September-October 2015 by Colorado Medical Society

September/October 2015

Volume 112, Number 5

Physician voice,

patient advocacy Award-winning publication of the Colorado Medical Society

Colorado Medicine for September/October 2015

contents Sept/Oct 2015, Volume 112, Number 5

Features. . . 14

Legal brief–In February, the U.S. Supreme Court ruled that a state board, with certain conditions, must be actively supervised by the state in order to enjoy state action antitrust immunity. The AMA was disappointed with the ruling and presents an analysis of the ruling and implications it has on regulating professionals.

Telehealth primer–Now that the Colorado legislature

CPEP celebration–CPEP (the Center for Personalized

Health care reform–Perry Dickinson, MD, talks about two timely opportunities for primary care physicians to participate in exciting new health care reform programs – the State Innovation Model (SIM) and EvidenceNOW Southwest.

Marijuana legalization–In this excerpt from an article

Final Word– Gregory Smith, DO, PhD, reflects on the work of the CMS WCPIC committee, whose members combined their efforts with CMS physician leaders to push through reforms that will make it easier to treat injured workers.

Cover story

Colorado Medicine revisits a year marked by member involvement and triumphs. No matter the level of a member’s involvement – whether actively participating in a committee, the board or the House of Delegates, or writing a dues check, this commitment to medicine in Colorado has made a difference in maintaining the stable liability climate, updating workers’ comp, shaping state initiatives, and more. Read more starting on page 8.

Inside CMS 5 7 32 34 36 38 39

President’s Letter Executive Office Update ICD-10 News Supreme Court CRNA Ruling Reflections COPIC Comment Looking Forward

Departments 40 44

Medical News Classified Advertising

Colorado Medicine for September/October 2015

has removed some of the restrictions limiting telehealth in Colorado, physician practices can explore the expansion of remote patient care. This article explores how to get paid for telehealth, how to choose the right technology for your practice, and how to maintain compliance with HIPAA.

Education for Physicians) is celebrating its 25th anniversary. It was created to fill an unmet need for personalized educational support for physicians and is now a national leader in assessments, education, and reentry to clinical practice.

originally published in the Journal of Medical Regulation, Doris Gundersen, MD, examines marijuana legalization in Colorado, both medical and recreational, and its effect on public safety and patient care. She gives advice to physicians who might see an increase in patients requesting marijuana for treatment.

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

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2014/2015 Officers Tamaan Osbourne-Roberts, MD President Michael Volz, MD President-elect Katie Lozano, MD Treasurer M. Robert Yakely, MD Speaker of the House Brigitta J. Robinson, MD Vice-speaker of the House Alfred D. Gilchrist Chief Executive Officer John L. Bender, MD, FAAFP Immediate Past President

Board of Directors JT Boyd, MD Charles Breaux Jr., MD Laird Cagan, MD Cory Carroll, MD Joel Dickerman, DO Greg Fliney, MS Curtis Hagedorn, MD Jan Gillespie, MD Kendra Grundman, MSS Mark Johnson, MD Richard Lamb, MD Tamara Lhungay, MS Lucy Loomis, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD Daniel Perlman, MD Scott Replogle, MD Floyd Russak, MD Charlie Tharp, MD Jennifer Wiler, MD Andrea Vincent, MSS Harold “Hap” Young, MD

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

COLORADO MEDICAL SOCIETY STAFF Executive Office

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

Division of Communications and Member Benefits

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

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

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

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

Mike Campo, Staff Support, Mike_Campo@cms.org

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

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

2015

Inside CMS

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

The beginning, the middle and the final kiss goodnight My friends, this has been an adventure. In just over two weeks from the date that I am writing this, I will hand over the leadership of CMS to the presidentelect, Michael Volz, MD, and as with any other large transition, I’m left with a wide range of feelings. On one level, I’m extremely proud; this has been an amazing year in which CMS has worked tirelessly on behalf of the physicians of Colorado, and it has been no small privilege to have had a direct role in influencing health care policy in our great state. On another level, I’m disappointed; the time has gone exceedingly quickly, and it seems like there is so much more left to do. On yet another level, I’m excited, and maybe even a bit relieved; my wife Camille, as well as my two children, will certainly enjoy having their husband and father around more, and I’m eager to explore what additional professional opportunities await me following my service to the physicians of Colorado. But, more than anything else, I feel… confused. It is not lost on me that my presidency has been a historic one, at a historic time for our state. I considered, at the outset of this year, that my identity as the youngest president in the 143-year history of the organization, as well as the first person of color to hold the presidency, might be symbolic of the organization’s overall desire to move forward in tackling the challenges of the future. This has proven quite true, and, compounded with the overall rapid evolution of the health care marketplace in Colorado, it has made for quite a busy year at the CMS offices, as well as down at the Capitol. The results

of this work are detailed in the cover story starting on page 8, and I encourage you all to take some time and learn just how much CMS is doing on behalf of the physicians of Colorado. However, despite my involvement in each part of this remarkable process; despite the many extra hours of work and effort; despite long days spent in front of legislators, policymakers, conference audiences and other physicians; I feel like I haven’t really done that much. In part, this is a testament to the amazing staff of CMS, who can make even the most difficult of task run smoothly and effortlessly. But even taking this into account, I was initially confused by how I could have gone through a year like this, filled with so many incredible moments, and feel like I haven’t really accomplished anything or been a real leader. And then, I realized it’s because I’m a physician. All physicians, everywhere, are leaders in their communities, simply by virtue of our shared profession. Our roles, by default, take us into people’s lives as guides and authorities, tasked with leading them through some of the most difficult and challenging moments of their lives. We serve as resources for our communities, guiding public health, serving as teachers, and even advising public officials. We do yeoman’s work. Despite this, the vast majority of us do it without giving it a second thought and, in so doing, forget just how important our individual leadership is to the greater good. This is perhaps understandable, given our training, our temperament and our

Colorado Medicine for September/October 2015

calling’s focus on others. Leadership is not something most of us consider on a daily basis. But given the vacuum of leadership we’ve seen in health care over the past several years and the pressing health care policy needs of the moment, perhaps it is time for us to start thinking about it. I am just one physician. Yet, over the past year, this one physician has overseen a review of governance structures for the largest and most powerful physician organization in the state; has worked with the governor’s cabinet, legislators and other policymakers on issues ranging from insurance market reforms to epidemic control policy; has influenced the public through multiple interviews with members of the state’s largest media organizations; and has even found time for self-reflection, self-care, time with family and the occasional vacation. All while continuing to work full time as a clinically practicing doctor. I realize that this type of policy leadership is not everyone’s cup of tea but imagine if every physician in the state took just a little bit more initiative in their own community to make things better. Used the respect and prestige of their position to push for what is right. Sacrificed just a little more time to influence their local policymakers. Started to believe, really believe, that they were more than just a leader by default…that, instead, they were a leader by choice and ability. Imagine what we could do. Take care, my friends. Good luck, Godspeed, and I’ll see you out there, in the trenches, serving our profession and our patients. n 5

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Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Colorado’s collaborative, consensus-based approach The 2015 Colorado Health Access Survey, conducted by the nonprofit, non-partisan Colorado Health Institute, announced this month that the state’s uninsured rate has fallen by more than half in the last three years. This is a spectacular manifestation of the methodical adoption and implementation of coverage expansion options afforded by federal law – the Medicaid expansion, a health insurance exchange and a health insurance co-op, along with employer-based coverage underpinned by a political culture that has long been committed to what is now formally adopted as a statewide goal to make Colorado the healthiest state in the nation.

blocks competing ideas. Ideas are more sustainable as policy, and easier to adjust over time – since policy perfection is an oxymoron – if the leaders are not focused on winning out over a competitor or getting even.

A prestigious national journal will soon publish their findings on what makes us tick, reaffirming our collaborative, consensus-approach: “Much of the Colorado health community embraces the concept of stewardship for the state government: the notion that the state has responsibility for improving the quality and controlling the costs of the health care system. Colorado carries out this role primarily through building consensus, rather than exerting its legal authority.”

We could post an honor roll of the qualitative talent and maturity of leaders in any sector – medical, hospital, health plan, and government who persistently and consistently do the work in what can be a frustratingly iterative and methodical process to get to the sweet spots. CIVHC’s recently published inventory of payment reform and delivery system redesign projects reads like a Who’s Who of those who have been there and are doing that. It is the gift that keeps on giving back to their communities. “Stewardship” is how the national publication will describe Colorado later this month. Stewardship is sufficiently embedded as to become a part of the Colorado cul-

According to the new data, less than 7 percent of Coloradans do not have insurance, the envy of most of the country, no doubt, and access has been maintained along with population health – with more serious work to continue in the gaps.

So the homegrown organics of these organizations are the underlying chemistry that produces sustainable results over the long haul, meaning there are enough mature adults with the right kind of leadership stuff and policy expertise – a been-there-done-that wisdom that comes from experience. If there is an X factor to explain Colorado’s progress, it is culture and leadership.

