May-June 2015 by Colorado Medical Society

May/June 2015

Volume 112, Number 3

The tip of the iceberg

Debate on out-of-network bill uncovers larger issue of network adequacy

Award-winning publication of the Colorado Medical Society

Colorado Medicine for May/June 2015

contents May/June 2015, Volume 112, Number 3

Features. . . 14

Legislative recap–CMS worked hard on your behalf during the 70th General Assembly. Now that the legislature has adjourned, read a summary of this year's important bills.

SGR repeal– Congress votes to repeal the broken Medicare

Public health initiative–A who’s who of public health experts meet at CMS headquarters to devise a plan for CMS to support a long-term public health initiative.

Spring Conference– CMS members, their families and

Leadership and governance– CMS is reviewing the

Case analysis review–Physicians learn about the COPIC case analysis process through an interactive education session with defense attorneys and COPIC risk managers.

Clinics without walls– Lucy Loomis, MD, and Simon Hambidge, MD, PhD, discuss how Denver Health has transformed its primary care delivery system and cut costs.

Honoring the “dean of deans”–Richard Krugman, MD, steps down as the longest serving dean in the history of the University of Colorado School of Medicine.

Final Word–AMA President Robert Wah, MD, applauds the efforts of physicians across the country after Congress finally repeals the flawed sustainable growth rate formula.

Cover story A debate in the Colo-

rado legislature over out-of-network charges by health care providers uncovered a much broader discussion of the complexity of network adequacy and fierce competition within the health insurance industry in the state. Read more about an upcoming interim study to address the issues starting on page 8.

Inside CMS 5 7 33 34 36 38

President's Letter Executive Office Update Looking Forward Advanced Physician Leadership Program Reflections COPIC Comment

Departments 39 45

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sustainable growth rate formula thanks in large part to the AMA’s leadership and physician advocacy.

guests gather in Vail for networking, fellowship, and interactive discussions on critical issues facing physicians.

society’s governance structure to strengthen and support the society’s strategic goals, and ensure future relevance.

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

Colorado Medicine for May/June 2015

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

2014/2015 Officers Tamaan Osbourne-Roberts, MD President Michael Volz, 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 John L. Bender, MD, FAAFP Immediate Past President

Board of Directors JT Boyd, MD Charles Breaux Jr., MD Laird Cagan, MD Cory Carroll, MD Joel Dickerman, DO Greg Fliney, MS Curtis Hagedorn, MD Jan Gillespie, MD Kendra Grundman, MSS Mark Johnson, MD Richard Lamb, MD Tamara Lhungay, MS 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 Charlie Tharp, MD Jennifer Wiler, MD Andrea Vincent, MSS Harold “Hap” Young, MD

AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Kay Lozano, MD Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD CMS Historian W. Gerald Rainer, MD CMS Connection Mary Rice, President

COLORADO MEDICAL SOCIETY STAFF Executive Office

Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Mellott-Yost, Director, Professional Services, Dianna_Mellott-Yost@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org

Division of Communications and Member Benefits

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

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

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

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

Mike Campo, Staff Support, Mike_Campo@cms.org

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

Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Chet Seward, Assistant Editor. Colorado Medicine Printed by Spectro Printing, Denver, Colorado

for May/June 2015

Inside CMS

president’s letter Tamaan Osbourne-Roberts, MD President, Colorado Medical Society

Awash in a sea of complexity I tend to take great pride in the many innovations now moving through Colorado’s medical policy world, and even greater pride in Colorado Medical Society’s involvement in so many of them.

will be able to use that data to improve care and design better practices, but worry more and more about whether that data will be used in meaningful and ethical ways.

ests in the state, CMS helps to focus our profession’s voice in the legislature and in other halls of policy. Through our work on physician wellness, CMS seeks to remove the things separat-

Some of these current initiatives include the State Innovation Model, which promises to revolutionize behavioral health care for all Coloradans; the Medicaid expansion, bringing health care coverage to an unprecedented number of the state’s most needy citizens; the All-Payer Claims Database, a unique collaboration designed to bring cost and quality data to the clinical level; the Commission on Affordable Health Care, one of Sen. Irene Aguilar’s signature initiatives, and natural successor to the 208 Commission; and most recently, an interim study on network adequacy, CMS’ own forward-looking brainchild to examine the nature of health insurance networks in Colorado, arising out of events this legislative session. We are rapidly working with others to build the future health care system of Colorado.

After a while, the landscape starts to look a bit like this month’s front cover: full of icebergs. These beautiful peaks, ready for exploration and harvest, bring much-needed refreshment to the ship of our profession, but much is looming under the surface and threatening to capsize us. We are floating in an ocean of unpredictable winds that will either clear the way for our journey or force the smaller bits of ice together, trapping us in for a long winter.

“It is a veritable sea of complexity, needing a skilled team at the front of the ship, charting a safe course forward, avoiding hazard and seeking opportunity. Thankfully the physicians of Colorado have that in their team at CMS.”

Perhaps understandably, I mention the headaches that go along with such change less frequently, particularly for practicing physicians on the ground. As health care systems change and offer more capacity to bring better care to more patients, the burden of delivering that care often falls on the shoulders of physicians. As the business environment changes, and as massive hospital systems and payers square off, doctors often get caught in the middle, sometimes negotiating for better reimbursement, sometimes taking collateral damage. As data becomes more accessible and more robust, physicians Colorado Medicine for May/June 2015

It is a veritable sea of complexity, needing a skilled team at the front of the ship, charting a safe course forward, avoiding hazard and seeking opportunity. Thankfully the physicians of Colorado have that in their team at CMS. Much has been made of the increasingly fractured nature of the modern physician’s life. The trend toward physician employment increasingly takes us away from one another. Expanding practice requirements give us less time to band together and protect our profession and our patients. The changing nature of the American career and family places additional demands on our time. And the business environment means we spend more time supporting the care we give, rather than supporting each other. In this increasingly lonely environment, CMS shines as a place where physicians come together. Serving as the convener for all physician inter-

ing physicians from health and happiness, as was recently highlighted by CMS President-elect Mike Volz’s topic for the Spring Conference, “Breaking Barriers.” And county medical societies provide much-needed social and networking space for physicians in their local communities. All careers come with headaches. The question is: How do we respond? And how do we get through? My own answer has always been that we succeed in the face of adversity with the help of other people. CMS stands ready to serve as the place where you can connect with your colleagues, to meet these challenges head on. (And maybe hand you a little ibuprofen). Until next time. n 5

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Colorado Medicine for May/June 2015

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Finding sweet spot for transparency, fairness and accountability The Senate Business, Labor and Technology Committee’s recent hearing of Sen. Irene Aguilar’s SB 259 on excessive out-of-network charges resulted in the decision to defer the topic to an interim study. On a partisan 5-4 vote, these senators told all of us in the room – the insurance companies, physicians, hospitals, patient advocacy organizations, businesses and regulators – that they will stand down for an interim study to see if we can find a sweet spot that allows for transparency, fairness and accountability. As this month’s cover story explains, physicians argued persuasively, with temporary success, that there's a lot more to the out-of-network story, and in this case the committee should invoke the time-honored rule that “hard cases make bad law.” For the time being the politics are on hold, and all but one insurance company understands the extraordinary opportunity that an interim conversation presents as perhaps our only chance during this decade to collaborate on a solution to this problem. The interim study offers a unique opportunity to build a policy consensus among those who will make the decisions and those who will live and practice by them. Otherwise it’s back to old school lobbying and zero-sum policy results. Danger of doing nothing Our view is that the outcome of doing nothing translates into something far worse in the marketplace for patients, physicians and insurance companies. It is important to note that there are some familiar, friendly faces in Colorado’s insurance community, notwithstanding the adversarial nature of this Colorado Medicine for May/June 2015

year’s legislation. These relationships will hopefully focus the interim study on evidence and the downstream effects of policy options. We joined national experts in warning that there are adverse direct and indirect consequences of attempting to globally cap one narrow aspect of a complex set of transactions that determine the nature and balance of business and clinical interests between insurance companies and physicians. We noted that such an approach would attempt to fix an underlying more complicated question of network adequacy by declaring the symptom illegal. A prominent professor we retained from the prestigious Kellogg School of Management explained in a sworn affidavit that the global cap would threaten the ability and desire of many physicians to practice in Colorado, and/or push more physicians into hospital employment. This expert also explained the adverse impact on the market forces that currently provide a level of balance. The senate committee understood that as insurance companies in Colorado and across the country drastically reduce the availability of physicians within networks, more physicians would find themselves out of network. This will be especially true in emergent settings where the physician has hospital staff privileges but is no longer part of an insurance company network. De-selections of physicians without cause by the health insurance industry permit the narrowing of the networks that threatens to take us back to the ’90s, along with all the familiar

variances in health plan criteria, some understandable, some more mercenary, and mostly not transparent. The consumer response in the ’90s was a major league backlash resulting in state consumer protection laws across the country. Instead of rational policy debates, the medical-insurance industry discussions were more akin to bar room brawls. In that broader, more relevant context of how insurance companies make the

“Our view is that the outcome of doing nothing translates into something far worse in the marketplace for patients, physicians and insurance companies.” rules that control where patients seek treatment and who is in and out-ofnetwork, we invited a study of the issues several months before SB 259 was filed. No patient should be blindsided with a bill that by any rational measure is excessive, nor should physicians find themselves at sea because an insurance company arbitrarily decides on some magical number of specialists and PCPs and the rest are thrown overboard. I hope we can all grasp the fact that we are all in the same boat, and this interim effort is the most important undertaking of the decade in terms of finding systemic approaches as opposed to symptomatic treatments. n

The tip of the iceberg

Debate on outof-network bill uncovers larger issue of network adequacy

Kate Alfano, CMS communications coordinator 8

Colorado Medicine for May/June 2015

Cover Story STORY HIGHLIGHTS • CMS opposed SB15-259, “Out-ofNetwork Health Care Provider Charges,” and pushed for an interim study that will bring together physicians, health plans and consumer representatives to address matters related to network adequacy. • Narrow networks happen when insurers negotiate lower rates with a smaller group of providers in return for higher volumes of patients. This allows them to decrease the cost of their insurance products. • Physicians testified before a senate committee that they often do not choose to be out of network; rather the insurer will not negotiate. They are concerned that patients unknowingly buy insurance products that do not provide adequate coverage. A debate in the Colorado legislature over out-of-network charges by health care providers has uncovered a much broader discussion of the complexity of network adequacy and fierce competition within the health insurance industry in the state. Senate Bill 15-259, “Out-of-Network Health Care Provider Charges,” filed by known patient advocate Sen. Irene Aguilar, MD, (D-Denver), aimed to enhance consumer protections from surprise bills by out-of-network providers by increasing disclosure requirements for physicians. CMS opposed the bill after an independent analysis of the bill revealed unintended negative consequences for physicians and patients: It could worsen an already unequal balance of power between insurers and doctors by allowing health plans to set and cap physician payment, would increase administrative burdens and expenses, and could worsen patients’ access to care by encouraging narrower networks. Colorado Medicine for May/June 2015

