May-June 2017 Colorado Medicine by Colorado Medical Society

May/June 2017

Volume 114, Number 3

Back in the spotlight:

How will federal health care reform work for Colorado? Award-winning publication of the Colorado Medical Society

contents May/June 2017, Volume 114, Number 3

Cover story

Since November, talk of federal health care reform has been rampant. Things cooled when Congress pulled the “repeal-and-replace” bill from vote but now, as of press time, it’s back on the table with amendments. The cover suite, starting on page 6, dives into this complex issue, taking readers through the situation at the federal and state level, member survey results and perspectives, what the “repeal-andreplace” debate taught us, what our Colorado senators are saying, and how CMS has approached health care reform over the past decade. Read more starting on page 6 and jump into the discussion on www.cms.org.

Inside CMS

36 2017 Annual Meeting preview 38 Corporate supporters/benefit partners 39 Leadership Skills Series 41 COPIC Comment 42 Reflections 44 Introspections

Features. . . 18

2017 all-member survey– CMS members express

Insurance market–National and state advocates urge Congress and the Trump administration to continue to fund cost-sharing reductions.

Legislative update–The 2017 state legislative session is

Health plan mergers– One more victory for patients and physicians came on April 28 when the U.S. Court of Appeals refused to overturn the lower-court ruling that blocked Anthem’s merger with Cigna.

Living the adventure–A CMS member describes her experience working in New Zealand.

End-of-life care and Prop 106–Jennifer Ballentine gives

Making a difference–The Clear Creek Valley Medical

Telligen and QPP: Here to stay–Physician practices can

Final Word–Matthew Wynia, MD, describes the uncertainty and opportunity brought by the health care reform debate and how organized medicine should respond.

significant frustration with the health care delivery system in Colorado, particularly when interacting with commercial payers.

nearly over. CMS updates readers on a series of managed care reforms and will report more in-depth in the next issue of Colorado Medicine.

an overview of the aid-in-dying law and myriad ways physicians can compassionately respond to requests for assistance. Society has partnered with a local community college physician assistant program to assist PA students and benefit physician members. get help with Medicare’s Quality Payment Program with tools and resources from Telligen.

Departments 45 48

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Colorado Medicine for May/June 2017

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OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF

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

Treasurer

Alfred D. Gilchrist Chief Executive Officer

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

AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Katie Lozano, MD Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD

Michael Volz, MD Immediate Past President COLORADO MEDICAL SOCIETY STAFF Executive Office Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Fetter, Director, Professional Services, Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org Division of Communications and Member Benefits Kate Alfano, Communications Coordinator, Kate_Alfano@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org Division of Health Care Policy Chet Seward, Senior Director, Chet_Seward@cms.org JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

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 Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Program Manager Adrienne_Abatemarco@cms.org Colorado Medical Society Foundation Colorado Medical Society Education Foundation Mike Campo, Staff Support, Mike_Campo@cms.org

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

Back in the spotlight:

How will federal health care reform work for Colorado?

Cover Story of the respondents said the administration “should do what they can to make the current health law work.”

Katie Lozano, MD, FACR President, Colorado Medical Society Have we reached a tipping point in this long, contentious debate on federal health care policy? Is there an opening for productive problem-solving in Congress? Since its enactment in 2008, the Affordable Care Act has been defined in sharply partisan terms, and the country split down the middle notwithstanding well-documented confusion as to content, design and purpose. We’ve all seen the paradoxical street interviews where respondents proclaim their disdain for Obamacare but their support for the Affordable Care Act, and voter belief that after each U.S. House vote to “repeal” (upwards of 70 times) the law was, in fact, repealed. After the Republicans’ effort to “repeal and replace” in March, has ownership changed hands? A recent Kaiser poll found voters, once confronted with losing coverage only recently acquired and held, opposed to disrupting that coverage. Are the visuals of crowded auditoriums shouting down Republican members of Congress symptomatic manifestations of the “you break it, you own it” rule, or are they orchestrated turnout by the Democratic party, or somewhere in between? Or does it matter? In politics, perception is reality.

The fix-what’s-broken position in our multi-payer, public/private system mirrors the findings of our CMS member survey prior to the statewide rejection of Amendment 69. Our longtime pollster, Benjamin Kupersmit, provides a more detailed review of what Colorado physicians think about the range of state and federal health system “fixes,” and the dissatisfaction with the current multi-payer system and specific complaints to target (see pages 18-19). Since the election, we have brought those collective views to our congressional delegation. We have also taken a suite of market-based insurance reforms pulled from those physician insights to the Colorado General Assembly. Most of those bills are making their way through the process to the governor’s desk, despite the determined resistance of the commercial health plans. Those advocacy efforts will most certainly carry over into the interim and into the 2018 session. Is this finally a teaching moment where our ideas, coming from the grassroots views in the exam room, can move congressional hearts and minds? Judging from what I hear from my colleagues, and measured by our regular polling of Colorado physicians, there is an understandable level of frustration with a debate that seems more partisan than informed. In the world of politics and public policy it is hard for physicians to see the end game. After all, we have been methodically building a physician

consensus and pressing our case for two decades (as explained in the infographic on page 17). I strongly share the core commitment of the medical profession to persistently and consistently advocate for a rational system that aligns the incentives and delivery paths that move closer to the bedrock of getting our patients – all of them – the right care at the right time, place and value. Progress is Sisyphean, but we continue to work hard to advance our ideas into public policy. I believe our advocacy rises from a commitment to our patients and our profession. Who better

“In the world of politics and public policy it is hard for physicians to see the end game. After all, we have been methodically building a physician consensus and pressing our case for two decades.” understands the needs of our patients and our colleagues? Given the shift in public awareness that appears to border on militancy, and perceived political perception that there could be consequences for not finding a “fix,” don’t we have an opening to help break through this impasse? We are all-in to remain engaged and committed, regardless of mixed signals, setbacks and the longterm nature of this debate. n

That irony is not lost on those among us who also understand that the ACA is not without structural flaws. This is not a case of “ain’t broke, don’t fix it.” In the same Kaiser poll, three-quarters Colorado Medicine for May/June 2017

Cover Story

2017 health system reform survey Benjamin Kupersmit, President, Kupersmit Research

Members prefer to preserve the individual mandate and Medicaid expansion Kupersmit Research is pleased to present the results of the 2017 CMS Member Survey on federal health system reform. Our survey was written in January (before the AHCA was formally proposed) to gauge CMS members’ attitudes toward potential reforms being considered by the new administration and Congressional leadership at that time. CMS has surveyed members since 2008 on health system reform; most recently, we focused on system reform in the context of Amendment 69 in 2016. • In 2008, a plurality of CMS members (41 percent) favored a system that would preserve commercial insurance but expand government regulation of payers (similar to the ACA), versus 33 percent

who favored a single payer system and 13 percent who preferred deregulation of commercial payers and a reduced role for government. • In 2016, 40 percent said their optimal health system would continue to build on the ACA, while 33 percent favored repeal of the ACA and 15 percent favored moving toward a national single payer system. Priorities: Preserve the individual mandate and the Medicaid expansion • CMS physicians are skeptical about eliminating the “requirement that individuals carry health insurance,” with 65 percent saying this would make things “worse” versus today’s health care system and 18 percent saying things would

get “better.” • The idea of moving to “continuous coverage” provisions to encourage individuals to maintain insurance is seen negatively as well, with 58 percent saying this would make things “worse” and 25 percent saying “better,” and 51 percent say that “higher deductible, lower premium” plans would make things worse (27 percent “better”). • CMS members are most positive about the idea of “allowing insurance to be purchased across state lines,” with 62 percent saying this would be an improvement over the current system (versus 10 percent who say it would make things “worse”). • A majority of CMS physicians (61 percent) support keeping “everyone on Medicaid who was added in the ACA.”

TABLE 1: Do you think the following reforms to the insurance system would make things better, worse or not make a real difference versus the current system for you and your patients?

Not better

Eliminating the requirement that individuals carry health insurance

-47

Continuous coverage provisions for those with pre-existing conditions that would allow insurers to charge more (up to 50% more) for those who have a break in coverage

-33

Higher deductible plans with lower monthly premiums

-24

Reduce tax deductibility of employer-based health care so individuals are exposed to their real health care spending and have more accountability for their costs

-17

Higher caps or maximum limits on financial contributions from patients over a lifetime

-14

Less government regulation of plan benefits, and allowing payers to offer “skinnier” plans with less coverage of services

-9

62%

10%

Allowing insurance to be purchased across state lines 8

Much + Much + Somewhat better Somewhat worse

Colorado Medicine for May/June 2017

Cover Story ance to be sold across state lines, if such ideas demonstrably move toward a system of affordable health insurance coverage for all Coloradans. As we saw in the Amendment 69 debate, there is a strong sense that state-based solutions alone are not sufficient to achieve this vision for Colorado (or other states across the nation).

TABLE 2: In your view, should the federal government strive to: Keep everyone on Medicaid who was added in the ACA (289,000 individuals in CO)

61%

Allow people who were eligible pre-ACA (35,000) to remain, but roll back the expansion in eligibility (remove 254,000)

Roll back the funding for the Medicaid expansion entirely

Other 7 Not sure • One in five (21 percent) support rolling back the expansion: 9 percent support rolling back the entire Medicaid expansion and 12 percent support allowing those who were eligible pre-ACA to remain, while removing those added via the eligibility expansion from the rolls. • By a 50 percent to 31 percent margin, CMS physicians believe that the Colorado Medical Society should continue to work toward a health care system that “achieves coverage and access to health care for all Coloradans,” with 7 percent unsure and 12 percent taking neither side on the question.

12 CMS physicians have significant concerns about reforms to the current health care system that would reduce coverage and increase costs for patients. We see strong opposition to eliminating the individual mandate, allowing continuous coverage provisions, encouraging higher deductible plans, eliminating the Medicaid expansion and other steps that they believe would make the current system worse for Coloradans. At the same time, CMS physicians are open and willing to engage in reforms at the federal level, such as allowing insur-

CMS physicians have spent significant time and effort focusing on health system reform for nearly a decade. They are willing to engage in a constructive process to address challenges in the system, and look forward to continuing conversations with interested parties and offering support to those who want to create a more patientcentric system in the days and months ahead. Methodology This survey was administered online by the Colorado Medical Society. The survey was in the field from March 1-21, 2017. A total of 661 Colorado Medical Society members responded to the survey, for a margin of error of +3.8 percent at the 95 percent confidence level. n

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Cover Story

What’s next in health reform? Kate Alfano, CMS Communications Coordinator

Predicting the future of federal health care reform through the repeal-and-replace debate The Affordable Care Act (ACA) is changing, or is it? It is difficult to discern whether it will be repealed, replaced or repaired, particularly as information changes from week to week. The Colorado Health Institute (CHI), a nonpartisan health policy research institute, has deployed a team of analysts to look at this evolving issue and will produce a series of reports through an effort they’re calling “Re:ACA.” The team’s first analysis – “What now? Five next steps for the Affordable Care Act in Colorado and five lessons learned from the repeal and replace debate” – published March 29, comes from Joe Hanel, CHI manager of public policy outreach. “The 18-day lifespan of the American Health Care Act (AHCA) left many open questions about the future direction of national health policy, but it also clarified the boundaries of the debate,” Hanel wrote. “Affordability of health care and insurance and the sustainability of private and government spending remain the primary challenges.” Federal lawmakers quickly learned that insurance coverage matters. After the Congressional Budget Office estimated that 24 million Americans would lose health coverage under the AHCA, news reports were flooded with footage of angry constituents at town hall meetings. “Future bills are likely to be judged against the coverage expansion brought by the ACA,” Hanel wrote. In Colorado, the uninsured rate under the ACA dropped by more than half, from 14.3 percent in 2013 to 6.7 percent in 2015. Colorado achieved near-universal insurance for children, with just 2.5 10

percent uninsured. An estimated 465,000 people joined Medicaid through the expansion and another 100,000 receive subsidies through Connect for Health Colorado, the state’s insurance exchange. CHI projects that the quick growth of Colorado Medicaid has stabilized to cover roughly one-quarter of the state’s population. “Any proposal, either in Colorado or nationally, that would raise the number of uninsured would have a hard time passing.” Colorado employs a program called the Accountable Care Collaborative (ACC) that has produced impressive cost savings in Colorado Medicaid since its inception six years ago, but without the federal government’s matching funds under the ACA – which covers 94 percent of the cost of the expansion – the expansion would certainly be unaffordable as state lawmakers already divvy out limited funds among competing priorities. Looking forward “With Congress seemingly stalled on health policy, states have a tool to start designing their own systems,” Hanel wrote. “The ACA offers states wide latitude to alter major parts of the law through what’s known as a 1332 waiver, as long as coverage and federal costs are not negatively affected. Congressional approval is not needed for these waivers, although they do need to be approved by the U.S. Department of Health and Human Services. With Congress at a stalemate, it’s possible the next big idea in health policy will be generated at the state level.” “Republican members of Congress pitched repeal of the ACA and its replacement by the AHCA as a simple fix for the coun-

try’s costly health system,” Hanel wrote. “The AHCA’s fate demonstrates that no easy solutions exist. Similarly, for proponents of the ACA, their victory in Congress does not mean that health care problems have been solved. Instead, future reforms will have to diagnose specifically what is wrong with the system and make targeted repairs. The work will be slow and painstaking.” Follow CHI’s continuing coverage of federal health care reform on their website, www.coloradohealthinstitute.org. n

AHCA fast facts • Continuous coverage requirement: If an enrollee drops coverage, insurers may add a 30 percent surcharge upon reenrollment. • Retains ACA ban on insurers denying coverage for preexisting medical conditions. • Retains ACA reform allowing young adults to stay on their parents’ plan until age 26. • Allows for age-based pricing; insurers may charge an older adult five times more than a younger adult. • Provides age-based tax credits, with income-based caps. • Medicaid expansion continues through 2020. • Federal Medicaid funding would transition to a per capita allotment in 2020. States could opt for block grants instead. Source: “How they stack up,” Colorado Health Institute. March 21, 2017.