This “fix-problem-not-blame” consensusbuilding approach allows for innovation and avoids what has plagued many states – the classic zero sum politics of health care policy where one move cancels another and the performance curve remains shallow to flat. We have thus far avoided the heroic autocrat model where an oligarchy of special interests or a powerful political cartel simply mounts up and rides over or Colorado Medicine for September/October 2015

ture, and thus grows into all corners of care delivery and innovation. It is the norm, not the exception. A recent and exciting blooming of this X factor falls in the workers’ compensation component of care delivery, where Pinnacol Assurance – the dominant comp carrier – has assembled a dream team of leaders and experts from Colorado’s talent pool of veterans. Former CIVHC CEO, Phil Kalin, heads the new team that includes former CMS President Rick May, MD, as senior medical director; Edie Sonn, an alumna of CMS and the Blue Ribbon Commission on Coverage, as patient advocate and senior vice president of communications and public affairs; and Karyn Gonzales as vice president of medical operations and health care strategy, who brings a stellar background in clinically integrated networks. Like their counterparts in other sectors, Pinnacol has a strong sense of community and ownership. With the full backing of the Pinnacol board, this dream team will focus on improving health and wellness in the workers’ comp system, including a move to integrate and align efforts between physicians and comp insurers, bridging the gap between workers’ comp and traditional health insurance, and a sharp focus on reducing the hassle factors within the system. n

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

Email letters to the editor to: dean_holzkamp@cms.org 7

Kate Alfano, CMS Communications Coordinator

Photos first row from left; all people identified from left to right. Elisabeth Arenales, Esq., member of the Commission on Affordable Health Care, speaks. CMS President Tamaan Osbourne-Roberts, MD, with Sen. David Balmer, R-Centennial, CMS contract lobbyist Jerry Johnson, and CMS senior director Marilyn Rissmiller following discussion of out-of-network bill SB 259. U.S. Sen. Michael Bennet, D-Colo., speaks with Osbourne-Roberts on repealing the SGR. CMS board member Mark Johnson, MD, addresses other public health leaders on a CMS initiative. Photos second row from left. Gov. John Hickenlooper, center, signs important telehealth legislation; with him are legislators, from left to right, Rep. Perry Buck, R-Windsor, Sen. Beth Martinez Humenik, R-Thornton, Rep. Joann Ginal, D-Fort Collins, and Sen. John Kefalas, D-Fort Collins as well as Osbourne-Roberts, Rissmiller and other CMS partners in supporting the legislation. Jeffrey Cain, MD, CMS representative on the Commission on Affordable Health Care, interacts with patients. CMS student leaders Tamara Lhungay, Amy Nelson and Bianca Pullen engage in the 2014 annual meeting. Photos third row from left; all people identified from left to right. Johnson, U.S. Sen. Cory Gardner, R-Colo., and Osbourne-Roberts at Gardnerâ&#x20AC;&#x2122;s installation. Sen. Irene Aguilar, MD, D-Denver, and Sen. Ellen Roberts, R-Durango, discuss health care costs. CMS CPMG section leader Kim Warner, MD, interacts with a patient.

Cover Story STORY HIGHLIGHTS • As CMS members from across the state are preparing for the 2015 Annual Meeting, the society takes an opportunity to look back at a year of member triumphs. • Most notable are successes in preserving the liability climate; workers’ compensation updates; integral involvement in state initiatives; and legislative advocacy. • Plan to join CMS for the annual meeting and convening of the House of Delegates to experience camaraderie and fellowship in a picturesque mountain setting, and to celebrate the achievements of the year. The Colorado Medical Society is only as strong as its members. As a result of the investment of time, talents and resources of each of the 7,500 physicians and medical students across the state, 2015 will stand out as a banner year. As Colorado physicians prepare to gather in late September for another annual meeting, your society takes the opportunity to reflect on your accomplishments since the last annual meeting. “As president-elect of the Colorado Medical Society, I’ve been able to see firsthand the real difference our members make as individuals and collectively,” said Michael Volz, MD. “I extend sincere thanks to each CMS member, no matter your level of involvement. Whether you actively participate in a committee, the board or the House of Delegates, or you make a phone call to advocate on an important issue, or you write a dues check every year, you are committed to Colorado medicine. As a united society of Colorado physicians, we accomplished significant achievements.” Here are some highlights of your CMS member triumphs this year.

Preserving the liability climate and professional review For the 11th legislative session in a row, CMS members led the fight to maintain Colorado’s stable liability climate in the 2015 General Assembly, thanks to involvement during the 2014 election cycle. This past summer CMS members conducted more than 60 interviews of candidates and meetings with sitting members of the legislature to explain and answer questions about medicine’s top legislative priorities. COMPAC, CMS’s political action committee, met several times over the summer and voted on local recommendations for endorsements, selecting 71 candidates or friendly incumbents for the November 2015 general election. The COMPAC chair and local physicians signed letters of support for candidates and friendly incumbents that were mailed to all physician members in their respective districts. CMS general counsel met with business and community leaders and Gov. John Hickenlooper to discuss the preferred qualifications for a candidate to be appointed to an open position on the Colorado Supreme Court. In June, CMS co-signed a letter to the governor with the Colorado Civil Justice League commenting on the three nominees for the Colorado Supreme Court Justice open position. The governor selected one of the CMS-recommended candidates. “This is a significant achievement and one that should benefit Colorado physicians as we look to continue our string of positive opinions over the past five years,” said Mark B. Johnson, MD, COMPAC chair. In addition, CMS leaders helped persuade the Colorado Supreme Court to clarify the hearsay rule in favor of physicians defending malpractice cases. Medicare SGR repeal and replace Congress passed a bill in April to repeal the sustainable growth rate (SGR), the flawed payment formula that left the Medicare program unstable and threatened patients’ access to care. The law

Colorado Medicine for September/October 2015

provides positive annual payment updates of 0.5 percent, starting July 1 and lasting through 2019. CMS physician leaders held meetings with members of the Colorado congres-

“The SGR repeal is a huge deal because we now have an opportunity to pursue real payment reform. The biggest barrier to changing the way we deliver health care to improve access for patients has been the way we pay doctors. I look at the SGR repeal as the beginning of real health care reform.” – Lynn Parry, MD, CMS delegate to the AMA sional delegation during the American Medical Association interim meeting in November 2013 and again during the AMA National Advocacy Conference in March 2014. And in 2015, seeing the best opportunity in a decade, CMS members repeatedly took up the call to contact their member of Congress and Colorado’s two U.S. senators. “The SGR repeal is a huge deal because we now have an opportunity to pursue real payment reform,” said Lynn Parry, MD, CMS delegate to the AMA. “The biggest barrier to changing the way we deliver health care to improve access for patients has been the way we pay doctors. I look at the SGR repeal as the beginning of real health care reform.” Regulation of health plan networks/network adequacy A debate in the 2015 Colorado legis-

Cover story (cont.) lature over out-of-network charges by health care providers uncovered a much broader discussion of the complexity of network adequacy and fierce competition within the health insurance industry in the state. A team of CMS members testified against the bill, expressing frustration that physicians are often left out of networks not by choice and that patients unknowingly buy insurance products that do not provide adequate coverage. The physicians pushed for and successfully achieved an interim study that has brought together CMS, health plans and consumer representatives to address matters related to network adequacy.

“There is a great deal of work ahead of us but our chances of success are greater if medicine is unified from a policy perspective, we know our bottom line and we hang together.” – Peter Ricci, MD, chair of the CMS Working Group on Managed Care CMS members, specialty society and component society representatives formed a new work group, the CMS Working Group on Managed Care, to propose potential policy on excessive charges and usual and customary fees, as well as language that non-participating physicians can provide patients on their billing statements to make them aware of the potential protections they may be afforded under existing Colorado statute. “Greatly assisting with our work to develop policy solutions on the major issues relating to out-of-network charges and billings are the results of an all-member survey on a broader array of pain points with managed care plans, including the 10

impact of narrow networks and provider directories,” said Peter Ricci, MD, chair of the working group. “There is a great deal of work ahead of us but our chances of success are greater if medicine is unified from a policy perspective, we know our bottom line and we hang together.” Commission on Affordable Health Care Jeffrey Cain, MD, a decorated family physician leader, was chosen among a pool of highly qualified CMS members to represent physicians on the state’s Commission on Affordable Health Care. The commission has been working to identify systemic and other underlying causes of excessive and unnecessary health care costs and propose specific legislative, regulatory and market-based strategies to reduce costs and improve care value. To help inform the cost commission on physician priorities, many CMS members joined the new CMS Task Force on Health Care Costs and Quality. The task force is cochaired by Laird Cagan, MD, and Alan Kimura, MD. “CMS members must be proactive in helping the commission better understand cost and quality from a physician’s perspective to provide solutions that work for physicians and for patients,” Cain said. “The commission will receive input from other stakeholders – from insurance companies, from hospitals, from employers – and the cost commission needs to be able to hear how the solutions will impact our ability to care for patients.” Physical and behavioral health integration – State Innovation Model (SIM) Gov. Hickenlooper announced in December 2014 that Colorado was awarded $65 million to implement its State Innovation Model (SIM) plan. Glenn Madrid, MD, of Grand Junction, was appointed as the physician representative on the SIM Advisory Board and Chet Seward, CMS senior director of health care policy, was appointed to the policy workgroup. CMS is working with SIM leadership to explore options to provide CME and maintenance of certification credit for SIM training activities.