Aguilar worked with stakeholders, including CMS, on several drafts of the bill. The medical society convened numerous conference calls with specialty and component society leaders to get a broad physician perspective on the legislation, and retained legal, practice analytics and market experts on out-ofnetwork pricing and dynamics to inform the debate. Even after removing the most controversial provisions from the bill regarding how providers are paid, the medical community still felt the disclosure requirements were administratively unworkable and the bill would have removed some of the existing consumer protections. Eleven physicians plus practice managers, medical society executives and other experts testified against the bill before the Senate Committee on Business, Labor and Technology at a hearing on April 20. The committee voted 5-4 to postpone the bill indefinitely. As an alternative to the legislation, a coalition led by CMS that included most component and state specialty societies, the Colorado Medical Group Management Association and others, persuaded the committee that the dynamics surrounding out-of-network charges and network adequacy are complex and interrelated, and should be studied in the legislative interim to develop sustainable, equitable and fair policy solutions for consideration in the 2016 General Assembly. “Most witnesses who testified on Senate Bill 259, regardless of their support or opposition, expressed a desire to protect patients,” said Sen. David Balmer (RCentennial), chair of the Senate Committee on Business, Labor and Technology. “No one disputes the fact that our health care system is complicated and relies on a delicate balance of market forces to function. The interim study ensures that all stakeholders participate in a process that moves us all forward.” “I am grateful to the physicians who took time out of their schedules to give their perspective on this complex is-

sue,” said Sen. Tim Neville (R-Littleton). “This debate opens the door for productive discussions on the function of health insurance and the ways we can encourage market competition and consumer choice.” CMS seeks a rational approach to protect patients from excessive pricing, while similarly protecting physicians

“Most witnesses who testified on Senate Bill 259, regardless of their support or opposition, expressed a desire to protect patients. No one disputes the fact that our health care system is complicated and relies on a delicate balance of market forces to function. The interim study ensures that all stakeholders participate in a process that moves us all forward.” – Sen. David Balmer (R-Centennial) from being exploited by health plans that may manipulate pricing databases to either deselect doctors or to inappropriately squeeze physician payments. “When needing surgery, the average consumer chooses their provider based on who will accept their insurance and they choose to have their surgery done at a facility that accepts their insurance because they know the cost of medical care can sometimes be outrageous,” Aguilar said. “Many consumers don’t realize that it is possible to have picked an in-network hospital and doctor and still have an out-of-network provider in

Cover story (cont.) your operating room. When that happens, if your plan is not regulated by the state, you could potentially have to pay the difference in charges between what

“Although being out of network is a rare occurrence for me, sometimes my only option to get one of these insurance corporations to the negotiating table is to refuse the contract that they offer me and go out of network.” – Ron Pelton, MD, PhD your plan pays and what your provider wants to bill. It is for patients like this that I filed this legislation and I look forward to continuing this discussion in

the interim and into the 2016 legislative session.” The rising trend of narrow networks Network adequacy, as defined by the Colorado Department of Insurance, refers to a health plan’s ability to deliver promised benefits by providing reasonable access to a sufficient number and type of providers, including in-network primary care and specialty physicians, facilities and all other health care services included under the terms of the contract. The Affordable Care Act took away some of the methods insurers previously used to offer insurance coverage to the consumer at a low price point and turn a profit. This has led to the narrowing of provider networks for many plans. Insurers negotiate lower rates with a smaller group of providers in return for higher volumes of patients, and in turn decrease the cost of their insurance products, which makes them more competitive on the state and federal health exchanges.

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As the DOI said in a frequently asked questions document, “adequate networks for managed care health plans are necessary to ensure that consumers have choices and access to covered benefits and quality health care services.” Insurance Commissioner Marguerite Salazar commissioned a study on network adequacy in Colorado in December 2014 to get a baseline picture of insurance networks, evaluate the ability of networks to provide reasonable and sufficient access, and assess recent trends in order to establish standards in the future. Salazar told the Denver Business Journal that the analysis shows insurers are offering sufficient options for customers to receive the health care they need, and that affordability of the plans must be considered along with the accessibility to care. “I really don’t have significant concerns right now,” Salazar said of narrowing networks in an April 17 DBJ article. “I think that’s the best way these insurance companies have to save money. I need to support that.” However, physicians voiced concerns at the April 20 hearing about the creation and administration of networks under health plans, and the effect on patients’ access to quality care. Neuroradiologist Peter Ricci, MD, provides screening and diagnostic breast imaging services through the state’s largest network of freestanding breast screening centers. “As of last Friday, those facilities were excluded from five payer network products in the state – not by choice mind you, but because payers won’t even negotiate with us for inclusion in those network products,” he said. “And it’s not about quality.” Ricci showed the committee data that compares his practice’s quality and cost effectiveness to national benchmarks. “Our recall rate for diagnostic studies following the screening mammogram is 25 percent lower than national benchmarks. Yet we diagnose cancer at a rate that is more than double the national averages. And we diagnose cancer at earlier stages – 15 percent better than national benchmarks. By any objective Colorado Medicine for May/June 2015

Cover Story measure, we offer a quality of breast imaging services to women in the state of Colorado that is on par with the nation’s best breast centers. To be clear, we are out of network not by choice but by the payers’ choice.” Ophthalmologist Ron Pelton, MD, PhD, said the worst part of being a solo practitioner, by far, is the constant struggle and incessant fighting with health plans about insurance contracts, payments and paperwork. “Three of my six employees work full time, every day, just dealing with billing, collecting and contracting with health plans. Although I contract with almost every company in Colorado, the fact is that the contracts I am offered by these huge corporations are pretty much take-it-orleave-it affairs. I have no real power to negotiate terms with them. Although being out of network is a rare occurrence for me, sometimes my only option to get one of these insurance corporations to the negotiating table is to refuse the contract that they offer me and go out of network.”

Pathologist Ron Lepoff, MD, said, “We believe that effective out-of-network legislation to benefit patients must require the state to rigorously evaluate and determine whether insurance networks are indeed adequate. Narrow provider networks that exclude physicians in critical medical specialty areas lead to patients receiving out-of-network services and balance bills. Ultimately, patients are best protected when insurance networks are adequate to meet all the patient’s medical needs.”

Diving deeper Some provider business practices may exploit out-of-network charges, though there are also instances of legitimate pricing of appropriate medical services that happen to be out of network through no choice of the treating provider. In a post-Affordable Care Act marketplace when more patients than ever have access to health insurance, how can health care providers, insur-

“These large managed care plans already hold all the cards,” he said. “If they refuse to pay, I have little recourse except to spend hours and hours rebilling, appealing, emailing and calling. After enough time, it sometimes costs me more in office wages than I actually collect.” Pediatrician David Markenson, MD, chief medical officer of Sky Ridge Medical Center, expressed concern about the lack of pediatric subspecialists in many of the state networks. “Many of these networks we’ve discussed may not have a single specialist in a pediatric field available,” meaning that parents must take on the burden of making a financial decision or getting necessary care for their child. “We need to be sure that when patients go out and purchase insurance they have adequate coverage, have access to the specialists they expect, and that the insurance companies are compelled to negotiate in good faith with providers to provide appropriate and reasonable care. I do agree there are outliers; I do agree we can do better. We need to study this,” he said. Colorado Medicine for May/June 2015

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Cover story (cont.) ers, legislators and employers ensure intense competition for price that also improves the quality of health care and patient experience? Is the health insurance market a race to the bottom to provide the lowest-price product that covers fewer providers and services, or will competition improve health care quality and patient experience? The inevitable debate is fully underway and will continue through the interim

study that will bring together providers, health plans and consumer representatives in facilitated meetings. The primary focus and objective shall be addressing the issues arising from outof-network services and charges, as well as related network adequacy matters as time permits. “We have been talking for quite a few months now with the Colorado Medical Society about network adequacy,

network size and certain billing practices, and we agree that we want to work with our colleagues in the medical field,” said Ben Price, executive director of the Colorado Association of Health Plans. “We have committed to doing that this summer.” CMS President Tamaan OsbourneRoberts, MD, said SB 15-259 was just the tip of the iceberg and will require deliberate exploration to uncover its depth and breadth. “We are committed to actively participate in what may prove to be the most important interim study of the decade for physicians and patients. We continue to seek a physician consensus to what we perceive to be a symptomatic manifestation of more complex structural dysfunctions that distort the value of appropriate services. The very nature of the building and subsequent narrowing of physician and other provider networks has similar distorting influences on care timing, pricing and delivery.” n

All donations to this committee are used exclusively to support legislative candidates who are 100% committed to maintaining Colorado's stable liability and confidential professional review climate. All friends of medicine are eligible to participate. Call 720-859-1001, ext. 6327 or 800-654-5653, ext. 6327 or donate online at www.cms.org/contribute/ 12