Colorado Medicine for May/June 2017

Cover Story

Thoughts from Capitol Hill CMS Staff Report

CMS President-elect expresses concerns to Colorado Senators Bennet and Gardner Editor’s note: Neither senator responded to a request to submit a separate column to elaborate their views on health care reform. CMS President-elect M. Robert Yakely, MD, expressed his concerns with the American Health Care Act (AHCA), the “repeal and replace” option for the Affordable Care Act (ACA), as well as other concerns about federal health care reform, to Colorado Senators Michael Bennet and Cory Gardner. Below are their responses to Yakely, which detail their thoughts on the legislation and the effort to reform the U.S. health care system. The Honorable Michael Bennet Thank you for writing me about the American Health Care Act (AHCA). I strongly opposed this bill for a variety of reasons. On March 6, 2017, Republicans in the House of Representatives introduced the Affordable Health Care Act. The bill included primarily age-based tax credits for purchasing health insurance from the individual market. The AHCA also proposed to alter Medicaid dramatically by ending the Affordable Care Act’s (ACA) expansion and placing caps on the program. These changes would threaten Medicaid benefits for children, disabled adults, and pregnant women in Colorado. The AHCA passed through the House Energy and Commerce Committee as well as the Ways and Means Committee prior to receiving an analysis from the Congressional Budget Office (CBO).

Colorado Medicine for May/June 2017

Once finalized, the CBO found that the proposal would result in loss of health care coverage for 24 million people by 2026. The report also concluded that nearly $840 billion would be cut from the Medicaid program. It also showed that the tax credits would be insufficient for older Americans who would face higher premiums under the bill. As you may know, the ACA resulted in coverage for over 600,000 Coloradans. According to the Colorado Health Foundation, household earnings rose $600 a year and 31,000 jobs were created as a result of the Medicaid expansion. I’ve said from the beginning that the ACA isn’t perfect and that we will need to continue to fix and improve the law. My office will continue to do everything it can to ensure that maintaining affordable health insurance becomes easier and more stable. I remain committed to improving the ACA, and will continue to collaborate with Democrats and Republicans, to ensure that we can increase the number of people with health insurance while preserving important protections. I value the input of fellow Coloradans in considering the wide variety of important issues and legislative initiatives that come before the Senate. I hope you will continue to inform me of your thoughts and concerns. For more information about my priorities as a U.S. Senator, I invite you to visit my website at http://bennet.senate.gov/. Again, thank you for contacting me.

The Honorable Cory Gardner Thank you for contacting me regarding health care reform. I appreciate you taking the time to write. It is an honor to serve you in the United States Senate and I hope you will continue to write with your thoughts and ideas on moving our country forward. On March 24, 2017, the House of Representatives elected to withdraw the American Health Care Act, their plan to repeal and replace the Affordable Care Act, without voting. This legislation intended to reform health care by eliminating taxes and mandates, expanding Health Savings Accounts, and implementing a monthly tax credit. It is vital that any replacement plan offers states the flexibility they need, while also ensuring stability for Colorado’s sickest and most vulnerable patients, concerns I raised in a March 6, 2017 letter to Senate leadership. As conversations around repealing the failed Affordable Care Act continue, I remain committed to replacing it with common-sense reforms that control costs, expand access to care, and protect the doctor-patient relationship, while also ensuring a stable transition and flexibility for Medicaid populations. I maintain my commitment to addressing the fundamental problem with health care in our nation: cost. In Colorado, and across the nation, families have faced significant premium increases. According to the Colorado Division of Insurance (DOI), the aver-

Cover story (cont.) age premium in Colorado increased by 20.4 percent on the individual market in 2017. This unsustainable policy has motivated multiple insurers to remove their plans from the state health exchange for this plan year. As a direct result, 43 of the 64 counties in Colorado have two, or fewer, insurance carriers to choose from. This decrease in competition has had a dramatic impact on Coloradans’ ability to purchase insurance and access care. Since the implementation of the Affordable

Care Act, over half a million Coloradans have lost their health insurance. Many Americans today choose not to visit the doctor or purchase necessary medication because they simply cannot afford to do so. This is unacceptable, particularly for individuals with preexisting conditions. Despite empty assurances that the Affordable Care Act would solve the rising cost of health care in this country, the price Coloradans are paying for necessary services has skyrocketed. In order to actually

lower the cost of health care, I believe we need real free-market solutions, not tax increases. Moving forward, I will continue to support policies that will the lower cost of health care while increasing the quality of care. Again, thank you for contacting me, and do not hesitate to do so again when an issue is important to you. n

BREAKING: Congress could revive AHCA with amendments On March 24, House leadership pulled the American Health Care Act (AHCA) from consideration. As of press time, May 4, an amended version passed the House. The debate shifts now to the Senate, where significant changes are expected. The AMA has remained opposed to the bill, saying the amendments take the AHCA from “bad to worse.” (See opposite page.) CMS President Katie Lozano, MD, FACR, released a statement following the May 4 action. “The House version is not likely to survive intact in the U.S. Senate, and it is impossible to speculate on what alterations will be made in the upper chamber at this early stage. The Colorado Medical Society informed the Colorado congressional delegation that it remains steadfastly committed to the principle of assuring the highest possible levels of coverage and access to care for our patients. In short, our position with our congressional delegation is to “first do no harm.” By that we mean we oppose any effort to roll back coverage or compromise our ability to assure that our patients can get the right care at the right time, place and value.” Stay tuned.

Colorado Medicine for May/June 2017

Cover Story Even with amendments, AMA remains opposed to AHCA The American Medical Association publicly opposed the American Health Care Act (AHCA) in a statement on March 22, citing projections that millions of Americans would lose health insurance coverage if it were to become law. In another letter on April 27, the AMA again urged Congress to oppose the amended AHCA as it would “still result in millions of Americans losing their health care coverage and could make coverage un-

Colorado Medicine for May/June 2017

affordable for people with pre-existing conditions.” The AMA launched a website, patientsbeforepolitics.org, to encourage physicians and patients to join the effort to increase access to affordable, meaningful coverage for all Americans. The site provides the latest information on health system reform legislation moving through Congress, as well as the AMA’s efforts to help shape the future of U.S. health care.

Cover Story

Member perspectives Kate Alfano, CMS Communications Coordinator

Physicians answer five questions about health care reform Question 1: Given that the House effort to “repeal and replace” has failed for now, Health and Human Services Secretary Tom Price, MD, will be managing regulatory control of the ACA. He is on record supporting repeal and replace of the ACA and supported the American Health Care Act. What would your advice to him be now that Congress failed to act on new legislation and Dr. Price has control of ACA regulatory levers?

Paul Hsieh, MD

PH: Minimize the regulatory burden on doctors, hospitals, and insurers as much as possible, while a genuine free-market health care reform plan gets hammered out.

BJ: Until Congress acts on its everytwo-year campaign promise to repeal and replace Obamacare, HHS Secretary Price has at his disposal an Obamacare Brian Joondeph, kill switch. AppearMD, MPS, FACS ing over 1,000 times in the ACA legislation, the secretary “shall” or “may” “determine” how the law is implemented. He could essentially “determine” that Obamacare “shall” be null and void. Alas only as a temporary fix as there will someday be a new administration that “may” feel otherwise. 14

Colorado Medicine asked a group of members who had previously selfidentified interest in health care reform to provide their perspective on how federal reform should be approached and managed, and how it will affect their practice of LL: The ACA is not a perfect bill. It is complex, and with many interweaving sections that can make it hard to separate what is working well from Lucy Loomis, MD what is not, and to identify unintended consequences. While there are clearly significant problems with the individual market, many of those existed before the ACA, and those affected are a relatively small portion of the total number of people whose access to health care has been greatly improved. I think the responsible thing for Dr. Price to do is support the current law until it has been repaired or replaced. TG: The mission of HHS (Dr. Price) is to enhance the health and wellbeing of Americans. Delivery systems are not the Thomas Billroth problem. People/ patients are not Gottlieb, MD the problem. The problem is financing of health care by multiple commercial insurance companies. Solution: Socialized insurance, Medicare-for-All.

medicine now and in the future. The physicians briefly answered five openended questions. Below is a selection of the wide range of responses we received. All responses can be found online at www.cms.org/articles/mayjune-perspectives. Add your thoughts to the health care reform debate The Colorado Medical Society is your community forum for educated discussion and action on issues that affect Colorado physicians and patients. Add your perspective by commenting on this article online. Log in with your CMS.org credentials to view and submit comments to the members-only discussion. Note: You must be logged in to view or comment. n AT: My advice to Secretary Price is to listen to the American people. Public opinion polls are very clear that a majority of Americans want to Adam Tsai, MD keep the coverage gains made under the ACA. Secretary Price and Congress should examine what could be done to cover more people and lower costs, rather than replacing the ACA with a system of tax credits that is projected to cause tens of millions of Americans to lose coverage. Improving access and lowering costs will require both parties to address the underlying drivers of high health care spending, such as high prices for services.

Colorado Medicine for May/June 2017

Cover Story Question 2: What should Congress do next? President Trump? PH: Congress and the White House should rally behind a genuine freemarket reform. A good start would be Sen. Paul’s plan. Another would be the “Whole Foods Plan” proposed back in 2009 by John Mackey: www.wsj.com/ articles/SB10001424052970204251404 574342170072865070. BJ: Congress needs to align their disparate factions and follow through on their campaign promise to “repeal and replace” Obamacare. President Trump, in keeping with “The Art of the Deal,” must mediate, negotiate, cajole and convince Congress into crafting and passing legislation consistent with their campaign promise to the American people. This is called leadership and is a reasonable expectation of our elected leaders.

LL: Despite some of the rhetoric, there is not a crisis and no evidence of impending implosion. Congress and Trump should take the time to understand what is working and what is not, and try to fix what is not. He should resist extracting tax revenue from a program that is improving access to health care for lower-income Americans in order to reduce taxes for those who are better off. TG: Congress: Propose a health reform plan that supports people, not profits. Preservation of a democracy requires that people guide our congressional leaders. People support a “single insurer” such as Medicare-for-All. Trump: Trump promises universal health care, higher quality, lower cost, no one loses coverage, and all with

pre-existing conditions will have access. Trump should not replace the ACA (Obamacare) until he offers a better plan. AT: Congress should work across the aisle as much as possible to advance policies that cover more people and lower costs. Both parties have ideas that could potentially lower insurance costs for people purchasing insurance on the health care exchanges. For example, Democrats favor adding a public insurance option, which would create more competition for private insurers. Republicans favor selling insurance across state lines; regional rather than state-based insurance exchanges might offer greater economies of scale to lower insurance costs.

Question 3: Given the vacuum created by lack of action on the American Health Care Act, what should organized medicine (AMA, state, county and national specialty societies) do right now to ensure optimal coverage and timely access to medical care? PH: Physicians should lobby their lawmakers to support market-based reforms that respect physician freedom to practice free from onerous government rules and practice guidelines. We’ve seen repeatedly that robust service markets thrive best under freedom, not when hampered by a large regulatory state. BJ: Organized medicine, while an important voice, is not Congress and cannot alone pass legislation. But they can make their voice heard through advocacy, just as they are now doing. Make sure legislators know our priorities for health care reform, for our patients and for the sustainability of our profession.

care delivery system. Access to quality health care should not be a partisan issue, a message we can effectively deliver when working with our legislative colleagues. However, organized medicine also needs to take the lead in promoting efforts to deliver the right care at the right time and increase the value, not just volume of care provided, providing good stewardship for the taxpayer dollars that are invested in expanding health care access. This should not be considered a blank check to the health care delivery system. We should continue to endorse reducing overall costs of care (as well as administrative burden and overhead).

LL: Organized medicine should continue to support what is best for the health of the entire population. Lack of insurance and access to health care creates problems that ripple through a community and the health

TG: Use the reform guidelines of affordability, equitable timely access, and cost savings in health care. Merging state medical assistance programs and acquiring private health insurers to reform Medicare

programs would be the most effective method (Medicare-for-All). Refer to www.hcacfoundation.org. AT: Organized medicine should continue its advocacy to maintain and improve access to care. The AMA’s recent public opposition to the American Health Care Act is a good example. State medical societies should advocate for their states to continue running insurance exchanges and to maintain expanded Medicaid coverage.

