear that the continued growth of health care costs, even though the growth rate has slowed in recent years, is unsustainable, and that the ever-higher cost curve is compromising individual Coloradans, our state budget and the future of our health care system. Across Colorado and the nation, smart and committed people are tackling the problem of spiraling medical costs. Many ideas are being tested and trials are being launched, ranging across a spectrum from free market solutions to regulatory interventions. We think that one promising strategy revolves around engaging and empowering consumers, a trend

Colorado Medicine for May/June 2014

Table 1: Health Insurance Status of Coloradans Who Did Not Receive Needed Doctor Care Due to Cost, 2013 43.8% 12.7% 43.5%

Commercial Insurance

Public Insurance

Uninsured

Source: 2013 Colorado Health Access Survey

springing from market-based forces, technological innovations, and state and national health reform efforts, including the Affordable Care Act (ACA). Armed with more information, and motivated by stronger incentives to select care options that offer the best value, we expect to see an influx of consumers who are engaged in, and financially responsible for, their health care in ways that we haven’t seen in the past. They will shop for health care that offers better service and the highest quality at the lowest costs – and they will have the tools and the motivation to find all three. They will be more than patients. Many of them will become true health care customers. Looking ahead, we expect these newly empowered customers to join health care providers on the front lines for a sustained assault on health care costs. The data: A view of the consumer Understanding this expected wave of engaged and empowered health care customers begins with the data.

$2.8 trillion in 2012, with 17.2 percent of the economy devoted to health care. This is down a bit from 17.3 percent in 2011. There’s a bit of good news hidden in these big numbers, with 2012 representing the fourth consecutive year of slower growth. In total, between 2009 and 2011, the annual increase in national health care spending was the lowest in 50 years. But health is a micro issue for most families. And health care is second only to food and housing when it comes to household expenses for services. This often means hard choices. For example, medical bills left 8 percent of Coloradans unable to pay for such basic necessities as food, heat or rent, the CHAS found. Nearly 13 percent took on extra debt to cover health care bills and about 5 percent said a family member worked more hours or took another job. Two percent said they were forced to file for bankruptcy. (Table 2, page 10). The most vulnerable Coloradans tend to be the most affected by unaffordable health care, the CHAS data show: • Nearly 21 percent of blacks said they didn’t get needed care because it cost too much compared to 11 percent of

At the macro level, U.S. health care spending increased 3.7 percent to reach

Cover story (cont.) whites and 13 percent of Hispanics. • About one of five low-income Coloradans between 101 percent and 200 percent of the federal poverty level (FPL) didn’t get needed care compared to about 5 percent of those above 400 percent of FPL. • Unemployed Coloradans were nearly twice as likely to have missed out on care as those with jobs. • Education played a role, with about

Still, the CHAS shows that Coloradans across the spectrum of education, income and insurance are impacted by high health care costs. These data tell us that even as more Coloradans gain health insurance, either through Connect for Health Colorado or Medicaid, the issue of affordability will not go away. Indeed, if the health cost curve doesn’t bend significantly, the success of health reform will be imperiled.

Table 2: Actions Taken by Coloradans Who Had Problems Paying Medical Bills in the Past 12 Months, 2013 Cut back on savings or took money out of savings

12.5%

Were unable to pay for basic necessities like food, heat, or rent

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Took on credit card debt

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Took out a loan Declared bankruptcy

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Source: 2013 Colorado Health Access Survey

23 percent of high school dropouts saying they didn’t get necessary care compared with 9.5 percent of college graduates.

The new health care customer Competitive markets share certain conditions. Consumers bear the cost for what they consume. Both consumers and

suppliers have complete and easy access to information in order to make choices. And barriers for new suppliers to enter the market are low or non-existent. For a long time, these conditions did not describe the health care market. That is beginning to change. First, health care consumers are paying more of their health care bills. The market-based theory is that consumers will make better choices, and forego unnecessary care, if they have a financial stake in the decision. Insurance companies are adding plans with higher deductibles, higher co-pays, and higher co-insurance. More employers are opting to offer these types of plans. And more consumers are choosing them, many enticed by the lower premiums. Colorado is proving to be a leader in this area. Colorado’s high-deductible plan enrollment reached 304,651 in January 2013, accounting for 8.4 percent of all private health insurance enrollment and placing Colorado in the top 12 states. Nationally, out-of-pocket spending on health care grew 3.8 percent in 2012 to $328.2 billion, up from a 3.5 percent expansion in 2011, reflecting higher costsharing and increased enrollment in consumer-directed health plans.

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For an application, or for more information about opportunities, responsibilities and benefits as a Clinical Faculty Member, please see www.medschool.ucdenver.edu/ocbme or contact Nicole Bost or Dennis Boyle at 303-724-0044 or Nicole.Bost@ucdenver.edu.

Colorado Medicine for May/June 2014

Cover Story Some economists point to the increase in high-deductible plans, and the resulting decisions by some households to scale back on visits to physicians, as part of the reason for the moderating growth in health care spending. Meanwhile, experts project $57 billion in annual savings if just half of the employees currently insured through their workplaces moved into high-deductible plans. The question is if consumer cost-sharing will help to bend the cost curve in the long term. The answer, according to research, is that cost-sharing is a useful tool for slowing cost growth among healthy populations, but it is not as effective among unhealthy populations. In addition, there is concern – and some evidence – that consumers faced with more costs will cut back on all health care, including essential care and even preventive care that wouldn’t cost them anything. Educating this newly-motivated consumer will be an important element in changing habits and saving costs. The Colorado Health Institute is watching a number of other efforts with the potential to bend the cost curve, including private insurance exchanges, defined contribution health plans and reference pricing. First, a quick rundown of defined contribution health plans and private exchanges. A company with this type of plan gives each employee a fixed amount of money to spend on health insurance. The employee chooses the plan. If employees want a plan that costs more, they pay the difference. The strategy is to maintain employee choice, allowing them to be involved in choosing their health insurance and health care, while limiting the risk of increasing premiums for employers. One way for employers to offer a defined contribution is through private insurance exchanges. These are usually online marketplaces established by large employers, where employees can comparison shop for various plans and purchase

Colorado Medicine for May/June 2014

insurance using their employers’ contribution. Many companies see private exchanges as an emerging opportunity. Taken to its logical conclusion, some experts predict that exchanges, coupled with defined contributions, will lead many employers to stop purchasing health insurance directly for their employees and instead help to offset the cost. This trend is likely to accelerate if both the public and private exchanges are working well and there are abundant choices.

Consumer-oriented trends: will they bend the cost curve? • Adoption of high-deductible plans • Emergence of defined contributions • Growth of private health exchanges • Innovations focused on reference pricing • Implementation of workplace wellness programs

Reference pricing, which counts on consumer involvement to help save costs, is gaining traction as well. An insurance company sets a “reference” price it believes is reasonable for a specific medical procedure – a knee replacement, for example. If a consumer chooses to have this procedure from a provider who requires payment above the reference price, the consumer must pay the difference. It maintains consumer choice, while limiting the risk of insurers. In one test by the California Public Employees Retirement System (CalPERS), reference pricing saw the cost of hip and knee replacements decline by 19 percent. CalPERS permitted hospitals that allowed charges of no more than $30,000 for the procedures to join its plan. Those that didn’t agree to limit the charge to $30,000 were excluded.

Some potential problems may arise in implementation, however, including consumers who don’t know how much the reference price is – or how much the hospital is charging. Critics point to the arbitrary nature of choosing a reference price. Other experts say that reference pricing is a policy worth exploring. Transparent data as well as consumer education will be key to making reference pricing successful. Finally, employer wellness programs are becoming increasingly popular. About half of the nation’s employers offer wellness promotion initiatives, and larger employers are more likely to have more complex wellness programs, according to a 2012 RAND Employer Survey conducted for the U.S. Department of Labor and the U.S. Department of Health and Human Services. About three of four employers offering a wellness program (72 percent) described it as a combination of screening activities and interventions. But the RAND study found that, at this early point, the objective evidence doesn’t yet show significant cost savings or health outcome improvement. (Table 3, page 12). Taken together, all of these efforts have one thing in common – an engaged and motivated customer. Price transparency Newly transparent insurance rates, a result of the ACA, have hit home in Colorado, which learned early this year that residents of Aspen, Vail and other mountain resort towns have the highest health insurance premiums in the nation. This reflects, at least in part, an increase in overall health care costs in these areas. For example, in 2009 the per capita payments for health care services, paid for by both insurers and patients, were 36 percent higher in Summit County than in Denver County. By 2012, they were 61 percent higher. Professional costs were a large driver of the difference. They grew 45 percent in Summit County over this

Cover story (cont.) time, compared to a 9 percent growth rate in Denver. These price variations have most likely been the case for a long time, but now people know about them. In response, Colorado Insurance Commissioner Marguerite Salazar has launched a study of the differences and potential state responses, another example of consumer power. In order for patients to become true customers with the ability to shop for care, transparency will extend into the clinical world, where there is growing pressure to publicly reveal prices that are charged. The federal government has begun revealing how much Medicare pays individual physicians. A study by University of Chicago researchers found that price transparency reduced the price charged for uncomplicated elective procedures by about 7 percent. The study revealed that most

providing tools to help customers make value-based choices. The Center for Improving Value in Health Care (CIVHC) has launched the web-based and searchable All Payer Claims Database. In June, a consumer portal is expected to be available in which consumers can compare what they are likely to spend for various services among different providers. Meanwhile, Engaged Public is leading an engaged benefit design pilot project that gives consumers more information and resources to make decisions about their care, with the goal of reducing the use of expensive but ineffective treatments. Again, consumers are the common denominator in these efforts. Technology In many cases, shopping for health care is becoming as easy as clicking on the keys of a laptop. About 45 percent of health care consumers report searching online for in-

Table 3: Percentage of Companies Offering a Particular Wellness Program to Their Employees, by Firm Size, U.S., 2012 80% Small Firms

70%

Large Firms

60% 50% 40% 30% 20% 10% 0%

Gym Membership

Smoking Cessation

Biometric Screening Weight Loss Program

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2012

of the price reductions occurred in areas with intense competition among providers. Overall, the evidence points to a reduction in health care prices for patients with an incentive to consider costs, the authors said. While payers are almost never responsible for the full price charged, some regulators believe that price charged is a consistent way to compare ultimate expenditures. A number of Colorado programs are 12

formation about treatment options. By comparison, only 7 percent say they have used the internet to decide which hospital to visit. But around half reported they would like access to tools or websites that would let them compare costs of care, evaluate its quality and read user reviews. Look to social media to make more inroads in health care, especially among younger consumers. About one of four respondents to the Deloitte Center for

Health Solutions’ survey of U.S. adult health care consumers said they used social media for health-related purposes, mostly to learn about specific illnesses or health problems. Still, physicians remain the most trusted source for reliable information at 44 percent. Independent health-related websites, such as WebMD, were trusted by 24 percent. Internet searches and social networking sites trailed far behind. Forward-thinking clinicians are experimenting with adding social media to their customer toolkit. For example, the Mayo Clinic is a leader in this area, with a dozen blogs, more than 500,000 Facebook “likes,” more than 750,000 Twitter followers, 17,400 YouTube subscribers, 10,000 Pinterest followers and more than 1.4 million Google+ views. The implications of these changes on costs have yet to be determined, but they hold promise. Again, it’s all about turning a patient into a customer. Conclusion While engaging and empowering health care consumers is an attractive option to control costs, we need more information on how best to make this happen. Ideas must translate to action. And action must translate to effective cost reductions. It will not be a quick or easy fix. A number of experts expect health costs to grow faster than inflation as the economy picks up steam and the pipeline of expensive technological advances continues unabated. The Colorado Health Institute will be monitoring whether the patient-as-customer initiative actually bends the curve. n Michele Lueck has been president and CEO of the Colorado Health Institute since 2010. She is a veteran of the health industry and is leading a team that is providing evidence-based research and analysis for state health care leaders that is relevant and actionable. Colorado Medicine for May/June 2014

Colorado Medicine for May/June 2014

Features

What if Colorado ranked No. 1? Kate Alfano, CMS contributing writer

2014 Colorado Health Report Card explores where and how Colorado can improve For the past eight years, the Colorado Health Foundation has published the Colorado Health Report Card, an annual update on the current status of health, health care and health coverage in Colorado using data provided by various sources. The report card, which is produced in conjunction with the Colorado Health Institute, provides data on 38 key health indicators over five life stages: Healthy beginnings, healthy children, healthy adolescents, healthy adults and healthy aging. A letter grade is assigned to each of the five life stages, along with Colorado’s rank from best (1) to worst (50) among all states. In this way, the report card provides a comprehensive picture of the health of Coloradans and where we need to improve.