Colorado Medicine for May/June 2015

Features

2015 end-of-session legislative recap Susan Koontz, JD, CMS General Counsel

STORY HIGHLIGHTS • The first regular session of the 70th General Assembly adjourned on May 6, 2015. • The CMS lobby team advocated for or against more than 50 bills to ensure legislation benefits physicians and their patients. • This legislative report summarizes the disposition of and significance to physicians of important bills in six categories. The Colorado Medical Society advocates for Colorado physicians and their patients in a tough legislative environment. In the 2015 regular session of the Colorado General Assembly, legislators addressed telehealth, clean claims, out-of network provider rates, scope of practice, women’s and children’s health issues, transparency in health care prices and Medicaid, among many other issues. CMS lobbied for or against more than 50 bills to ensure legislation benefits physicians professionally and helps improve the health and wellness of Colorado patients. The CMS Council on Legislation (COL) and its policy and public affairs professionals reviewed each bill to understand its intent, its possible outcomes and the political landscape to collectively determine how and at what level CMS should engage. Demonstrating that organized medicine in Colorado is not an oxymoron, CMS, state and component medi 14

cal societies united on numerous bills to enhance impact and assure positive outcomes. The accomplishments of the session can be divided into six categories, as follows. Administrative simplification SB 15-259: Out-of-Network Health Care Provider Charges CMS worked diligently and tirelessly alongside various component societies, stakeholders and lobbyists, to oppose this bill with the common goal of creating an interim study, which had been agreed to by the Colorado Association of Health Plans (CAHP) and CMS. The bill was heard on April 20 before the Senate Business, Labor and Technology Committee. On that day, CMS President Tamaan Osbourne-Roberts, MD, along with CMS physician members Ron Lepoff, MD, David Markenson, MD, Ron Pelton, MD, PhD, David Friedenson, MD, Eric Olsen, MD, John C. Kefer, MD, F. Brent Keeler, MD, Peter Ricci, MD, James Regan, MD, and J.T. Boyd, MD, and practice managers Melissa McCormick and Jennifer Souders, testified in opposition to this bill. See the cover story on page 8 for more details. The bill was killed at that hearing by a vote of 5 (Republicans) - 4 (Democrats). SB 15-057: Clean Claims Task Force Reporting The CMS-supported Medical Clean Claims Task Force continues to work toward development of a standardized set of claim edits. The creation of a uniform set of claim edits and payment rules enable claims to be filed with any payer using one uniform set of trans-

parent rules. This bill continues this work and was signed into law by Gov. John Hickenlooper on March 18. SB 15-074: Transparency in Health Care Prices Act CMS lobbied in opposition of this bill, which would have required all physicians to provide a list of estimated charges upon patient request. CMS supports transparency in health care billing; however, this bill would have created unnecessary administrative burdens on physicians. The bill was heard before the House State, Veterans and Military Affairs Committee on March 18. On that day, F. Brent Keeler, MD, and Murray Willis, MD, testified in opposition to the bill. The bill was killed by a vote of 6 (Democrats) - 5 (Republicans). CMS has agreed to work with the bill sponsor Sen. Tim Neville (R-Littleton) over the interim, to address his concerns about transparency and physician charges. Practice innovations HB 15-1029: Health Care Delivery Via Telehealth Statewide We are pleased to report that the governor signed the telehealth bill on March 20. This bill was initiated by the CMS House of Delegates and CMS Past President John Bender, MD. Passage of this legislation removes the population limitation of 150,000 or fewer residents for telehealth regardless of where a person resides in our state and will now ensure that more Coloradans are afforded timely access to high-quality primary and specialty health care. This law also requires health plans to reimburse physicians the same amount for Colorado Medicine for May/June 2015

Features a telehealth encounter as a physical encounter. HB 15-1281: Newborn Heart Defect Screening Pulse Oximetry This bill would require that all newborns born in a birthing center that is located at an elevation below 7,000 feet be screened for congenital health defects using pulse oximetry prior to the infant leaving the health facility. Pulse oximetry is a noninvasive test that estimates the percentage of hemoglobin in blood that is saturated with oxygen and, when performed on newborns in delivery centers, is effective at detecting critical, life-threatening congenital heart defects that might otherwise go undetected using current screening methods. It is believed that many newborn lives may be saved by the use of the screening required by this bill. COL voted to support this bill, which passed through both the House and the Senate. SB 15-071: Pharmacist Substitute Interchangeable Biological CMS supported this legislation, which allows a pharmacist to substitute a biological product if the FDA has determined that the biological product is therapeutically equivalent with the prescribed biological product and if the physician has not indicated that the prescription must be dispensed as written. The governor signed SB 15-071 into law on April 3. Medicaid SB 15-228: Medicaid Provider Rate Review This bill establishes a process enabling the Department of Health Care Policy and Financing to review provider fee rates under the Colorado Medical Assistance Act. The bill will create a Medicaid Provider Rate Review Advisory Committee consisting of 24 members who will serve without compensation and reimbursement for expenses. The president of the Senate, speaker of the House of Representatives and minority leaders of the Senate and House will appoint these members. There will

Colorado Medicine for May/June 2015

Legislative recap (cont.) be three physicians on this committee: CMS will recommend one specialist to be appointed by the House speaker, a statewide association for primary care physicians will recommend another physician member, and the third physician member of facility-based physicians (which includes anesthesiologists, emergency room physicians, neonatologists, pathologists and radiologists) will be appointed by the House minority leader. The long bill will include a 0.5 percent across-the-board increase in all Medicaid reimbursement rates with a few providers excluded. The bill passed through both the House and the Senate. Scope of practice HB 15-1075: Registered Naturopathic Doctor Treating Children Under current law, registered NDs have been prohibited from treating a child who is under 2 years of age. This bill permits NDs to do so when they have met the following requirements: provided the child’s parents the current recommended immunization schedule

for children; successfully completed five hours per year of education or practicum training solely related to pediatrics; obtained a signed informed consent from the child’s parents; has, on the first visit, referred a child who does not have a relationship with a pediatric health care provider to a licensed physician who treats pediatric patients for a wellness evaluation; and has complied with director rules pertaining to training, referral and communication requirements. COL supported this bill, which passed through both the House and the Senate and was signed by the governor on March 26. HB 15-1182: Scope of Practice Certified Nurse Aides Prior to the introduction of this legislation, certified nurse aides (CNAs) had been performing certain tasks. However, due to the rescission of policy guidelines, the filing of this legislation was necessitated. HB 15-1182 allows a CNA to perform the following tasks:

digital stimulation, insertion of a suppository or the use of an enema, or any other medically acceptable procedure to stimulate a bowel movement; G-tube and J-tube feedings; and placement in a client’s mouth of presorted medication that has been boxed or packaged by a registered nurse, a licensed practical nurse or a pharmacist. (C.R.S. § 12-38.1-108.5 added.) COL voted to support this bill, which passed through both the House and the Senate. The measure became law on March 31. HB 15-1352: Naturopathic Doctor Formulary Changes The COL scope of practice workgroup along with the NDs worked together on the draft bill for more than a year. The bill, similar to the Direct Entry Midwife statute, allows NDs to obtain and administer (not prescribe) medications from registered or licensed wholesalers, manufacturers or prescription drug outlets, including providing the medication; obtaining and administering

Colorado Medicine for May/June 2015

saline, sterile water, topical antiseptics and local anesthetics, including those with epinephrine, in connection with minor office procedures; obtaining and administering oxygen in emergency situations; prescribing and administering vitamins B6 and B12; obtaining, administering or dispensing FDA-regulated substances that do not require a prescription to be dispensed; and obtaining and administering vaccines, in accordance with the ACIP guidelines, for patients who are at least 18 years of age. The bill passed through both the House and Senate without amendment. HB 15-1360: Acupuncturists Practice Injection Therapy Since 1999 acupuncturists have engaged in injection therapy under a policy adopted by the Colorado Office of Acupuncture and Licensure. Due to change in the pharmacy laws, acupuncturists are unable to obtain substances for injection therapy. This bill provides statutory authority for the acupuncturists to obtain these substances. Injection therapy is defined as the injection of sterile herbs, vitamins, minerals, homeopathic substances or other similar substances into acupuncture points by means of hypodermic needles. The bill also requires acupuncturists to obtain substances for injection therapy from a registered prescription drug outlet, registered manufacturer or registered wholesaler. The CMS Scope of Practice Workgroup held a series of meetings with acupuncturists with regard to the draft bill. The COL voted to support this legislation and the bill passed through the House and Senate without amendment. SB 15-053: Dispense Supply Emergency Drugs for Overdose Victims COL voted to support this bill, which passed the Legislature and was signed on April 6 by Gov. Hickenlooper. It expands the ability of an employee or volunteer of a harm reduction organization or a first responder to prescribe opiate antagonist under protocols. Colorado Medicine for May/June 2015

SB 15-197: APN Prescriptive Authority Current law requires an APN to complete 1,800 hours of prescribing in a preceptorship and to complete 1,800 hours of prescribing in a mentorship in order to achieve full prescriptive authority. This bill reduces the requirement to 1,000 practice hours in order to achieve full prescriptive authority. In addition, the bill requires a licensed physician or an APN who has full prescriptive authority to mentor an APN. Upon completion of the mentorship requirement, an APN with provisional prescriptive authority must develop an articulated plan for safe prescribing that documents how the APN intends to maintain ongoing collaboration with physicians and other health care professionals in connection with the APN’s practice of prescribing medication within his or her role and population focus.

ency to women who may be considering the termination of a pregnancy. SB 15-285 would have required that a physician provide full disclosure to a pregnant woman, which included providing the current ultrasound of the unborn child and all medical information, including the viability of the pregnancy, gestational age of the unborn child, description of the development of the unborn child as well as discussing the physical and psychological risks associated with termination of the pregnancy. It also required that a woman submitting to an abortion provide voluntary and informed consent to an abortion. SB 15-285 would have created a civil right of action for noncompliance with the bill’s requirements, making a physician’s noncompliance with the requirements a crime. The bill was killed in the Senate Health and Human Services Committee by a vote of 3-2.

The bill passed through both the Senate and the House and was sent to the governor for signature.

HB 15-1041 Protect Human Life at Conception The bill sought to prohibit abortion, making a violation a Class 3 felony. Exceptions to the prohibition were: a licensed physician performing a medical procedure intended to prevent the death of a pregnant mother; the physician making reasonable medical efforts to preserve both the life of the mother and the life of the unborn child in a manner consistent with conventional medical practice; a licensed physician rendering treatment to the mother resulting in the accidental or unintentional injury or death to the unborn child. CMS opposed the bill. HB 15-1041 was defeated in the House Judiciary Committee.

A bad idea killed SB 15-275 Protections Information Provided to General Assembly This bill would have allowed any state employee to disclose to any member of the general assembly (House or Senate) confidential, privileged or private information, including protected health information and professional review records. The legislator could use the protected information in open hearings. The bill would have precluded the state agency from sanctioning the employee for disclosing the confidential, privileged or private information, even if the employee knows that the information is confidential, and even if the employee is making a false representation or providing a falsified document. CMS lobbied against this bill. SB 15275 was killed on the Senate floor during second reading. Other bills SB 15-285 A Woman’s Right to Accurate Healthcare Information This bill sought to provide transpar-

HB 15-1112: Born Alive Infant Protection Act The bill sought to prohibit a person from denying or depriving an infant of nourishment with the intent to cause or allow the death of the infant for any reason. CMS opposed the bill. HB 151112 did not make it out of the House Committee on Public Health Care and Human Services. n

Features

SGR repeal American Medical Association staff

Medicare payment formula bites the dust The sustainable growth rate (SGR) formula is no more. Thanks to new legislation adopted Tuesday, April 14, Medicare patients and the physicians who care for them no longer will be threatened by the flawed payment formula that left the Medicare program unstable and threatened access to care.

sicians – facilitating the implementation of innovative care models that will improve care quality and lower costs,” American Medical Association Executive Vice President and CEO James L. Madara, MD, said in a statement. “Patients will be able to get the care they need and deserve.”