From the beginning CMS has actively participated in the plan’s development by submitting detailed written comments. The CMS board sees this as an opportunity to advance CMS payment and delivery system reform priorities. As it is implemented, SIM will accelerate public and private sector collaboration on multi-payer models and delivery system transformation and open unique opportunities for CMS to drive innovation and health plan standardization. CMS members and their patients stand to greatly benefit as SIM funds assist practices in integrating physical and behavioral health care. ICD-10 transition The Colorado delegation to the AMA led the way on one of the most important policies passed at the 2015 AMA Annual Meeting in June, which directed the AMA to seek a two-year grace period for ICD-10 to allow physicians to avoid financial disruptions following implementation. The AMA and Centers for Medicare and Medicaid Services announced on July 6 that for a one-year period starting Oct. 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes submitted, as long as the physician billed using an ICD-10 code from an appropriate family of codes. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. To avoid potential problems with midyear coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if the federal CMS experiences difficulties in accurately calculating quality scores. To help physicians and their staffs prepare for the switch to ICD-10, CMS worked with local physicians and component societies to host a series of ICD-10 documentation seminars at several locations along the Front Range in late August and early September. The speaker, James Taylor, MD, senior medical director of clinical analytics/ performance improvement at Colorado

Colorado Medicine for September/October 2015

Cover Story Access, volunteered his time and expertise to help physicians gain a better understanding of the documentation differences between ICD-9 and ICD-10. Taylor will record a webinar presentation for those who cannot attend in person. CMS has also been an active leader of the Colorado ICD-10 coalition for the past two years, which has raised awareness for the requirements and provided resources to ease the transition. Caring for injured workers Over the past 18 months, members of the CMS Workers’ Compensation and Personal Injury Committee (WCPIC) have been working to upgrade the Colorado system of workers’ compensation to ensure physicians caring for injured workers can thrive in the system and physicians not currently participating will register and participate. WCPIC has been acting on five tactics they developed late last year that were approved by the CMS Board of Directors in January: regulatory relief, administrative simplification and practice efficiency, stakeholder collaboration and relationship building, physician education and resources, and membership recruitment.

addressing this problem,” Smith said in his testimony. Telemedicine The use of telemedicine is expected to grow throughout the state, with the goal to reduce health care costs, improve the efficiency and quality of care, improve access to care, and provide needed specialist consultations. Recognizing the promise of telemedicine, the Colorado Medical Society House of Delegates passed a resolution during the 2014 An-

nual Meeting that updated CMS policy on telemedicine and telehealth and directed CMS to push for legislation in the 2015 session. A bill was successfully passed and will take effect on Jan. 1, 2017. CMS Past President John L. Bender, MD, helped draft the bill and recruit its sponsors, and the CMS Council on Legislation voted to support it. Physicians testified in front of the medi-

WCPIC Chair Greg Smith, MD, testified before the Division on Workers’ Compensation at their rulemaking hearing on July 30, providing comments on the new fee schedule, reimbursement, physician reviewers and independent pre-authorization. Thanks to WCPIC’s work, the DOWC is implementing a big change: Physicians who are reviewing prior authorizations or who are recommending services for denial have to be accredited. This goes a long way to resolve a complaint WCPIC raised on behalf of physicians caring for injured workers that physician reviewers located out of state were unfamiliar with Colorado Workers’ Compensation Treatment Guidelines and were incorrectly denying requests for services, which then adversely affected patient care as they waited with no alternative care plan. “This has been a major impediment to access to proper care, in our assessment, and a major cost driver for providers, as we need to spend large amounts of additional time Colorado Medicine for September/October 2015

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Cover story (cont.) cal board in November 2014. As a result, DORA hosted a telehealth symposium on Feb. 23 that brought together all regulatory bodies so different practitioners and organizations could explain how telehealth might work in Colorado and the regulatory bodies could consider updates to their licensure. In mid-August the Colorado Medical Board updated their policies to be in line with the CMS policy and legislation that is to take effect in 2017. From the physicians’ perspective DORA’s outdated policies were one last hurdle to be removed to ensure the appropriate use and expansion of telehealth services in Colorado. Patient safety CMS members passionately support efforts to reverse the escalating trend of opioid abuse and misuse and its often tragic consequences in Colorado. The 2013 HOD approved a CMS platform on prescription drug abuse and the BOD appointed a special Committee on Prescription Drug Abuse in 2014.

CMS members and staff actively participate in the Colorado Consortium to Reduce Prescription Drug Abuse and CMS has been educating members about the crisis over the past two years. CMS alerted members to a November deadline for mandatory PDMP registration and promoted the “Take Meds Seriously” campaign, which educates patients about safe use, safe storage and safe disposal. The campaign website provides handouts that can be customized to individual physician offices or pharmacies. In response to the 2014 Ebola epidemic, the largest in history, the board of directors appointed an advisory committee headed by public health officials Christine Nevin-Wood, DO, and Mark B. Johnson, MD. They worked with state and local public health officials to monitor the situation and develop an educational CME webinar targeted to inform office-based physicians of proper safety procedures. CMS also maintained a comprehensive list of resources from around the country on a designated resource

page to keep members up-to-date on the latest recommendations and resources. Public health Nevin-Wood and Johnson also took leadership of a CMS initiative to support a long-term public health initiative as part of its core work. They hosted a meeting in March at CMS headquarters that brought together more than 20 of the state’s top public health officials. Attendees included CMS President Tamaan Osbourne-Roberts, MD; CMS Presidentelect Mike Volz, MD; Colorado’s Chief Medical Officer Larry Wolk, MD, and several other leaders from the Colorado Department of Public Health and Environment; multiple representatives from local public health agencies around the state; and leaders from the University of Colorado School of Medicine and the Colorado School of Public Health. Instead of focusing on just one public health initiative over the next decade, the invited guests recommended more formalized engagement for public health within the CMS structure by fostering partnerships, flexibility and relationships at multiple levels.

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“Fortunately, public health has a long history of focusing on communities and CMS has a long history of focusing on physicians and their patients,” said Osbourne-Roberts. “A long-term commitment between CMS and public health leaders can help connect clinical physician practices and public health agencies to keep our patients and communities healthy. CMS helps provide the framework and coordination so desperately needed to be effective in this arena.”

October 17, 2015 » PPA Event Center » Denver, CO Register now at AnnualSymposium.org

The 2015 Annual Meeting: NextGen CMS When physicians gather in Breckenridge for the 2015 Annual Meeting and convening of the House of Delegates, they will experience camaraderie and fellowship in a picturesque mountain setting, and will have a great opportunity to celebrate the achievements of the year. They will also combine their strengths and ideas to keep CMS on the cutting edge for the benefit of their patients and practices. Find more information on the meeting at www.cms. org/events/annual-meeting. n Colorado Medicine for September/October 2015

Features

AMA legal brief American Medical Association

Managing antitrust risks post-North Carolina Board of Dental Examiners v. FTC Supreme Court opinion STORY HIGHLIGHTS • In February, the U.S. Supreme Court ruled that a state board, with certain conditions, must be actively supervised by the state in order to enjoy state action antitrust immunity. • The AMA was disappointed with the ruling; they had warned that requiring active state supervision of licensing boards as a condition for antitrust immunity would subordinate public health to antitrust considerations, discourage service on regulatory boards, and disrupt a 150year tradition of regulating professionals. • In the wake of this opinion, a state should carefully choose among a variety of regulatory structures. In February, the United States Supreme Court, in North Carolina State Board of Dental Examiners v Federal Trade Commission, 135 S. Ct. 1101 (2015) (hereinafter “Dental Board”), decided that the antitrust defendant Dental Board–a state agency–could not invoke state action antitrust immunity when it prohibited non-dentists from whitening teeth. The Supreme Court held that a state board on which a controlling number of decision-makers are active market participants in the occupation the board regulates must be actively supervised by the state in order to enjoy state action antitrust immunity. 14