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

Cover story (cont.) Question 4: Given all that you observed and read about the strongly held positions on all sides of this contentious debate, are you more or less inclined to be politically active in the future and why? PH: More active. This is our best chance to avoid the dangers of Europeanstyle “single payer” system. BJ: I will continue to make my voice heard, through my writing and radio appearances. While a lone voice, if I don’t make the effort, who will? If physicians sit in the back of the bus, we abdicate driving the bus to lobbyists and industry: Hospitals, insurance companies, pharma and politicians, all of whom have different priorities than practicing physicians. LL: As a safety net provider, I have seen first-hand the benefits of improved access to health care for the patients we

serve. As a community health center, we have worked successfully with both parties by emphasizing the importance of CHCs in providing access to quality cost-effective health care for underserved populations. Providing good health care should not be partisan issue. I think it is our duty as leaders in organized medicine to emphasize this point, and try to guide conversations around how best to provide health care, and be accountable for the outcomes. We can also be very effective in sharing stories of our own and our patients’ experiences in gaining (or not) access to health care.

TG: More! Sadly, health care reform is not a scientific evidencebased movement, but a political movement. If we are serious regarding medical ethics and democracy, then only a grassroots political movement will be effective. AT: I am more inclined to be politically active. Despite the many great things about the United States, we remain very much an outlier compared to the rest of the developed world when it comes to providing health care for our people.

Question 5: What are the three most important things about health care delivery and the practice of medicine you would tell your member of Congress to keep in mind, whichever way this debate finally goes? PH: Make insurers compete across state lines, reduce regulatory burdens on hospitals/doctors/insurers, and allow widespread use of HSAs. BJ: 1) Health care is a right. Or at least an entitlement. Founding documents aside, we have become an entitlement society. Completely privatizing health care, leaving it to the free market, is politically impossible and a nonstarter. 2) Health care is a privilege. Taxpayers and businesses cannot afford to pay for top-of-the-line medical care for everyone, without limit and on demand. Some form of rationing is an economic necessity. Create a sensible scheme to acknowledge and implement this reality. 3) Health care can be both a right and a privilege. A two-tiered approach works in many countries, a parallel public and private system. Then the thorny political question of “right versus privilege” doesn’t need an answer. It can be both. While not perfect, it is politically feasible, accommodating both sides of the partisan debate. LL: 1) There continue to be problems

with the U.S. health care system. It is not equitable; there are still many examples of health disparities. We overvalue expensive interventions, and undervalue primary and preventive care. We tend to treat social problems with an expensive medical model, when what may be more effective is addressing the underlying social determinants of health. Congress needs to invest in primary care and prevention. 2) As we continue to strive to improve systems, we need to work together with payers and Congress to increase the value of the health care. 3) Don’t forget the Quadruple Aim! 4) Reduce the administrative burden on our providers. TG: 1) The major problem is the multiple payer commercial insurance business. Physicians/ providers and people/patients are not the major problem. 2) Financing of health care is the problem that can be fixed by socialized insurance, not socialized medicine. 3) A business plan is needed to accomplish these

“important things” and is available as: U.S. Healthcare Financing Reform, Consolidation of the Health Insurance Industry, www. hcacfoundation.org. AT: 1) A pure free market approach to health care is not a feasible option, as much as some policy makers would like it to be. Health care is complex. It is not pejorative to say that many people are not capable of being sophisticated “consumers” of care; it is reality. Health care is not selling cars. 2) Every other wealthy country in the world guarantees health care to its citizens in some form. It is way overdue for us to join the rest of the developed world. 3) To the politicians who think that individual responsibility can cure all our health care problems, I invite you to spend a day in the exam room with me treating chronic medical illness.

Colorado Medicine for May/June 2017

Cover Story

ColoradoMedical MedicalSociety SocietyHistory History Colorado ofHealth HealthCare CareReform Reform of By Chet Seward, Senior Director, Division of Health Care Policy By Chet Seward, Senior Director, Division of Health Care Policy

more than a decade health care reform been a priority Colorado Medical Society (CMS). ForFor more than a decade health care reform hashas been a priority forfor thethe Colorado Medical Society (CMS). As As debate continues nationally locally what ideal framework health care should is important debate continues nationally andand locally onon what thethe ideal framework forfor health care should be,be, it isit important remember where CMS been understand underscore Colorado physicians’ experiences, to to remember where CMS hashas been to to understand andand underscore Colorado physicians’ experiences, perspectives commitment getting health care reform right. following a timeline of activity over perspectives andand commitment to to getting health care reform right. TheThe following is aistimeline of activity over past decade. thethe past decade.

CMS champions in Colorado CMS champions bill bill in Colorado legislature to study health reform legislature to study health carecare reform recommend solutions. andand recommend solutions.

Creation of CMS Physicians’ Congress Creation of CMS Physicians’ Congress Health Care Reform, development for for Health Care Reform, development approval of new guiding principles andand approval of new guiding principles reform. for for reform. Colorado Blue Ribbon Commission Colorado Blue Ribbon Commission on on Health Care Reform SB208 Health Care Reform (aka(aka SB208 commission) develops reform commission) develops reform proposals recommendations to the proposals andand recommendations to the legislature, all which of which assessed legislature, all of areare assessed using CMS evaluation matrix. using CMS evaluation matrix. CMS supports hospital provider CMS supports hospital provider feefee to to increase eligibility Medicaid increase eligibility for for Medicaid andand Children’s Health Insurance Plan. thethe Children’s Health Insurance Plan. Affordable Care passes Affordable Care ActAct passes andand is is signed signed intointo law.law. After extensive membership After an an extensive membership engagement process, CMS supports engagement process, CMS supports Colorado’s to the Medicaid Colorado’s optopt in toin the Medicaid expansion under ACA. expansion under thethe ACA.

CMS House of Delegates votes CMS House of Delegates votes to to pursue health reform pursue health carecare reform as aas a priority. priority. Physicians’ Congress develops Physicians’ Congress develops thethe evaluation matrix, a 71-point evaluation matrix, a 71-point tooltool to to assess reform proposals based upon assess reform proposals based upon physician values priorities. physician values andand priorities.

Ritter announces Building Blocks Gov.Gov. Ritter announces Building Blocks Health Care Reform. CMS assists for for Health Care Reform. CMS assists in development supports. in development andand laterlater supports.

CMS uses evaluation matrix to assess CMS uses evaluation matrix to assess federal Affordable Care federal Affordable Care ActAct (Obamacare) conducts extensive (Obamacare) andand conducts extensive member surveying outreach. member surveying andand outreach.

CMS supports Hickenlooper’s CMS supports Gov.Gov. Hickenlooper’s State of Health to make Colorado State of Health planplan to make Colorado healthiest state in the nation. thethe healthiest state in the nation.

CMS supports Colorado’s State CMS supports Colorado’s State Innovation Model (SIM) proposal Innovation Model (SIM) proposal to to transform Colorado’s health system transform Colorado’s health system through integration of primary through integration of primary carecare behavioral health. andand behavioral health.

CMS supports Medicare Access CMS supports thethe Medicare Access & & CHIP Reauthorization to repeal CHIP Reauthorization ActAct to repeal thethe Medicare Sustainable Growth Medicare Sustainable Growth RateRate formula initiate biggest reform formula andand initiate thethe biggest reform of physician payment of physician payment andand carecare delivery in 20 years. delivery in 20 years.

CMS evaluates current CMS evaluates bothboth thethe current multi-payer system proposed multi-payer system andand thethe proposed constitutional amendment constitutional amendment 69 69 (ColoradoCare). (ColoradoCare).

CMS surveys members latest CMS surveys members on on latest federal health reform (Trumpfederal health carecare reform (Trumpcare) priorities provides findings care) priorities andand provides findings along analysis of American along withwith analysis of American Health Care to Congressional Health Care ActAct to Congressional Delegation. Delegation.

Colorado Medicine for May/June 2017

Features

2017 all-member survey Benjamin Kupersmit, President, Kupersmit Research

Members express clear desire to overhaul health care delivery system in Colorado Kupersmit Research is pleased to present the results of the 2017 CMS member survey focused on member priorities for reforms to the health care delivery system in Colorado. (Unless otherwise indicated, data below is among physicians in active practice who accept commercial insurance (n=488, approximately 80 percent of CMS members overall). We also focus on “decision-makers” in their practice who participate in contract negotiations with payers, (typically owners/partners in officebased practices; n=113, approximately 20 percent of CMS members). CMS physicians in active practice who contract with insurance, and particularly decision-makers, express significant frustration with commercial payers and a clear desire for reform:

• Physicians, and particularly decision-makers, feel they must contract with commercial payers to remain financially viable, with 79 percent of decision-makers saying as such regarding top Colorado insurers United HealthCare and Anthem. • Yet, just 28 percent of decisionmakers say criteria for participation have been explained at least “somewhat” clearly; among the 30 percent of decision-makers removed from a network or plan in the past year, just one-third (34 percent) were given written notice and just 9 percent say they were given an explanation for their removal. • Nearly three-quarters of CMS active practice physicians (70 percent) say that their patients’ medications are changed by their insurer; a 2015 member

survey found that 66 percent feel medication regimen changes by insurers have caused adverse events for their patients. • A majority (54 percent) of active practice physicians and 79 percent of decision-makers say patients have discontinued care because of insurance changes. • Nearly half (46 percent) of active practice physicians and 63 percent of decision-makers say they have difficulty finding in-network referrals. • We see significant support for key legislative reforms at the state level among those surveyed: • Sixty-nine percent of all active practice CMS physicians and 86 percent of decision-makers say efforts to allow physicians to file with the DOI would “directly benefit” them now.

TABLE 1: Please check off any area below where you have a strong, direct interest in seeing CMS support that legislation to benefit you in your practice:

ALL CMS Decision members makers Allow physicians to file insurance carrier complaints with the Division of Insurance (currently only patients are able to file complaints)

69%

86%

Prohibiting plans from retaliating against physicians who advocate against them 63

Consumer notification of out-of-network billing, holding patients harmless and carrier fair payment of out-of-network (OON) charges

Public input and transparency on health plan mergers

Allowing physicians to choose the telehealth solution of their choice

None of these

Not sure

Transparency and fairness in network selection and deselection of physicians

Colorado Medicine for May/June 2017

Features â&#x20AC;˘ We see similarly strong scores for addressing network selection and deselection (65 percent among all, 74 percent among decision-makers) and protection of physicians from retaliation by health plans (63 percent among all, 67 percent among decisionmakers). â&#x20AC;˘ Other priorities include addressing OON billing issues (with 53 percent among all and 60 percent among decisionmakers) and ensuring public input and transparency for health plan mergers (with 53 percent among all and 55 percent among decision-makers). Physicians want local solutions now Over the years, we have watched as more and more physicians move to an employee role. This survey reminds us that the choice to be employed versus an owner/partner in a physiciancontrolled practice is being driven in some part by the desire to avoid the hassles and stress of contracting, authorizing and being reimbursed fairly and transparently by commercial insurers. Physicians across the system report that insurance companies are interfering in medical decisions, and that lack of communication and constant change regarding insurance status are causing problems for patients and physicians alike. Not surprisingly, physicians feel that patients blame them, and that the physician-patient relationship is deteriorating from this ongoing intrusion of financial and administrative hassles into the exam room. CMS physicians strongly believe that key reforms are needed at the state level, and expect those reforms to directly and immediately impact their practice in a positive way. Their priorities are allowing physicians to file complaints with the DOI, transparency in selection and deselection of physicians for networks, and protection of physicians from retaliation by health Colorado Medicine for May/June 2017

plans. There is also strong interest in seeing steps to address the issue of OON billing, as well as ensuring public input and transparency regarding health insurance potential mergers. Methodology This survey was administered online by the Colorado Medical Society. A total of 661 CMS members completed the survey, resulting in a margin of error of +3.8 percent at the 95 percent confidence level. The sample of active physicians who accept insurance (i.e., excluding med students, retired physicians, and the 1 percent in concierge practices) carries an n=488, with a margin of error of +4.4 percent, and the sample of decision-makers has an n=113 and carries a margin of error of +9.2 percent. The survey was conducted from March 1-21, 2017. n

Serving the Continuing Medical Education needs of Colorado physicians Your bridge to quality improvement in health care

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

Features

Insurance market Kate Alfano, CMS Communications Coordinator

Time is short for critical action to stabilize individual market Vital funding that reduces the costs borne by 7 million Americans who purchase coverage through the health insurance exchanges will soon be endangered if Congress and the Trump administration do not act quickly to ensure it continues to be available to the low- and moderate-income patients who need it. There is great uncertainty surrounding these cost-sharing reductions (CSRs), which 60 percent of individuals who buy coverage through the health insurance exchanges rely upon to help with deductibles, co-payments or outof-pocket limits. The payments are the subject of a lawsuit filed by members of Congress in 2014, put on hold after the 2016 presidential election, and still pending in the federal courts until at least the end of May, days before insurers must file their insurance plans for 2018. Two high-profile letters have been sent to federal elected officials asking for this funding to continue. On April 12, the American Medical Association and seven other organizations representing physicians, hospital systems, insurers and businesses wrote to the Trump administration and congressional leaders to encourage them to stabilize the individual market for 2017 and 2018 by removing uncertainty about continued funding for CSRs. In addition to the AMA, the signatories were America’s Health Insurance Plans, the American Academy of Family Physicians, American Hospital Association, American Benefits Council, Blue Cross Blue Shield Association, Federation of American Hospitals and U.S. Chamber of Commerce. 20