Following years of advocacy by the nation’s physicians standing up for their patients and their practices, the U.S. Senate followed the U.S. House of Representatives’ lead and passed a bill to immediately repeal the SGR formula.

In addition to addressing Medicare payment, the legislation outlines several provisions that should be beneficial for physicians, including:

The Medicare Access and CHIP Reauthorization Act was adopted by a vote of 92 – 8 on the eve that a 21 percent cut to physicians’ Medicare payments was set to take place. Instead, the bill provides positive annual payment updates of 0.5 percent, starting July 1 and lasting through 2019. Claims that were held for the first half of April will be processed and paid at the rates that were in place before the 21 percent cut was scheduled to take effect. “Passage of this historic legislation finally brings an end to an era of uncertainty for Medicare beneficiaries and their phy-

• Medicare’s current quality reporting programs will be streamlined and simplified into one merit-based incentive payment system, referred to as “MIPS.” This consolidation will reduce the aggregate level of financial penalties physicians otherwise could have faced. • Protections are included so that medical liability cases cannot use Medicare quality program standards and measures as a standard or duty of care. • Incentive payments will be available for physicians who participate in alternative payment models and meet certain thresholds. • Technical support will be provided

to help smaller practices participate in alternative payment models or the new fee-for-service incentive program. • While the bill supports physicians who choose to adopt new payment and delivery models, it also retains Medicare’s fee-for-service model. Participation in new models is entirely voluntary. The legislation takes an important first step by eliminating the SGR formula, and the AMA has pledged to continue working to ensure that implementation bolsters the sustainability of physician practices and empowers physicians to provide the best possible care for patients. Additional challenges physicians continue to face in the Medicare program include impractical requirements of the electronic health record meaningful use program, eliminating the Independent Payment Advisory Board and the costly transition to the ICD-10 code set. As part of its Professional Satisfaction and Practice Sustainability initiative, the AMA strives to clear these roadblocks to improving the nation’s health. n

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Colorado Medicine for May/June 2015

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Features

Public health initiative Focusing a lens on public health As many of you know, as your president, I recommended and the board approved that CMS should support a long-term public health initiative as part of its core work. While this idea was enthusiastically embraced by the entire board, two board members who have dedicated their careers to public health – Mark Johnson, MD, and Christine Nevin-Woods, MD – voluntarily took on leadership of this initiative, which led to a grand meeting of more than 20 of the state’s top public health officials at the CMS office in March. The attendees included myself; CMS President-elect Mike Volz, MD; Colorado’s Chief Medical Officer Larry Wolk, MD, and several other leaders from his Colorado Department of Public Health and Environment; multiple representatives from local public health agencies around the state; and leaders from the University of Colorado School of Medicine and the Colorado School of Public Health. Before the meeting, CMS asked our invited guests to consider which public health initiatives deserve primary focus over the next decade of those proposed by the CMS Board of Directors. Marijuana and immunization rates were

Tamaan Osbourne-Roberts, MD CMS President

ranked highest, and the collection and use of public health data, health equity, diabetes and obesity were also deemed priorities. However, after lengthy discussion about the topics, those in attendance agreed that they did not want to focus on a singular public health issue, or even multiple issues. They are particularly interested in public health having a more ubiquitous role at CMS, influencing the many policy decisions made at a higher level. They want more formalized engagement for public health within the CMS structure and created a proposal they feel will create partnerships, flexibility, and relationships at multiple levels. Their recommendations are to: 1. Create a section on the CMS Board of Directors that represents public health, and 2. Create a standing committee as part of the section structure. While my own interest in this initiative derives largely from my own career experiences, beginning at a federally qualified health center as a Colorado Health Service Corps member, and continuing now at a rural critical access hospital, it has long been my belief that most CMS

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

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

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

members are deeply interested in public health, viewing it as a foundational discipline within the wider realm of health care policy. However, it has also been my experience that, for multiple reasons, many physicians working outside of public health often view health care policy primarily through the lenses of cost and quality, and may not necessarily know how to incorporate public health into their other advocacy. Fortunately, public health has a long history of focusing on communities and CMS has a long history of focusing on physicians and their patients. A longterm commitment between CMS and public health leaders can help connect clinical physician practices and public health agencies to keep our patients and communities healthy. CMS helps provide the framework and coordination so desperately needed to be effective in this arena. And we’re aided by such efforts as the State Innovation Model, which will fund care coordination efforts for behavioral health and primary care in Colorado; project ECHO, which uses videoconferencing for patient visits and physician training, and is an effort that the state is currently considering; and initiatives present within the Affordable Care Act. If approved by the board, the members of the new public health section will identify what public health initiatives to work on, work to recruit public health members to CMS, and work to create strong partnerships with other public health advocacy groups. I welcome hearing from members on our efforts to advance CMS’s public health presence. Don’t hesitate to email me at president@cms.org. n Colorado Medicine for May/June 2015

Colorado Medicine for May/June 2015

Features

Spring conference Photos by Kate Alfano, CMS communications coordinator

Members gather in Vail for fellowship, education Thank you to all members who attended the Colorado Medical Societyâ&#x20AC;&#x2122;s 2015 Spring Conference at the Sonnenalp Hotel in Vail, May 1-3. CMS members enjoyed social events such as the welcome reception Friday evening hosted by the Intermountain Medical Society (IMS) and the dessert reception Saturday evening hosted by COPIC. Attendees also came together for interactive learning sessions. Discussions and suggestions gathered during the small-group breakouts on how to break down barriers in health care will be used to guide the course of the society in the coming years. n Photos, this page: Members enjoy the Friday evening reception hosted by the Intermountain Medical Society (IMS). Photos, opposite page, clockwise from top left: CMS President-elect Michael Volz, MD, welcomes members to the conference. IMS members congratulate the winner of the reception giveaway. Attendees from Boulder County gather for a group picture. Michael Volz, MD, presents the Breaking Down Barriers award to Marjie Harbrecht, MD, for her many years of work as CEO of HealthTeamWorks. Members make new acquaintances and greet old friends. Christine Ebert-Santos, MD, of Frisco, welcomes members to the Friday reception on behalf of IMS. 22

Colorado Medicine for May/June 2015

Features

Colorado Medicine for May/June 2015

Features

Leadership and governance Kate Alfano, CMS communications coordinator

CMS members explore alternative governance structures STORY HIGHLIGHTS • The CMS Governance Reform Task Force is coordinating the review of CMS’s governance structure. They will present recommendations to the Board of Directors in July and the House of Delegates in September. • Joe Gagen, JD, facilitated a discussion on governance reform at the 2015 Spring Conference in Vail. He outlined CMS’s current governance structure, reviewed what other states are doing to maintain relevance, and presented data from CMS surveys and past events. • All CMS members and component staff are urged to participate in the process. Materials are posted for comment at www.cms.org/ articles/governance-reform. The Colorado Medical Society is in the process of reviewing its governance structure to identify ways to strengthen and support the society’s strategic goals. Coordinating this effort is the CMS Governance Reform Task Force, chaired by past president Jan Kief, MD, and composed of 17 physician leaders and component society executives. The GRTF has set it guiding principles: To maximize the efficiency and effectiveness of the society in its decision-making while also keeping a member-centric focus, promoting the profession, maintaining transparency, and maximizing member 24

engagement. They will present their recommendations to the Board of Directors in July and to the House of Delegates in September. Joe Gagen, JD, facilitated a discussion on governance reform at the 2015 Spring Conference in Vail. He reviewed the current policymaking process of CMS, which is based on a geographic model, detailing the roles of the House of Delegates, Board of Directors, CMS committees and sections, and affiliate organizations. He then presented information gathered from leaders of other state medical associations that have explored governance reform and acted upon their members’ recommendations. In their discovery process, the associations found that modern technology could be used more effectively to engage members and gather their input. Some of this is led by generational preferences: For the most part, people born in the 1980s and later prefer communicating virtually rather than attending meetings and don’t appear to be getting involved in the leadership pipeline at rates equal to their older colleagues.

making processes are too slow to keep up with the rapid pace of change and a short-term resolution-driven policymaking process opens up the association to inconsistencies with deliberately constructed strategic plans. These states looked at the latest nonprofit association management and governance literature that emphasizes that effective governance is essential to executing strategic goals, including having boards of directors that are smaller in size – trying to drive better accountability and preventing members from “hiding” within large board structures. Almost every state also found that current governance models were very expensive given the number of people that are engaged. Gagen presented data on Colorado’s current standing: There are 310 delegate slots in the House of Delegates but in recent years only 260-270 delegates have registered to attend and only 90-

Other states a l s o fo u n d that current Joe Gagen, JD, facilitated a discussion on governance reform during the Saturday evening fireside chat at the 2015 Spring Conference in Vail. decisionColorado Medicine for May/June 2015

Features 120 were present to vote. The HOD was forced to change its requirements for a quorum in 2012 when low attendance was preventing delegates from conducting business. Additionally, the average age of delegates is 59 years old after excluding medical students. There are 38 slots on the CMS Board of Directors, three of which are currently vacant. CMS membership surveys conducted in 2008, 2010 and 2013 have showed declines in the perception of how CMS communicates with members, the presence of opportunities for members to provide input and suggestions, whether CMS positively impacts the Colorado health care system, whether CMS positively impacts physiciansâ&#x20AC;&#x2122; careers, and whether CMS reflects membersâ&#x20AC;&#x2122; priorities. In most other states where changes were made, the associations chose to eliminate their Houses of Delegates; create annual member forums; hold regular policy forums on selected issues; create policy councils; directly elect officers and their boards; reduce the size of their boards; and create a nominations committee to ensure diversity of expertise, experience and perspective. All members and component staff urged to participate Respondents at the spring conference were receptive to the data suggesting that CMS should adopt some of these reforms to improve the governance process and make the organization more representative of the larger membership. This discussion is crucial to the future success of the society and CMS encourages all members and component society executives and staff to continue to participate in the governance reform process. The task force met April 17-18 and will meet again June 19-20 with individual committee meetings as needed. All documents related to the work of the GRTF are posted on the CMS website, www.cms.org/articles/governance-reform. Members are strongly encouraged to log in to view and comment on these documents. Send additional thoughts to governancetf@cms.org. n Colorado Medicine for May/June 2015