This decision comes as a disappointment to the AMA and other national medical societies who in an amicus brief warned that requiring active state supervision of licensing boards as a condition for antitrust immunity would subordinate public health to antitrust considerations, discourage service on regulatory boards, and disrupt a 150 year tradition of regulating professionals. Notwithstanding these ongoing concerns and adverse outcome, the Court’s opinion is filled with advice for how state boards might comply with the active state supervision requirement. I. Background facts of North Carolina Dental Board The Supreme Court’s opinion recites that in the 1990s, North Carolina dentists started whitening teeth. When non-dentists began offering the same service, dentists complained to the Dental Board about their new competitors. Few complaints warned of possible harm to consumers. Most expressed a principal concern with the low prices charged by non-dentists. In response, the Dental Board, comprised largely of dentists who earned substantial fees for teeth whitening services, issued cease-and-desist letters to non-dentist teeth whitening service providers and product manufacturers. These letters had the intended result. Non-dentists ceased offering teeth whitening services in North Carolina. In 2010, the Federal Trade Commission (FTC) filed an administrative complaint charging the Dental Board with engaging in concerted action in violation of the antitrust laws by anticompetitively excluding non-dentists from the market for teeth whitening services in North Carolina. The Dental Board defended

this action on the basis that it was a state agency authorized by law to make scope of practice decisions and therefore entitled to immunity from the antitrust laws. The FTC concluded, however, that state authorization to regulate dentistry was insufficient to immunize the Dental Board. It reasoned that because six of the Dental Board’s eight members were licensed dentists, it was a public/private hybrid that must be actively supervised by the state to claim immunity. Finding that the Dental Board was not actively supervised, the FTC further concluded that the Dental Board was not entitled to immunity. Moving to the merits of the case, the FTC found that the Dental Board had unreasonably restrained trade in violation of antitrust law. In reaching this conclusion, the FTC rejected the Dental Board’s public safety justification because “a wealth of evidence” suggested that non-dentists provided safe teeth whitening services. The Court of Appeals affirmed the FTC in all respects, and the Supreme Court agreed to review the case. II. Supreme Court opinion In its opinion, the Supreme Court observed that the similarities between agencies controlled by active market participants and private trade associations are not eliminated simply because the former are given a formal designation by the state, vested with a measure of government power, and required to follow some procedural rules. When a state empowers a group of active

Colorado Medicine for September/October 2015

Features market participants to decide who can participate in its market, and on what terms,” the need for supervision” says the Court, “is manifest.” Rather than delegate to entities controlled by active market participants questions such as whether teeth whitening is the practice of dentistry, active state supervision was necessary to ensure that the anticompetitive conduct of the practicing dentists on the Dental Board promoted state policy, rather than merely the participants’ individual interests. Thus, essentially the Court embraced the FTC’s position. The Supreme Court then turned to the question of whether the Dental Board, in the case at hand, complied with the active state supervision requirement. The test, emphasized the Court, requires the state to review and approve policies made by the entity claiming immunity. The Court observed that the Dental Board relied upon cease-and-desist letters that threatened criminal liability, rather than invoking available oversight by a politically accountable official. For example, the Dental Board could have sought a court injunction or could have promulgated rules and sought their approval by a commission appointed by the state legislature. Under these circumstances, there was no evidence of any decision by the state to initiate or concur with the Dental Board’s actions against the non-dentists. Accordingly, the Court concluded that it was not entitled to immunity. III. Looking forward a. State Choices Among Regulatory Structures In the wake of the Supreme Court’s Dental Board opinion, a state should carefully choose among a variety of regulatory structures. It can re-constitute its medical board so that it is not composed of a controlling number of physicians and therefore likely exempt from federal antitrust law whether or not they are actively supervised by other state officials. Alternatively, a state can staff a medical board with active market participant physicians. In that event, if immunity is the goal, then there must be appropriate

Colorado Medicine for September/October 2015

AMA legal brief (cont.) supervision by disinterested officials to ensure that the board’s actions indeed reflect state policy. Third, a state may give a physician-controlled board substantial discretion and opt not to provide any active supervision. If that is the state’s choice, the board would lack immunity and would therefore be prohibited from engaging in any anticompetitive agreement or conduct in violation of antitrust law. b. Achieving Active State Supervision It is doubtful that many states will decide to protect their medical licensing board members from antitrust liability by re-comprising the boards to consist of less than a controlling number of practicing physicians. As the Supreme Court acknowledged in its Dental Board decision, there are substantial benefits to staffing licensing boards with experts in complex and technical subjects – certainly true of medical boards. But if a state decides to rely on active market participant physicians and wants them to be immune from antitrust liability, it should provide active supervision. i. Principles of Active State Supervision The Supreme Court opinion is laced with principles that should inform states how to immunize state medical boards. The guiding principle is that the purpose of the active state supervision test is to provide “realistic assurance that the board’s licensing decisions promote state policy, rather than merely their individual interests.” Accordingly, the test requires that financially disinterested state officials accept political responsibility for the board’s decisions. Therefore, as the Court explained, the state supervisor should have and exercise power to review and approve the substance of licensing board policies and disapprove, veto or modify those that fail to accord with state policy. Mere potential for state supervision is not an adequate substitute for a decision by the state. Whether the active state supervision requirement is met will depend on both the practical op 16

eration of the relevant legal supervisory scheme and all the circumstances of the case. Finally, the Court said, that the inquiry regarding the adequacy of supervision is flexible and context dependent. Perhaps then, not all board rules are at risk but only those that favor the interests of the active market participants – the physicians – who control the board. Clearly state supervision is required for immunizing decisions/ rules that affect non-physicians, such as typical scope of practice decisions. But would it make sense to insist upon active state supervision in cases of a board disciplining an individual physician? Arguably not. (Moreover such a disciplinary decision would not generally make any difference in the marketplace and thus would ordinarily not present an undue antitrust risk.) ii. Alternative Operational Approaches for Achieving Active State Supervision General counsel and government affairs staff interested in encouraging medical licensing board activities should determine the current status of their state boards with respect to the likelihood of meeting the Supreme Court’s active state supervision test. If they believe that the principles of active state supervision are not being met, they might consider the following operational approaches for satisfying the active state supervision test: • housing the regulatory board within an umbrella state agency that has supervisory authority over the licensing board. • limiting the board to performing primarily advisory functions, with decisions concerning the regulation of the profession assigned to independent state officials. • requiring that regulations adopted by the licensing board be approved by another state body to become effective or be

subject to review and potential disapproval by disinterested officials, perhaps the state attorney general. • empowering legislative committees or other officials to review regulations, to recommend that the legislature override them, and in some cases to suspend the operation of such regulations pending the legislature’s action. c. State Provisions for the Defense and Indemnification of Medical Board Members Whether a state attempts to comply with the active state supervision requirement – the contours of which will be eventually defined by the courts (a process that could take years) – or chooses to forgo state action antitrust immunity for its medical boards, all board members will be operating under great uncertainty with respect to antitrust exposure. The exposure has the potential to be significant since prevailing plaintiffs are entitled to treble damages and attorney’s fees. Moreover, the cost of defending antitrust cases can be prohibitive. Consequently, states need to act now to provide incentives and protection for physicians to serve on medical licensing boards and when serving, to use their initiative in carrying out their responsibilities to protect the public. The Supreme Court’s Dental Board opinion is sympathetic to this concern. The opinion expressly states that states may provide for the defense and indemnification of board members in the event of litigation. This is the solution offered by new AMA model state legislation. It provides for the defense (by private counsel) and indemnification of medical board members from the broadest range of claims and demands, including but not limited to intentional tort or antitrust claims. The bill also contains a provision enabling the medical licensing board to purchase and maintain insurance against any liability, including antitrust liability.

Colorado Medicine for September/October 2015

Features IV. Preparing for future litigation Antitrust challenges inspired by the Supreme Court’s Dental Board decision are likely to proliferate. For example, on May 29, 2015 a federal district court in Austin, Texas found that an antitrust challenge to a Texas Medical Board telemedicine rule is likely to succeed on the merits. The plaintiff in the case is Teladoc, the country’s largest telemedicine provider. The defendants are the Texas Medical Board and the individual board members. Teladoc’s antitrust claim is simple: 1) the defendant board engaged in joint action and 2) this joint action amounted to an unreasonable restraint of trade. Allegedly, the telemedicine rule would produce anticompetitive effects by increasing prices, reducing choice, reducing access, reducing innovation and reducing the overall supply of physician services. The court concluded that plaintiff’s claim that anticompetitive effects would likely occur was supported by the evidence. Accordingly, the Texas Medical Board had the burden of persuading the court that

the rule was justified and, on balance, was procompetitive because it enhanced quality. Unfortunately the court was unpersuaded by the board’s quality of care defense. The court observed that the board had presented only anecdotal evidence – affidavits from medical practitioners – detailing deficiencies in telephone-only diagnosis. No statistically reliable evidentiary studies were submitted. Thus, the court found, the board’s evidence on quality was rebutted by Teladoc’s countervailing affidavit testimony from patients. Consequently, the court entered an injunction against the Texas Medical Board’s telemedicine rule. The best way for medical boards to prepare for expected antitrust challenges is to attempt to comply with the active state supervision requirement. Attempts to comply, even if unsuccessful, should prove helpful in defending an antitrust challenge on the merits. For example, the process of obtaining the approval of a state legislative, judicial or executive

Colorado Medicine for September/October 2015

branch entity (the state supervisor) could encourage boards to develop an administrative record that identifies a legitimate reason for the licensing restriction (how it promotes state policy by protecting the public, ensuring quality and safety and so on). The record could further explain why the restriction is reasonably necessary and narrowly tailored to meeting the legitimate objective. If the state supervisor after reviewing this documentation of the reasonableness of the rule were to approve the board’s action as in furtherance of state regulatory policies, a board could have reasonable confidence that its decision would enjoy state action immunity. And if in antitrust litigation it were determined that the board did not enjoy that immunity, the board would be in a good place to defend the antitrust action on the merits. n Disclaimer: Nothing contained in the article is to be considered as the rendering of legal advice for specific cases, and readers are responsible for obtaining such advice from their own legal counsel. The article is intended for educational and informational purposes only. ©2015 American Medical Association. All rights reserved.