And on April 20, Colorado Insurance Commissioner Marguerite Salazar sent a letter to Colorado’s congressional delegation with a similar ask, saying that uncertainty is “making everyone nervous” and that “this uncertainty is going to hurt Colorado consumers.” “Uncertainty about the regulatory environment may cause carriers to raise premiums,” Salazar wrote in her letter. “If the CSRs are not funded, at a minimum, Coloradans are estimated to see a 12-19 percent rate increase for that alone. At the worst, carriers could decide to forgo the increased risk and simply exit the individual market in Colorado, leaving consumers with fewer choices in carriers and plans. Using the CSRs as a bargaining chip is tantamount to gambling with Coloradans’ access to health care.” The funding covers consumers who earn less than 250 percent of the federal poverty level, and “Americans will be dramatically impacted” if costsharing reductions end, the AMA and other organizations stated in their letter. The likely outcomes include fewer choices for health insurance consum-

ers and higher premiums in 2018 and beyond. Analysts have estimated that the loss of cost-sharing reductions would raise premiums for all consumers in the individual market by at least 15 percent, regardless of whether they buy coverage through the exchange marketplace. “Higher premium rates could drive out of the market those middle-income individuals who are not eligible for tax credits,” the AMA stated. The AMA continued: Providers will experience more uncompensated care, further straining their ability to meet the needs of their communities and raising costs for everyone – including employers who sponsor group health plans for employees. Taking steps to strengthen and stabilize the individual insurance market is one of the nine objectives guiding the AMA’s health care reform discussions with the administration and Congress. The AMA supports measures to maximize the number of people, including healthy Americans, who sign up for coverage on the individual market. n

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Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or email susan_koontz@cms.org Colorado Medicine for May/June 2017

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Colorado Drug Card

Features

Legislative update Susan Koontz, JD, CMS General Counsel

CMS advocates for health plan reform, stable liability climate Numerous surveys of CMS members demonstrate deep dissatisfaction with the current multi-payer system. Last summer, a good-faith mediation between CMS and the Colorado Association of Health Plans (CAHP) failed when a few insurers insisted CAHP discontinue discussions, and the plans were reluctant to resume discussions prior to the 2017 Colorado General Assembly. In response, the Colorado Medical Society is pursuing the passage of a series of managed care reforms in the 2017 General Assembly, as directed by the CMS Board of Directors. These reforms have inspired a healthy and long-overdue debate over the relationship between physicians and payers that will hopefully turn the focus of interactions to value rather than market share and volume. CMS is deeply grateful to members of the General Assembly who have been willing to step up and promote fairness and greater transparency in the system, as well as the many CMS members who have completed our surveys, testified at hearings and taken the time to contact their elected officials.

may investigate complaints by health care providers regarding the improper handling or denial of benefits by a health insurance company. The bill requires the commissioner to investigate provider complaints and notify the provider of the results of the investigation. The commissioner is directed to include information on provider complaints in an existing annual report to the General Assembly. The commissioner must determine if there is a pattern of misconduct by a health insurance company and, if there is a pattern, must impose an appropriate remedy or penalty as an unfair or deceptive practice. The Department of Insurance has now agreed to a pilot program and the initial pilot framework and data to be collected; thus, the bill has been voluntarily postponed indefinitely. At present, we are actively engaged in the process of establishing the CMS/DOI Provider Complaint Pilot Program.

health care providers the standards the carrier uses for: • Selecting participating providers for its network of providers; • Tiering providers within the network; and • Placing participating providers in a narrow or tiered provider network. The governor signed the bill into law on April 16. SB17-198 - Public Participate Review Acquire Control Insurer Position: Support Sponsors: K. Priola / A. Garnett Current law requires an opportunity for public notice and a hearing for proposed transactions that would result in the acquisition of control of a domestic insurer, which is one that is incorporated or formed pursuant to Colorado law.

The bill sought to eliminate the cap on noneconomic damages recoverable in an action for the wrongful death of a child under the age of 21 years. Non-economic loss or injury damages are currently set at $300,000 in a medical malpractice action. This bill would render jury awards limitless, thus greatly impacting the stability of Colorado’s medical liability environment.

For mergers involving non-domestic health plan companies, the bill requires the commissioner to provide public notice with a description of the process including public input within five days of any proposed acquisition filing. Instead of a more costly “investigation” the changes require a “review” if the proposed acquisition creates a prima facie violation of the Competitive Standard. The bill requires public disclosure of any markets, insurance products, and market share that create a prima facie violation of the competitive standards and gives the commissioner 60 days from Form E filing to conduct a hearing or review with stakeholder input. The commissioner may then issue any order adverse to the acquisition.

Though the bill passed through the House, it was ultimately defeated by a vote of 3-2 in the Senate Committee on State, Veterans and Military Affairs.

Finally, the bill clarifies that nothing in the law prohibits a carrier from making

SB17-133 - Insurance Commissioner Investigation of Provider Complaints Position: Support Sponsors: J. Tate / D. Young Currently, the commissioner of insurance

SB17-088 - Participating Provider Network Selection Criteria Position: Support Sponsors: C. Holbert | A. Williams / K. Van Winkle | E. Hooton This bill requires a health insurer to develop, use and disclose to participating

SB17-1254 Noneconomic Damages Cap Wrongful Death of Child Position: Oppose Sponsors: K. Becker | J. Salazar/D. Kagan

Colorado Medicine for May/June 2017

Features its competitive impact analysis (Form E) available for stakeholder inspection. The bill has passed the Senate and House and awaits the governor's signature. HB17-1173 - Health Care Providers and Carriers Contracts Position: Support Sponsors: C. Hansen / T. Neville Current law requires a contract between a health insurance carrier and a health care provider to include a provision that prohibits a carrier from taking an adverse action against the provider due to a provider’s disagreement with a carrier’s decision on the provision of health care services. The carrier cannot terminate the health care provider’s contract for disagreeing or for assisting his or her patient in seeking a reconsideration. The bill requires the contract to also contain provisions that prohibit a carrier from: taking adverse actions for communicating with public officials on health care issues; filing complaints or reporting to public officials about conduct by a carrier that might negatively affect patient care; providing information concerning a violation of this provision; reporting alleged carrier violations to the appropriate authorities; or participating in an investigation of an alleged violation. The governor signed the bill on April 6.

Colorado Medicine for May/June 2017

SB17-206 - Out of Network and Surprise Bills Position: Support Sponsors: B. Gardner / J. Singer This bill was intended to provide a framework to resolve the long-standing out-ofnetwork balance billing problem by requiring that carriers, facilities and providers all notify patients of their legal protection for OON bills under current Colorado law. With the approval of the house of medicine, this bill was postponed indefinitely in committee by the bill’s sponsor. SB 17-106 Sunset Registration of Naturopathic Doctors Position: Support Introduced Bill, Oppose House Amendments Sponsors: I. Aguilar | D. Coram | J. Kefalas / J. Singer The introduced bill implements recommendations of the Department of Regulatory Agencies (DORA), as contained in DORA’s Sunset Review of Naturopathic Doctors dated Oct. 14, 2016, reauthorizing the regulation of naturopaths (NDs) under Colorado’s sunset review process. During the February Council on Legislation (COL) meeting, the council voted to support the bill based upon the DORA report. However, the council unanimously

agreed to oppose any expansion to the NDs’ scope of practice. Thereafter, the bill was amended in the House to expand the prescriptive authority of NDs to allow them to obtain, administer, dispense, prescribe and treat patients with intravenous minerals and amino acids, as well as hormones. The council was troubled by language associated with the House amendments regarding authorization to treat, specifying that nothing would have limited the ability of an ND to make an independent judgment or to require supervision by a physician or APN. In addition, there was concern with the term “hormone” because it was not defined and would have been open to a more broad and more dangerous interpretation and authorization for NDs to treat patients. The Senate rejected the House amendments and adhered to their original position; ultimately, the amendments were withdrawn by the House. The bill has now passed without the inclusion of the House amendments. Stay tuned! Because this issue of Colorado Medicine went to press prior to the end of the legislative session, stay tuned for an in-depth look at the 2017 session in the July/August issue. n

Features

Health plan mergers Kate Alfano, CMS Communications Coordinator

Landmark ruling upheld, protecting U.S. patients and physicians On April 28 Anthem suffered another setback in its determined push to overcome a district court ruling and a breakup lawsuit by its future-ex-acquisition, Cigna, when the U.S. Court of Appeals for the District of Columbia upheld a lower court’s tough-worded ruling against Anthem that blocked their proposed $54 billion insurance mega-merger. The opinion aligned closely with the federal district court’s finding that the merger acquisition was anti-competitive and agreed with the Department of

Justice’s argument – supported by the American Medical Association, Colorado Medical Society and 16 other state medical associations where these mergers would have been most harmful, as well as Colorado Attorney General Cynthia Coffman and several other state attorneys general – that the acquisition would, like its predecessors, suppress the clinical authority of physicians; raise, not lower, premiums; and grant impermissible market concentrations that would invite abuse and unaccountability. In short, Anthem would have both monop-

olistic and monopsonistic powers over those markets, physicians, their patients, and other caregivers and institutions. “The appellate court sent a clear message to the health insurance industry: a merger that smothers competition and choice, raises premiums and reduces quality and innovation is inherently harmful to patients and physicians,” said AMA President Andrew W. Gurman, MD. “The result of 21 months of advocacy before the U.S. Department of Justice (DOJ), congressional leaders, state attorneys general, insurance commissioners, and federal court, this outcome shows again that when doctors join together, the best outcome for patients and doctors can be achieved.” It is not yet known if Anthem will persist and petition the U.S. Supreme Court, but Anthem to date has vigorously fought Cigna’s lawsuit to bail out of the merger-acquisition and has moved to flank the courts politically, giving generously to the presidential inaugural activities, publicly endorsing a number of aspects of the White House-backed “repeal and replace” of the Affordable Care Act, and has seen one of their top antitrust lawyers moved to head the Antitrust Division of the Department of Justice. “We must remain steadfast in our resolve to block Anthem’s power play,” said CMS President Katie Lozano, MD, FACR. “We are deeply grateful for the talent and resources brought to bear in this legal challenge by the AMA’s expert team, our very own Attorney General Coffman, and our colleagues in the most affected states.” n

Colorado Medicine for May/June 2017

Features

Colorado Medicine for May/June 2017

Features

Living the adventure Genie Pritchett, MD

Working as a physician in New Zealand

Genie and Ballard Pritchett

In late 2015 I told my husband it was time for our next adventure. Six months later, and after lots of paperwork, I started working in a community hospital in Timaru, South Canterbury, New Zealand, on the Pacific coast of the South Island. Three months after that my husband joined me (after selling our home and packing our possessions in storage). Here we are, living the adventure. When we are not climbing mountains, tramping (hiking), kayaking or walking to the ocean five minutes from our home, I spend my days working as a senior geriatric consultant at Timaru Hospital. My husband works as a business consultant telecommuting with clients and partners in the U.S. And yes, friends and family make the trek down under to visit. It is a different system to work in, and frankly one that is less stressful and by far more functional than the current model in the United States. Coming here for a “life chapter” has been a great move. That view is shared not only by numerous other Americans who work here, but by Brits, Europeans and Asians as well. Here’s a glimpse into life as a physician in a small city in New Zealand. My day in the 20-bed Assessment, Treatment and Rehabilitation Unit (AT&R) starts at 8:15 with a teambased “morning report” consisting of two geriatricians, two house officers, the head nurse, social worker, physical therapist, occupational therapist, and 26

Pritchett and her husband, Ballard, enjoy hiking all over New Zealand and meeting people from all over the world. Picture at top of page: Pritchett and her husband hike Routeburn Track, one of the Great Walks in New Zealand and a “must-do” three-day tramp. three clinical nurse specialists (CNS). I supervise house officers (who do initial workups, orders and charting), attend family meetings, and conduct residential and nursing home visits. These visits are for at-risk frail elderly, challenging geriatric cases such as complex dementia, worsening Parkinson’s, repeat falls, unusual neurologic cases, etc. I average six visits a week. I conduct geriatric and palliative care consults on the medical and surgical wards as requested, an average of one to two a day. I assist

general practitioners with the task of deprescribing for patients with polypharmacy. I conduct teaching rounds twice a week and attend hospital-based “grand rounds” and other educational forums. I have time to read articles and write thorough, well-researched consults and presentations. Morning tea is schedule for around 10:30, lunch is mid-day, afternoon tea is 3:30. I head home around 4-4:30. No call. No weekends. Colorado Medicine for May/June 2017