Features

Case analysis review Kate Alfano, CMS communications coordinator

Interactive medical liability programming educates physicians STORY HIGHLIGHTS • CMS and COPIC collaborated to present an interactive case review session. • Physician attendees listened to fictitious medical liability cases presented by defense attorneys, then watched a mock claims committee, then broke into small groups for discussion. • The case review garnered positive feedback because it engaged attendees in the conversation and allowed them to examine care from all angles – medical, legal and ethical. The CMS Spring Conference was built around the theme of “breaking down barriers to better patient care,” and one of

its main goals was to develop ideas to address the critical issues facing physicians. One such issue is medical liability. “If you look at national data, 99 percent of surgeons will have a lawsuit by the time they are 65,” said COPIC CEO Ted Clarke, MD. “If you’re in primary care, it’s about 77 percent.” To give physicians insight into the case analysis process, CMS and COPIC collaborated to present an interactive case review session. Defense attorneys presented fictitious medical liability cases based upon current medical trends and incidents. Then a large panel of CMS physician members and COPIC physician risk managers simulated a case review by asking questions to analyze the cases. Attendees broke out into small groups for discussion facilitated by COPIC risk managers, focusing on the cases in terms of appropriateness of care, medico-legal

issues, patient behavior and other related aspects. These discussions presented attendees with the unique opportunity to interact with health law defense attorneys who partner with COPIC. At the end of the session, the defense attorneys gave their insights on the biggest changes in health care they’ve seen over the past five years. Steve Hensen, JD, identified the rising use of the electronic medical record as a barrier to communication. “I think it’s fair to say [EMR usage] has a lot of advantages; however, one disadvantage we see from patients when they start talking about what the problem was, is perceived lack of attention. If you sit behind a computer screen or have some physical barrier between you, you don’t have good eye contact, you don’t have good interaction. One thing we hear a lot is ‘the doctor never talked to me, the doctor didn’t listen to me or look at me. Instead the doctor was sitting there typing on a computer,’” he said. Hensen also talked about the rising use of scribes in medical settings. This process enables the physician to speak directly to the patient while another person records the encounter, but may open up the opportunity for error. “One problem we see is whether the scribe accurately wrote it down and whether the doctor actually reviewed it afterward because the plaintiff’s attorneys are using those medical records.”

COPIC CEO Ted Clarke, MD, center, introduces the panel of CMS physician members and COPIC physician risk managers who lead the interactive case review session. 26

What can happen is the scribe either didn’t hear the doctor ask a question or didn’t record the answer correctly and the Colorado Medicine for May/June 2015

Features doctor never checked the record, Hensen said. Then two, three or four years later, the physician has no independent recollection and the chart shows an error. Steve Michalek, JD, said he has seen significant changes in the cases that are brought because of the complexity of medicine and all of the different specialties and midlevels that get involved in care. “Most of the cases we see are filed against more than one health care provider,” he said. “Continuity of care, I think, is something that may break down in certain situations. It’s those handoffs that we have to make sure get done smoothly so that things don’t fall through the cracks.”

tion with you, or when you want them to contact you to direct the care of the patient. “That varies for each practice and you have to decide that ahead of time so that they have a clear understanding of when to contact you. That’s a clear communications barrier you can work on.” Additional defense attorneys involved in this process included Kay Rice serving as a speaker and Barb Glogiewicz and Doug Wolanske as case presenters.

The case review session garnered positive feedback because it engaged attendees in the conversation and allowed them to examine care from all angles – medical, legal and ethical. And while the review followed a structured format, unplanned discussions emerged that led to interesting questions and innovative ideas that will help attendees examine their own concerns and provide further understanding of the medical liability challenges health care providers face. n

“I’ve seen more and more of the midlevel cases with the PAs and the NPs where sometimes the folks don’t know who their supervising physician is at that time,” he continued. “Is it the one who’s registered at the medical board? Is it the one who happened to be on call? And when do they need to exercise their own judgment to elevate this clinical situation to get input from the supervising physician?” Jeff Varnell, MD, a COPIC physician risk manager, said one of the ways to overcome those barriers is to have a very clear understanding of when you feel comfortable with a midlevel seeing the patient, when he or she should have a consulta-

Colorado Medicine for May/June 2015

Attendees broke out into small groups for discussion facilitated by COPIC risk managers. From left to right, Leto Quarles, MD; Alfred Carr, MD; and Karen Davis, MD.

Features

Clinics without walls Kate Alfano, CMS communications coordinator

Denver Health 21st century care Denver Health, a vertically integrated system that includes a large acute hospital, an emergency room, an emergency response system, the Department of Public Health, and a network of eight federally qualified health centers, received a $20 million Health Care Innovations grant from the federal Centers for Medicare and Medicaid Innovation nearly three years ago to transform its primary care delivery system to provide individualized care to more effectively meet patients’ medical, behavioral and social needs.

Have they succeeded? Simon Hambidge, MD, PhD, Denver Health’s chief ambulatory care officer and CEO of Denver Community Health Services, and Lucy Loomis, MD, presented data at the Spring Conference that indicates they have. In fact, the organization shows real progress in achieving the triple aim of improving access, improving health and lowering costs. Through their 21st Century Care program, Denver Health provides teambased care, coordinates care across

health settings, and offers self-care support between visits enabled by health information technology and team-based patient navigators who reach out to patients in a variety of ways. The program also integrates physical and behavioral health services in collaboration with the Mental Health Center of Denver in existing primary care settings and in newly created high-risk clinics for the most complex patients. Last year Denver Health facilities treated nearly 140,000 patients, mostly Medicaid beneficiaries or uninsured, at over 430,000 visits. They had already determined that 1 percent of patients accounted for 22 percent of the health care costs and 50 percent accounted for 1 percent of costs. “If we want to be responsible in using our resources we want to understand what’s driving the excess costs in the higher utilizers and what we can do to help improve that,” said Loomis, who is director of family medicine at Denver Health. “It’s not all about money; certainly it’s nice to save some money but the goal is to actually improve the care for those patients.” One key to bending the cost curve in primary care is to break down some of the silos, Loomis said, and care coordination is a way to reestablish the connections in a patient’s care. “You need to know your population and be able to identify who your high-risk patients are, and be able to develop services for them. Care coordination at this level means tracking patients, including when they receive services outside of your practice with the overall idea being to reduce care fragmentation.”

Colorado Medicine for May/June 2015

Features Hambidge described the process. To start, they determined their patient population to be any primary care patient, any of their Denver Managed Care patients even if they hadn’t been seen in the system, and frequent users of the emergency department and hospital. Then they stratified them, separating adults and children, into nine tiers from healthy to disastrously ill using 3M’s Clinical Risk Grouping (CRG) software. They decided to modify the CRG tools, which are based on past utilization, because they felt this metric alone wasn’t capturing everything. They also determined that they would translate nine CRG tiers into four clinical tiers, spending hours going line by line through thousands of lines of codes and diagnoses. “This was really driven by the physicians involved in the process,” Hambidge said. “For instance, if you are a high utilizer and it hasn’t yet shown up on the CRGs, we’re going to make sure you get seen sooner rather than later. If you were on the registry for kids with special needs, we didn’t care if you hadn’t been seen in our system; we’re going to put you in the highest tier so you can get care coordination. So we overrode some clinical common sense into the tool.” The higher the tier, the more likely an override has been applied. “By the time you are a tier 4 kid, half of those are assigned by utilization of CRGs and half are assigned by being on the special needs registry or having a mental health diagnosis,” he said. “If you split out our inpatient, outpatient, professional and other costs and look at the tiers, it looks like it’s working. We felt we could move ahead with this scheme; we had identified higher-cost populations and also populations that we felt were clinically more at risk so it felt good from a clinical and cost perspective.” After risk stratifying the adults and children into two pyramids, they assigned clinical services to each of the tiers. Tier one, the largest group representing the healthy patients, basically received standard care plus text message reminders of vaccinations or well visits. For tier 2 patients, they rolled in patient navigators Colorado Medicine for May/June 2015

for the management of stable chronic disease, as well as behavioral health consultants. Tier 3 pediatric patients had access to nurse care coordinators and tier 3 adults had access to clinical pharmacists. For tier 4 patients, they set up specialized clinics. For example, they had a multidisciplinary clinic for kids with special health care needs and an intensive outpatient clinic for adult high utilizers with serious mental and medical disease. This ambulatory ICU was located near the emergency department and allowed these patients to be treated more in an ambulatory setting. To support the enhanced care coordination services and boost team-based care, they integrated new staff into the clinics, the patient navigators, more pediatric nurses and clinical pharmacists, and behavioral health consultants. “It’s a lot of phone calls,” Hambidge said. Before a tier 4 child comes into the clinic, the nurse does pre-visit work: Checking on the referral, reviewing the chart, making sure the problem list is up to date, and conducting a case conference by phone. At the visit they have a multispecialty consult, if necessary, and develop a detailed care plan with the family. After the visit, staff reviews additional referrals, the care plan and care transitions.

The original cost savings goal was 2.5 percent relative to trend; overall savings in 2013 alone was $7.5 million or 2.7 percent, Hambidge said. Most of this, $4.8 million, came through tier 4 adults – Medicaid dual eligible patients who used the ambulatory ICU – but they also achieved $1.3 million in cost savings with the tier 4 children, likely from increased access to providers over the phone as they didn’t have to go to the emergency department as much. “It’s time-consuming, it’s difficult to get there, but it’s really rewarding,” Hambidge said. “I don’t have data on physician satisfaction but I can tell you anecdotally that it’s extremely high because when they see their most complex patients, they now have something they can do with them. They’re no longer spinning their wheels trying to figure out how to help this really complex patient.” With the grant coming to a close, Hambidge said their actuaries and finance department believe targeting intensive care coordination services may support a sustaining care model. They’re conducting experimental analyses to try to figure out the most valuable parts of the program to continue to achieve high patient and physician satisfaction and reduce overall health care costs. n

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Features

Honoring the “dean of deans” Mark Couch, communications director, University of Colorado School of Medicine

Richard Krugman, MD

Richard Krugman, MD, steps down after 24 years of service Editor’s note: This article is an excerpt of “Sometimes Things Line Up Just the Way They Are Supposed to,” written by Mark Couch and published in the Fall 2014 issue of CU Medicine Today. It has been edited and published with permission. For more than two decades, the sun rose in the east, flowers bloomed in the spring, snow fell on the mountains, the Broncos and Rockies took the field and Richard D. Krugman, MD, was the dean of the University of Colorado School of Medicine. As the longest-serving dean

in the history of the School of Medicine and the longest-tenured leader of any medical school in the United States, Krugman earned the nickname “dean of deans.”