make vast improvements in health and health care. If Colorado ranked No. 1 • 7,000 more babies would be born to mothers who received timely prenatal care • 66,600 more children would engage in 20+ minutes of vigorous physical activity four or more days per week • 27,600 fewer adolescents would be living in families with incomes below the poverty level • 458,200 fewer adults would be uninsured • 137,600 fewer Coloradans would report poor mental health and • 21,600 fewer older adults would report limited activity due to poor physical or mental health

correlates directly to health care costs and improving them could have a large impact on reducing health spending in Colorado. For instance, preterm births account for approximately 35 percent of all health care spending on infants in the United States. Regular prenatal care is important in identifying risk factors for preterm births. And children who are not physically active are more likely to become obese, which increases their risk for many other health issues. Colorado spent $1.6 billion treating diseases and conditions related to obesity in 2009. Using the Colorado Health Report Card, stakeholders can set ambitious goals to improve the state’s rankings and grades, directing policy efforts to improve the health of Colorado. n

Reduced cost connections Improving these key health indicators

2014 report card revelations • Healthy beginnings – C (grade), 23.8 (rank) • Healthy children – C, 24.8 • Healthy adolescents – B, 15.2 • Healthy adults – B, 15.2 • Healthy aging – B+, 11.5 This year’s report card supplement explored national and local initiatives that are tackling some of the toughest issues affecting the health of Coloradans. The supplement, “A Roadmap to Number One,” illustrates what it would mean if Colorado were to achieve the top ranking in each particular indicator and focuses on best practices within key indicators that could help Colorado Colorado Medicine for May/June 2014

Promoting health care decisions that are non-duplicative, evidence-based, free from harm and truly necessary Visit www.cms.org/choosing-wisely 15

Features

Consumer cost-sharing Kate Alfano, CMS contributing writer

Colorado Health Institute report examines the effect of cost-sharing on health care costs Nearly one-fifth of the U.S. gross domestic product (GDP) is comprised of health care spending, but the return on investment in terms of overall health and health outcomes doesn’t measure up. That’s the rationale that led the Colorado Health Institute (CHI) to release a report in February 2014, “Sharing the Cost: A Changing Landscape.” This report is the first in CHI’s Consumer Engagement and the Health Care System series through which they will analyze efforts to improve the quality and efficiency of the health care system with a focus on market-based solutions, and study whether these approaches lead to more engaged and informed consumers who take greater responsibility for their health and health care. They seek to know whether programs that are successful in the private sector can be transferred to the public sector

and whether these initiatives can lower the growth of health care costs in the United States while improving the overall health of its citizens. “Sharing the Cost” delves into the issue of consumer cost-sharing. “Any discussion of rising health care spending is sure to touch on the concept of consumer cost-sharing,” the authors stated in the report, identifying the three common forms of cost-sharing as co-payments, where the consumer pays a fixed dollar amount for services; deductibles, where the consumer pays a specified sum each year before insurance kicks in; and co-insurance, where the consumer pays a percentage of all costs even after meeting the deducible. While insurance premiums generally are not considered to be an element of costsharing, the premium amount and the level of cost-sharing are related. “The idea behind it is simple: The more that

Available from AMA: Point-of-care pricing toolkit As cost-sharing increases, it has become increasingly important for physician practices to collect payment at the time of service. The American Medical Association has made available a toolkit to help physicians and their staffs learn how to use electronic health care transactions, such as the electronic eligibility benefit inquiry and response transactions, to help facilitate point-of-care pricing and improve cash flow. The AMA Point-of-Care Pricing Toolkit guides users through the process of collecting payment from patients at the time of service. Go to the AMA’s website, www.ama-assn.org, and search “Point-of-Care Pricing Toolkit” to access this resource.

people pay for something, the more that market forces kick in and the more they think critically about their purchasing decisions and demand greater value for their money.” This has led to a drastic increase in health insurance plans with higher deductibles, higher co-pays and higher coinsurance. Colorado’s high-deductible plan enrollment reached 304,651 in January 2013, accounting for 8.4 percent of all private health insurance enrollment and placing Colorado in the top 12 states for private insurance enrollment in high-deductible plans. Nearly half of Colorado employers report that they offer high-deductible plans with deductibles of $1,000 or more. This is a reflection of a national trend; more people are opting for high-deductible plans. CHI found that while cost-sharing can slow cost growth among healthy populations, it is not as effective among unhealthy populations. They report that increasing the level of cost-sharing leads to less use of medical care, which does equate to cost savings but comes at a risk of patients avoiding effective and appropriate care – some of which is preventive care that is covered by insurance. It contributes to worse health for low-income people who are already sick. And it motivates some people to select less-costly options such as generic drugs or fewer specialist visits, but fails to curb the highest users of medical care as they reach their deductibles quickly and then have no financial incentive to avoid more expensive services. n

Colorado Medicine for May/June 2014

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Features

Legislative update Susan Koontz, JD, CMS General Counsel

Colorado nears end of legislative session With approximately two weeks left in the 2014 Regular Session, there is still much work to do at the Capitol. The Colorado Medical Society has been tracking more than 40 bills this legislative session and working diligently with our allies in medicine to protect and empower physicians and patients in Colorado. Below are bills that we are following. SB14-187: Colorado Commission on Affordable Health Care The bill creates the Colorado Commission on Affordable Health Care and tasks the commission with studying and making recommendations regarding health care costs, focusing on evidence-based cost controls and access and quality of care. The governor and legislative leadership from both houses and parties are to appoint the 12-member commission, assuring representation from across the state and by individuals with expertise in various subject areas, including health care administration, financing, delivery, and consumption. Additionally, the commissioner of insurance, the executive directors of the departments of Public Health and Environment, Human Services, and Health Care Policy and Financing, and an administrator from the All-Payer Health Claims Database serve as ex officio, nonvoting members of the commission. The commission is to make recommendations regarding legislative and 18

regulatory modifications that could make health care affordable while improving access and quality of health care. Cost containment routinely rates very high on the list of top concerns for Colorado physicians and patients. CMS views this bill as a vital step in addressing the top drivers in skyrocketing health care costs. Update: The bill passed the Senate and is awaiting scheduling in the House Health, Insurance, and Environment Committee. HB14-1054: Restrict Minors Access Artificial Tanning Devices This bill would have restricted the use of artificial tanning devices for minors under the age of 18. This is the second session that a bill of this nature has been pushed for by Coloradoâ&#x20AC;&#x2122;s medical community but it has come up against strong business interests each time. The CMS Council on Legislation (COL) voted to support the bill. Update: Unfortunately, this bill was postponed indefinitely (PI) in the Senate Appropriations Committee on April 16. HB14-1207: Household Medication Take-back Program The program allows individuals to dispose of unused medications at approved collection sites, and for carriers to transport unused medications from approved collection sites to disposal locations.

The COL voted to support the bill with the recommendation from the CMS Prescription Drug Abuse Committee, finding it in line with CMS policies on reducing prescription drug abuse in Colorado. Update: The bill passed the House and Senate and is now on its way to the governor for signature. HB14-1283: Modify Prescription Drug Monitoring Program This bill makes modifications to the electronic prescription drug monitoring program (PDMP). The COL and CMS Prescription Drug Abuse Committee voted to support this bill. CMS physicians and staff have been an integral part of the Colorado Consortium on Prescription Drug Abuse Prevention that made the recommendations outlined in the bill, demonstrating CMSâ&#x20AC;&#x2122; influence in the statewide effort to reduce prescription drug abuse. Update: CMS continues to show strong support for this bill and is pushing it through the legislative process. This bill was heard before the Senate Health and Human Services Committee on April 24 and passed with amendments that struck language that would have allowed HCPF access to PDMP data for Medicaid patients and added language that will limit a physician's responsibility to a designee's negligent breach of confidentiality of information obtained from the PDMP. As Colorado Medicine for May/June 2014

Features introduced, the physician would have been responsible for a designee's willful intentional actions. Two bills that would have expanded the scope of practice of alternative health care providers have been stopped in their tracks: SB14-128: Modify Naturopathic Doctor Act This bill would have allowed a naturopathic doctor (ND) who does not satisfy the education and examination requirements determined last year by HB13-1111 but who holds an active certification in good standing from the American Naturopathic Medical Certification Board to obtain a stateissued ND registration. As previously reported, the bill was PI'd in the Senate Health and Human Services Committee on Feb. 13. SB14-32: Naturopath Providers Treat Children The bill would have repealed the restrictions on the ability of alternative health care providers to treat children of any age. After a tough fight, CMS and our allies prevailed and the bill was PI'd in the House Health, Insurance and Environment Committee on April 3.

next legislative session and beyond. SB14-155: Medical Marijuana Health Effects Grants Program Within the Colorado Department of Public Health and Environment, this bill will create a sub account in the medical marijuana cash fund that will provide funding for medical marijuana health research. The COL voted to support this bill.

SB14-18: Prohibit Nicotine for Minors Under current law, it is illegal to furnish tobacco products to anyone under 18 years of age. This bill expands the prohibition to include all nicotine products. The COL voted to support this bill. It successfully passed through the legislature and was signed by the governor on April 11. n

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New bills that CMS has been tracking since March include: HB14-1288: Student Immunizations Prior to School Attendance As originally drafted, this legislation would have put into place modest educational requirements for parents who were considering use of the “personal belief exemption” for opting out of immunizing their children. Unfortunately, the bill was amended to remove the educational requirements and all that remains is a requirement that schools report vaccination rates. The COL voted to support this bill and the CMS lobbying team continues to negotiate this bill as it moves through the process, but anticipates that the fight for stricter educational requirements around an increasing vaccine opt-out rate will continue into Colorado Medicine for May/June 2014

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Features

Colorado physicians support 133,000 jobs Kate Alfano, CMS contributing writer

New study demonstrates Colorado physicians drive $20.1 billion in economic activity Colorado’s 12,263 patient care physicians fulfill a vital role in the state’s economy by supporting 132,971 jobs and generating $20.1 billion in economic activity, according to a report released on April 16 by the Colorado Medical Society and the American Medical Association. “Physicians carry tremendous responsibility as skilled healers charged with safeguarding healthy communities, but their positive impact isn’t confined to the exam room,” said AMA President Ardis Dee Hoven, MD. “The new study illustrates that physicians are strong economic drivers that are woven into their local communities by the economic growth, opportunity and prosperity they generate.”

total of $20.1 billion in economic output statewide. • Wages and benefits: Each physician supported an average of $910,600 in total wages and benefits and contributed to a total of $11.2 billion in wages and benefits statewide. • Tax revenues: Each physician supported $64,686 in local and state tax revenues and contributed to a total of $793.2 million in local and state tax revenues statewide.

The study found that, in comparison to other industries, patient care physicians almost always contribute more to the state economy than each of the following: higher education, home health care, legal services, nursing and residential care. To view the full report and an interactive map of the United States, go to www.ama-assn.org/go/eis. n

The report notes that given the changing health care environment, it is paramount to quantify the economic impact physicians have on society. To provide lawmakers, regulators and policymakers with reliable information, the report measured the economic impact of Colorado physicians according to four key economic barometers. The overall findings in the state of Colorado include: • Jobs: Each physician supported an average of 10.84 jobs and contributed to a total of 132,971 jobs statewide. • Output: Each physician supported an average of $1.6 million in economic output and contributed to a

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Features

What has the government made public? Catherine Hanson, JD, WhatleyKallas, LLP

What physicians need to know about their public Medicaid payment data In an historic reversal of policy, on April 9, 2014, the Centers for Medicare and Medicaid Services (CMS) released extensive information about the payments it made to physicians and other providers of Part B Medicare services. The public release includes every person or organization that billed for these services in 2012 – over 880,000 providers. The information is posted for download on the CMS website at www.cms.gov in a section entitled “Medicare Provider Utilization and Payment Data.” It includes all the following data fields for 100 percent of the calendar year 2012 final-action, physician/supplier Part B non-institutional line items for the Medicare fee for service population: • Biller demographic data: 1) NPI number; 2) last or organization name; 3) first name; 4) middle initial; 5) credentials (license type); 6) gender; 7) entity type (Individual (I) or Organization (O)); 8) street address; 9) street address 2; 10) city; 11) ZIP code; 12) state; 13) country; 14) provider type (specialty) • Medicare participation indicator (Y/N) • Place of service (Facility (F)/Outpatient (O)) • HCPCS (CPT) code and HCPCS description • Line service, unique beneficiary and distinct beneficiary/per day service counts • Average Medicare allowed amount and standard deviation Medicare allowed amount • Average submitted charge amount Colorado Medicine for May/June 2014

and standard deviation average submitted charge amount • Average Medicare paid amount and standard deviation Medicare paid amount For those who don’t want to wade through these enormous spreadsheets, the Wall Street Journal has posted an easier to navigate – although less complete – database. It is available at http:// www.projects.wsj.com/medicarebilling/. This database includes physician or other provider name, address, specialty and total Medicare payment amount, and then a drill-down screen showing the number of each procedure billed by CPT/HCPCS code, the average Medicare payment amount for each service, and the total paid for each service type in 2012 (to protect beneficiary identity, only services involving at least 11 beneficiaries are included). How hard is it to figure out what I was paid? It takes only a few seconds to look up any physician or other Part B Medicare provider and find out what the government is reporting Medicare paid them, and for what services. It is also easy to see how the top physicians or other health care providers in the aggregate – or in a particular specialty – rank in terms of total Medicare payments. And it is equally easy to do this search by state or city.