Features The system is sane, civilized, uncomplicated. New Zealand has a global, government-based health care model that provides for all citizens and permanent residents. A doctor’s decision to hospitalize is not questioned. No insurance or financial questions are asked when patients are admitted. Patients do not see a hospital bill upon discharge. Pharmaceuticals are reasonably priced. For accidents, citizens and visitors receive free medical care under an additional tax-funded scheme. Health care quality leaves little to complain about. For example, our hospital has state-of-the-art MRI and CT scanners. A stroke victim can arrive in the emergency department and within 10 minutes imaging studies can be done and decisions made regarding thrombolysis. If appropriate, alteplase will be delivered within 20 minutes of arrival. A telemedicine arrangement with radiologists provides consultation at any hour. A patient with NSTEMI (Non-STelevation myocardial infarction) will be treated in Timaru. A patient with MI (myocardial infarction) requiring catheterization will be transported via 30-minute helicopter ride to Christchurch, a large city with a major medical center and world-class services. General surgery and most orthopedic surgery is done in Timaru. Neurosurgery or urologic surgery requires a two-hour ambulance drive or 30-minute helicopter ride. Normally, care is delivered where you live. If you live in Timaru, you receive care in Timaru, unless the medicallyindicated care is not available, in which case you are transported to the closest medical center where the next level treatment can be provided. Residents can choose to purchase insurance policies and receive medical care wherever they want. For the remote areas of the country, helicopter transportation is used to move people to the most appropriate medical setting. People have no fear of not receiving health care. Few people misuse the system. In large cities such as Auckland and Colorado Medicine for May/June 2017

Pritchett and her husband explore Milford Sound, one of many fiords on the Tasman Sea, on a boat. Christchurch, private hospitals serve patients who choose to pay for elective procedures at the time of their choosing. Wait times for non-urgent services vary. Timaru has one ophthalmologist and the routine cataract surgery waitlist is about six months. What is physician pay compared to the U.S.? The Medical Council of New Zealand (MCNZ) sets a recommended pay scale for physicians based on factors such as educational level and years of practice. Most hospitals employ physicians using the MCNZ pay scale. Extra pay is provided for physicians who work after hours (on call) and for “colleague leave cover.” For my position as a senior consultant,

the base pay is $216,000 New Zealand dollars ($152,000 U.S.) with an additional $15,600 New Zealand dollars ($11,000 U.S.) for colleague leave cover, six weeks of paid vacation and 10 additional paid national holidays. I also receive an additional $16,000 New Zealand dollars ($11,200 U.S.) of annual CME funds to use wherever I choose. I am going to the European Geriatric Conference in Nice, France, in September. Where’s the rub? How can this system seem so ideal? • There is no burdensome fear of liabil-

New Zealand (cont.) ity lurking in the hearts and minds of physicians. Virtually no malpractice lawsuits occur. • Paperwork (with no billing!) is minimal, including reasonable documentation requirements. • Medical specialties are almost never oversupplied. Medical schools graduate the numbers of physicians needed to cover the population appropriately. That number increases yearly as the population is growing. • Physicians working in the public system are paid a decent wage, not an extravagant wage. If doctors want to work longer hours they can make more money in the private system in larger cities. Some consultants work part time in the public system to enjoy the medical educational/teaching hospital system, the patient diversity, and service to the population, and also work part time in the private system to earn additional money. • Wait times exist, although not to the detriment of those who need urgent care. For most Americans,

the idea of waiting six months for an elective hip replacement is unacceptable. Here it is considered acceptable by most patients. • General practitioners provide the bulk of care in the community and are the primary medical providers for New Zealanders. They are well trained and able to manage a broad array of pathology in the community. Consultants and specialists are hospital-based and manage high-acuity, challenging diagnoses and treatments. Consultants do have outpatient clinics where they diagnose and treat, and then turn patients over to the general practitioners to manage ongoing care. There are open positions for an internist and a palliative care specialist in Timaru. Many more New Zealand communities need physicians. Think about it! Join a group of international physicians, have a great lifestyle, a delightful professional experience and explore some of the most magical places on earth.

Pritchett and her husband’s “overnight luxury accommodations” in a magical bird-filled jungle during a two-day kayaking trip on Doubtful Sound. I hope some Coloradans come to work! For the rest of you, I hope to see you here when you come to see the splendor of New Zealand. n

Colorado Medicine for May/June 2017

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End-of-life care and Prop 106 Jennifer M. Ballentine, MA, President, The Iris Project

Compassionate responses to suffering at the end of life I’m so sick of being sick, can’t we just get this over with? If you care for patients with serious or terminal illness, you’ve likely heard this or statements like it many times. Delivering the bad news of a terminal diagnosis and responding to a patient’s suffering in the face of approaching death are never easy. The Colorado End-of-Life Options Act (CO-EoLOA; see Box 1) changed everything about responding to patients’ suffering. The question coming to you might be as oblique as that above or as blunt as: Can you get me that end-of-life prescription? Depending on the position you’ve taken on medical aid in dying (see Box 2), the answer may now ultimately be “yes.” However, from another perspective, the new law has changed nothing: Any such question requires a compassionate and appropriate response. This article presents insights from the clinical literature and palliative care practice about the desire to hasten death and how to respond to requests for assistance. There is broad consensus on these points: • The desire to hasten death is extremely common among people with serious, progressive, chronic or terminal illness. Mostly the desire is fleeting, tending to reassert when symptoms flare, the disease worsens or surrounding circumstances deteriorate. • In about 10 percent of patients, the desire becomes prominent and persistent; in less than 2 percent, it conColorado Medicine for May/June 2017

solidates into suicidal ideation or a determined request for medical assistance in dying.1 • The etiology of this desire is more often psychosocial-existential-spiritual in nature than physical. Pain and symptoms can worsen such a desire, but it mostly arises from depression, hopelessness, loss of pleasure in life’s activities, loss of autonomy and “selfness,” or feeling a burden on others.2 These causes or symptoms are identical in patients who commit suicide and those who seek medical aid in dying or euthanasia. The strongest predictors of the desire to hasten death and suicide attempts are hopelessness, depression, and loss of meaning and purpose. • Specific interventions to accelerate treatment for depression, strengthen patient autonomy, relieve caregiver burden, enhance dignity, and reframe meaning and hope are available and effective. • Even explicit requests for help in dying are “paradoxically, requests for help with living.”3 When such expressions are heard as the proverbial cry for help and efforts are made to alleviate suffering, the desire to die dissipates—even when the efforts are not 100 percent successful. The mere presence of a compassionate listening ear and sincere attempts to address concerns are balm. It’s also common for physicians to be uncomfortable engaging with their patients’ expressions of hopelessness, suffering and desire to hasten death. This

Box 1. Colorado End-ofLife Options Act • Passed by voters as ballot-initiated statute; effective Dec. 16, 2016. • Allows adult, terminally ill Colorado residents with mental capacity to request and receive a prescription for life-ending medications from their attending physician. • The attending physician must determine mental capacity, Colorado residency, terminal illness with prognosis of six months or less, and that the patient is making a voluntary, informed decision; counsel the patient on a number of items related to informed decision making; and refer to a consulting physician to confirm terminal diagnosis and prognosis, mental capacity and informed decision making. • If either physician has concerns about mental capacity to make an informed decision, they must refer the patient to a mental health professional. • Once the patient is qualified, the attending physician dispenses the lethal medications or transmits a prescription to a pharmacist for pickup by the patient or authorized person. • The patient may choose to self-administer the drugs, or not. If the drugs are not used, they must be disposed of safely according to specific rules. • A more complete summary of the Act, and the details of the requirements and process may be downloaded from The Iris Project website: http://bit. ly/2osx1di and http://bit.ly/2pwd8IQ.

End-of-life care (cont.) discomfort has several origins: • Perceived lack of time, clinical skills or knowledge of the related issues. • Conviction that addressing psychosocial-existential-spiritual issues is beyond the scope of the physician– patient relationship. • Assumption that depression and hopelessness in the face of inevitable death are not “problems” that are possible to fix. Such reactions amount to a kind of “therapeutic nihilism”4 that leaves patients feeling abandoned in their suffering and only serves to exacerbate a desire to die. A number of frameworks for appropriate responses are offered for clinicians in different disciplines (noted with an asterisk on extended list of endnotes on www.cms.org). Here is a general outline:

1. Do some preliminary self-reflection to understand and neutralize your own views about hastened death and medical aid in dying. Your immediate, nonverbal response will set the tone for the rest of your conversation with patients. If your reaction is dismissive (“You don’t really mean that”), negative (“That’s not something I would ever consider doing”), or judgmental (“It’s not my job to kill patients”), it will not only shut down productive discussion but also could cause real harm. Whatever your views, an open, authentic concern and commitment to addressing your patient’s distress is essential. 2. Determine the meaning and motivation of the statement from the patient’s perspective. The first followup question can be simply “Tell me more” or “What’s bothering you most right now?” or “What can we do to make your life better today?” Box 3

Box 2. Possible positions with respect to medical aid-in-dying participation Taking a position on Prop 106 is not just a “Yes, always” or “No, never” choice. Here are some possible positions. These are not prescribed by the law, but reflect the range of stances taken by physicians and agencies in other states where such laws are enacted. Opt out: “I will not prescribe medical aidin-dying drugs, nor serve as an attending or consulting physician to qualify patients for medical aid in dying, nor will I assist patients in pursuit of it. However, I will provide appropriate care within my specialty and training, including discussing available choices for treatment and care of the terminal condition and any related distress or concerns.” Arm’s length: “I respect my patients’ choices, but I will not prescribe medical aid-in-dying drugs, nor serve as attending physician under the Act. I will provide appropriate care for my patient, including discussing available choices for treatment, care of the terminal condition, and any related distress or concerns. If requested, I will refer my patient to external resources for information about medical aid

in dying and to participating physicians. If my patient decides to ingest life-ending drugs, and I am still involved in the patient’s care, I would like to be informed of the planned death.” Educate and support: “I support my patients’ choices, including a choice for medical aid in dying. I will do my best to identify and address any distress, openly discuss all available options for relief, and provide all needed information. If my patient elects to utilize aid in dying, I will facilitate the process including referring to and coordinating with an attending physician, consulting physician and, if needed, mental health professional. I will not prescribe the medication, but I will remain involved in the patient’s care up to and through death from any cause.” All in: “I will serve as an attending or consulting physician for patients wishing to utilize medical aid in dying, including supervising the qualification process, keeping and reporting required records, prescribing medical aid-in-dying medications and, if desired, being present with the patient at self-administration of the medications and death.”

summarizes some of the likely root concerns of desire-to-die statements. 3. Explore the patient’s goals of care into the future and out to the end of life. What is most important to them during this time? What functions are most important to preserve or support? What activities are most pleasurable? What are their biggest fears, worries, concerns? What are their hopes? A productive discussion around goals requires honest descriptions of illness trajectory and options for treatment, including no treatment, and care. Extra support for family and caregivers can be organized through hospice, assisted living or nursing facility placement, home health, caregiver aides, or volunteer networks. Physicians often skirt difficult talks about prognosis or the end of life for fear of extinguishing hope; however, hope can be reframed in realistic possibilities. These possibilities could include: better quality of life, living until a certain milestone, savoring the pleasures of every day, managing pain and symptoms, spending time with family, reflecting on life’s meaning and rewards, or achieving a peaceful death. 4. Assess for depression and, if indicated, suicidal ideation. Depression is present to clinically significant degrees in 23 to 44 percent of palliative care patients, about 30 percent of cancer patients and 63 percent of patients who are likely to seek medical aid in dying, but it is notoriously under-recognized and difficult to diagnose in patients with terminal illness. Classic symptoms of depression such as fatigue, changes in appetite, or insomnia can be indistinguishable from symptoms of disease. Intermittent depressed mood can be a normative aspect of the anticipatory grief associated with dying. Thus, depressive disorders in seriously or terminally ill patients are best diagnosed by cognitive symptoms such as anhedonia, loss of self-worth, pervasive and unremitting sadness, hopelessness and despair—all of which are also strong risk factors for suicide in indiColorado Medicine for May/June 2017

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Box 3. Possible root concerns of desire-to-die statements and suggested responses “It’s going ok for now, but if I get to the point where I’m wearing diapers, I’m done.” • Fear of future suffering; losses of function, privacy, independence, personal dignity; fear of burdening family members. • “What concerns you most about the idea of wearing diapers?” • Probe specifics of expressed concern; clarify trajectory of illness and likely/unlikely scenarios for the end of life; correct misunderstandings or unfounded worry; look for supports or alternatives to minimize distress. “If all I’ve got is a few months left, what’s the point?” • Loss of meaning, purpose, self-worth and significance. • “What would you most like to do with the time you have left?” “What’s most important in your life right now?” • Encourage activities to support finding meaning, for instance writing an “ethical viduals who are older or ill. Standardized screening for depression can be exhausting for seriously ill patients, and some researchers have found the straightforward question “Are you depressed most of the time?” can be just as accurate as sophisticated assessments. Psychostimulants may offer quicker, more effective relief than antidepressants for patients whose life expectancy is measured in weeks. 5. Assess for and address new or under-treated physical symptoms and pain and respond to other psychosocial-spiritual issues to the extent your skills permit. Refer to other professionals as appropriate. Make referrals to community services or other supports for family and caregivers. Consider formally referring your patient for a hospice evaluation or palliative care consult. Palliative-trained professionals have the most robust toolkit for responding to multifactorial suffering. 6. Reassure your patient that you have heard their concerns and are committed to finding solutions. Develop Colorado Medicine for May/June 2017

will,” life review, guided reminiscence, dignity therapy, reconciliation, reaching out to family or friends, connecting with faith community or leader. “I don’t want my family waiting on me and wearing themselves out for nothing. Isn’t there something you can do?” • Loss of autonomy; loss of “place” or role in the family; burdening family members, specifically financial concerns, work of caregiving, diverting their time or energy from other activities or family members. • “How has your illness impacted your family so far?” “What does your family think about taking care of you?” • Explore practical supports for family caregivers such as hospice, additional paid help, community-based free or low-cost services. Encourage family members to preserve and respect the patient’s role and function in family. a specific plan of care and schedule follow-up appointments as needed. Coordinate with other professionals, services and supports. This process is strongly recommended for patients who express any kind of a desire to hasten death. However, it can be employed proactively to more deeply explore and address aspects of suffering before they coalesce into a cry for help. In the very few cases where the desire to hasten death culminates in a determined and explicit request for medical aid in dying, you may proceed according to your personal values or organizational constraints, but always with respect and compassion. n Endnotes 1. As an example, a study of patients in Oregon who would have been eligible for physician-assisted death but did not pursue it found that for every 1 person who ingested lethal drugs under the law, 9 made a serious first request to their physicians, and 200 considered it (Tolle, Tilden, et al., 2004). 2. Financial worries are almost never cited by patients as a motivating concern;