Features

Telehealth primer Kate Alfano, CMS Communications Coordinator

Making remote visits work in your practice STORY HIGHLIGHTS • A billed passed by the 2015 Colorado General Assembly will make it easier for physicians to pursue telehealth, or remote, visits. The law takes effect on Jan. 1, 2017. • When choosing telehealth equipment, a physician must consider what type of services he or she wants to provide. For example, a physician conducting a mental health visit could use a simple cloud-based application with a computer and webcam but a cardiologist might need an electronic stethoscope.

First, the specifics. As defined in the law, telehealth is a mode of remote health care delivery through telecommunications systems to facilitate the assessment, diagnosis, consultation, treatment, education, care management or self-management of a patient while he or she is located at an originating site and a provider is located at a distant site. Health care services can include medical, mental, dental or optometric care, hospitalization or nursing home care. This law does not include care delivered via telephone, fax or email.

• Because HIPAA does not contain any special section devoted to telehealth, all personal health information handled during a telehealth visit must meet the same Health Insurance Portability and Accountability Act (HIPAA) requirements as an in-person visit.

The law takes effect on Jan. 1, 2017. It removes the current population restriction of 150,000 or fewer residents, opening up payment for telehealth for any patient in any area of the state. It bars health plans from requiring an initial physical encounter before telehealth can be used and it requires health plans to reimburse providers the same amount for a telehealth encounter as a physical encounter. Providers do not have to demonstrate that a barrier to in-person care exists before engaging in telehealth.

Colorado legislators voted to remove some of the restrictions to telehealth during the 70th General Assembly, paving the way for expanded access to remote primary and specialty care for patients across the state. Now that House Bill 15-1029 has been signed into law, there are a few things for physician practices to consider when moving forward with telehealth visits.

Getting paid Once the law takes effect, Colorado third-party payers will reimburse the treating or consulting provider the same amount for a telehealth visit as an in-person visit. Until then they are only required to reimburse for telehealth in those smaller-population counties, though some carriers have telehealth operations in place or in development. Practice staff would need to contact

the insurer of a potential telehealth patient and inquire about their policy or contact Colorado’s Telehealth Resource Center, Southwest TRC (www. southwesttrc.org) for information. Colorado Medicaid currently reimburses for telehealth for any service already covered by Medicaid regardless of location. And Medicare reimburses telehealth at 100 percent equal to a face-to-face service with the telehealth modifier “GT” if the originating site of an eligible Medicare beneficiary is in a rural Health Professional Shortage Area located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, or in a county outside of an MSA. See Table 1, next page, for a list of reimbursable codes. The Centers for Medicare and Medicaid Services lists “acceptable practitioners” for telehealth as the following. • Physicians. • Nurse practitioners. • Physician assistants. • Nurse midwives. • Clinical nurse specialists. • Certified registered nurse anesthetists. • Clinical psychologists and clinical social workers. • Registered dietitians or nutrition professionals. The agency designates most health care settings as acceptable originating sites for service, including physician or practitioner offices, hospitals, federally

Colorado Medicine for September/October 2015

Features TABLE 1: CY 2015 MEDICARE TELEHEALTH SERVICES Service

Healthcare Common Procedure Coding System (HCPCS)/CPT Code

Telehealth consultations, emergency department or initial inpatient Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs Office or other outpatient visits CPT codes Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days Individual and group kidney disease education services Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training Individual and group health and behavior assessment and intervention Individual psychotherapy Telehealth Pharmacologic Management Psychiatric diagnostic interview examination End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment Individual and group medical nutrition therapy Neurobehavioral status examination Smoking cessation services Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services Annual alcohol misuse screening, 15 minutes Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes Annual depression screening, 15 minutes High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 min. Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes Face-to-face behavioral counseling for obesity, 15 minutes Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) Psychoanalysis (effective for services furnished on and after Jan. 1, 2015) Family psychotherapy (without the patient present) (effective for services furnished on and after Jan. 1, 2015) Family psychotherapy (conjoint psychotherapy) (with patient present) (effective for services furnished on and after Jan. 1, 2015) Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (effective for services furnished on and after Jan. 1, 2015) Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (effective for services furnished on and after Jan. 1, 2015) Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit (effective for services furnished on and after Jan. 1, 2015) Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit (effective for services furnished on and after Jan. 1, 2015)

HCPCS codes G0425-G0427 HCPCS codes G0406-G0408 99201-99215 CPT codes 99231-99233 CPT codes 99307-99310 HCPCS codes G0420 and G0421 HCPCS codes G0108 and G0109

CPT codes 96150-96154 CPT codes 90832-90834 and 90836-90838 HCPCS code G0459 CPT codes 90791 and 90792 CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961 HCPCS code G0270 and CPT codes 97802-97804 CPT code 96116 HCPCS codes G0436 and G0437 and CPT codes 99406 and 99407 HCPCS codes G0396 and G0397 HCPCS code G0442 HCPCS code G0443 HCPCS code G0444 HCPCS code G0445

HCPCS code G0446 HCPCS code G0447 CPT code 99495 CPT code 99496 CPT codes 90845 CPT code 90846 CPT code 90847 CPT code 99354

CPT code 99355

HCPCS code G0438 HCPCS code G0439

SOURCE: Samantha Lippolis, Telehealth Manager at Centura Health; April 28, 2015

Colorado Medicine for September/October 2015

Telehealth (cont.) qualified health centers, skilled nursing facilities and community mental health centers. A patient’s home or an independent renal dialysis facility are not currently acceptable to Medicare as an eligible originating site. Choosing the technology When choosing telehealth equipment, the type of services to be provided will determine what type of equipment is needed. For example, a physician conducting a mental health visit could use a simple cloud-based application with a computer and webcam but a dermatology visit would require a general exam camera or a digital camera where a close-up of a skin condition would be captured and sent to the provider prior to the visit. A cardiologist might need an electronic stethoscope and an otolaryngologist might need an ENT scope. Physicians must also consider their budget, system portability, HIE or EMR integration requirements, scalability, and hosting and data archiving.

“There really is not a one-size-fits-all approach to telehealth equipment,” said Ryan Westberry, MS, MBA, project manager and business analyst for the Colorado Telehealth Network. “It is also important to consider the telehealth platforms or solutions being used by affiliate hospitals and practices. Interoperability is critical.” “You can spend 15 minutes online and find all kinds of gizmos and gadgets that you can plug into your computer or smartphone that can give EKG readings, temperature, pulmonary function tests or let you listen to the heart,” said Clay Watson, MD, an infectious disease specialist and director of infection prevention at Saint Joseph Hospital in Denver. “All of those things are already out there and for sale and they’re getting cheaper by the day. Where telehealth robots or the big systems that cost $20,000 or $30,000 used to be the standard, now you can get into the market with a tablet or smartphone and a frontfacing camera. It’s evolving to the point where now it’s affordable for everyone.”

“Remember the Internet connection has to be HIPAA secure,” Watson said. “That’s your first step. Then I would just start with simpler visits and see what you’re really missing. What pieces of information do you really need to obtain and then find the gadget that helps with that.” Telehealth and HIPAA The Consortium of Telehealth Resource Centers (more information available at: www.telehealthresourcecenter.org) outlines considerations for physicians regarding compliance with HIPAA. As the Consortium says in a fact sheet, it is more complex than simply using products that claim to be HIPAA-compliant. True compliance entails an organized set of monitored, documented security practices within and between covered entities. Because HIPAA does not contain any special section devoted to telehealth, all personal health information (PHI) handled during a telehealth visit must meet the same HIPAA requirements as an in-person visit.