University of Colorado’s vice-president of health affairs and executive vice chancellor of the Anschutz Medical Campus, of Krugman. “Dick provides a model of integrity, trust and collaboration.”

Krugman stepped down from his post at the end of March as his successor, John J. Reilly, Jr., previously of the Department of Medicine at the University of Pittsburgh, took office on April 1.

His tenure lends tremendous value to the entire institution, says CU President Bruce Benson. “He has a huge national reputation. He’s been here as dean for over 24 years, and that helps the School of Medicine, the Anschutz Medical Campus and the university. It’s a huge deal to have somebody with his stature.”

“He really is the gold standard of medical school leadership,” says Lilly Marks,

During his more than 24 years at the helm of the School of Medicine, he has presided over an era of unprecedented growth and prestige for the venerable institution by nurturing careers, mentoring colleagues and building a team of physicians and scientists who are training a generation of new leaders in research and medicine, while also providing world-class care to patients from across Colorado. More than 4,000 physicians, physician assistants, physical therapists and medical scientists have earned degrees from the school and launched their careers during this time. Krugman has appointed all department chairs, major center directors and senior leadership at the school; established a workplace that values collaboration; directed the school’s move to the nation’s newest academic medical center campus; and strengthened the school’s financial foundation by overseeing the growth of its successful physician practice plan, University Physicians, Inc. (UPI). 30

Colorado Medicine for May/June 2015

Features He managed an enterprise that has a $1.1 billion annual budget and more than 3,000 faculty members who practice medicine at five affiliated health care facilities and other sites across the state and around the world. In 2014, UPI reported annual revenues of $609 million, its best year ever, extending an unbroken string of more than 20 consecutive years with double-digit percentage growth.

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

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

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

“So many people interpret leadership as ‘follow me up the hill; I’m going to lead you into battle,’” Marks says. “Dick established a sense of trust and created an environment that allowed people to do incredibly bold things without having a revolution. He built a team that was a real team and he empowered them. He was very generous in allowing them to do things and he didn’t try to steal the spotlight.” Krugman plans to enjoy his family, including seeing more often his seven grandchildren who live in such faraway places as Boston, Baltimore, Atlanta and Tokyo. He also hopes to pick up some scholarly pursuits that were delayed when he assumed his office. He served as director of the Kempe Center for the Prevention and Treatment of Child Abuse and Neglect from 1981 to 1992 and during his career has published more than 100 papers, chapters and editorials, and four books on the subject. As one of the nation’s leading experts on the subject, his plan was always to compare the difference between the American system and how European nations handle such cases. “Professionally, I was on my way to do a study and try to make some major changes in the child abuse field in 1990 when I got into this job,” Krugman says. “I put off a sabbatical at that time to become acting dean because I thought it would only last a year or two. Interestingly, the problems I was trying to work on in that field are still there 24 years later, and I think I’d like to have the next phase of my career be just a professor working in the area that is pretty important for me.” n Colorado Medicine for May/June 2015

Colorado Medicine for May/June 2015

Inside CMS

CMS and COPIC staff report

CMS and COPIC support local communities When you are part of health care, there are unique opportunities outside of dayto-day operations where you can impact local communities. This is something that CMS and COPIC have recognized over the years and a responsibility that is embedded in our missions. Through these opportunities, we are able to expand our understanding of the myriad of factors that influence health care, and this helps to identify additional ways we can provide support. Grants in health care are an essential part of funding that help drive innovation. Since 1992, the COPIC Medical Foundation has provided more than $5 million in grants. And two of the grants we provided in 2013 are emerging to influence the future of health care in positive ways. • COPIC provided a grant to the Colorado Children’s Immunization Coalition that supported an engagement and strategic planning process to improve tracking of vaccination schedules and updates. Recently, a Board of Health hearing ended with a unanimous vote to adopt recommended immunization rule changes. Starting in 2016, the new rules require parents seeking non-medical exemptions for pre-kindergarten children to submit exemption forms at each age when recommended vaccines are due. From kindergarten to 12th grade, forms will need to be submitted annually. The Colorado Department of Public Health and Environment will publish immunization rates annually on its website and launch an online education module to better inform people on diseases that vaccines prevent. Colorado Medicine for May/June 2015

• The Colorado Rural Health Center, along with researchers from the University of Denver and the Center for People of Power, received a grant to evaluate the role of community engagement skills in relation to physician retention in rural communities. The project included collaboration with the Colorado School of Medicine, with the goal of identifying community-informed curriculum for its rural track. There was a wealth of knowledge gained through this project that will be used to address rural physician retention, a critical topic in the issue of access to health care. In addition, a collection of stories by rural physicians is being compiled to share these experiences with a broader audience. CMS supports physician leaders by identifying their needs and providing resources and education. • The CMS Foundation and the Regional Institute for Health and Environmental Leadership coordinate the Advanced Physician Leadership Program, with funding from COPIC, the Colorado Health Foundation and the Physicians Foundation. This year-long training strengthens the ability of physicians to assume leadership roles within the profession and their communities. They conduct projects that apply and test their new and existing leadership skills, many of which address local health care issues. The first cohort graduated in March 2012 and the second cohort graduated in March 2015. • In October 2014, CMS teamed up with the state’s top health organiza-

tions to refine statewide plans for responding to a possible case of Ebola. To assist physicians in their preparations, CMS developed an Ebola resources page on CMS.org to connect physicians to the latest resources from state and federal sources, and held a live webinar to prepare office-based physicians for a possible Ebola case by educating them on the use of personal protective equipment, triage of suspected patients, logistics of providing ongoing care, and appropriate control procedures for hazardous material handling and disposal. • The CMS Foundation is supporting Engaged Public, a Denver-based public policy firm, with a three-year $1.1 million contract to extend its Engaged Benefit Design program statewide. Engaged Benefit Design removes financial barriers to evidence-based chronic disease care for specific services, covers patient decision aids that help patients understand their treatment choices, and provides objective information to patients to better understand the risks and limited benefits of services that in many cases are of questionable value. The grant, which was awarded in November 2013, is funding large-scale, cross-coverage demonstrations of Engaged Benefit Design through gradual implementation by the state Medicaid program, outreach to promote program adoption by Colorado employers, and community-wide implementation in the San Luis Valley. CMS and COPIC will continue to work together to identify physician and community needs and provide funding, education, and resources to improve health and well-being. n 33

Inside CMS

Advanced Physician Leadership Program Chet Seward, senior director, Division of Health Care Policy

Thirty-three physicians graduate from APLP armed with new strategies to lead and transform systems of care Thirty-three physicians from across Colorado stepped up to commit to a yearlong leadership-training program through the Advanced Physician Leadership Program (APLP) to attain the tools and skills to have an impact on how health care should work for physicians and their patients. The APLP Class of 2015 graduated in March, armed with new strategies to effectively lead and transform systems of care. The objectives of the program are to strengthen the ability of physicians to assume leadership roles within the profession and their communities, and to nurture a group of Colorado physician leaders who are trained, willing and confidently able to serve as champions to improve the delivery of cost-effective, high quality and safe care. They achieved these objectives through four weekend sessions featuring expert training from the Regional Institute for Health and Environmental Leadership (RIHEL) on collaborative leadership, teamwork, negotiation, systems thinking and emotional intelligence; coaching for leadership growth and advocacy; group

Kathy Kennedy, professor of preventive medicine and director of RIHEL, teaches a session during the 2014-2015 APLP. 34

projects to apply and test new and existing leadership skills; and networking with other physicians and organizations. “Leadership is not just about the individual person,” said Kathy Kennedy, DrPH, professor of preventive medicine and director of RIHEL. “If no other people are affected, then it’s not leadership. The curriculum in the leadership institute is all about increasing self-knowledge, developing self-awareness, understanding the things you do as a leader that are working, what you can do more of, and what you want to lead to change.” Some of the group projects are community oriented and some focus on health systems issues. “Where people choose to lead is totally up to them; they have to follow their own passions,” Kennedy said. Dulcy Wolverton, MD, applied for the program because she recognized there were a number of issues she wanted to fix in her professional setting but felt her leadership style wasn’t very effective. She said she tended to be pedantic and make demands to achieve change. “You go through a whole lot of inventory to find out what kind of person you are. I’m an introvert; I’m not very good at being outgoing or at touchy-feely networking and politicking. That’s just not my style.” “Part of the program was identifying my skills and how my style can interfere with what I want to do,” Wolverton continued. “Because I now know what I was doing wrong, I have tools to better work in a team to get buy-in from the team so that they work toward the goals that

I want to achieve. That’s so much more effective. It’s definitely a work in progress and I have a lot more to learn but it’s a great exposure to the ideas that I never learned in medical school.” APLP’s most important measures of impact are in confidence, willingness to lead and optimism that a physician will be effective in leading, Kennedy said, and confidence is the mechanism that grows for most people, even in those who arrive feeling confident. New for the second cohort was the implementation of peer coaches. Participants were asked to have a conversation with a peer coach – which includes nonphysician professionals – at least once a month while they were in the program. That ensured accountability and continued progress. “Physicians hold implicit positions and voices of authority in our society, and concentrated efforts to harness and leverage physician leadership have repeatedly been shown to have profound effects on pressing public policy issues,” Kennedy said. “APLP is proud to assist these physicians in continuing the profession’s long history of advocating for the patients and communities they serve.” The program is coordinated through the Colorado Medical Society Foundation with RIHEL. The Colorado Health Foundation, the Physicians Foundation, COPIC and the Colorado Medical Society generously provided funding for this cohort. Planning for the next cohort is underway. Watch for more information. n Colorado Medicine for May/June 2015

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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.