ployees, your friends, your enemies, the press . . . anyone and everyone is now privy to your Medicare billing practices. To make matters worse, this is just raw claims data. Without any way to put this data in context, the potential for viewers to misunderstand this raw data is significant. What physicians should do? Most importantly, review your data! This is not the time to put your head in the sand. The “transparency” genie is not going back in the bottle – ever. And of course, where Medicare goes, private payers usually are not far behind. As discussed below, there are a number of steps physicians can and should take to protect themselves from the potential adverse consequences of this publicity. But if you don’t know what has been published about you and where you really rank in comparison to similarly situated physicians in your specialty or sub-specialty, you can’t protect yourself. The first step is to look at your numbers and confirm whether they are correct. Historically, there have often been major data errors in databases of this type. If CMS has it wrong, you should get the information corrected as soon as possible. What do I do if I’m not listed? There are a number of reasons why you might not be listed. Assuming you treat-

Thus, your patients, your competitors, the managed care plans with which you contract, your former or current em23

Payment data (cont.) ed Medicare patients in 2012, the two most common reasons you won't be listed are either because your services were billed under a group NPI and Taxpayer Identity Number (TIN), or because all your patients were covered by Medicare Advantage. The database only includes fee-for-service Medicare payments; services provided in 2012 to the 27 percent of the population covered by Medicare Advantage are not included. Again, if there is a mistake and you should have been included, you may want to start by reviewing and updating your listing in the National Plan & Provider Enumeration System at https:// nppes.cms.hhs.gov/NPPES/Welcome. do, and then contact CMS. If you were not included and your patients are asking why, you may want to work with the organization that billed on your behalf to develop an appropriate public response. Among other things, your employer will want to answer questions and allay any fears your patients or potential patients may be expressing. For example, where evidence suggests that physicians should perform at least a certain minimum number of a specific procedure to obtain optimal outcomes, you may want to be able to demonstrate that you met that threshold. What to do if the numbers are correct, but the impression they convey is misleading? There are many reasons why the numbers may give your patients or the public the impression that you are making a lot

more money from Medicare than others in your specialty, or than you are taking home. Those reasons may include, among others: • Others bill under your provider ID, such as physician assistants or nurse practitioners. • You have been miscategorized, and actually practice in a different specialty or subspecialty than the one that is listed. • The services you provide include expensive drugs or other services that you pay for, like chemotherapy drugs. • Fee-for-service Medicare patients comprise a larger than average portion of your practice (you don't see many patients covered by Medicare Advantage, commercial health insurance or other programs). • Your particular patient population is sicker than average because you are a subspecialist, or otherwise handle more complex patients. • Your overhead is substantial – the public generally has no idea that most physicians spend 50 percent or more of their gross income by the time they pay for their staff, rent, equipment, supplies, health information technology, professional liability insurance, professional licenses, certifications and continuing medical education, education loans, etc. You may want to develop an explanation you can share with your patients, referral sources, managed care plans, regulators or the press that puts this in-

Join Now! Colorado Medical Political Action Committee Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org 24

formation in perspective. To the extent the data demonstrates your extensive experience with a particular procedure, you may want to point that out. You can also reference the things that make your practice stand out, like state-of-the-art equipment, foreign language competencies, extended hours, etc. You may also want to take this opportunity to highlight your professional qualifications, including, but certainly not limited to, successful participation in the government’s eprescribing, electronic health record (EHR) meaningful use or PQRS programs. Finally, take this opportunity to review your profile on the CMS Physician Compare website at www.cms. gov/physiciancompare. Make sure that website contains your up-to-date demographic information and correctly reflects your accomplishments. What should I do if my numbers concern me? Physicians should use this opportunity to look at their data in comparison to their peers. While it may be justifiable for a physician to be an outlier, there is no question that outlier status invites scrutiny. These now publically available spreadsheets have dramatically upped the stakes. There are experts who have analyzed the entire public database and can tell you where you rank by specialty and locality, and whether your data raises particular red flags. You owe it to yourself to know where you stand and take charge of your profile. n Catherine Hanson is the former AMA senior vice president for Public and Private Sector Advocacy and former California Medical Association general counsel. She is currently practicing law with WhatleyKallas, LLP, a firm skilled and experienced in addressing physician billing, payment, recoupment and fraud and abuse issues with an office in Aspen, Colo. NOTICE: The information provided in this article constitutes general commentary and information on the issues discussed herein and is not intended to provide legal advice on any specific matter. This article should not be considered legal advice and receipt of it does not create an attorneyclient relationship. Colorado Medicine for May/June 2014

Colorado Medicine for May/June 2014

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Features

Roadmap to reentry Elizabeth J. Korinek, MPH Chief Executive Officer, CPEP

Resource supports clinicians seeking to return to practice after extended absence With the implementation of the Affordable Care Act (ACA) and the need for additional primary care providers, now more than ever it is critical to identify innovative, cost-effective and timely pathways to address primary care workforce shortages. Health care practitioners returning to practice have the potential to be an important part of the solution to the workforce shortage; however, significant barriers exist that discourage providers from returning to practice or cause significant delays in returning. A new resource developed by the Center for Personalized Education for Physicians (CPEP) and the Physician Reentry into the Workforce Project provides guidance for returning clinicians and the entities that employ them, establishing a safe, more efficient return to clinical practice. Health care is multifaceted and involves many stakeholders, all with their own set of rules and regulations. As a result, reentry to practice can be a complex and daunting process for clinicians who must fulfill a multitude of requirements from a variety of entities. Physician reentry, as defined by the American Academy of Pediatrics’ Physician Reentry into the Workforce Project, is returning to professional activity/clinical practice for which one has been trained, certified or licensed after an extended period of time. It is separate and distinct from remediation, although there are some traits common to both groups. These clinicians have the potential to be an important part of the solution Colorado Medicine for May/June 2014

to workforce shortages, but often are discouraged by the complexity of the current system. The roadmap helps overcome these barriers to reentry by identifying solutions, and providing clear guidance to physicians and physician assistants wanting to return to practice.

assistants in all specialties,” said Holly J. Mulvey, MA, co-director of the Physician Reentry into the Workforce Project.

The comprehensive 37-page booklet was developed through a series of facilitated meetings funded by the Colorado Trust’s Convening for Colorado program. To maximize the efficiency of the Convening sessions, participants were provided with pre-meeting information so they would have a common understanding of reentry barriers. The two in-depth meetings attracted key leaders from state government, health plans, hospitals and hospital systems, rural and safety net provider groups, associations and not-for-profit organizations, medical defense insurers, medical educators, and private corporations. Rather than communicate with these organizations (or sectors) in silos, bringing stakeholders together provided an opportunity to foster collaboration, and determine common requirements and shared solutions. Approaches agreed upon by stakeholder participants were collected and distilled into one comprehensive resource now available publicly for providers in Colorado and across the nation.

• Licensure and board certification • The reentry plan: Options for reentry clinicians • Preceptorships • Hospital credentialing and privileging • Health plan contracting and credentialing • Liability and risk management • Cost of reentry • Ways to make the reentry experience positive

“Although many of the resources and contact information are specific to the state of Colorado, overall, the roadmap is widely applicable beyond the state and for physicians and physician

This first-of-its-kind resource includes Information on important topics including the following.

To access the “Roadmap to Reentry” free of charge, visit www.roadmap toreentry.org or www.physicianreen try.org. n

LOOKING? Whether you’re looking for new opportunities or selling your product or service, CMS’ classified ad section is the place to be seen. To place your ad call (720) 858-6310

Features

Physician heroes: Stories of service Kate Alfano, CMS contributing writer

Colorado emergency physician serves military 33 years on seven continents Editor’s note: There are several warning signs of professional burnout, including having feelings of being rundown or drained of physical or emotional energy, feeling misunderstood or unappreciated by your coworkers, feeling that you’re under too much pressure to succeed, feeling frustrated by organizational politics or bureaucracy, or feeling that there is more work than you practically have the ability to do. The Colorado Medical Society recognizes the prevalence of burnout among physicians, particularly in this time of great change in health care. To help our members reflect on the meaningful difference they're making in the lives of their patients and community and to recognize extraordinary actions, Colorado Medicine launched the Physician Heroes series. We will profile as many different members as we can who have gone above and beyond in the profession to help his or her colleagues or community. We hope you’ll see your own values reflected in these stories and be reminded of the joy of medicine. Members are invited to nominate themselves or a colleague by contacting Dean Holzkamp at dean_holzkamp@cms.org or 303-748-6113.

John Ogle, MD, MPH

CMS member John Ogle, MD, MPH, is an emergency physician in Longmont and a colonel in the United States Air Force. Over his 33 years in the military he has devised his own “anti-burnout” strategy; he has deployed on humanitarian and combat missions to seven continents with military and civilian relief organizations. He travels voluntarily, going where he feels he can make a difference. “I’m drawn to unique places where I’m going to be doing something interesting and meaningful with the skill set I have. Like many ER docs, I have a touch of ADHD, which craves variety.” Ogle currently serves as the commander of the 153rd Medical Group, based out of Cheyenne, Wyo. The group is part of the 153rd Airlift Wing of about 1,000 service men and women age 18-60 from around the country. Ogle’s medical group comprises 67 health care professionals including dentists, optometrists, surgeons and critical care doctors. “We’ve got a mishmash of specialties, super-talented, devoted, patriotic people,” Ogle said. “Everyone’s involved for slightly different reasons but we all focus on delivering world-class care in the world’s most hostile environments. Our team delivers high-tech medicine around the globe. Part-time military service is a great antidote against professional fatigue for many doctors.”

Airmen of the 332nd Expeditionary Medical Group carry a patient aboard a waiting Air Force C-17 for a medical evacuation flight from Balad Air Base in Iraq to Landstuhl Regional Medical Center in Germany for further treatment on Feb. 27, 2007. Credit: U.S. Air Force photo by Airman First Class Nathan Doza. 28

An admitted shutterbug, Ogle tells his “war stories” through pictures. He flipped through images of a field hosColorado Medicine for May/June 2014

Features reached Balad survived – a statistic unmatched in any previous conflict.” He told another story from Balad. “I’m placing a subclavian SwanGanz catheter and threading a wire through the introducer aiming for the right ventricle. It was the critical few seconds, and I was nervous that I’d screw up the delicate procedure. Thankfully the wire passed into the heart easily and we were all focusing on the arrhythmia that I was inducing to make sure the catheter would be in the right place.

John Ogle, MD, MPH, at Bagram Airbase in 2009, when he was deployed with the 455th Air Expeditionary Wing, which is part of NATO International Security Forces.

pital in New Orleans after Hurricane Katrina, refugee medical facilities in Tunisia, and the airborne ICU in the back of a C-17 aircraft. He came across a series of photos from the 332nd Air Force Theater Hospital at Balad Air Base in Iraq where he deployed in 2007. It was during “the surge,” the busiest trauma operation of the war, and he worked in the combat hospital. “Basically a MASH unit,” he said, the hospital comprised a massive series of interconnected tents. There were four generatordriven air conditioners devoted to the radiology wing to cool equipment and provide some relief through the canvas against the 120-degree desert heat. They were north of Baghdad, about 80 miles outside of the Green Zone. “We were shelled constantly and had to place sandbags around the tents for shrapnel protection. After just three weeks I had this little award that read, ‘Survived 100 mortar attacks.’” Most days were tough, but the staff rarely complained because just a few moments with the severely wounded American and Iraqi casualties put it all in perspective and reColorado Medicine for May/June 2014

minded everyone why they choose to be doctors, Ogle said. “We were sweaty but had it easy compared to those brave folks. Army, Navy and Air Force doctors of every specialty were humbled to treat some of the worst casualties of the war. I am very proud that during the Iraq war, 98 percent of the wounded who

“Just at that moment, the daily mortars decided to rain down. The power goes out everywhere. Even the backup power goes out. What are the odds for this poor patient? The nurse and I were left standing in the dark in sterile garb, hands frozen in position trying to devise the next move since the catheter was not yet on the wire. Everyone else in the ICU tent was on the floor, attack in progress. Luckily guys came out with flashlights within seconds – though it seemed like hours – I withdrew the wire, aborted the procedure and stopped the bleed-

Airborne over Colorado in a C-17 practicing in-flight ICU operations in January 2014. 29

Physician heroes (cont.) him. The patient deteriorated to full cardiac arrest but one shock reversed his ventricular fibrillation. Things looked bad, but Ogle was able to temporarily restore coronary circulation with thrombolytics. “I’m on the ice shelf. There are no cardiologists on the entire continent, and no paved roads within 3,000 miles. What are we going to do?” John Ogle, MD, MPH, at the geographic South Pole in November 1999 with his favorite drink – Mountain Dew – frozen solid in the negative 78 degrees F weather.

ing. The power came back on, I took a big breath, opened a new kit and r e- a c c o m p l i s h e d the pulmonary artery catheterization. The patient survived transfer to Germany eight hours later.”