Colorado Medicine for September/October 2015

Features Some products may contain elements or features that allow them to be operated in a HIPAA-compliant way like a telehealth software program with an encryption feature or password protection. According to the fact sheet, “the entity will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity and availability. While some specifications exist, each entity must assess what are reasonable and appropriate security measures for their situation.” Additionally, regulations state that for transmission security, practices must “implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network.” Practices would need to assess their network, including their wireless connection, to ensure it meets requirements. This caution extends to web-conferenc-

ing systems like Skype and FaceTime, which have been used as platforms to provide clinical telehealth services, but fall under the classification of a “conduit” – an entity that transports information but does not access it except on a random or infrequent basis as necessary to perform the transformation services. Ultimately it is up to the practice to determine whether they can use certain technology or outlets and still “implement procedures to regularly review records of information system activity, such as audit logs, access reports and security incident tracking systems.” Other considerations There are many other issues to be considered before embarking on remote patient visits, including the following. • Whether the bandwidth between locations is adequate to ensure a good connection. • Whether the payer requires the presence of a patient presenter during the telehealth visit and who can act as a presenter. There is no

Colorado Medicine for September/October 2015

requirement for Medicare; however, it would be difficult to have a patient use a general exam camera or stethoscope on him or herself. • How the encounter will be documented and who is responsible for ensuring the information is recorded in the patient’s medical record. • How the patient exam room is set up – lighting, camera view, etc. – to ensure that the provider gets the best view of the patient as possible. Quality is important to ensure that it is equal to an in-person visit. • How to provide training on the use of the equipment and best practices during a telehealth visit regarding eye contact and clear communication. The promise of telehealth is great but this new frontier should be explored thoughtfully and carefully. n

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Colorado Medicine for September/October 2015

Features

Celebrating success Beth Korinek, MPH

CPEP celebrates 25 years supporting physicians STORY HIGHLIGHTS • CPEP celebrates its 25th anniversary. The organization was created to fill an unmet need for personalized educational support for physicians. • CPEP is now a national leader in assessments, education and Reentry to Clinical Practice, supporting proactive intervention to help retrain and retain physicians in their communities. • CPEP is positioned to help physicians meet the demands of the rapidly changing health care system. New programs focus on prescribing controlled drugs and inter-professional communication. When questions arise regarding physicians’ clinical competence, education and remediation can often produce more value to society than mere sanctions. In 1986, this was the realization of the Colorado Foundation for Medical Care, which pulled together a multi-organization Consortium to explore the creation of a personalized education program for physicians. The Consortium, consisting of several pillars of the Colorado health care community, including the Colorado Medical Society, came together for a common mission – to promote quality patient care and safety by enhancing the competence of physicians. In 1990, it was in that spirit of collaboration that CPEP, originally known as the Colorado Per-

sonalized Education Program for Physicians, was born. Twenty-five years later, what is now the Center for Personalized Education for Physicians continues to fulfill this mission as an independent non-profit organization with locations in Denver and Raleigh, N.C. CPEP, created as a response to pressing needs of the day, continues to grow, adapt, and lead as a vibrant member of the health care community. Many of the challenges of the 1980s – like the need to help physicians practice with safety and confidence – remain with us today, and CPEP has achieved national recognition as the gold standard in clinical competence assessment and personalized education plans. As the needs of the health care system, and health care professionals, evolve, CPEP is leading the way with new programs and services both locally and across the nation. Over the course of 25 years, CPEP has addressed the educational needs of just over 4,000 health care professionals nationally, almost 700 of whom live here in the Centennial State. Along with other key stakeholders in the Colorado community, CPEP has worked to create a legal environment that supports proactive voluntary agreements and confidentiality for its participants – making Colorado a state that supports its physicians and fosters a culture of continuous improvement. CPEP was a key player in the effort to create a unique reentry medical license in Colorado. CPEP has mobilized reentry physicians to address workforce shortages in communities nationally. Here in Colorado, CPEP’s Reentry to Clinical Practice Program (RCP) has worked with nearly 80 reentry candidates, a “rapid deployment force” of physicians bringing much-needed capacity to communi-

Colorado Medicine for September/October 2015

ties statewide where physician shortages are often critical. Recognizing the special challenges facing physicians and other professionals in today’s health care environment, CPEP continues to develop new courses here in Denver to address them head-on. Prescribing Controlled Drugs: Critical Issues and Common Pitfalls© is being offered in collaboration with the Vanderbilt Center for Professional Health. This three-day course is intended for clinicians who wish to take proactive steps to improve their practice or have engaged in misprescribing activities. Another new seminar, Improving Inter-Professional Communications: Working Effectively in Medical Teams, is designed for professionals who require new perspectives on how they work with others and new skills to improve their interpersonal skills and enhance patient care. As a 501 (c)(3) non-profit, CPEP could not perform these missions without the support of the community. Thanks to the on-going generosity of COPIC, CMS, numerous Colorado hospitals, and others, CPEP is able to offer a fee support program for Colorado participants, making CPEP services far more accessible to those in need. Over the years, more than 300 Colorado participants have received fee support worth $622,000. As CPEP celebrates its past and present, it is at the same time prepared for the future, with new courses, new locations, and new relationships across the country. Of course, while CPEP serves the needs of a national audience, Colorado will always be “home,” striving to fulfill the original vision of its founders while working with today’s leaders across the state to address the needs of today and tomorrow. n 23

Features

Health care reform Perry Dickinson, MD

Changing how care is delivered and paid for – the time is now!

Perry Dickinson, MD and Colorado is ready!

We have been talking about “health care reform” for years and it seems the time for action on a large scale is finally presenting itself, ripe with opportunity –

It has been a long time coming and many of us have been preparing for this in various capacities for years. Perhaps you remember the CMS Physicians’ Congress for Health Care Reform – the group of committed physician leaders that began meeting on Saturdays starting way back in 2008? You are also probably well aware of

EVIDENCENOW SOUTHWEST WHO: • Primary care practices with adult patients; 10 or fewer providers. WHAT: • 9 months of in-office practice facilitation. • 2 collaborative learning sessions. • Focus on cardiovascular risk management. • Aspirin, Blood Pressure, Cholesterol, Smoking Cessation. • Prepare for future cohorts of SIM in 2017 and 2018. HOW: • For information and to apply, go to: www.EvidenceNOW.org WHEN: • Apply now – first cohort begins Nov. 2015. 24

some of our pioneers that have been working on medical homes, systems of care, transitions of care, meaningful use and behavioral health integration into primary care, starting way before these terms became part of everyday conversation. Well, now it’s time to go mainstream! It’s time for an “all in” approach to improving the health of Coloradans, balancing a focus of reducing the cost of care, while also improving the experience of care for patients, families and health care teams. Practices that are prepared should do well in the changing system; those that do not pay attention now risk falling by the wayside. Payers are now ready to take what started out as pilots to scale in a major way. By 2019, the Center for Medicare and Medicaid (CMS) has committed to a goal that 90 percent of Medicare payments will be directly tied to value. The commercial carriers and Colorado Medicaid are on a similar trajectory. However, being paid for value, not activity, means new models of care delivery must be implemented that can demonstrate value – with comprehensive data, including clinical as well as claims data. The new models involve challenging changes in care delivery and the use of data. Practices benefit greatly from support in making these changes, which take time and certainly do not happen overnight. Two opportunities in particular are available statewide for primary care participation. The Colorado State Innovation Model (SIM) is open to primary care practices, with a focus on assisting practices in moving to advanced primary care that includes behavioral health integration and alternative payment models. Through SIM along with other collaborative projects, the payers are building

COLORADO STATE INNOVATION MODEL (SIM) WHO: • Primary care practices. • EHR required. • Experience with elements of medical home. • Commitment to improving behavioral health. WHAT: • Advanced primary care with behavioral health integration and alternative payment models. • 2 years of practice facilitation. • 6 core measures in year one. • 2 collaborative learning sessions per year. • Up to $5,000 stipend, plus small grants. • Potential compensation from payers. HOW: • For information and to apply, go to: http://www.ucdenver.edu/anschutz/ about/practicetransformation or call 303-724-8968. WHEN: • Apply now – first cohort begins Feb. 2016. an aligned framework for a new system of care and payment. While the details of the payment reforms for SIM are not yet fully known, payers have committed to supporting practices in this effort. Please visit www.coloradosim.org/payers-sim to learn more on this exciting opportunity. The other opportunity is the AHRQ-funded EvidenceNOW Southwest, with a focus on cardiovascular risk mitigation and the new CVD guidelines for managing heart health for adults. EvidenceNOW is also a

Colorado Medicine for September/October 2015

Features great initial preparation for practices not quite ready for SIM, but wanting to engage with SIM in 2017 or 2018, or otherwise begin to prepare for the new payment models. Applications are being accepted now for both programs, and we welcome your interest and participation. For additional SIM information and to access the application please go to ucdenver.edu/practicetransformation. For additional information on the EvidenceNOW SW program, please visit www.EvidenceNOW.org . n

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The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. These opportunities and more are offered through the Colorado Health Extension System, a collaborative of more than 20 organizations in Colorado that provide support for practices in various quality improvement and practice transformation projects. CHES provides a mechanism for coordinating practice transformation support across Colorado, aligned with the emerging payment models.