“Can’t you just give me that knock-out pill I’ve been hearing about?” • Seeking reassurance that you would take a request seriously; “testing the waters;” looking for information about how the medical aid-in-dying law might work; may also indicate current suffering; don’t neglect the possibility that the question expresses suicidal intent. • “What’s bringing this up for you right now?” “Have you had a change in your symptoms or are there other things you’re concerned about?” “What can we do for you now to make things better?” • Explore motivation for question; offer information, if requested, in neutral, factual manner; discuss briefly your position on prescribing lethal medications while still validating patient’s concerns and your commitment to providing care; address new or worsening symptoms. If indicated, assess for suicidal ideation. however, they may play a role in the perception of being a burden on family. 3. Monforte-Royo, Villavicencio-Chávez, Tomás-Sábado, & Balaguer, 2001, p. 799. 4. Chochinov, 2001. See the extended list of endnotes at www. cms.org/articles/prop-106-may-june. Jennifer Moore Ballentine, MA, is president of The Iris Project (www.irisproject. net), an independent health care consulting company based in California but serving clients nationwide. With deep roots in Colorado, Ballentine held several leadership positions in hospice and palliative care education in the state, notably as executive director of Life Quality Institute. Immersed for several years in the research, policy and clinical implications of medical aid in dying, she has been closely involved with provider education on the California End-ofLife Option Act and observing close-up the operational and ethical challenges medical aid in dying presents. Since mid-January, she has offered 11 all-day programs on the Colorado End-of-Life Options Act in nine locations around Colorado. 31

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Making a difference Kate Alfano, CMS Communications Coordinator

CCVMS partners with local PA program to support students and community The Clear Creek Valley Medical Society (CCMVS) has partnered with the Red Rocks Community College Physician Assistant Program to connect area physicians with physician assistants (PAs) early in their training and careers, and strengthen working relationships among the health care team. During a strategic planning session, CCVMS board members expressed the need to put more of their resources toward supporting local community programs. Because neither of the Colorado medical schools is contained in the counties comprising the society, they turned to the RRCC PA program –

a highly regarded institution with which they were already involved. The RRCC PA Program is fully accredited and has graduated physician assistants since 2000. In the fall of 2017, they will matriculate their first Master’s degree cohort. The program previously offered Master’s level curriculum through a partnership with St. Francis University in Loretto, Penn., but Colorado legislation was changed in 2013 to allow the RRCC PA program to be the only community college in the nation to offer a Master’s degree. The RRCC PA program is housed on the Arvada campus of Red Rocks Community

“The students, who are probably local area residents, know that local area physicians want to be involved with them and help put them through the program – we want to support them. And that’s pretty important.” - Stephen Boucher, CCVMS Executive Director College, and the mission of the program focuses on primary care training and serving underserved populations. There are two phases to the CCVMS/ RRCC PA program partnership: a preceptorship program that brings PA students into local physician practices and a new annual CCMVS scholarship for a RRCC PA student. Students who enter the preceptorship program receive valuable, real-world experience in a local physician’s practice, and CCVMS physicians who agree to precept PA students receive help with introductory medical skills that frees up time for existing personnel.

A Red Rocks PA student practices pediatric exams on “bring your child to class” day. 32

“We can show that having physicians involved early in a PA student’s career, Colorado Medicine for May/June 2017

Features whether academic or professional, is great for not only future PAs but for the physicians themselves,” said Stephen Boucher, CCVMS executive director. “Especially in an advocacy light, physicians do an inadequate job of having good resources to connect with nurse practitioners or advanced practice nurses, so when we get to the legislative battles on scope of practice, it feels like we are two sides battling instead of all being on the same team. … We now know that it’s better for everyone if physicians have an earlier touch in these students’ careers.” “This partnership provides more opportunities for our students to train with well-respected physicians in our community,” said RRCC PA Program Director Christa Dobbs, MPAS, PAC. Students are required to have at least 2,000 hours of paid health-carerelevant experience prior to applying for the program and, as a result, are well prepared for clinical rotations. “We are committed to providing the best clinical experiences with the best providers to uphold the reputation of our program, our graduates and students,” Dobbs continued. “I see our partnership providing more practicing PAs for the west-Denver metro area and building PA-physician partnerships that benefit patients and practices. The strength of our program is built upon the strength of our clinical partnerships.”

program keep tuition as low as possible but they do so much with it,” Boucher said. “The total cost of the degree is $65,000 – very much on the low end compared to other programs. Also, a typical PA program lasts two years but theirs is 27 months to allow for more flexibility for their students’ lives.” “We knew with this scholarship we could have a big impact,” he continued. “The students, who are probably local area residents, know that local area physicians want to be involved with them and help put them through the program – we want to support them. And that’s pretty important.” CCVMS will hold a dinner presentation on the preceptorship opportunity on May 18 at CCVMS offices in Lakewood, and they will hold a fundraiser for the scholarship program on June 4 at Addenbrooke Park in Lakewood. For more information on these events or how to get involved, go to www.ccvms.org or contact Stephen Boucher at stephen. boucher@ccvms.org. n

“I see our partnership providing more practicing PAs for the west-Denver metro area and building PAphysician partnerships that benefit patients and practices. The strength of our program is built upon the strength of our clinical partnerships.” - RRCC PA Program Director Christa Dobbs, MPAS, PA-C

The scholarship, currently funded at $2,000 but with the potential for higher awards in the future, is available to any RRCC PA student and makes a difference in their educational expenses. Funds go directly to the awardee. The program has a non-traditional student base: Many are older with families, and who have a health care background but are starting their second or third career. Their cohort size is 32 students and typically 30-31 graduate. Boucher says the high graduate rate, as well as a higher likelihood of the student remaining in the area after graduation, reinforces the case for CCVMS investment. “The administrators of the Red Rocks Colorado Medicine for May/June 2017

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Telligen and QPP: Here to stay By Lyndsay Fluharty, MA, Senior Marketing and Communications Consultant, Telligen

Providing quality improvement support to physicians Perhaps you’ve heard the name Telligen mentioned a few times over the past couple of years – at a conference, maybe a guest speaker for a Colorado Medical Society presentation, or possibly someone from Telligen stopped by your organization.

The QPP will reimburse physicians and other clinicians participating in Medicare and ultimately provide them with the opportunity to earn more by focusing on quality patient care. The details of the program are meticulous; therefore, the federal CMS has enlisted QIN-QIOs across the country to assist in the transition. Telligen is a national health management solutions organization based in Des Moines, Iowa. In August 2014, Telligen acquired a majority of the Colorado Foundation for Medical Care’s (CFMC’s) health care quality improvement contracts with the Centers for Medicare and Medicaid Services (federal CMS). The integration brought together two organizations, both executing the health care quality improvement work as part of 34

the federal CMS’ Quality Improvement Organization (QIO) program. At the time of the union, the agency was also transitioning into a regional model for the QIO work, which now calls the multistate model Quality Innovation NetworkQuality Improvement Organizations (QIN-QIO). Today, Telligen holds the QIN-QIO contract for Colorado, Iowa and Illinois, as well as other federal quality-improvement-related work in five other states. As part of the QIN-QIO work, Telligen offers cost-free quality improvement assistance to health care providers by offering technical assistance, convening learning and action networks for sharing best practices, and collecting and analyzing data for improvement. By aligning statewide partners, Telligen supports ongoing health care initiatives to create a higher value health care system and better coordination of care. Since the beginning of the contract, Telligen has been working with clinicians and home health agencies to improve the cardiac health of Medicare beneficiaries; working with communities to provide diabetes self-management classes to rural and underserved populations, and partnering with pharmacies and nursing homes to decrease the use of unnecessary antipsychotic medications. As of last fall, Telligen began partnering with outpatient settings to create antibiotic stewardship programs to fight the spread of antibiotic resistance. Quality Payment Program A central element to Telligen’s work is the newly implemented Medicare Quality Payment Program (QPP), which was passed in 2016 with bipartisan support

and began in January of this year. The purpose of the QPP is to give clinicians the tools and resources they need to serve the more than 55 million Americans who receive health care through Medicare. The QPP is a shift to highvalue, patient-centered care over volume. The program is designed to reimburse physicians and other eligible clinicians participating in Medicare Part B and provide them with the opportunity to earn payment incentives based on evidencebased and practice-specific quality data. The QPP will reimburse physicians and other clinicians participating in Medicare and ultimately provide them with the opportunity to earn more by focusing on quality patient care. The details of the program are meticulous; therefore, the federal CMS has enlisted QIN-QIOs across the country to assist in the transition. Aspects of the QPP in which Telligen can provide support include: navigating the requirements of the incentive-based performance categories, assistance in the selection of applicable reporting measures, education on successful implementation of improvement activities, and the virtual availability of experts to provide tailored technical assistance. There are many nuances to the QPP, thus making it feel like additional work. “The intent of the QPP is to release the reporting burden for practices. Since the program isn’t going away, our job is to provide technical assistance and set practices up for success,” said Courtnay Ryan, quality improvement facilitator at Telligen, To streamline the process, Telligen has Colorado Medicine for May/June 2017

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AMA recommends regulatory changes to improve the Quality Payment Program At the request of the Centers for Medicare and Medicaid Services, the American Medical Association has provided recommendations for changes to the regulatory structure of the Quality Payment Program (QPP) that the agency created to implement the Medicare payment and delivery system changes called for in the Medicare Access and CHIP Reauthorization Act (MACRA). The input is timely as federal CMS officials are currently working on QPP regulations. The suggestions were developed with input from the specialty and state medical society representatives who serve on the AMA MIPS and APM work groups. The AMA will also be working with these groups to identify possible legislative initiatives to improve the program. Below is an abbreviated list of recommendations. See the full list on www.cms.org. Merit-based Incentive Payment System (MIPS) • Establish a more gradual transition period. • Promote successful participation. • Simplify MIPS scoring. Quality • Maintain the reporting thresholds. • Maintain a minimum 90-day reporting period. • Maintain minimum point floor for reporting on measure(s). • Reduce the number of required measures to three. • Eliminate administrative claims population health measures. • Allow specialties to exercise flexibility and innovation in Qualified Clinical Data Registries (QCDRs). • Eliminate the requirement of end-to-end reporting to receive bonus points. • Eliminate requirements to report one outcome or high priority measure.

partnered with the Colorado Medical Society and other organizations across the state to create a top-notch coalition of QPP experts. “The Colorado QPP Coalition is an amazing group of people across the state, dedicated to making sure all Colorado practices succeed. We are very fortunate in Colorado – I’ve never been a part of such a truly collaborative effort,” Ryan said. If you have additional questions about Colorado Medicine for May/June 2017

• Allow specialty societies the opportunity to determine when a measure is relevant to their specialty. • Improve transparency around “topped out” measures. • Release MACRA measure development funding. Cost • Keep the cost category’s weight in the composite score at zero in 2018. • Create and expand a pilot program in years three through five. Meaningful Use/Advancing Care Information (MU/ ACI) • Maintain a 90-day reporting period. • Remove mandate to update versions of Electronic Health Records (EHRs). • Avoid a one-size-fits-all approach. • Avoid duplicative reporting on technology. • Expand facility-based exemptions. Improvement Activities (IA) • Allow flexibility in performing activities. • Avoid complex reporting requirements. • Create stability in program requirements. • Increase the weight of the IA category. MACRA Alternative Payment Models (APMs) • Do not increase the current nominal risk threshold. • Increase flexibility for medical home models. • Increase opportunities for physicians to succeed in MIPS through APM participation. • Adopt physician-focused APMs. Interoperability • Increase the transparency around EHR costs. • Prohibit vendor data blocking. • Refocus ONC’s Certification Program.