Ogle made the call to fly him out on a dedicated, ski-equipped LC-130 as a critical care patient to the nearest chest pain center – in Christchurch, New Zealand, a 10-hour one-way trip – for a stent.

John Ogle, MD, MPH, in front of the medical tent at Incirlik Airbase in Turkey during Operation Northern Watch in 1999.

Natural and manmade disasters are challenging but the rewards are immense. “Whether civilian or military, planning for a global medical response forces physicians to think outside the box, gaining comfort in chaos. You may not have your favorite drawer, be with your favorite nurse, or be able to

Ogle paused on one photo from a deployment in Antarctica in 1999. Deployed at the same time was a dentist from Boulder who was hiking across the Ross Ice Shelf Heather Ogle, MD, and John Ogle, MD, MPH, when he sat down with their dog Suki in front of Longmont Hospital; abruptly with pal- an updated photo taken 11 years after . . . lor and nausea. A nurse recognized signs of a heart at- “Here we were with an tack and ran across the frozen ocean unstable heart patient to trigger the alarms. A medical team who was also a friend picked him up in a track vehicle and and professional col- . . . one taken in 2003 when the couple was contemplating they called Ogle to help resuscitate league. We all felt help- a travel-intensive anti-burnout strategy. less, but we did what we could with the tools available and park in your favorite parking space, luckily there was an excellent out- but you might be surprised how well come.” Ogle and the patient later you’ll function away from your compublished a joint account in a medi- fort zone. It is easy to rally a team cal journal of this first-ever full Ant- when the clear, common goal is optiarctic cardiac resuscitation. Though mal patient outcome. I believe global this is obviously an unsustainable medical service enriches all physistandard, that successful mission re- cians because it helps us develop an ally made an impression on him early adaptability and team skills. Togethin his career. “With resources and er we reap incredible and intangible John Ogle, MD, MPH, at the Libyan technology, it is amazing how much rewards by delivering familiar service Refugee Camp in in Southern Tunisia in modern medicine can do for some- in unfamiliar environments – burnbody.” out unlikely!” n August 2013. 30

Colorado Medicine for May/June 2014

Features

CAFP family physician of the year John L. Bender, MD, FAAFP

Raquel J. Rosen, CAFP Chief Executive Officer

CMS president John Bender, MD, wins coveted award John Bender, MD, FAAFP, CEO of Miramont Family Medicine and current president of the Colorado Medical Society, has been named the 2014 Colorado Academy of Family Physicians (CAFP) Family Physician of the Year. In addition to managing a growing enterprise and a full panel of patients, Bender is a physician leader in advocating for reforms that support primary care and the patient-centered medical home. Bender, receiving his medical degree from Creighton University in 1992, became a Flight Surgeon in the United States Navy. Bender’s service in the U.S.

purchased a family medicine practice in Fort Collins, Colorado. Since then, Miramont Family Medicine has been growing all across the state of Colorado, including in rural and underserved areas. When Bender and Teresa purchased the small practice, at that time consisting of about 1,000 patients, the office had one computer and one employee. During that same time, 34 primary care physicians had left the area and eight practices had gone bankrupt. Today, Miramont Family Medicine has seven locations and the enterprise sees over 30,000 patients with over a quarter coming from Medicaid, Colorado’s public health insurance program for those who earn less than 133 percent of the poverty line. From 2001 to 2012, Miramont Family Medicine grew exponentially with revenue growing from $169,000 to $4.8 million a year. Bender and Teresa, also his practice administrator, accomplished this with a set of practice transformation techniques and quality improvements.

CAFP President Rick Budensiek, DO, honors John Bender, MD, as family physician of the year. Navy lasted from 1988 to 2000 with multiple tours. He then joined the U.S. Army and was an Army physician touring in Kosovo with NATO Allied Forces. “Before I moved back, I was bouncing around for almost 20 years,” Bender said. “I had moved 17 times in 17 years with the Navy and Army.” In 2002, Bender and his wife, Teresa, Colorado Medicine for May/June 2014

“Practices that fail often are the ones that have not effectively managed labor costs,” said Bender to Medical Economics in their cover story titled “Family Medicine’s Revival: Managing Escalating Costs and Reinventing Primary Care Delivery.” “I cannot simply pay my staff less. If anything, I have to pay them more because we are in such a high-density of services and digitalization,” he continued. “What Miramont does differently is through Lean principles and leveraging information technology.”

Bender’s practices follow the five principles of lean production that originated from the Toyota Production System. Lean principles are used to help identify value and eliminate waste. For more information on Lean, please visit lean.org. Miramont Family Medicine also became an NCQA-recognized patient-centered medical home in 2008. “Becoming NCQA-recognized meant a lot but where it had the most impact was the workflow redesign process,” said Bender. “We put pedometers on our providers and staff in order to make our practice more efficient and require the least amount of steps.” In 2011, the Colorado Academy of Family Physicians recognized Miramont Family Medicine as the patient-centered medical home of the year and in 2010 won the national HiMSS Nicholas E. Davies Award of Excellence for outstanding achievement in the implementation and value from health information technology. In 2013, Bender took his years of practice experience and became the president of the Colorado Medical Society. Before his ascension to his current position, Bender had served as the president of the Colorado Academy of Family Physicians, delegate to the AAFP Congress of Delegates and was a delegate at the American Medical Association. Several of Bender’s resolutions are now policy with the American Medical Association, the Colorado Academy of Family Physicians and the American Academy of Family Physicians. n

Inside CMS

Legal update Nicholas Ghiselli, JD, Kari Hershey, JD, and Richard Holme, JD

New interprofessional guidelines and CRCP 45 ease litigation conflicts between lawyers and medical professionals Editor’s note: In 2010, Colorado Medical Society was asked to renew its endorsement of the Interprofessional Code, a document written by lawyers regarding the interactions of lawyers and professionals, including physicians. In reviewing proposed changes to the 35-page code, it was clear that the code had become increasingly oriented to plaintiffs and was so lengthy and full of legalese that it was not useful to practicing health care providers. Accordingly, organized medicine worked with the Bar Association to develop the Interprofessional Guidelines, which are expressed more succinctly and neutrally than their predecessor. The organized medical community withdrew their endorsement of the code and now endorse only the guidelines. For as long as attorneys have had to rely on medical professionals in legal matters, there have been disagreements regarding the scope of records and testimony such professionals must provide. Such disagreements frequently concern the scope, timing and costs associated with legal requests. For example, attorneys who need medical records and testimony to prove elements of their client’s case or defense often issue subpoenas to treating health care providers to produce medical information and to testify. Yet, health care providers are prohibited by federal and state law from disclosing confidential health information without authorization, and may be booked far in advance to provide needed care to patients and want to be compensated for their time. The needs of a patient/litigant who requires medical testimony for their case and who may not have the ability 32

to pay the requested compensation can conflict with a treating provider, whose time is valuable, has care obligations to other patients and who may not be comfortable testifying about matters beyond the specific care provided to the patient. Colorado Interprofessional Guidelines Accordingly, Colorado’s medical and legal communities have collaborated on guidelines to provide standards and suggestions to facilitate interaction between medical professionals and attorneys. The Colorado Interprofessional Guidelines were enacted in 2012 and set forth expectations and courtesies appropriate for legal and health care professionals, particularly in the course of litigation. The guidelines have been endorsed by the Colorado Bar Association, Denver Bar Association, Colorado Medical Society, Denver Medical Society, Boulder County Medical Society and the El Paso County Medical Society, and are available electronically at www.cobar.org/index.cfm/ ID/20100/subID/28380/CITP//. The purpose of the guidelines is to encourage cooperation and respect between the attorneys and health professionals, and to foster an understanding of the responsibilities of the professions. See guidelines §1.1. A predecessor interprofessional code was first enacted to assist with interprofessional disputes in 1986 and updated in 1997; however, the Denver Medical Society and Colorado Medical Society withdrew their endorsement of the code in 2011. The guidelines urge health care professionals to under-

stand the necessity of medical testimony in court proceedings and to “engage in the legal process in a professional and responsible manner that demonstrates respect for an attorney’s duties, role and circumstances, as well as the needs and rights of their patients.” At the same time, attorneys are reminded of their corresponding duty to engage health care professionals in such a way as to show respect for that professional’s duties, roles and circumstances. Because a health care professional’s primary duty is to provide patient care, attorneys should try to minimize disruption to the health care professional, patients and health care practices. The interprofessional guidelines establish a Medical/Legal Dispute Resolution Sub-Committee of the Interprofessional Committee as a mechanism for solving disagreements arising between health care professionals and attorneys. The sub-committee is comprised of members of the plaintiff and defense bars and members or staff of the Colorado Medical Society. If a dispute arises between a health care provider and an attorney, both parties are encouraged to submit a summary of the dispute along with supporting documentation to the sub-committee. Members of the sub-committee may further investigate the dispute by interviewing those involved. Following such review, recommendations are made for resolving the problem. Such recommendations are reviewed by the full subcommittee, which issues a final written opinion. The goal is to have the final written report issued within 60 days of Colorado Medicine for May/June 2014

Inside CMS the initial submission of the dispute. The sub-committeeâ&#x20AC;&#x2122;s recommendations, however, are not binding unless both parties agree to them. Additionally, the operations of the sub-committee do not affect the availability of litigation or other avenues of alternative dispute resolution for parties that disagree. Resolving fee disagreements The guidelines aim to mitigate disputes that arise in connection with fees health care professionals charge for services in legal proceedings. Health care professionals may testify either as a treating expert witness, where testimony is based on facts gained from personal observation of a patient, or as a specially retained expert witness, where opinions are based upon facts furnished to the professional in the course of litigation outside their direct care and treatment of a patient. The guidelines provide that a health care professional is allowed to charge a reasonable fee when retained either as a treating or as a specially retained witness. For a fee to be reasonable, a health care provider generally should charge the same amount that he or she would have likely earned during the time required to render the testimony or other services provided. In the event of cancellation or postponement of scheduled medical testimony, the health care professional may be entitled to compensation, depending on the timeliness of the notice and amount of disruption to the professionalâ&#x20AC;&#x2122;s practice.

ultimately the patient, not the attorney, is responsible for payment of fees for services. Correspondingly, attorneys should take note that medical rules of ethics prohibit fees for medical testimony from being contingent upon the outcome of litigation. Resolving common scheduling issues Another area of disagreement between attorneys and health professionals is triggered by last-minute changes to arrangements for a health care professionalâ&#x20AC;&#x2122;s testimony or services. Although such changes may be unavoidable in litigation, the guidelines urge all parties to determine in advance how scheduling

disputes will be addressed to eliminate disagreements that could later arise. Attorneys are responsible for scheduling the services of a health professional with enough advance notice and in such a manner to minimize inconvenience to the professional, patients and the health practice. This includes the duty to notify the health care professional of any trial or hearing dates at the time the trial or hearing is set, and to promptly inform the professional of any schedule modifications. Subpoenas and Rule 45 Another common area of contention

The interprofessional guidelines urge attorneys and doctors to determine fee arrangements, cancellation fees and other financial arrangements in a formal written agreement executed before services are provided. If an attorney requests document review, medical reports, conferences or medical testimony from a health care professional, then it is conclusively presumed that the attorney has made definitive arrangements with the client for payment of all reasonable charges. The health care professional is encouraged to submit an itemized bill to the attorney for services, and the attorney must promptly compensate the health care professional for the services rendered. Health care professionals, however, should note that Colorado Medicine for May/June 2014

Legal update (cont.) involves the timing of subpoenas. The guidelines aim to resolve other problems caused by subpoenas between the legal and health professions, particularly in light of recent amendments to Rule 45 of the Colorado Rules of Civil Procedure. At the outset, the guidelines provide that when serving a health professional with a subpoena, attorneys should schedule service of the subpoena so as to minimize inconvenience to health professionals and limit disruption to patients and to the practice. Attorneys are urged to explain, to the extent possible, the nature and subject of the subpoena as a matter of courtesy. At the suggestion of the Colorado Supreme Court, Rule 45 of the Colorado Rules of Civil Procedure was amended to address issues that frequently arose in connection with subpoenas duces tecum for privileged documents. One particularly troublesome problem was the practice by attorneys to issue subpoenas to health providers for privileged medical records. Health care institutions that

produce records in response to a subpoena without the knowledge or consent of a patient may violate patient privilege. Amendments to the rule aimed to solve this problem became effective Jan. 1, 2013. Rule 45 now protects the subject of a subpoena by requiring any subpoena for privileged records to include either a signed authorization from the privilege holder or a court order permitting production of the documents. The interprofessional guidelines harmonize the policy objectives of the amended CRCP 45 with the obligations of the legal and medical professions. For example, the guidelines provide that “[a] health care professional or institution should not release medical records without a patient authorization or a court order, unless there is some statutory exception that allows the release of the records….” This language tracks closely with the new language in CRCP 45(c)(2)(B)(i) and highlights for health providers the importance of maintaining patient privilege and confidentiality in the litigation process.