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The application process is simple and the review process is completely confidential. For more information or to obtain an application form, please contact Tom Wilson at the Colorado Medical Society at 720-858-6316 or by e-mail at tom_ wilson@cms.org. Visit www.cms.org/about/cochems-trust to download an application form. 25

Features

Marijuana legalization Doris C. Gundersen, MD

A prescription for trouble? Editor’s note: This article was originally published as “critical thinking on issues of medical licensure and discipline” in the Journal of Medical Regulation, Volume 101, Number 1, 2015. This excerpt has been reprinted with permission. The United States is clearly divided over the legalization of marijuana. Those in favor argue that legalization of marijuana protects individual rights and eliminates criminal convictions and incarceration for minor offenses. They also maintain that it would do away with the black market and provide significant tax revenue to each state. Those opposed to its legalization express concern about a possible escalation in use with concomitant adverse mental and physical health effects, increased medical costs and negative societal consequences.3 Many of these concerns appear to be unfolding today in Colorado. In August 2014, the Rocky Mountain High Intensity Drug Trafficking Area Investigative Support Center released a report summarizing the impact of the recent easing of federal marijuana arrests and the eventual legalization of marijuana in Colorado.1 According to the report, the ramifications of these developments in the state are widening. Public health and safety impacts, for example, include an increase in traffic fatalities involving drivers testing positive for marijuana. The majority of driving-under-the-influence-of-drugs arrests in Colorado involve marijuana. In 2013, 48 percent of Denver adult arrestees tested positive for marijuana, a 16 percent increase from 2008. From 2011 through 2013 there was a 57 percent in 26

crease in marijuana-related emergency room visits. Hospitalizations related to marijuana have also increased. In the state’s schools, marijuana use is higher than national averages. In 2012, Colorado ranked fourth in the nation for marijuana use among 12 to 17 year olds and 39 percent higher than the national average. Drug-related school suspensions/expulsions increased by 32 percent between 2009 and 2013; the vast majority were for marijuana violations. The use of marijuana among adults in Colorado is also much higher than national norms, with the state ranking third in the nation in 2012 – 42 percent higher than the national average. Other concerning trends have been observed since the de facto and actual legalization of marijuana. Butane hashish oil (aka BHO) labs are emerging. Infusing hashish oil with butane and smoking or vaporizing the concoction produces an intense mind-altering experience. Whereas an average-size marijuana “joint” contains 10 to 15 percent THC, BHO can contain up to 90 percent THC. The emergence of these THC-extraction labs has posed unique challenges to law enforcement officials and physicians alike. Flash fire explosions have originated from the butane used in the extraction process. In 2013, there were 12 THC extraction lab explosions. In the first half of 2014, the number of explosions more than doubled. In 2013 there were 18 documented injuries from THC extraction labs and in the first half of 2014 there were 27 documented injuries. While “dabbing”

(e.g., smoking BHO) has gained popularity in recent years, others consider it the “crack of pot” and fear it could jeopardize the marijuana legalization movement.1 “Black market” marijuana was expected to disappear once the substance was legalized in Colorado. However, marijuana illegally cultivated on federal land in Colorado is a thriving business. There is no evidence to suggest that the legalization of recreational marijuana has diminished the illegal production of marijuana on national forest system lands.1 Given the high taxation on legal marijuana and demand for the drug in neighboring states, it is unlikely that this underground business will disappear. Similarly, the applications for medical marijuana cards were expected to diminish with the passage of Amendment 64. Instead, Colorado’s Medical Marijuana Registry reveals that the CDPHE’s issuance of medical marijuana cards almost tripled between December 2009 and April 2014. A possible cause is the fact that marijuana dispensed for medicinal purposes is taxed at a lower rate than that purchased for recreational use.1 Proponents theorized that legalizing marijuana would reduce alcohol consumption in the state of Colorado. However, the data does not support that this is occurring. Alcohol consumption in Colorado is consistently above the U.S. average of gallons of alcohol consumed per year.1 When recreational marijuana became legal on Jan. 1, 2014, a flood of con-

Colorado Medicine for September/October 2015

Features sumers began to visit dispensaries. The proliferation of marijuana “edibles” surprised state officials and industry alike. Cookies, candies and drinks (e.g., “soda pot”) infused with THC became quickly popular, accounting for 45 percent of the legal marijuana marketplace. Unfortunately, of those new consumers, many were not aware of the potent THC content in edibles. Three deaths resulted. A 19-year-old college student, after consuming a marijuana-infused cookie, became agitated and jumped off a hotel balcony. An adult male Denverite shot and killed his wife after eating a THCcontaining piece of candy. A 23-yearold skier visiting from out of state shot and killed himself after ingesting edibles. Hospital emergency rooms continue to treat children, adolescents and adults who develop paranoia, anxiety and/or psychosis following intentional or accidental exposure to these edibles. In addition to unpleasant psychiatric effects, more hospitals are treating chronic marijuana users for Cyclic Vomiting Syndrome, a cannabinoid-induced hyperemesis that has created a burden to the health-care system as it often leads to costly gastrointestinal workups and hospitalizations.1 The promise of large state tax revenues from the sale of marijuana may have served as an enticement for the legalization of marijuana. However, tax revenue from marijuana sales has fallen short of what was anticipated. In December 2014, state tax revenues received from marijuana sales were predicted to top $100 million but in reality were on pace for a little more than half that amount.24 Limitations in marijuana research Clearly, the legalization of marijuana has increased the acceptability, accessibility and use of this drug, and it should be noted that some results from medicinal marijuana use appear to show promise. A few families, for example, have traveled to Colorado to legally obtain cannabidiol tinctures for their children who suffer from intractable epilepsy and, more specifically, Dravet Syndrome – and for some, the results have been encouraging. In a recent study of 19

children with epilepsy, two children experienced complete remission from seizures. Another eight children experienced a significant reduction in seizures and six experienced a reduction of 25 to 60 percent in their symptoms.8 While promising, however, this small sample size does not provide the kind of efficacy and safety data the FDA would demand before introducing a new drug to the public. What is more common, and more troubling, is a general murkiness that can cloud scientific discovery when the availability of medicinal marijuana is exploited by recreational users and financial opportunists – as in the spike in diagnosis of “severe pain” among young men in Colorado between 2009 and 2014. Effective public health policy depends on accurate health reporting and scientific analysis – neither of which is possible when bad actors, whether they are patients or the physicians who treat them, are distorting health care decision-making for personal benefit. It is ironic that at a time when we are emphasizing evidence-based medicine and conducting vigorous smoking cessation campaigns, marijuana is being promoted – despite the known health hazards, such as pulmonary disease, vascular complications, neurotoxicity to the developing brain, cognitive deficits in adults, addiction and other psychiatric problems, including psychosis.8 While the Institute of Medicine’s 2003 authoritative report identifies potential benefits of marijuana related to its anti-inflammatory, antiemetic, antispasmodic and analgesic properties, in addition to its ability to lower intraocular pressure, studies conducted in the past had several limitations. Research on the use of marijuana for medical purposes is lacking, partly because it is currently classified as a Schedule I drug, making it virtually impossible to conduct the randomized, double-blind, placebo-controlled prospective studies that are normally employed to assess efficacy and safety. Studies thus far have been retrospective in nature with small subject numbers. Differing cannabinoid concentrations, differing exclusion criteria

Colorado Medicine for September/October 2015

and confounding variables limit the reliability of earlier study outcomes.8, 11, 14, 25

Complicating matters, the THC potency, as measured in marijuana obtained through interdiction seizures, has steadily increased from approximately 3 percent in the 1980s to 12 percent or higher in 2014. Thus, the marijuana available today may be associated with more hazards than previous studies reflect. In short, for medical professionals and public health officials, we are clearly putting the cart before the horse in terms of public policy and our ability to provide the most accurate scientific information about any associated health risks or benefits related to marijuana use. What path forward for regulators? All of this creates great challenges for state medical boards. If public health and safety is potentially impacted by marijuana use, how can regulators ensure that the actions of licensees are not contributing to public harm? How do regulators ensure the safety of patients when much-needed, large-scale research is lacking, and when, at the same time, public opinion seems to be colliding with the medical evidence? How do regulators navigate the conflict between state and federal laws? As more states move in the direction of legalizing marijuana for medicinal purposes, we can anticipate more patients inquiring about its risks and benefits – and in the current atmosphere it is likely they will receive conflicting advice. This will create difficulty in making judgments about medical competence. We can also anticipate more patients requesting marijuana for treatment, and regulators in medical marijuana states should consider identifying a core set of practices to guide physicians as prescribing continues to increase. For physicians choosing to recommend marijuana for medicinal purposes, it should only be done in the context of a patient- physi-