QPP, visit the Colorado QPP Coalition website at www.cms.org/coqpp. If you have questions about Telligen’s work or would like to partner with Telligen on their other quality improvement initiatives, visit www.telligenqinqio.com. The QPP is more than physician reimbursement — it is the future of our health care system. And for that reason, Telligen is here to stay. n

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

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

Kate Alfano, CMS Communications Coordinator

Sail away to fun, socializing, education and more at the 2017 CMS Annual Meeting in Breckenridge Fun, collegial and informative. These three words summarized last year’s reengineered CMS Annual Meeting and our 2017 annual meeting workgroup is already hard at work to build on its successful format that emphasized social events and professional development sessions. The 2017 meeting will be held Sept. 15-17 at Beaver Run Resort in Breckenridge, and we hope you and your family will make plans to join us. As always, there is no registration fee for members and we have secured discounted group pricing on lodging at the resort. Once again, our annual meeting will be entirely devoted to celebrating the community of medicine, bringing Colorado physicians together for social, clinical and intellectual stimulation. Attendees will experience informative panel discussions and worthwhile workshops on the hottest topics in medicine, led by an impressive slate of state and national speakers, including: • End-of-life care, • Loose change/Compassion fatigue with live actors, • Cyber security and telehealth, • Practice transformation, • Alternative practice models, 36

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

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

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ANNOUNCING THE CANDIDATES FOR THE AUGUST 2017 ALL-MEMBER

ELECTION OF CMS OFFICERS All Colorado Medical Society members are eligible to elect CMS officers via electronic ballot.

The candidates for 2017-2018 office are: President-elect Deb Parsons, MD AMA Delegates/ Alternate Delegates David Downs, MD Henrique Fernandez, MD Carolynn Francavilla, MD Jan Kief, MD Rachell Klammer, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MD Patrick Pevoto, MD, RPh, MBA Brigitta Robinson, MD Michael Volz, MD Matthew Wynia, MD

Be sure to read the next issue of Colorado Medicine for information on the candidates, including their biographies and personal statements. Colorado Medicine for May/June 2017

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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 US Fleet Associates 303-753-0440 or visit www.usfacorp.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit www.copicfsg.com * CMS Member Benefit Partner Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com LendKey â&#x20AC;&#x201C; Student Loan Refinancing 888-549-9050 or visit www.LKrefi.com/co-med * 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 GreenLight 866-602-1778 or visit www.Greenlight.md *CMS Member Benefit Partner MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, or visit www.medjet.com/cms *CMS Member Benefit Partner

PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit www.alnmm.com Carr Healthcare Realty 303-817-6654 or visit www.carrhr.com Dynamic Physician Billing Solutions 303-913-0508 or visit www.dynamicphysicianbilling.com Eide Bailly 303-770-5700 or www.eidebailly.com/healthcare First Healthcare ComplianceTM 888-54-FIRST or visit www.1sthcc.com *CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit www.medteleco.com * CMS Member Benefit Partner The 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 TSI 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner

MEDICAL PRACTICE SUPPLIES AND RESOURCES, CONT. University of Colorado Hospital/CeDAR 877-999-0538 or visit www.CeDARColorado.org

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Leadership skills series Chet Seward, Senior Director, Division of Health Care Policy

Multi-generational leadership: Thriving in the workplace At the second Physician Leadership Skills Series on April 22, CMS members learned practical, real-world strategies for effective teamwork based on identifying the generational attributes of staff members and capitalizing on each generation’s assets. Speaker David Remson, who has been teaching, training and learning about the multi-generational workplace for over 15 years, defined the working generations: • Baby Boomers, born 1946-1964, • Generation X, born 1964-1982, • Millennials, born 1982-2002, and • Post-Millennials, or Generation Z, born after 2003. As he explained, four generations working side by side presents unique challenges to achieve maximum productivity, efficiency and employee engagement while avoiding generational culture clash. Millennials expect transparency, participation, collaboration and affiliation. Engaging Millennials means

deploying cooperative collaboration, giving them multiple tasks, giving them lots of attention, and fostering “everyone wins” scenarios. Offer coaching, build mentor relationships and ask for their ideas. Millennials can contribute to the workplace by learning to observe, listen and respect others’ knowledge. Generation X is squeezed between Millennials and Baby Boomers. They prefer directness, sincerity, technology, compensation and independence. Managing Gen X takes finesse: focus on tangible rewards and results, and try not to micro-manage. Gen Xers can work on being approachable, asking for others’ input, giving feedback and celebrating milestones. Baby Boomers are facing a big decision, to “retire or rewire.” Engaging Boomers means being friendly and welcoming, acknowledging and recognizing their contributions, allowing them process time and being inclusive. Don’t manage Baby Boomers; rather, consult with them, give them lead-

ership opportunities and emphasize teamwork. Boomers can help by being available, not taking things personally, working to modernize, and engaging the team in decision-making. Generation Z is coming soon. This generation will likely not drive, want to work full-time in a physical workplace, or use cash, email or postage stamps. To attract Gen Z, it’s important to focus on culture, creativity, recognition, connectedness and meaning. Regardless of which generations comprise a physician’s team, Remson advised attendees to create an environment of inclusion, talk to the team about accommodating differences, and learn more about the strengths of each generation: embrace generational differences as an opportunity. Make plans to attend future Physician Leadership Skills Series events online or in person. See the full schedule, register for an upcoming program and learn more at www.cms.org/events/ leadership-skills. n

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

Colorado Medicine for May/June 2017

Inside CMS

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

COPIC’s 2017 education seminars Gain valuable knowledge and earn COPIC points Each year, COPIC offers an array of in-person seminars that are designed for medical providers and feature expert speakers. These seminars are scheduled at locations across the state, generally last an hour, and enable attendees to earn COPIC points, which apply toward an annual premium discount. COPIC’s physician risk managers and legal team oversee the development of content for these activities. This involves a rigorous process to identify topics based on insight drawn from claim reviews, input from our staff, recent trends in health care, feedback from insureds, and current medical literature. The following are some key categories of seminars with examples to illustrate the types of education activities available. 1. Communication, Teamwork and Systems—Claims experience shows that effective communication skills are directly related to a decreased risk of claims and lawsuits. These seminars are designed to strengthen the communication skills of medical professionals and provide a greater understanding of interpersonal interactions in the medical setting. • Diagnostic Errors—Thinking Like Sherlock—This seminar explores the issues associated with diagnostic errors. Participants will discuss the importance of diagnostic errors and review examples of these types of errors. In addition, we examine the different root causes of biases and describe practical suggestions to improve your diagnostic process. • Difficult Clinician-Patient Encounters—This seminar uses interactive, case-based vignettes to teach you how to improve your techniques with difficult patients. It focuses on determining what constitutes a difficult patient interaction, then describes how to diagnose relationship issues and formulate a skill set to use in difficult encounters. 2. Patient Safety and Medical Legal Curriculum—These seminars focus on key issues related to patient safety and risk management that addresses common areas where liability concerns often emerge. Several activities are updated annually to reflect current trends in health care. • Maximizing Safe and Effective Practice with PhysiColorado Medicine for May/June 2017

cians, PAs and NPs—This seminar reviews the regulatory and scope of practice elements that are the most important for safe and effective practice involving PAs and NPs, along with the physicians who work with them. • The Opioid Crisis Part I—The Pain that Won’t Go Away; and Part II—Strategies for Reducing the Burden—Part I examines the scope of the opioid problem based on guidance from the CDC, FDA, medical boards and other best practices to describe practical approaches to practice more safely with opioids. Part II reviews the reasoning and criteria for opioid dose reduction and discontinuation while teaching techniques to encourage patient buy-in with a focus on overcoming fear and resistance. 3. Legal Aspects of Medicine—COPIC draws upon the expertise of its legal team and attorney partners to offer these seminars as opportunities to gain valuable insight on top legal issues. • Developments in Colorado Telehealth Law—This seminar helps you learn and understand the ins and outs of telehealth law in Colorado. It focuses on identifying the myriad of definitions and terminology associated with telehealth followed by a discussion about state and federal regulations influencing the practice of telehealth. • HIPAA: Into the Breach—Learn what to do in an emergency breach situation and develop strategies to help prevent it from happening. Participants learn to recognize the appropriate steps to take when responding and how to remain in compliance with the HIPAA Privacy, Security and Breach Notification Regulations. Sharing knowledge with others is essential to improving medical outcomes. COPIC remains committed to investing time and resources to develop education that supports medical providers and their efforts to stay informed. Visit www.callcopic. com/education to learn more about the education seminars that COPIC offers and to register for upcoming activities. n

Inside CMS

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

Sarah Axelrath University of Colorado School of Medicine

Sarah Axelrath is a Colorado native and fourth-year medical student at the University of Colorado School of Medicine. Sarah grew up with a love of reading and writing and continues to wonder what we can learn about healing our patients and ourselves through the act of writing. Sarah is inspired by physician-authors such as Danielle Ofri, Paul Kalanithi, Abraham Verghese, Sherwin Nuland and Siddhartha Mukherjee, who revitalize and renew her love of medicine. She is looking forward to residency and the start of a career as an urban/underserved primary care doctor.

My first patient The first patient I ever took care of was a corpse with pink toenails. On the day of our first meeting, however, I had only one piece of certain historical information: She was dead. As I stared down at her, the fluorescent lights radiating from above seemed to reflect off of her pale, waxy body, making it shine almost luminescent on the cold, stainless steel table. Gritting my teeth, I made the first opening incision down the midline of her back from the base of her skull to her sacrum. I remember feeling confused by the sensation of her flesh beneath my fingers as they pulled her skin taut under the scalpel. Human 42

flesh, at once familiar and alien. The impossibility of these dual realities clashed in my brain as I tried to focus on my task for the next four hours, to neatly enter the dura mater of the spinal cord and isolate just one of the elusive, delicate, and easily destroyed dorsal root ganglia. With a stiff exhale, I bent my head to the grim work of getting to know this very first patient. Over the next 12 weeks, my three teammates and I dutifully probed, sliced and sawed our way to a deeper understanding of the mechanism of the human body. We worked section by section, progressing from the back to the abdomen to the limbs. Finally, after weeks spent carefully dissecting the musculature of the thigh, delicately unraveling formaldehyde-soaked gauze as we inched our way down the lower leg toward the ankle, we deliberately unwrapped our patient’s left foot and were greeted by a sight even more jarring than that of a dead foot on a table: a dead foot on a table adorned with impeccably painted, sparkly pink toenail polish. The unexpected discovery of a characteristic so unique, so charmingly human, so carefully concealed by a patient I thought I had come to know intimately, humbled me in that moment, as it would two years later when I rotated through my clerkships. The memory of those pink toenails haunted me in clinics and on the wards as I constantly wondered what my patients weren’t sharing with me, what I was failing to elicit from them. What was the man with atypical chest pain in room 824 afraid to ask me? When was the last time the woman with fibromyalgia in room 2 thought about suicide? What unique, charmingly human, carefully concealed mysteries had contributed to their hospitalization or would shape their course to safe discharge? These are the questions that aren’t covered on the shelf exam when, as third-year medical students, we transplant our learnColorado Medicine for May/June 2017

ing from the lecture hall to the bedside. At the bedside, patients become our teachers and their living bodies the cryptic texts that we’ll spend countless hours learning to decipher, as we once did the corpses. William Carlos Williams, the renowned physician-poet, described medicine as “the thing which gained me entrance to these secret gardens of the self,” but I counter that third-year medical students are more likely to find this entrance, like so many aspects of learning clinical medicine, obscured. Patients don’t tell medical students about their pink toenail polish, and so we may never learn about the loving daughter who took unpaid leave from her job in order to provide 24-hour care for her ailing mother; who spent anxious, insomniac nights gently painting those toenails as her dying mother slept too peacefully. These stories are the mysteries that reveal themselves to us under only the most careful, deliberate, unraveling hands. These are their stories, and now ours. n

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Colorado Medicine for May/June 2017

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Departments Inside CMS

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

Learning about the doctor-patient partnership Natalie Poliektov, Rocky Vista University School of Medicine At the patient’s one-year post-treatment visit, he sat with his wife in the oncology clinic at Porter Adventist Hospital awaiting the results of his lymph node biopsy. He had received his cancer treatment through a clinical trial, and I was his Clinical Research Coordinator. He had been in remission from Diffuse Large B Cell Lymphoma for the past year but felt a lump in his neck and was worried the cancer had returned. After we completed the research portion of his visit, we sat in silence for a few minutes. I flipped through his research chart with all of the notes I had taken during each of his prior visits. I saw the stack of chemotherapy infusion notes and imaging reports taken throughout the duration of his treatment and follow up; I saw the tables of adverse events and concomitant medications he had been given to relieve his symptoms. All of his follow-up results until today had been positive news. The oncologist knocked on the door and entered the room. He had a copy of the pathology report in his hand. He spoke calmly: “The biopsy report shows recurrent lymphoma.” The patient looked down for a few moments while his wife quietly wiped the tear that rolled down her cheek. He collected himself and asked, “So what does this mean?” The physician looked at me and confirmed what he knew: Since the patient had relapsed, he was to be withdrawn from the research study and followed clinically. The oncologist then discussed the patient’s options with him. He was an older man who had a really hard time with chemotherapy; he constantly received dose reductions and was hospitalized often for severe symptoms. He could attempt second line chemotherapy, receive palliative treatment to ease pain, or do nothing. They talked in more detail about the specifics, and the physician told the patient to discuss the options with his family and come back in a couple days once he had decided. I later spoke with the physician who told me the patient did not wish to undergo any further treatment. 44