Similarly, the guidelines and Rule 45 complement each other in advising those issuing subpoenas to health professionals and institutions to take reasonable steps to avoid imposing undue burden or expense, which provide that “[a] party or attorney responsible for issuing and serving a subpoena must take reasonable steps to avoid imposing undue burden or expense on a person subject to the subpoena.” Conclusion By outlining the goals of interaction between legal and health care professionals, the interprofessional guidelines offer a workable standard for professional courtesies and responsibilities. The recommended approach to common areas of contention allow both attorneys and health care professionals to plan their relationships in a way that minimizes the potential for future disagreements. Further, by adopting language that conforms with amendments to CRCP 45, the guidelines give additional protection to patients and litigants who otherwise may be caught in the middle of professional disputes. n

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Colorado Medicine for May/June 2014

CMS Corporate Supporters and Member Benefit Partners

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

AUTOMOBILE PURCHASE/LEASE Rocky Mountain Fleet Associates 303-753-0440 or visit www.rmfainc.com * CMS Member Benefit Partner

PRACTICE VIABILITY (cont.) Bluestein Law Firm, PC 720-420-1777 or visit www.bluesteinlaw.com

FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit www.copicfsg.com * CMS Member Benefit Partner

Diagonal Medical Billing 303-551-7944 or visit www.diagonalmedicalbilling.com

Sharkey, Howes & Javer 303-639-5100 or visit www.shwj.com. * CMS Member Benefit Partner

GL Advisor 877-552-9907 or visit www.gladvisor.com/cms * CMS Member Benefit Partner

Wells Fargo 303-863-6014 or visit www.wellsfargo.com * CMS Member Benefit Partner

HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner

INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit www.callcopic.com *CMS Member Benefit Partner

IC System www.icmemberbenefits.com

UnitedHealthcare 877-842-3210 or visit www.UnitedhealthcareOnline.com MEDICAL PRACTICE SUPPLIES AND RESOURCES BioTE Medical 877-992-4683 or visit biotemedical.com

Massive Networks 303-800-1300 or visit www.massivenetworks.net 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 *CMS Member Benefit Partner

CO-POWER 720-858-6179 or www.groupsourceinc.com *CMS Member Benefit Partner

TransFirst 800-613-0148 or visit www.transfirstassociation.com/cms *CMS Member Benefit Partner

Hamilton Linen & Uniform 800-628-0846 or visit www.hamiltonlinen.com

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

PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit www.alnmm.com athenahealth 888-402-6942 or visit www.athenahealth.com/cms. *CMS Member Benefit Partner Colorado Medicine for May/June 2014

Transcription Outsourcing 720-287-3710 or visit www.transcriptionoutsourcing.net Transworld Systems 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner 35

Inside CMS

CMS Board of Directors Kate Alfano, CMS contributing writer

Board acts on issues that impact all physicians The Colorado Medical Society Board of Directors met on Friday, March 14, to conduct business integral to the success of the society and its members.

to which CMS should be involved. The board asked CMS staff to carefully follow these developments and keep the board appraised.

Strategic plan refresh The board reviewed and revised the recommendations that came out of the two-day strategic plan refresh retreat conducted in January and moderated by Joe Gagen, a paid facilitator. The recommendations are intended to enhance CMS’ progress in achieving our strategic goals.

And in communications, the board directed the CEO to retain a qualified consultant to perform a communications audit to assess internal and external communications functions and to develop recommendations to upgrade these functions in a manner that increases the media exposure of CMS and enhances physician engagement with CMS.

In governance, the board has approved the formation of a task force chaired by Immediate Past President Jan Kief, MD, to conduct a comprehensive review of the governing structure of CMS including the composition and selection of the House of Delegates and the Board of Directors to maintain transparency, enhance efficiency and effective decisionmaking, and utilize additional avenues of input on policymaking. The task force will develop a proposal with a report for action at the July board meeting.

Actions of the Committee on Employed Physicians The board discussed the report of the Committee on Employed Physicians and approved their recommendations. CMS will continue a collaborative philosophy with the Colorado Hospital Association and individual hospitals during outreach to and recruitment of employed nonmember physicians in 2014. The board believes that services to employed physicians to the extent possible should also be beneficial to the employer and under no circumstances be detrimental to the needs of physicians in traditional private practice.

In advocacy, the board voted that the Committee on Professional Education and Accreditation explore the most effective role for CMS in increasing primary care residency programs in Colorado and report back to the board by the end of the year. Also in advocacy, retreat members raised an idea regarding cost transparency. The board held an extensive discussion on health care costs, implications of recent developments in the context of a Department of Insurance study and anticipated legislation that would create a cost study commission, and the extent 36

Staff will contact a sample of hospital and ambulatory chief medical officers or CEOs to determine their interest in attending an event for the purpose of identifying additional services or activities CMS could provide that would be of value to employed physicians and their employer, and report back to the board. The committee also reported on model medical staff bylaw amendments relating to allegations that an adverse action is a result of anticompetitive conduct. These

model bylaws were developed and agreed to by CMS and the Colorado Hospital Association and will be forwarded to CHA-member hospitals with follow-up surveys at six and 12 months to assess whether the proposed practices and recommended procedures approved have been adopted. Policy on telemedicine The board voted to direct the Committee on Physician Practice Evolution to review and update CMS’ policy on telemedicine and electronic communications, taking into consideration current law and regulations regulating telemedicine, telemedicine marketplace solutions inhibited by state law and regulations, the physician-patient relationship, other state experiences, workforce, and the consumer and business perspective. The board also approved the convening of a workgroup comprising representatives from CMS, the Colorado Association of Health Plans and other stakeholders as appropriate to produce a report on telemedicine/telehealth issues before the 2015 legislature convenes. Prescription drug abuse Lastly, the board approved a report by the new CMS Committee on Prescription Drug Abuse – charged with implementing CMS’ prescription drug abuse platform – that recommended that CMS support legislation that requires all physicians with a DEA number to register with the PDMP (though not require them to use it) and that allows a physician to delegate to as many as three qualified designees authority to access the PDMP database. CMS greatly appreciates the work of the board of directors. n Colorado Medicine for May/June 2014

Inside CMS

Prescription drug abuse update Kate Alfano, CMS contributing writer

Pharmacy board, legislature work on PDMP upgrades The Colorado Board of Pharmacy and the Colorado General Assembly are working on two fronts to update the state’s Prescription Drug Monitoring Program (PDMP) in the continuing effort to reduce the incidence of prescription drug abuse and misuse in Colorado. The pharmacy board administers the PDMP and they’re working with the PDMP software vendor on technical upgrades to the system with the support of $200,000 in grant funding from the United States Bureau of Justice. In collaboration with the Colorado Consortium on Prescription Drug Abuse Prevention, the board held a stakeholder meeting with the vendor, Health Information Design (HID), on Feb. 19. “The prescriber and pharmacist PDMP user stakeholders viewed the new interface as presented by the PDMP’s vendor on that date, and the group was very impressed with both the appearance, speed, and availability of data from the new interface,” said Cory Everett, senior advisor to the division director and director of strategic and external affairs for the Colorado Department of Regulatory Agencies. Lynn Parry, MD, member of the CMS Committee on Prescription Drug Abuse, and Terry Boucher, CMS consultant who staffs the committee, attended the meeting. Boucher said the top criticisms he has heard from physicians about the system is that it’s hard to use, requires numerous check-ins and can only be accessed by physicians – making it time-consuming for the doctors to utilize effectively. HID began the meeting with a presentation on upgrades they will implement this year. These include new screens that are Colorado Medicine for May/June 2014

easier to use that feature fewer “clicks” to access information and perform functions. • Query history – Everything will be visible on one screen, including method of payment. • Search history – All queries can be made from this single screen, including delegates and DEA number. • Prescriber DEA query – All patient recorders will be available in the system by prescriber, and users will be able to set a default time (using the options of one day, one month or one year). • Multi-state query – Will require only name and date of birth. • Report query – Will create a PDF file report of a patient record and be available in one click. • User management – Prescribers will be able to update their profiles and change their passwords on this screen. • Help query – This will contain a training guide, online help and frequently asked questions. • Log out – This can be performed with one click. The stakeholders were then given a list of 15 additional cost modules available for the PDMP software to make the system more user-friendly. Stakeholders discussed the options and made recommendations on which ones would be useful in the new PDMP system, prioritizing them to make the most meaningful use of the grant funding. These additional enhancements include various query options, pre-set date ranges for prescribers and pharmacists to speed up data query, peer-to-peer alert management, and providing prescribers with “morphine equivalent dosage excessive reports.” While HID couldn’t commit to completing

the additional enhancements before Aug. 31, 2014, when the federal grant expires, the board staff intends to apply for future grants and to continue to work with the vendor to complete all enhancements recommended by stakeholders, Everett said. “We hope to achieve a higher utilization rate of the PDMP by prescribers and pharmacists so that these practitioners can make a more informed decision when considering prescribing and dispensing a controlled substance to patients in an effort to reduce prescription drug abuse in Colorado.” In addition to the work at the Board of Pharmacy, the General Assembly is considering bills to make necessary legal changes to the PDMP. HB14-1283, Modify Prescription Drug Monitoring Program, was introduced in the House in mid-February by Rep. Beth McCann (D), Sen. Linda Newell (D) and Sen. John Kefalas (D). The legislation would permit delegated access to the PDMP, allowing a physician or pharmacist to delegate query tasks to registered delegates. It also authorizes functionality to provide unsolicited reports to notify prescribers and pharmacists of potential problems. It requires physicians to register for the PDMP – but does not mandate usage. It allows use of PDMP data for public health reporting and health care coordination. And it requires daily uploading of data from pharmacies to the PDMP system, which represents an administrative change from the current two-week requirement. The CMS Council on Legislation supports the bill. As of publication, it had passed the House and was under consideration in the Senate. The session is scheduled to adjourn sine die on May 7. n 37

Inside CMS

ICD-10 update Marilyn Rissmiller, Senior Director, Health Care Financing

A delay should not stop your momentum The bill that stopped a scheduled 24 percent Medicare pay cut to physicians also delayed the transition to the ICD-10 code set for at least an additional year. The U.S. House of Representatives passed H.R. 4302, the “Protecting Access to Medicare Act of 2014,” on March 27. The Senate passed an identical version of the bill on March 31 and President Obama signed the legislation into law on April 1. Experts speculate that including the ICD10 delay in the bill was likely done to appease physicians who opposed another temporary SGR patch. Congress was unable to find a way to pay for a permanent

repeal of the SGR, a cost of $140 billion over 10 years. But the ICD-10 delay won’t be cheap either; the Centers for Medicare and Medicaid Services estimates that this delay could cost between $1 billion and $6.6 billion, as referenced in a statement from the American Health Information Management Association (AHIMA). “This is approximately 10-30 percent of what has already been invested by providers, payers, vendors and academic programs,” AHIMA said in the statement. “Without ICD-10, the return on investment in EHRs and health data exchange will be greatly diminished.”