Anireddy Reddy University of Colorado School of Medicine

Ani Reddy is a fourth-year medical student at the University of Colorado School of Medicine. She serves as the student director for C-STAHR (Community-Students Together Against Healthcare Racism), an organization comprised of health professional students and community partners with the mission of addressing discrimination in health care. She additionally serves as the Class of 2016 Co-President and participates in CU-UNITE urban underserved track. Ani’s career aspiration is to become a pediatrician.

Dot on my head “Well, you see, she’s been constipated for months. Not months exactly. She’s had rabbit turds about once a week.” This was the opening line from a 12-year-old girl’s father as I sat in a claustrophobic exam room filled with the rancid smell of stale smoke. I felt very much like my pediatric emergency medicine rotation was quickly turning into outpatient pediatrics, and constipation was my bread-and-butter. I listened patiently, eliciting a colorful description of the patient’s bowel movements and methodically moving through the components of the history and physical: History of Present Illness Past Medical/Surgical History Medications Allergies 36

Social History: “Is there anyone in the household who smokes?” “Yes, her step-mother and I, we both smoke.” “Do you smoke inside or outside the home?” “Well, we smoke inside,” the father admitted sheepishly, but he rushed on to say, “it’s only since we moved into this new apartment. It’s not as nice as where we lived before. There are a lot of foreigners, I mean people who are straight off the boat. I don’t want to sound racist but we’ve got these Indians—and I don’t mean Native American Indians, I mean ‘dot on the forehead’ Indians—who live in the building. They’re just dirty, running around barefoot and leaving chicken bones in the hallway. We don’t like to leave the apartment much. So anyway, that’s why we smoke inside.” [Pause] “I see. That must be difficult for you.” I was speechless, unable to do anything but reach for those stock “good communication” phrases we are taught in medical school. Inside, my head was swirling with emotions. Confusion because this father could not detect that I, in fact, was a “dot on the forehead” Indian. Indignation because my culture was being dubbed “dirty.” Frustration because this father had what I thought was a pathetic excuse for exposing his child to cigarette smoke. As a dutiful medical student, however, I moved past my shock and continued the interview until I had enough information to present to my attending. “Amelia is a 12-year-old female who presents with two months of constipation. Her father thinks that she has had mild decrease in appetite and weight loss, but otherwise denies any fever/chills/night sweats/nausea/abdominal pain/vomiting. Vitals are within normal limits. On exam, patient is a pleasant and talkative girl in no apparent distress, with a non-tender, non-fluctuant right upper quadrant abdominal mass. I think we should get an abdominal film.” Colorado Medicine for May/June 2015

Inside CMS The patient was taken to X-ray and I had a moment to reflect upon the father’s words. Surprisingly, I was less offended than I anticipated. I found the explicit nature of his words actually made them more palatable—they were so outrageous and misplaced that I could readily dismiss them. It reminded me of the time I was called “nigger” and told to sit in the back of the bus when we learned about the civil rights movement in grade school. Clearly my 8-year-old peers were unaware of what they were saying (or the fact that their racial profiling was inaccurate), so I did not take them seriously (though perhaps I should have mourned the state of the public education system). It is infinitely more troubling when you have an odd sense that you are being treated differently and you are not sure why. There is a nagging feeling in the pit of your stomach, but you cannot pin exactly what put it there. It is impossible to disregard, because it cannot be named in the first place. Before you know it, you start believing that you must be doing something wrong, that you somehow deserve to feel this way. That is what I learned shakes me most about life and medicine – when what you are facing is an unknown enemy, an uncertain reality – moments when the truth is hidden, below the surface, subtle and wholly unexpected. Like getting the abdominal film for a 12-year-old female with constipation and realizing it shows an unresectable abdominal mass with pulmonary metastasis. n

Colorado Medicine for May/June 2015

Please help support the CMS Foundation 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.

Inside CMS

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

Defining patient safety and its role Oftentimes, conversations about improving health care highlight the significance of patient safety. It is a term we hear a lot about, but also something that can be interpreted differently. The Agency for Healthcare Research and Quality (AHRQ) released a publication, titled “Advances in Patient Safety: New Directions and Alternative Approaches,” which sought to establish a clear definition for patient safety as “a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events.” This definition emphasizes that patient safety is “both a way of doing things and an emergent discipline.” Over the years, COPIC has integrated principles of patient safety into the education and resources we develop for medical professionals. In addition, we support initiatives that seek to enhance our approach to patient safety and how it is implemented and measured. Patient safety education emphasizes nonmedical aspects of care. The AHRQ publication notes that patient safety methods “come largely from disciplines outside medicine, particularly from cognitive psychology, human factors engineering, and organizational management science.” Several of COPIC’s educational activities reinforce the value of communication. For example, our “Communication in Patient Safety” course focuses on interactions with patients, from thorough discussions on informed consent to delivering news that may trigger negative reactions. Our “Handoffs in Clinical Practice” course seeks to illustrate best practices regarding communication between providers during transfers of care. Sharing patient safety knowledge leads to broader improvements. Because of our role in health care, COPIC draws upon a collection of experiences that offer insight on patient safety. We believe that disseminating this knowledge is essential. We engage in forums, like the Telluride Patient Safety Conference, that allow us to connect with peers in health care to discuss current challenges and ways to address them.

And our physician leaders continue to serve as contributing authors for publications, such as “Patient Safety in Surgery,” a medical reference book edited by Philip F. Stahel, MD, and Cyril Mauffrey, MD, both of Denver Health Medical Center. Supporting new ideas in patient safety is core to COPIC’s mission. Another way we promote patient safety is through grant funding by the COPIC Medical Foundation. In health care, grants are essential to connect new ways of thinking to broader audiences and assist efforts to transform ideas into tangible results. Recently, our Foundation supported the Patient Safety in Surgery journal with a grant that will allow them to develop and publish articles over the next several years. The journal is the first open‐access, peer‐reviewed, online journal in the field of surgical patient safety that provides a transparent forum for analyzing and learning from medical errors. During the last several years, we also watched another initiative that we supported grow into a bigger idea. In 2012, emergency room physician Caleb Hernandez, MD, and a team of medical professionals received a grant from COPIC Medical Foundation to support a project that asked the question: Can the accuracy and speed of drug dosing in pediatric cardiac arrest situations be improved with a system of prefilled, color-coded syringes? A study was conducted and the results were published in a February 2015 Annals of Emergency Medicine article. The results showed that the color-coded medication delivery system “reduced time required to prepare and administer medications, reduced overall dosing errors, and eliminated critical dosing errors during simulated pediatric resuscitations.” At this stage, Hernandez and the others involved are moving forward, knowing that their idea has a strong potential to positively impact pediatric care. As the area of patient safety evolves, COPIC is committed to being at the forefront of this topic and contributing our ideas and resources. It is part of who we are, and will continue to define who we become. n

Colorado Medicine for May/June 2015

Departments

medical news COPIC promotes Gerry Lewis-Jenkins to chief operating officer; will continue to focus on market growth and expansion COPIC announced in March that Gerry Lewis-Jenkins has been promoted to the position of chief operating officer. Lewis-Jenkins will continue to focus on market growth and expansion, legislative activities and the oversight of COPIC’s information technology, marketing and communications, and sales departments along with COPIC Financial Service Group. Additionally, she will oversee COPIC’s underwriting department and the operational areas of COPIC’s patient safety and risk management department. “Gerry has earned the trust and respect of many in our industry and in the health care community. She is an invaluable member of COPIC’s senior management team and an engaged leader who inspires others. In her expanded role, she will play a pivotal role as COPIC moves forward in a challenging environment,” said COPIC President Steve Rubin in a press release.

Center and is the immediate past chair of the board of directors for the Colorado Regional Health Information Organization. In addition, she was appointed to the American Hospital Association’s Committee on Governance and is a fellow of the Physicians Insurers Association of America. Lewis-Jenkins holds a degree in Health Care Administration and an MBA from Regis University. n

Gerry Lewis-Jenkins, COPIC COO

Lewis-Jenkins has been with COPIC since 1991 and held the position of executive vice president before this promotion. Prior to joining COPIC, she was executive director of Humana Health Plans of Colorado. She also has a background as a registered nurse with more than 15 years of experience in clinical and hospital management. “Gerry’s promotion is an acknowledgment of the talent and skill she brings to the organization. We look forward to her ongoing innovation and creativity that helps make COPIC unique among its peers,” said COPIC CEO Ted Clarke, MD, in the release. Currently, Lewis-Jenkins serves on the board of the Platte Valley Medical Colorado Medicine for May/June 2015

Departments

medical news Colorado Public Radio reports PDMP registrations are up but still fall short Have you registered your account with the Colorado Prescription Drug Monitoring Program (PDMP)? A Colorado law passed in 2014 requires physicians with a DEA registration to create an account to use the PDMP. This topic has garnered the attention of local media, with Colorado Public Radio publishing the statistics concerning registration and utilization of the PDMP on March 20. The deadline to register a PDMP account has now passed and, as of January 2015, 91 percent of physicians had registered. While this is an enormous leap from the 30 percent registered in December 2013, it falls short of the 100 percent required by law. Registration

takes about five minutes. If you have not yet registered an account, please do so now at www.hidesigns.com/copdmp. If you already have an account, you may consider adding delegated sub-accounts for members of your team to check the PDMP on your behalf. Learn more at www.hidesigns.com/copdmp. Go to www.cpr.org to read the full CPR story, “A surge in doctors checking opioid prescriptions, but for how long?” This article includes an interview with Director Lauren Larson on how DORA’s Division of Professions and Occupations is implementing the changes to the PDMP. n

Colorado PDMP registrants, January 2015 Nurses with Rx authority.....93% Dentists......................................94% Physicians.................................. 91% Physician Assistants.............. 99% Optometrists............................79% Podiatrists.................................97% Veterinarians............................85% Pharmacists..............................96%

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Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720.858.6309 Colorado Medicine for May/June 2015

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medical news Health Care Policy and Financing enhanced primary care rates now available Effectively immediately, the enhanced payment rates for evaluation and management (E&M) and vaccination codes for Medicaid beneficiaries are available and the difference for all claims submitted since Jan. 1 will be retroactively paid, the Colorado Department of Health Care Policy and Financing (HCFP) announced. It was announced last year that Colorado Medicaid would reimburse covered office visit (E&M) and vaccine administration procedure codes at a rate equal to 100 percent of the December 2014 Medicare reimbursement rate from Jan. 1, 2015 to June 30, 2016. This enhanced rate was delayed as HCFP awaited ap-