I did not envy the patient for the difficult decision he had to make. I imagined how devastating it was to hear this news, especially after being cancer-free for the last year. And I empathized with his wife: What would I have done if this were my husband? I also did not envy the physician. Breaking bad news to a patient – someone you have seen regularly for over a year, someone you have seen suffer through treatment and then celebrate being in remission — has to be heartbreaking. At the time, I assumed the physician would jump to treating him again; I believed it was the duty of the physician to do everything in his power to cure the patient’s disease. If the physician wanted to, I’m sure he could have convinced him to try second line chemotherapy. I didn't understand why he let the patient do nothing when he knew he would succumb to his illness. Perhaps I was biased because I wanted the patient to undergo treatment and enter remission again. Importantly, the oncologist understood the patient’s unique condition. His treatment goals were specific to that patient in that situation. He appreciated that the patient had suffered with chemotherapy before, and that he was competent and able to make his own decision about his health. He gave the patient options and respected his wishes. He considered his quality of life and the potential impact more chemotherapy would have on him and his wife. When I was able to realize this, my paradigm changed. I have always believed that the doctor should provide compassionate care of the highest caliber. I now understand and appreciate the meaning of medicine being a partnership. It is easy to assume the physician knows best; after all, the physician knows about evidence-based medicine and the likelihood that a patient will respond to treatment. However, this view ignores the most crucial element: the individual patient. It is up to the patient to consider the emotional, physical and financial commitments that his care will require. If patients are well informed about their conditions and the future implications of their conditions, perhaps we can foster a world rooted in health and informed decision making. n Colorado Medicine for May/June 2017

Departments

medical news CMS presents forums for Fremont County and Western Slope physicians

AMA offers opioid guidance to doctors The American Medical Association Task Force to Reduce Opioid Abuse released new recommendations for physicians to promote safe use, storage and disposal of prescription opioids. These new recommendations are part of the Task Force’s ongoing efforts to empower and enable physicians to take steps that can help reverse the nation’s opioid epidemic.

Physicians in the region of the Fremont County Medical Society attended a Colorado Medical Society Regional Forum on April 11, enjoying refreshments and socializing, as well as dialogue on policy priorities in the state legislature, changes coming in practice management, CMS resources for physicians, and more. The event was held at Le Petit Chablis in Cañon City.

“These new recommendations can further reduce the amount of unwanted, unused and expired medications – making their diversion to nonmedical use much less likely,” said Patrice A. Harris, MD, MA, chair of the AMA Board of Trustees and chair of the Task Force. “By taking these important steps, physicians can communicate common-sense approaches to their patients that can directly reduce the potential for harm.” The recommendations are:

On the Western Slope, physicians in Delta County Medical Society and Curecanti Medical Society attended a regional forum at the Mountain View Winery in Olathe on April 20. Interested in scheduling a regional forum in your area? There is no better way to let CMS know what matters to your practice than to hold a face-to-face gathering with CMS leaders in your community. CMS staff will help plan the details, especially if your component society is not active. Email president@ cms.org or call 720-858-6321 to schedule a 2017 Regional Forum today. n

Colorado Medicine for May/June 2017

• Physicians should talk with their patients about the safe use and storage of prescription opioids. More than 70 percent of people misusing opioids are getting them from family and friends. Diversion of these drugs is illegal and may be deadly. • Physicians should remind their patients to store medicines so children can’t reach them and others would have difficulty finding or stealing them. • Physicians should urge their patients to safely dispose of expired, unwanted and unused medications. Patients should take advantage of local “take back” programs, mail back programs, and medication drop boxes at police stations and pharmacies. The new recommendations can be downloaded at www.ama-assn.org/ opioids-disposal. n 45

Departments

medical news Medical students meet to discuss priorities

The Medical Student Component of CMS met on March 30 at the Lowry Beer Garden to discuss the priorities for each medical school. The discussion was facilitated by Brandi Ring, MD, a member of the Young Physicians Section. They also discussed special student-focused public policy programming at the 2017 Annual Meeting in September. n

AMA convenes roundtable of Colo. physicians and consumers and politics to the “real-life” impact on people – patients and their families, and the physicians who care for them. n

Six Colorado physicians met with six patients at Colorado Medical Society headquarters on April 18 to share stories about the personal impact of health system reform. The facilitated roundtable conversation was convened by the American Medical Association. The AMA captured these stories on video and aim to use them to help refocus the debate about the future of health system reform from policy

CMS Immediate Past President Mike Volz, MD, participates in the AMA Colorado Health Care Reform Rountable.

Levine retires from position as chief medical officer of Centers for Medicare and Medicaid Services Region VIII Mark A. Levine, MD, has retired from his position as chief medical officer for the Centers for Medicare and Medicaid Services Region VIII, which Mark A. Levine, MD he held for 14 years. In this capacity, he was active in developing and maintaining agency initiatives in clinical quality, payment reform, value-based payment and delivery system innovation. “The work of improving health and health care is very challenging and a critically important calling,” he said. “I am proud to have been your partner.” The Centers for Medicare and Medicaid Services is the federal agency 46

responsible for administering Medicare and partnering with states to administer Medicaid and the Child Health Insurance program. Region VIII, located in Denver, Colo., has responsibility for the states of Colorado, Utah, Wyoming, Montana, North Dakota and South Dakota. As the regional chief medical officer he advised the regional administrator on health care policy and served as clinical advisor to all program areas within the agency. He conducted data analysis and participated in activities to assess and improve the delivery of services. He also served as liaison to the health care community and its professionals and institutions. In addition to regional activities, he contributed to the development of national programs and activities such as evolving measures of physician resource use

for the merit-based incentive payment system (MIPS); serving on the steering committee for the Center for Medicare and Medicaid Innovation (CMMI); developing the Medicare Shared Savings Program (accountable care organizations); developing the curriculum of the Innovation Advisors Program and serving as a mentor and faculty lead; and serving as a reviewer and operational advisor for the Health Care Innovation Awards program, the Comprehensive Primary Care Initiative, and the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. He has been a clinical professor of medicine in the division of geriatrics at the University of Colorado Anschutz Medical Campus since 1968. He founded the Colorado Patient Safety Coalition and practiced general internal medicine in the Denver area for over 20 years in a variety of practice settings. n Colorado Medicine for May/June 2017

Departments

medical news Boulder County physicians engage legislators at annual Legislative Forum

Spike in Colorado heroin use, overdose leads to partnership As heroin use continues to climb in Colorado and across the country, a recently formed multi-agency work group has released a report providing a detailed look at usage, overdose and treatment data. “Law enforcement has seen significant increases in incidents of heroin seizures and arrests across the state,” said Tom Gorman, director of the Rocky Mountain High Intensity Drug Trafficking Area and co-chair of the multiagency work group. “We must work to reverse this trend, not only for current heroin users and their families, but also to prevent others from experiencing the tragic outcomes of addiction.” The report, “Heroin in Colorado,” also includes a survey of Colorado heroin users conducted at methadone clinics across the metro area. Survey results provide a rare glimpse into users’ perspectives, including why they use heroin, how their addiction began and what obstacles they faced trying to end their addiction.

The Boulder County Medical Society held its 2017 Legislative Forum on March 23, giving physician members a unique mid-session opportunity to discuss the hottest topics of the Colorado General Assembly with their elected officials. Physicians and invited Boulder County legislators enjoyed great food, drinks and conversation, moderated by CMS CEO Alfred Gilchrist. Top: BCMS Immediate Past President Leto Quarles, MD, engages with the speaker. Bottom: BCMS member David Morrissey, MD, of Boulder Valley ENT, poses a question. n

Colorado Medicine for May/June 2017

In addition, the report details some of the health effects of heroin use, including disease transmission as a result of shared needles and the increase in neonatal abstinence syndrome, which occurs when babies are born opiate dependent. The comprehensive report was compiled by the Heroin Response Work Group, which includes representatives from the Drug Enforcement Administration, Rocky Mountain High Intensity Drug Trafficking Area,

Medical news (cont.) the Colorado Department of Public Health and Environment, Colorado Department of Human Services, the Colorado Attorney General’s Office and the Colorado Consortium for Prescription Drug Abuse Prevention. Report highlights include: • Heroin-related deaths among Colorado residents doubled between 2011 and 2015. • There was a 2,035 percent increase in the number of heroin seizures between 2011 and 2015. • Between 2011 and 2015, there was an 80 percent increase in the number of hepatitis C virus cases among people ages 15 to 29 years old. Hepatitis C often is contracted when needles are shared. Results in the report from the methadone clinic study show: • Heroin use spans demographics. While the income and age range of respondents varied, many current or former heroin users reported having a college education, living in their own home and being employed. • Seventy percent of respondents said prescription painkillers played a role in their decision to use heroin. • When asked what could have prevented their heroin use, respondents said they might not have used heroin if they had never taken pain pills, had different friends or had more education about the effects of drug use. “Colorado has an opportunity to be a model for the rest of the country in bringing law enforcement, treatment, recovery and prevention together in a true partnership to address the heroin problem,” said Larry Wolk, MD, executive director and chief medical officer of the Colorado Department of Public Health and Environment. “Each of our agencies recognizes collaboration is vital if we want to see reductions of heroin and other opioid use in coming years.” n

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

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Features

the final word Matthew Wynia, MD, MPH, FACP

Health care reform and our shared professional ethics Not long ago, reports of unsafe and poor quality care proliferated, and a dysfunctional malpractice system prevented the learning necessary to improve. Millions of Americans were locked in jobs for fear of losing their insurance. Others found their coverage didn’t include basic needs like mental illness or pregnancy care, or their insurers found creative ways to rescind coverage after illness arose, or health plans would cut off coverage when a patient with a devastating illness reached a lifetime coverage limit. Many millions of people, especially the roughly 30 million Americans with a pre-existing condition, were priced out of the insurance market altogether, leading to almost 50 million Americans having no health insurance. In those days, I frequently had to tell uninsured inpatients that our hospital was functionally unable to provide any follow-up outpatient care – they would have to seek care at the county hospital and figure things out on their own after discharge. Those conversations were heart wrenching, and they were guilt-inducing. One need not be an old-timer to remember the bad old days of 2013. Today, the situation is far from perfect – there are physicians who say some trends have even gotten worse, with persistently strained state Medicaid budgets, rising premiums, narrow physician panels and high deductibles – and the threat that they could get much worse again is very real. Organizations that have proven extremely valuable in developing safer and more effective and efficient care are at significant risk. Recent budget proposals include the complete elimination of the federal Agency for Health Care Research and Quality (AHRQ). The Patient Centered Outcomes Research Institute (PCORI), created by the Affordable Care 50

Act (ACA), is on the chopping block along with the rest of “Obamacare.” Replacement plans for the ACA might let insurers charge much higher prices for people with pre-existing conditions and coverage could, once again, exclude very basic services. Even the NIH and the CDC are endangered by proposed massive funding cuts. Perhaps worst of all, tremendous uncertainty reigns in the health care world. And yet, this is also a time of remarkable opportunities. Having worked so painstakingly and for so long on the digitization of health care, some doctors are finally poised to actually capitalize on information technology. It’s possible that big data, deep learning and new partnerships could emerge that might help us create continuously learning health care systems. What’s more, many novel technologies, from genomics to pharmaceuticals to surgical approaches and devices, are raising hopes for improvements in human health and wellbeing that were only recently the stuff of science fiction. How any of these issues will evolve is uncertain, but three things are clear: the threats are not new, every risk also brings opportunities, and our profession is ready. We are ready because organizations representing physicians, including CMS and the AMA, have been toiling in the trenches of health reform battles for many years. And we have known the challenges we faced would not end, because improving the health care system is a complex adaptive challenge, not amenable to simple or quick fixes. In a complex adaptive challenge, every proposed solution, even if worth pursuing, can be expected to raise new issues

and problems of its own. That’s why health reform is almost always about taking small steps forward, sideways and sometimes backward – it’s never about one big change that will solve everything. Treating complex adaptive challenges as merely technical problems that can be fixed with a single intervention would reflect a fundamental misunderstanding of the type of problem we face. Most importantly, CMS and AMA leaders have realized that the hallmark of complex adaptive challenges like reforming health care is that different groups of people see them very differently, typically disagreeing on the basic causes of problems as well as on most proposed solutions. In that light, our organizations recognized an existential risk of increasing tribalism in medicine around specialties or around political parties as health care reform options are discussed, rather than professional coalescence around our shared core values. In response, several years ago we moved beyond simply responding to and arguing about individual proposals, to articulating sets of shared core ethical principles to guide our actions, regardless of the particular problems or opportunities that might arise. CMS created a comprehensive matrix of principles to guide advocacy and policy around health reform, emphasizing universal coverage, access to a basic set of health care benefits, transparent and participatory quality reporting and more. Medicine will continue to face challenges and opportunities, both in politics and in science – that is the nature of the important work we do. The patients we serve are counting on us to work together, and to hold fast to the ethics that guide our profession. n Colorado Medicine for May/June 2017

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