Physician practices have been working for the past two years to transition from ICD-9 to ICD-10, which adds more than 50,000 codes for diseases and procedures to allow for greater specificity in billing and mortality and morbidity data. The U.S. Department of Health and Human Services already delayed the ICD-10 compliance date once, in August 2012, from Oct. 1, 2013, to Oct. 1, 2014. The current delay measure states, “The Secretary of Health and Human Service may not, prior to Oct. 1, 2015, adopt ICD10 code sets as the standard for codes sets.” AHIMA CEO Lynne Thomas Gor-

Colorado Medicine for May/June 2014

Inside CMS dan called the delay “unfortunate” and has said they will seek clarification on the exact length of the delay “on behalf of our more than 72,000 members who have prepared for ICD-10 in good faith.” Russell Branzell, president and CEO of the College of Healthcare Information Management Executives (CHIME), also criticized the delay in a statement. “We are extremely disappointed by today’s vote. We understand the considerable hours, resources, and money CHIME members and their organizations have spent preparing for the transition. This pause in momentum discredits the significant work our industry has spent training staff, conducting testing and converting systems; not to mention the hold on improving care quality and accuracy, advancing clinical reporting and research, and patient safety outcomes.” “CMS must now provide new guidance to the industry on what the delay means for providers, vendors, clearinghouses and other concerned parties. The delay leaves numerous unanswered questions from testing, training and revamping the agency’s education resources.” Experts speculate that the federal CMS could allow organizations ready to implement ICD-10 to implement the code set voluntarily. Or they could forego ICD-10 altogether and instead wait for ICD-11, which is due to be released in 2017 and will be used throughout much of the rest of the world. The Colorado ICD-10 Training Coalition encourages practices not to lose momentum. Those ready for implementation can access archived webinars on the coalition website, www.cms.org/icd-10, to refresh and improve your skills, and those who need another year can increase your readiness through proactive education, practice and testing. Use this postponement to increase your knowledge, review and adjust documentation quality and clinician education, and adjust coding and billing procedures – without the weight of the 2014 deadline. The coalition will continue to hold webinars and post resources on our website and we’ll provide more information on the delay as it is available. n Colorado Medicine for May/June 2014

Inside CMS

Clean Claims Task Force Marilyn Rissmiller, Senior Director, Health Care Financing

Unprecedented progress toward uniform set of claim edits A Colorado task force has made unprecedented progress toward developing a standardized set of health care claims edits and payment rules, and is recommending that the federal Health and Human Services (HHS) designate this initiative as a national pilot. The Colorado Clean Claims Initiative is an effort by the state of Colorado, strongly supported by CMS, to standardize CPT claims edits across all private payers. The initiative was enacted by the Medical Clean Claims Transparency and Uniformity Act in 2010 – also strongly supported by CMS – that was designed to save the state millions of dollars a year with the understanding that payers and providers will undergo less administrative redundancy and

waste. Current estimates place the savings of standardization of the millions of claims edits at $80 million to $100 million a year in Colorado alone. “By creating uniform medical claim edits and payment rules to be shared among all payers in Colorado, both payers and providers will be unburdened of tens of millions of dollars of administrative redundancy and outright waste, which can be redirected toward reducing the actual cost of care,” said Barry Keene, co-chair of the task force and the president of KEENE Research and Development. The legislation laid a framework for the group’s work: “The base set of rules and edits shall be

identified through existing national industry sources that are represented by the following: (I) The NCCI; (II) CMS directives, manuals and transmittals; (III) the Medicare Physician Fee Schedule; (IV) the CMS National Clinical Laboratory Fee Schedule; (V) the HCPCS Coding System and directives; (VI) the CPT coding guidelines and conventions; and (VII) national medical specialty society coding guidelines. “The task force shall consider standardizing the following types of edits, without limitation: (A) unbundle; (B) mutually exclusive; (C) multiple procedure reduction; (D) age; (E) gender; (F) maximum frequency per day; (G) global surgery; (H) place of service; (I) type of service; (J) assistant at surgery; (K) co-surgeon; (L) team surgeons; (M) total, professional or technical splits; (N) bilateral procedures; (O) anesthesia services; and (P) the effect of CPT and HCPCS modifiers on these edits as applicable.” The group’s work is also intended to provide greater transparency across payers and to make it easier for patients to determine the cost of treatment and their financial obligations.

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Colorado Medical Political Action Committee Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org 40

CMS actively participates in the 28-member task force, which also comprises representatives from major private payers, claims software vendors, the Colorado Medical Group Management Association, the American Medical Association, local physician billing personnel and the state of Colorado. The work of the task force is guided by principles that focus on administrative simplification: Consistency, standardization, transparency and improved system efficiency. Colorado Medicine for May/June 2014

Inside CMS The task force submitted a report to the General Assembly in January 2013, which resulted in a bill sponsored by Sen. Irene Aguilar, MD, and Rep. Sue Schafer concerning the development of standardized rules in processing medical claims and extending the deadlines for the task force, and authorizing appropriation of state funds for the development of a set of rules. In the report, the group noted it has had more success getting and keeping key stakeholders involved and achieving consensus on difficult issues than any other state or national initiative of its kind.

force hopes to be a model for the rest of the nation – where the savings could be multiplied across many states. Colorado physician leaders met with the Colorado congressional delegation in March 2014 as part of the American Medical Association’s National Advocacy Conference (NAC) in Washington, D.C. All delegation members expressed support for federalization. In fact, Colorado’s two U.S. Senators, Sen. Mark Udall (D) and Sen. Michael Bennett

(D), previously worked together on an administrative simplification provision of the Affordable Care Act that would allow the HHS secretary to designate Colorado’s Clean Claims Initiative as the national model. For more information on the initiative and the task force, go to www. hb101332taskforce.org. n

“Despite coming to the table with different concerns and perspectives, task force members have demonstrated their commitment to finding consensus on a standardized set,” the report’s authors wrote. All stakeholders – especially specialty societies in Colorado and nationally – were invited to be engaged in the entire process. Aggregated comments were posted online and considered by the task force for inclusion in the resulting set of rules. The process required initial consensus from all members of the task force on the initial draft, distribution for public review and comment, second review by the task force, and official response to comments and final consensus. Now, after nearly four years of work, the group has made tremendous progress toward achieving its goals. Key accomplishments include: • Compiling definitions and associated payment rules from several different sources for 32 payment rule modifiers; • Achieving consensus on a list of 24 payment rules; • Completing the rule development process for all payment rules; • Drafting the governance for a transitional entity to maintain the edits; • Procuring a vendor to perform data analytics functions during the 2014 period; and • Making substantial progress in creating a model for sustaining the output of the task force into the future. Colorado leads the nation in efforts to standardize claim edits and payment rules across private payers, and the task Colorado Medicine for May/June 2014

Inside CMS

Reflections Reflective writing is an important component of the CU School of Medicine curriculum. Beginning in the first semester, all medical students participate by writing essays or poems that reflect what they have seen, heard and felt. This column is selected and edited by School of Medicine faculty members Steven Lowenstein, MD, MPH and Henry Claman, MD.

Chelsea Wolf, MA

Chelsea Wolf, MA, is a graduating medical student at the University of Colorado School of Medicine. She will begin her residency in psychiatry this summer at the University of Virginia. In the future, she plans to pursue a career in emergency psychiatry and medical education.

Twenty-two Twenty-two Twenty-two times I presented you. Like a film in slow motion, I remember when you were assigned to me. The bright fluorescent lights glaring at the dingy peach and turquoise ICU curtains. A ventilator ping-pingpinging incessantly. A cart of barely touched trays of hospital food sitting idly, waiting to be removed. Two overnight nurses chattering on about a recent first date. Me, nodding eagerly at the resident as he told me of your condition, your scans, and your labs, as if I understood what any of those numbers meant. And inside myself, the same reel playing over and over: please don’t give him to me, please don’t give him to me, please don’t give him to me, please. Knowing what I know now, knowing how my life, my path would be changed because of you, I can’t believe that I didn’t want you then. And yet two days into the rotation, all I knew of the ICU was a huge, roving mass of white that traipsed 42

each morning from room to room, towering not only over the patient but also the unlucky soul forced to present. I did not want to be that soul pelted with questions and fumbling under the hard glare of the ivory tower personified. So, the reel within me played on: please don’t give him to me, please don’t give him to me, please don’t. Yet it was as if the universe had another plan for us, and despite my fervent pleas you were assigned to me and I to you. That first night I poured over your records, trying to understand who you were, what you were facing. The next morning, I was in your room for an hour examining you, hearing your soft, strained voice for the first time. And then as the dark morning sky began to lighten and the harsh overhead fluorescence was replaced with the muted natural sun, I was there in front of the white mass; my voice wavering, my hands shaking, I rattled off a seemingly endless list of your medical problems, your medications, your numbers. Was your creatinine up or down, were your in’s greater than your out’s or vice versa? I don’t know. I don’t recall. But what I do remember as clearly as if it was just this morning was the way you looked up at me, nodding, smiling, trusting, as I told this group of strangers in white about you, as I bared your physical being to them. That, and I remember the roughness of the white sheet covering your bloated leg as I held onto you for those five minutes. You supporting me, though I didn’t recognize it at the time. You holding me up even though it was supposed to be the other way around. Twenty-two times I presented you. Twenty-two times I reviewed your morning labs and twenty-two times your evening labs. Twenty-two times I listened to your murmur, to your lungs. I recorded how much you consumed and how much you excreted. I rejoiced as the large bruise on your calf grew smaller, the border slowly retreating from the permanent marker outline that never seemed to fade. I watched in horror as the bruise on your arm grew larger, angrier, harder, causing you Colorado Medicine for May/June 2014

Inside CMS to wince in pain each time you tried to move. I knew of the weeping ulcer on your sacrum and of the many tears on your edematous scrotum; your pride cast aside for the time like your worn black shoes in the plastic belongings bag.

no longer be able to see you. You, once again, supporting me just as you had that very first day in the ICU. In that moment as I held onto you, I came to know your tremendous strength, the strength you so willingly shared.

Over the weeks, you shared more and more with me. Your little brother killed in front of you. Your faith in God ripped from you in one, horrific moment. Your resolution to never again shed a single tear. Your longing to return to your home on the open plain beneath the boundless sky. Who was I to deserve this great privilege, to know your stories, your fears, your dreams? Who was I to sit beside you, holding your hand, waiting for the surgeon to remove the mass that was steadily choking you? Who was I to be the last one to hear your voice before it was cut out along with the cancer? Me, the one who didn’t even want you in the beginning.

And no one has ever appeared as strong as you did in the moment that I turned to leave and saw a solitary tear course its way down your unshaven cheek. n

I thought I knew you after those twenty-two days. But, it wasn’t until the last day, the day I had to say goodbye that I truly came to know you. You could no longer talk, but you held my hand as I, with tears streaming down my face, explained that my time at the hospital was ending, and I would

Join Now! Colorado Medical Political Action Committee

Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org

Colorado ICD-10 Coalition helping physicians prepare for coding switch The Colorado ICD-10 Coalition, a statewide organization of interested educators, consultants, physician and practice representatives, continues to help Colorado physicians prepare their offices for the scheduled implementation of the ICD-10 diagnosis codes in advance of the deadline that has recently been extended to at least Oct. 1, 2015. "Despite the recent delay in the implementation of ICD-10, physicians and their staffs would be wise to continue their preparations so they don’t feel overwhelmed when it eventually goes into effect," said Marilyn Rissmiller, CMS senior director of the Colorado Medical Society Division of Health Care Financing. The coalition’s resources include a series of webinars, educational events, worksheets, task lists and apps that are available on the group’s website, www.cms.org/icd-10. The two most recent webinars, Project Planning Phase 1 and 2, provide viewers with information on how to jumpstart this transition. To learn more and to access resources to help you navigate the ICD-10 maze, go to www.cms. org/icd-10.