Colorado Medicine for May/June 2015

proval by the Centers for Medicare and Medicaid Services before being able to load them into their claims processing system. The new rate is now available to all enrolled providers who submit fee schedule claims for office visits or vaccine administrations; providers are not required to attest to providing primary care. As promised in a bulletin in January, HCPFâ&#x20AC;&#x2122;s fiscal agent will mass adjust all qualified claims paid since Jan. 1 and repay them at the higher rate. Due to a limit on how many mass adjustments can be processed at a time, this process will take place over the next few weeks

until all providers have been â&#x20AC;&#x153;made wholeâ&#x20AC;? for claims submitted since Jan. 1. Please note that, although Medicare rates may be adjusted on a quarterly basis, Colorado Medicaid rates will not be adjusted to match these changes and payment will remain at the December 2014 level. HCFP will update providers if the rates benchmark changes. n

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medical news CMS senior and junior state science fair award winners show promise for the future Laura Clark and Jayden Durbin won the Colorado Medical Society Award for Excellence in the Health and Behavior Sciences in the junior and senior

chemical reagent to make a colorimetric model of a diagnostic medical test using the microfluidic properties of paper. She determined the paper diagnostic model to be both effective and accurate, concluding that the microfluidic properties of paper combined with its practical benefits as an inexpensive, lightweight and portable material could have positive applications for medical diagnostic testing in the developing CMS judge Cory Carroll, MD, right, congratulates CMS Colorado world. State Science Fair junior division winner Laura Clark. divisions of the 60th Annual Colorado State Science and Engineering Fair held on April 10 in Fort Collins. A longtime supporter of the science fair, the CMS Education Foundation presents an award each year to one student from the junior high division and one student from the senior high division. These students receive $100 and an invitation to the CMS Annual Meeting to display their project and receive recognition before the CMS House of Delegates. Colorado Medical Society members Cory Carroll, MD, and Regina Brown, MD, served as the official CMS judges at this year’s fair. Junior division winner Laura Clark presented her project, “Paper Microfluidics: Medical Diagnostics for the Developing World.” Inspired by the international health work of her father, she used common household items and a simple 42

“Laura designed a global application,” Carroll said. “If you can easily and costeffectively screen for serious medical conditions you’ll make a tremendous impact on these populations.” Senior division winner Jayden Durbin presented “Vitamin D Stimulates the mRNA Expression of ACPP in LNCaP Cells.” She studied the correlation between prostate cancer incidence and ultraviolet exposure by region to determine whether vitamin D can be beneficial as a treatment option for prostate cancer.

by the gene ACPP, is an enzyme produced primarily by the prostate in males and is overexpressed in patients with metastatic prostate cancer. The ACPP gene is alternatively spliced into several different isoforms. Jayden performed reverse transcriptase polymerase chain reaction to understand the differing ACPP splice variants that are present in human LNCaP cells during regular growth conditions. After compiling results, she tested the relative change of ACPP in response to vitamin D and found that ACPP was highly expressed in response to vitamin D at all time points in the secreted isoform of ACPP, indicating that ACPP can be a direct target of vitamin D and with further study may allow vitamin D to work synergistically with immunotherapy to eradicate metastatic prostate cancer cells. “Jayden thought outside the box to solve a complex problem,” Carroll said. “By using technology, she was able to better understand how our bodies work and recommend a therapy instead of a pharmaceutical drug.” n

Prostatic acid p h o s p h a t a s e CMS judge Cory Carroll, MD, right, congratulates CMS Colorado (PAP), encoded State Science Fair senior division winner Jayden Durbin. Colorado Medicine for May/June 2015

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

AUTOMOBILE PURCHASE/LEASE Rocky Mountain Fleet Associates 303-753-0440 or visit www.rmfainc.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit www.copicfsg.com * CMS Member Benefit Partner Sharkey, Howes & Javer 303-639-5100 or visit www.shwj.com * CMS Member Benefit Partner INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit www.callcopic.com *CMS Member Benefit Partner UnitedHealthcare 877-842-3210 or visit www.UnitedhealthcareOnline.com MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or visit www.coloradodrugcard.com *CMS Member Benefit Partner CO-POWER 720-858-6179 or www.groupsourceinc.com *CMS Member Benefit Partner University of Colorado Hospital/CeDAR 877-999-0538 or visit www.CeDARColorado.org PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit www.alnmm.com athenahealth 888-402-6942 or visit www.athenahealth.com/cms *CMS Member Benefit Partner Colorado Medicine for May/June 2015

PRACTICE VIABILITY (cont.) Carr Healthcare Realty 303-817-6654 or visit www.carrhr.com Diagonal Medical Billing 303-551-7944 or visit www.diagonalmedicalbilling.com First Healthare ComplianceTM 888-54-FIRST or visit www.1sthcc.com *CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit www.medteleco.com * CMS Member Benefit Partner Solve IT 303-800-9300 or visit www.solveit.us *CMS Member Benefit Partner The Health Law Firm 407-331-6620 or visit www.TheHealthLawFirm.com The Legacy Group at Re/MAX Professionals 720-440-9095 or visit www.legacygroupestates.com/physicians TransFirst 800-613-0148 or visit www.transfirstassociation.com/cms *CMS Member Benefit Partner Transcription Outsourcing 720-287-3710 or visit www.transcriptionoutsourcing.net Transworld Systems 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner 43

Colorado Medicine for May/June 2015

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

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Colorado Medicine for May/June 2015

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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

SEEKING PRIMARY CARE PHYSICIANS OR CLINICS IN THE DENVER METRO AREA If you are considering: • A new practice opportunity, • Integrating your current practice into a progressive group, • The sale of your practice, or • A change of employment. We offer a unique opportunity: • To be part of a progressive primary care group that has been a Level 3, Patient Centered Medical Home since 2009, • With a competitive compensation package, • Achieve a work/life balance, and • Care for patients without administrative headaches. If interested, contact us at (303) 493-5276. All inquiries will be kept in strict confidence and will receive a prompt response. 45

Features

the final word Robert M. Wah, MD, AMA president

Over the SGR hurdle and looking forward to the future How did we get over the SGR hurdle? The short answer is simple: We did it together. The long answer involves a strenuous, uphill marathon of more than a decade. We physicians all have stories about how the sustainable growth rate (SGR) formula’s perennial threats of steep payment cuts created instability for our practices and uncertainty about access to care for our patients who relied on Medicare and TRICARE. Through the years, we had countless interactions with our lawmakers about this issue and made it clear that Medicare had to be fixed. And we poured on the steam this year, calling on Congress to seize the opportunity to eliminate the SGR formula through bipartisan legislation introduced in March.

Here are five ways our health care system will begin to look different: 1. Medicare and TRICARE patients will no longer face constant uncertainty over whether they might lose their access to care. The perennial threat of devastating payment cuts under SGR made it difficult for many physicians to know whether they would be able to keep their doors open for treating these patients. 2. Physicians’ practices will be more sustainable. Under the new law, many of

In a five-week sprint that got underway with a formal letter to Congress signed by more than 750 medical associations, we physicians and our patients used the AMA’s Fix Medicare Now campaign to flood our members of Congress with messages to pass this legislation. Here’s how they heard from us: • More than 26,700 social media actions • 60,229 phone calls • 243,907 emails This unified effort paid off. We overcame the SGR hurdle with overwhelmingly favorable votes in both chambers of Congress. With SGR behind us, we now can build a forward-looking health care system that puts patients first—a system in which we can provide cost-effective care with topnotch health outcomes in a sustainable practice environment. 46

the competing quality-reporting programs in Medicare will be consolidated and better aligned. The risk of penalties also has been substantially reduced, and physicians now have potential for earning significant bonuses. 3. The path will be cleared for new models of care. The new law not only removes the financial instability caused by the SGR formula but also provides monetary and technical support for those who choose to adopt new models of care suited to the 21stcentury needs of physicians and their patients.

4. Health outcomes will be improved in the clinic setting and the community. Chronic diseases have become the primary sources of poor health and death today. Treating these conditions requires new approaches, and the new law permanently requires Medicare to pay for care management of these patients. 5. Physicians in training will be taught how to practice in the new health care environment. Even as the health care system undergoes dramatic change, an AMA consortium of medical schools is exploring how to prepare the next generation of physicians for practicing in the new environment. Students will learn how to succeed in new models of care, provide high-quality but cost-effective care, and team up with other health care professionals and the community so their patients can lead the healthiest lives possible. While details of how the law will be implemented still need to be figured out (and rest assured that the AMA will diligently press for appropriate execution of the law), we have overcome our chief obstacle and are moving toward a brighter future. The new era of health care now before us is one of promise. Our patients will have greater stability in their access to care, our practices will be more sustainable, and doors will open for new models of care, improved health outcomes and advanced medical education. There’s still a lot to do to reach our goals for a healthier nation, but we will achieve them by continuing to work together. Let’s continue this race and finish it strong. n Colorado Medicine for May/June 2015

Colorado Medicine for May/June 2015

LEASE AND PURCHASE NEGOTIATIONS:

New Offices | Expansions | Relocations | Practice Acquisitions | Lease Renewals

“CARR HEALTHCARE REALTY FOUND A NEW OFFICE THAT WAS

TWICE THE SIZE AT HALF

THE LEASE RATE AND I AM SAVING OVER

$3000 A MONTH!”

– ANDREAS EDRICH, MD HERITAGE HILLS FAMILY MEDICINE

WHETHER YOU ARE CONSIDERING A RELOCATION OR RENEWAL, LEASING OR PURCHASING A NEW OFFICE, OR ARE SIMPLY CURIOUS ABOUT THE CURRENT REAL ESTATE MARKET, ALLOW OUR TEAM OF EXPERTS TO HELP YOU CAPITALIZE ON YOUR NEXT OPPORTUNITY.

PERRY BACALIS

DENVER METRO 303.945.5270

PERRY.BACALIS@CARRHR.COM

MACK SCHUTZ

WESTERN SLOPE 970.691.2360

MACK.SCHUTZ@CARRHR.COM

DAN GLEISSNER

BOULDER NORTHERN COLORADO 303.748.7905

DAN.GLEISSNER@CARRHR.COM

KENT HILDEBRAND

COLORADO SPRINGS SOUTHERN COLORADO 719.440.0445

KENT.HILDEBRAND@CARRHR.COM

Medicine for May/June 2015 ONLY HEALTHCARE. ONLY TENANTS AND BUYERS.™ Colorado WWW.CARRHR.COM