Colorado Medicine for May/June 2014

Inside CMS

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

Reducing liability claims and supporting good medicine Connecting our efforts to better outcomes and improved patient safety In the data-driven world of health care, success often depends on having the numbers to support your actions. Qualitative research guides us as we seek to improve medicine and measured results confirm if we’re on the right path. At COPIC, one way we evaluate our efforts is by reviewing medical liability claims data. Specifically, we look at frequency – how often medical providers face a claim or lawsuit. Overall, there is still concern about frequency. A 2011 study published in the New England Journal of Medicine, showed that approximately 99 percent of physicians in high-risk specialties – neurosurgery, cardiothoracic surgery, general surgery, orthopaedic surgery and plastic surgery – will experience a medical liability claim by age 65. Data for the lowest risk physicians – pathology, family practice, dermatology, pediatrics and psychiatry – showed that 77 percent face a claim by age 65. On a national level, frequency of medical liability claims is down, and for COPIC-insured physicians, it is at an alltime low. Why? We believe there are three key factors that contribute to this: 1. A substantial investment in patient safety and risk management programs Over the years, COPIC has emphasized a proactive, preventative approach to reducing medical errors. Our Patient Safety and Risk Management department offers programs and guidance to mitigate risk and address challenges in health care. From educational activities to an online library of medical guidelines, we continue to invest in an array of resources that are relevant. In particular, two COPIC programs have received recognition for addressing unexpected outcomes and improving care: • A recent article in Health Affairs highlighted COPIC’s 3Rs (Recognize, Respond, and Resolve) Program as a national model for “communication-and-resolutionprograms” that encourage the disclosure of unanticipated care outcomes to affected patients and proactively seek resolutions. • Each year, we perform more than 2,200 Practice Quality site visits that review patient records and internal systems. Specially trained nurses use “Level One Guidelines” developed by COPIC to assist medical practices in reducing system failures, improving documentation, and ultimately preventing avoidable adverse outcomes. 44

2. Claims management that seeks to resolve issues in a fair and timely manner One of the biggest challenges with a medical liability claim is the amount of time it takes to resolve it within our legal system. A 2013 Health Affairs article highlighted that the average physician spends 50.7 months of an assumed 40-year career with an unresolved, open medical liability claim. The article also stated that “Time to resolution is an important component of the cost of medical malpractice resolution to both physicians and patients… . Physicians and their institutions may also be delayed in implementing changes in quality- and safety-related procedures to prevent similar adverse events from occurring again.” Data shows that COPIC has a lower average number of days to resolve a claim when compared to national figures. One of the reasons we are able to achieve this is by reinforcing the importance of early incident reporting. This allows our team to proactively help insureds address the issue upfront, and facilitate discussion and treatment that meets the patient’s immediate needs with the intent of preserving the patientphysician relationship. 3. Active legislative advocacy that seeks to educate and inform COPIC’s Public Affairs department focuses on year-round outreach to legislators with a focus on tort reform and patient safety as essential to accessible, affordable quality health care. The complexity of health care and the debates surrounding its future are filled with vast amounts of data, research and opinions. Our efforts seek to represent the perspective and concerns of those on the frontlines – medical professionals, physicians and health care facilities – and reinforce the importance of a stable medical liability environment. The decrease in frequency of claims is something we are proud of, but it is also an achievement that we share with our insureds. Their involvement in the following areas support efforts to improve health care and enables all of us to make a difference: • Participating in the patient safety and risk management resources available through COPIC. • Embracing early incident reporting where they report early and often. • Being engaged on legislative issues that impact health care in Colorado. n Colorado Medicine for May/June 2014

Departments

medical news Attention retired physicians: volunteer to “train the trainer” Research indicates that a critical step on the path toward safer, higher quality care is to encourage and facilitate patient and family engagement, which in turn improves health care experiences and outcomes. Citizens for Patient Safety (CPS) is proud to offer the Patient and Family Care Coordination/Advocacy Curriculum’s Train the Trainer Program, grantfunded training designed to establish retired physicians and nurses as educators and resources for engaging patients and family in care coordination. This value-added program will significantly

Colorado Medicine for May/June 2014

enhance current patient safety and quality efforts of Colorado hospitals, while increasing the overall knowledge and wellbeing of their communities – all at minimal cost. They’re looking for retired physicians, nurses and others to volunteer to train patients and their families about care coordination/advocacy and engaged team-based health care, and/or to serve as patient/family care coordinators/advocates. Ideal candidates are individuals willing to provide the leadership and guidance necessary to make health care safer in Colorado.

Engagement starts with health care professionals and hospitals in hopes of making Colorado the safest and healthiest state in the nation. Training began in January 2014. To sign up or learn more, contact Patty Skolnik at (303) 226-5526 or patty@citizensfor patientsafety.org. The Colorado Medical Society (CMS), Colorado Hospital Association (CHA) and COPIC have endorsed this program. n

Departments

medical news CHA and Citizens for Patient Safety soliciting nominations for Michael J. Skolnik Award for patient safety she provides training for consumers and continuing education for health care professionals.

The Colorado Hospital Association and Citizens for Patient Safety are currently soliciting nominations for a new award, the Michael J. Skolnik Award for Patient Safety. The award will recognize an individual or group that advances the quality and safety of health care for patients across Colorado. Michael, the namesake of the award, died in 2004 at age 22 following complications related to medical errors.

“Citizens for Patient Safety views safety as an essential part of quality health care,” she said. “We hope to encourage widespread activity that will help create patient safety improvement throughout Colorado. The Michael J. Skolnik Patient Safety Award is this call to action.”

His mother, Patty Skolnik, founded Citizens for Patient Safety and serves as the organization’s executive director. She spearheaded passage of the Michael Skolnik Medical Transparency Act, which requires all state-licensed health professionals to maintain online professional profiles so Coloradans can access these profiles and make informed health care decisions. Through CPS,

The nominee must be a person, team or organization that is actively involved with patient safety initiatives in Colorado. Nominees will be judged based on impact or benefit of the work performed, innovation or creativity of the work, and sustainability and replicability of the work. Nominees can include direct caregivers, health care executives or leaders, health care organizations, in-

dividuals from inside or outside health care who have actively promoted improvement in patient safety, or students who have shown notable leadership. The awardee will receive $3,000 and be honored at the CHA Patient Safety Leadership Congress on Oct. 28, 2014. Anyone can submit a nomination and self-nominations are accepted. Submit a completed nomination form – available on www.cha.com – with an attached narrative by e-mail to safety.award@cha. com. The deadline is June 30, 2014. For more information about the award, contact Patty Skolnik at (303) 226-5526 or Nancy Griffith, CHA director of quality and patient safety, at (720) 3306067, or go to www.cha.com. n

Gold Level Sponsors

Colorado Drug Card COPIC Financial Services Wells Fargo IPC/Senior Care of Colorado Intel Health Solutions, LLC University of Denver

Colorado Medicine for May/June 2014

Departments

Defense Health Agency’s Colorado Springs Military Health System enters Colorado’s Health Information Exchange The recently established Defense Health Agency’s Colorado Springs Military Health System entered the state’s health information exchange (HIE) in March to improve medical information flow between military and civilian providers. By joining the Colorado Regional Health Information Organization (CORHIO), Evans Army Community Hospital and the medical clinics at the United States Air Force Academy, Peterson, and Schriever Air Force bases will be able to share electronic health data with all hospitals in the local Colorado Springs region, all hospitals in the state with greater than 100 inpatient beds, all major laboratories in the state, and more than 460 office-based health

care providers in El Paso and Teller counties. “This partnership will improve care quality and coordination while reducing costs in the TRICARE provider network,” said Col. Timothy D. Ballard, MD, the Colorado Springs Military Health System’s director, in a press release. “It will reduce redundant diagnostic exams and labs, eliminate barriers to care for community referrals, reduce the workload on records sections in tracking referral reports, and provide us near real-time visibility of beneficiaries using civilian facilities.” HIE systems research by the Agency for Healthcare Research and Quality shows that sharing health records benefits

Nominate a colleague for “Physician Heroes” Physicians have been trained to be other-directed – patients always come first – which means that they frequently make their own health a low priority. Add demanding schedules, increasing administrative burden and endless technology requirements, and it’s no surprise that 30 to 40 percent of physicians experience burnout.

be able to reflect on the meaningful difference these heroes are making in the lives of their patients and communities, see their own values reflected in these stories and be reminded of the joy of medicine that led them to join the profession.

We at the Colorado Medical Society are interested in changing this, to help physicians be healthy and enjoy long careers in medicine. One of the ways we hope to decrease burnout is with a new series in Colorado Medicine, “Physician Heroes.”

We have intentionally kept the definition of “hero” broad. It could mean someone who has served in the military, figured out a tricky diagnosis, volunteered with a community health program, served rural or underserved patients, traveled many miles to treat a patient or comforted someone struggling – anything that inspires others.

Through physician heroes, CMS will profile as many different members as we can who have gone above and beyond in the profession to help their colleagues or community. We hope physicians will

We need your help to identify these extraordinary physicians. Please consider nominating a physician for this series by contacting Dean Holzkamp at dean_ holzkamp@cms.org or (303) 748-6113. n

Colorado Medicine for May/June 2014

patients by reducing exposure to radiological imaging, reducing unnecessary admissions, and eliminating redundant laboratory tests by up to 49 percent. Other studies reported that emergency department use of HIEs improved access to patient information. This ultimately reduced the number of medical facility admissions and the overall cost of ED visits by an average of $29 compared to a control group. The first phase allows military medical providers to quickly access TRICARE beneficiaries’ network clinical results, hopefully eliminating redundant appointments and freeing up nurses who currently have to track down clinical results to focus more on preventive care. The second phase starts when military treatment facilities fully interact with the HIE system. The same participating community and statewide providers will have access to TRICARE beneficiaries’ community health records, to include demographic information, lab/pathology, radiological and transcribed reports, medical and medication history, immunizations, and past hospitalizations. The system will notify the network providers that their patient is a TRICARE beneficiary and for the first time, they will be able to access their medical information. “This is a tremendous opportunity… employing an HIE system is a low-cost technological solution to electronic medical record interoperability,” Ballard said. “The HIE will not only improve care delivered to beneficiaries, it will improve community partnerships, simplify our business processes and practices, saving money; it’s a win/win situation for everyone involved.” n 47

Departments

medical news Connect for Health Colorado: Over 124,000 signed up for private insurance More than 124,000 Coloradans signed up for private health insurance coverage through Connect for Health Colorado, officials from the health insurance marketplace announced on April 14. This exceeds the goal for Colorado of 92,000 enrollments set by the Centers for Medicare and Medicaid Services. The open enrollment period spanned Oct. 1, 2013 to March 31, 2014. Those unable to complete their enrollment before the March 31 deadline were given until April 15 to finish enrolling. Of the individuals enrolled, 20 percent are age 25 or younger, 18 percent are between the ages of 26 and 34, 16 percent

are between the ages of 35 and 44, 19 percent are between the ages of 45 and 54, and 27 percent are between the ages of 55 and 64. Fifty-nine percent of individuals enrolled in private insurance received financial assistance; 41 percent enrolled in private insurance did not receive financial assistance. During this enrollment period, Connect for Health Colorado offered 150 health plans for individuals and families through 10 different insurance companies. The marketplace also offered 92 health plans through six insurers to small businesses through its SHOP program.

“Our goal was to create a new, competitive marketplace where Coloradans could shop for health insurance and access new tax credits to reduce costs,” said Patty Fontneau, CEO of Connect for Health Colorado, in a press release. “We continue to focus on the needs of our customers, keeping in mind that both small businesses and individuals and families that have either lost health insurance coverage or had changes in their lives can continue to enroll throughout 2014.” The health insurance marketplace opened for business Oct. 1, 2013, and provided support through a customer service center with 250 employees, nearly 400 certified application counselors and staff, nearly 450 communitybased health coverage guides and over 1,550 licensed agents/brokers. “Less than three years ago, Colorado chose to create a new health insurance marketplace with the mission of increasing access, affordability and choice for individuals and small businesses in our state,” said Board Chair Gretchen Hammer. “We are proud of the hard work and commitment of our staff and partners, focusing on our mission and following our own path toward improving the health care system in Colorado.” The next open enrollment period opens Nov. 15, 2014. Only small businesses and Coloradans with a life-changing event like the birth of a child or loss of coverage may enroll in health insurance between now and 2015. Eligible Coloradans can enroll in Medicaid year-round. n

Colorado Medicine for May/June 2014

Departments

medical news CU School of Medicine Dean Krugman to retire after 24 years in post Richard D. Krugman, MD, University of Colorado vice chancellor for health affairs and dean of the School of Medicine, announced in January that he will retire from serving as vice chancellor and dean. In his role at CU, he oversees all clinical programs of the university at its five affiliated hospitals. He became dean of the CU School of Medicine on March 1, 1992, after serving as acting dean for 20 months. He is currently the longestserving dean of a medical school in the United States. “I can’t remember what I wrote on my medical school application any more, but I have loved all of the 40-plus years I have been in medicine,” said Krugman in his biography on the CU website. “I have never had a day that I woke up and didn’t want to come to work. The growth and development of this won-

derful school of medicine has been a joy to watch and be part of.” He came to the School of Medicine in July 1968 as an intern in pediatrics. He completed his residency at the School of Medicine and joined the faculty in 1973. In 1981, he became director of the C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, where he served until being appointed dean in 1992. In an announcement to the university, Don Elliman, chancellor for the University of Colorado-Denver, and Lilly Marks, University of Colorado vice president for health affairs and executive vice chancellor of the Anschutz Medical Campus, thanked Krugman for serving with distinction as dean for more than two decades. “Dr. Krugman is an outstanding col-

league, a valued administrator and a treasured friend,” Elliman and Marks wrote. “His passionate and effective leadership has helped build one of the premier centers of academic medicine in the country, a school that consistently ranks among the top 10 public medical schools in grants from the National Institutes of Health and is a leader in research, learning and clinical care. His careful stewardship has attracted top talent from across the country and fostered a culture of respect. It is a legacy that will pay dividends for Colorado and future generations of physicians and researchers. While Krugman will retire from his service as dean and vice chancellor, Elliman and Marks wrote that he plans to return to the Kempe Center in the Department of Pediatrics “to pursue the long-deferred projects he put on hold in 1990.” n

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?

E-mail: Letters to the editor dean_holzkamp@cms.org Colorado Medicine for May/June 2014

Departments

medical news Colorado legislature honors Medical Reserve Corps of El Paso County The Colorado Legislature presented a resolution to honor the volunteers of the Medical Reserve Corps of El Paso County (MRCEPC) on Thursday, April 24, in recognition of their efforts during the Waldo Canyon and Black Forest fires. Mobilized during both fires, 144 volunteers provided more than 2,100 hours of volunteer medical and behavioral health support at shelters, disaster assistance centers, town hall meetings

and as residents returned to their devastated neighborhoods. A delegation from MRCEPC, the El Paso County Medical Society (EPCMS) and the Colorado Medical Society (CMS) sat on the House floor and were introduced by the co-prime sponsors, Reps. Bob Gardner and Janak Joshi. “We are proud to honor the selfless work

Members of the Medical Reserve Corps of El Paso County, along with the El Paso County Medical Society and the Colorado Medical Society surround Rep. Janak Joshi (front, middle) and Rep. Bob Gardner (back, middle) after the Colorado legislature passed a resolution honoring the corps’ work.

In memoriam: M.G. “Jerry” Klein M.G. “Jerry” Klein, 82, of Grand Junction, died April 1, 2014, at Hope West and Hospice. Klein was a longtime member of the Colorado Medical Society Board of Directors representing Mesa County and a pathologist. He is survived by his wife, Diane; sons, Eric and Jeffrey; daughter, Debbie Klein-Knoeckel; and seven grandchildren.

of the Medical Reserve Corps of El Paso County,” said CMS President John L. Bender, MD. “The commitment of these volunteer physicians to meet the physical, mental and emotional needs of their neighbors in times of crisis is a true inspiration to us all.” MRCEPC prepares and trains continually for disasters such as the Waldo Canyon and Black Forest Fires. As a fully integrated component of the Colorado Springs area emergency response system, MRCEPC’s near 200 credentialed and trained volunteers serve as a force multiplier. Public health officials have estimated that it would cost local agencies at least $1.5 million annually to do what MRCEPC does on less than $10,000 a year. MRCEPC was created on Sept. 12, 2001, in response to the 9/11 terror attacks when EPCMS, whose Foundation houses MRCEPC, recognized the need for the community to integrate all parts of its local health care community in disaster. Disaster Response for Health in El Paso County joined the national Medical Reserve Corps program in 2003, thus renaming MRCEPC. “The El Paso County Medical Society and our physician members recognize the need to have an integrated community response to a disaster scenario,” said Mike Ware, EPCMS executive vice president. “We’re honored to operate the MRC of El Paso County, and want to thank all of our volunteer physicians, nurses and medical personnel for the 2,100 hours of volunteer medical and behavioral health services they provided during the Waldo Canyon and Black Forest fires.” n

Colorado Medicine for May/June 2014

Departments

medical news Young science fair winners show solid scientific method The junior division winner, Madison Werschky, presented her project, “Got Gluten?” The purpose of her project was to test meals laA longtime supporter of the science fair, beled as “gluten each year the CMS Education Founda- free” at various tion awards a $1,000 grant to support restaurants to the state science fair and also presents see if they were gluten individual awards to one student from truly the junior high medicine and health free. She hy- CMS members Regina Brown, MD, left, and Cory Carroll, MD, division and one student from the se- pothesized that right, congratulate CMS Colorado State Science Fair Senior nior high medicine and health division. some gluten-free Division winner Jonathan Snedecker. These students receive $100 and an meals actually invitation to the CMS Annual Meet- contain traceable amounts of gluten. low 5 on the health of fruit flies by ing to display their project and receive tracking longevity and reproduction recognition before the CMS House of “Madison did a blinded study for a prac- over three generations. tical reason, she has celiac disease,” CarDelegates. roll said. “A restaurant says this is safe He found that Yellow 5 caused developColorado Medical Society members but she didn’t believe it and she proved mental issues of both the reproductive Cory Carroll, MD, and Regina Brown, them wrong. It has applicability as more system and other systems in male fruit MD, served as the official CMS judges people are sensitive to gluten. It’s a pub- flies. Red 40 was toxic to both sexes of lic health issue, it’s a trust issue.” at this year’s fair. flies and caused physiological developmental issues, but not reproductive deThe senior di- velopmental issues, in male fruit flies. vision win- Saccharin was highly toxic to the fruit ner, Jonathan flies, as it acted as a hepatotoxin and as S n e d e c k e r , a microflora inhibitor. Aspartame was presented “Are toxic to fruit flies, but it also acted as a Food Additives microflora promoter. Health Subtractives? The “This is pertinent to medicine because Drosophila in of the concerns of additives in diet and the Coal Mine.” their effect on health,” Carroll said. “He Jonathan stud- looked at different foods, specifically ied the effects those made for children. He did a good of the anthro- job presenting the information.” n pogenic food additives sacchaCMS members Regina Brown, MD, left, and Cory Carroll, MD, rin, aspartame, right, congratulate CMS Colorado State Science Fair Junior Division FD&C Red 40, winner Madison Werschky. and FD&C YelMadison Werschky and Jonathan Snedecker won the Colorado Medical Society Award for Excellence in the Health and Behavior Sciences in the junior and senior divisions of the 59th Annual Colorado State Science and Engineering Fair held on April 10 in Fort Collins.

Colorado Medicine for May/June 2014

Departments

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

➤ PROFESSIONAL OPPORTUNITIES CLIA DESIGNATED LABORATORY DIRECTOR – (Contractor needed for 1 to 4 hrs/mth + retainer) Weld County Department of Public Health and Environment in Greeley, Colorado is in need of a CLIA Designated Laboratory Director. Request for Proposal can be found on the Weld County Purchasing website at http://www.co.weld. co.us/Departments/Purchasing/index. html located under “Current Request for Bids” or call Cheryl Darnell at 970304-6415 X2270.

➤ Miscellaneous SEEKING OUTFITTED SUBLEASE – Integrative Family Med seeks outfitted sublease f/t or p/t in Greater Metro Denver (incl S Den). Min 2 Tx rms, work space area, secure internet, reception, storage, & modern conf rm in building for group consultations. Email waytowellness@comcast.net

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 at

720-858-6306 or e-mail tim_yanetta@cms.org 52

Seeking Primary Care Physicians/Practices in the Denver Metro Area We are seeking quality physicians to join our existing Englewood clinic OR Physicians/Practices that could add to our geographic coverage of the metropolitan area. If you are a physician or group that would like to: • Join a group with a fully integrated Electronic Health Record, • Be a part of an NCQA Recognized Level 3 Medical Home, and • Make a change but maintain your current patients We can offer a unique opportunity to get back to treating patients and stop worrying about administrative and personnel headaches. We are not a broker and will not respond to broker inquiries. If interested, contact Janelle at (303) 493-5276. All inquiries will be kept in strict confidence and will receive a prompt response.

Westmed Family Healthcare is seeking a Part-time Family Physician Westmed Family Healthcare is a well-established Family Practice. We are currently seeking a part time Family Physician to join our busy practice in a much sought-after location in Westminster Colorado to do strictly outpatient care with no OB. This position has the potential to turn into fulltime if desired. Westmed Family Healthcare offers a competitive salary, excellent benefits including a one-in-ten call schedule. Your work/life balance will be enhanced by a flexible work and call schedule. Please submit your resume to: lori@westmedfamilyhealthcare.com Lori Anderson Practice Manager Westmed Family Healthcare

Colorado Medicine for May/June 2014

Departments

Position Title: Associate Medical Director (AMD) for Reentry and Education Services Definition:

This person is responsible to provide direct client services and provide clinical support primarily to CPEP’s Reentry Evaluation, Reentry Education and Educational Intervention Services. The person in this position is expected to support an atmosphere at CPEP that conveys respect and concern toward participants and an overall ethic of accountability. The employee is also expected to maintain objectivity in all proceedings with participants and referring organizations.

Status:

60% FTE Staff Position

Supervisor:

Medical Director

Responsibilities: ❉ Reentry Services ➢ Provide direct oversight of all Reentry Evaluations: o Conduct intake interviews and participate in other aspects of Evaluation process. o Prepare Reentry Report and Reentry Plan (Plan) and consistently meet CPEP report timelines and expectations. ➢ Monitor Participant(s) progress through Reentry Plan. o Work with CPEP staff to supervise and oversee the Participant’s progress. o Conduct regularly scheduled conference calls to consult with and provide guidance to the Participant and preceptors involved in the Plan. o Review medical records and written materials submitted by Participant. o Review the Participant’s activities and progress. o Guide staff in addressing problems with Participant progress in plans. o Assist staff with organizational needs and process improvement activities. ➢ Participate in the development of targeted preceptor sites for Colorado reentry Participants and subsequent placement of Participants. ➢ With the Medical Director and staff, assist in development of integrated care curriculum and other activities of the Reentry Grant. ➢ With Medical Director and staff, participate in activities related to program development and long-term planning for Reentry Services. ❉ Education Services ➢ Provide education monitoring services for participants in CPEP Educational Intervention Program (non-Reentry): o Assist staff in development of Education Plans and identification of appropriate educational resources to address participant needs. o Conduct regularly scheduled conference calls with Participant and preceptors. o Review medical records and written materials submitted by the Participant. o Review the Participant’s activities and progress in the Educational Intervention. o Follow policies and procedures established by CPEP in the development, monitoring, and reporting of Educational Intervention services. o Assist staff with organizational needs and process improvement activities. ❉ Other ➢ At the specific request of a CPEP staff member and according to the policies established by CPEP, the Associate Medical Director shall perform administrative services necessary to the performance of the foregoing services, including meetings with managers and staff, resource development, and other general administrative duties. ➢ In collaboration with Medical Director and staff, participate in program development and process improvement activities. ➢ Other duties as assigned. Qualifications: ❉ Active Colorado Medical License, without restrictions or stipulations ❉ Current board certification with an ABMS or AOA-approved member board ❉ Prior experience in graduate medical education strongly preferred ❉ Must demonstrate the capacity to work in a team setting, to think strategically, and to approach problems from a constructive, collaborative perspective ❉ Must possess excellent written and verbal communication skills as well as strong computer skills, including Windows applications For more information, please contact Mary Minobe at mminobe@cpepdoc.org or 303-577-3232.

Colorado Medicine for May/June 2014

Features

the final word Sen. Irene Aguilar and Sen. Ellen Roberts

Colorado Commission on Affordable Health Care Costs seeks to bring stakeholders together to control costs Most physicians by now have heard that we, along with our House colleagues Reps. Stephens and Schafer, have proposed the creation of the Colorado Commission on Affordable Health Care Costs, an eclectic, bipartisan collection of legislators, experts from both the public and private sectors, employers and payers, as well as caregivers and care-receivers who are charged with producing evidencebased recommendations to the governor and the General Assembly for the next three legislative sessions before sun-setting in the summer of 2017. Most physicians and many of our colleagues at the statehouse, regardless of their party allegiances, already understand that unless we bring our state’s collective talents to bear to flatten the cost curve, the sheer weight of uncontrolled health care expenditures will compromise our ability to grow our

economy and assure a prosperous business climate. It will also crowd out the state's investments in vital infrastructure – not only health services but other essentials like water supply and quality, roads and bridges, and public and higher education, to mention a few. We know there are successful working models here in Colorado and across the country that motivate patients toward treatment adherence and healthier lifestyles, defragment care delivery, and trim redundant, unnecessary or suboptimal services to get more of our fellow citizens the right care at the right time, place and value. The commission’s charge is to first conduct cost driver forensics so we are confident of the epidemiology of health care costs relevant to our state, and subsequently evaluate, consolidate, propagate and adapt those best practices to Colorado, whether in the form of market-based solutions,

public policy reforms that support that urgent premise, or both. Colorado's thought leaders across the political spectrum have a long history of coming together when confronted with a clear and present danger to our state's general health. We have an enviable track record of consensus building, notwithstanding often vigorous debate, that seeks to fix problems rather than blame. We strongly believe this complex undertaking will require a collaborative, thoughtful approach, based on where the evidence and a consensus among these experienced, capable professionals in the field lead us. We look forward to working with the Colorado Medical Society, and are grateful for your steadfast commitment to the underlying principles of transparency and accountability in health care delivery. n

Bi-partisan support for new cost commission Sen. Irene Aguilar (D-Denver) “The efforts to bring health coverage to more working Coloradans is meaningless if we can't also assure those patients get the right care for the right value.” Sen. Ellen Roberts (R-Durango) “Cutting health care costs requires a surgical approach. It demands precision and good analytics so that we are trimming fat – redundant and unnecessary care – not healthy tissue.” Rep. Sue Schafer (D-Wheat Ridge) “Our commission of experts will help us analyze a body of good national data and apply it locally to Colorado.” Rep. Amy Stephens (R-Monument) “Increasing health care expenditures makes state budgeting a zero-sum game. Unless we can get these costs under control, fewer dollars will be available to educate our kids, repair our highways and improve our infrastructure.”

Colorado Medicine for May/June 2014

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Colorado Medicine for May/June 2014