Marijuana (cont.) cian relationship that includes regular follow up and reassessment. Physicians should also: • Obtain a thorough clinical history and any needed laboratory evaluation before making a recommendation for marijuana. • Provide informed consent based on the most current literature available about the benefits, risks and alternative treatments to marijuana. • Maintain a chart on every patient and have regular follow up to monitor progress and identify any unintended consequences or side effects from the marijuana treatment. • Recommend patients not drive or operate machinery when under the influence of the drug to avoid accidents. • Caution patients to keep their marijuana in a secure place to reduce the risk of child and adolescent exposures. • Screen for contraindications. Any physician recommending marijuana for medicinal purposes should be able to diagnose substance use disorders and recognize mental illnesses that have the potential to be aggravated by the use of marijuana. • Stay abreast of advancing science and adjust practice accordingly. • Check with their malpractice carrier

to make sure they are covered adequately for this practice. Conclusion The CDPHE has established a Medical Marijuana Scientific Advisory Council in an effort to gather new scientific evidence about marijuana. Grants will be awarded to seasoned researchers in Colorado and other states with the hope of delineating the benefits and risks associated with its use. Until then, other states facing legislative efforts to legalize marijuana should consider Colorado’s experience as a cautionary tale. Approving medical treatments by ballot initiatives sets a dangerous precedent for public health. This will be one of the great social experiments of the century. n About the Author Doris C. Gundersen, MD, is an assistant clinical professor in the Department of Psychiatry, University of Colorado Health Sciences Center. She also serves as the president of the Federation of State Physician Health Programs. References Note: References follow the numbering of the original article. 1. Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) Investigative Support Center, “The Legalization of Marijuana in Colo-

rado: The Impact,” Volume 2, August 2014. 3. Richter KP, Levy S. Big Marijuana – Lessons from Big Tobacco New England Journal of Medicine 371;5, July 31, 2014. 8. Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse Health Effects of Marijuana Use, New England Journal of Medicine 370;23 June 5, 2014. 11. Wallace M, Schulteis G, Atkinson JH, et al. Dose-dependent effects of smoked cannabis on capsaicininduced pain and hyperalgesia in healthy volunteers. Anesthesiology 2007;107:785-96. 14. Nussbaum AM, Boyer JA, Kondrad EC, “But my Doctor Recommended Pot”: Medical Marijuana and the Patient- Physician Relationship, J Gen Intern Med, August 24, 2011 [Online]. Available at: http:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC3208453/. 24. Marijuana Policy Group. Market Size and Demand for Marijuana in Colorado. A study for the Colorado Department of Revenue, National Survey on Drug Use and Health, marillow.com, Colorado Department of Revenue. 25. Institute of Medicine. Marijuana and Medicine: Assessing the Science Bases. [Online]. Available at: www.com.edu/REPORTS/2003/ Marijuana-and-Medicine.

Colorado Medicine for September/October 2015

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Colorado Medicine for September/October 2015

Inside CMS

ICD-10 news round-up Marilyn Rissmiller, Senior Director, Division of Health Care Financing

Oct. 1 ICD-10 implementation deadline arriving STORY HIGHLIGHTS • As Colorado physicians prepare for the implentation of ICD 10, Colorado Medicine presents a collection of last-minute developments worthy of attention for physican practices. Federal CMS names “ICD-10 ombudsman” With less than one month to go before the Oct. 1 implementation deadline for ICD-10, the Centers for Medicare and Medicaid Services is working to pro-

vide additional clarity and assistance for physicians. The agency has named an “ICD-10 ombudsman,” emergency room physician William Rogers, who currently serves as director of the agency’s Physicians Regulatory Issues Team. In this role, he will be a “one-stop shop” for physicians with questions and concerns and will serve physicians as their advocate within the agency, said federal CMS Acting Administrator Andy Slavitt on a national provider call. Physicians can contact Dr. Rogers via email at icd10_ombudsman@ cms.hhs.gov.

The agency also announced that its new ICD-10 Coordination Center in Baltimore will begin operating at the end of September. The goal of the center will be to “manage and triage issues” relating to the transition from the ICD-9 code set. Both provisions were included in an agreement the American Medical Association and federal CMS announced in July. That agreement established an ICD-10 grace period to help make the transition less disruptive to physician practices. The idea for the grace period originated with the Colorado delegation to the AMA and was passed at the AMA Annual Meeting in June. It assures that, for the first year ICD-10 is in place, Medicare Part B claims will generally not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes. Agency releases final round of testing results About 1,200 physicians and other health care professionals participated in the federal CMS’s final end-to-end testing week in late July. The acceptance rate for July was similar to rates in the previous two testing weeks. Here are the final end-to-end testing numbers: • • • •

29,286 test claims received. 25,646 test claims accepted. 87 percent acceptance rate. 1.8 percent of test claims were rejected as a result of an invalid submission of

Colorado Medicine for September/October 2015

Inside CMS ICD-10 diagnosis or procedure code. • 2.6 percent of test claims were rejected as a result of an invalid submission of ICD-9 diagnosis or procedure code. The agency suspects that some testers intentionally included errors to make sure the claim would be rejected. Additional rejections were from non-ICD10-related errors, including incorrect National Provider Identifiers, health insurance claim numbers or submitter IDs, dates of service outside the range valid for testing, or invalid place of service. Still time to prepare Though time is running out, there are still steps practices can take to be ready for the transition to ICD-10. The AMA and federal CMS have resources to polish a practice’s implementation plan over the next few weeks. • A free online module in the AMA’s STEPS Forward collection that offers materials to help you prepare. Access it at www.stepsforward.org/modules/ ICD-10-implementation-plan. • A special series at AMA Wire examines what you need to do each month to prepare for the transition, whether you’re an ICD-10 expert or just getting started. Access it at www. ama-assn.org/ama/ama-wire/blog/ ICD-10_Monthly_Primer/1. • Additional ICD-10 content at AMA Wire provides important insights for what you need to know about the new code set. Access it at www.amaassn.org/ama/ama-wire/blog/ICD10/1. • The AMA’s ICD-10 webpage offers important information and resources on implementation planning, from cross-walking between ICD-9 and ICD-10 to testing your readiness. Access it at www.ama-assn.org/go/ icd-10. • The federal CMS is offering free assistance for smaller physician practices through its “Road to 10” website. This collection includes primers for clinical documentation, clinical scenarios and other specialty-specific resources to help with implementation. Access it at www.roadto10.org. n Colorado Medicine for September/October 2015

Inside CMS

Working together Jan Gillespie, MD, Past President Colorado Society of Anesthesiologists Board Member, Colorado Medical Society

CMS, CSA and a Supreme Court ruling As a past president of Colorado Society of Anesthesiologists (CSA) and board member of the Colorado Medical Society (CMS), I was glad to learn on June 1, 2015, that the Supreme Court overturned a far-reaching decision of a lower court that the governor “opting out” of Medicare physician supervision requirements for anesthesia delivered by CRNAs impacts only Medicare reimbursement and is not a determination of Colorado law. CMS and CSA joined together in 2010 to challenge then-Gov. Bill Ritter’s decision that exempted Colorado’s rural hospitals from the federal regulation requiring a physician to supervise a nurse anesthetist delivering anesthesia during

surgery. This is the type of collaboration that facilitates wins for patient safety and for doctors. Colorado Medical Society and CSA brought suit against the governor arguing that the exemption was contrary to Colorado state law. A Colorado District Court ruled in 2011 that Colorado law permits independent practice by CRNAs and the Colorado Court of Appeals upheld the lower court decision in 2012, an interpretation with which CMS disagreed. The decisions by the lower courts threatened to create precedent highly detrimental to anesthesiologists throughout the state and resulted in CMS and CSA requesting review by the Colorado Supreme Court.

Support the Colorado Medical Society Foundation The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans. The CMSF Board of Trustees is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. We need your help to meet our goals.

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Although the June 1 Colorado Supreme Court decision did not erase the governor’s Medicare opt-out election, it does negate the major portion of the earlier rulings and reinforces the standing of CMS and CSA to challenge the Ritter decision, in order to protect patient safety in anesthesia care. Because of the Supreme Court’s favorable rationale restricting application of its decision, CMS council did not feel it prudent to either risk a revised unfavorable decision or submit statements into the public court record. CSA council concluded it unlikely that the Supreme Court would even rehear the case, with the further concern that the court would then reach the same conclusion as the two lower courts. In addition, the Supreme Court justice most receptive to patient safety arguments retired in 2013 and the court’s opinions have trended since to be more legally technical in nature. Considering all of these factors, CMS legal counsel felt this ruling clarifying that the governor’s decision is not a legal interpretation of either Colorado’s Medical or Nursing Practice Acts was very likely the best outcome that anesthesiologists could get. I, as an anesthesiologist, agree and support the decision not to seek a rehearing. I am truly grateful for the productive and collegial collaboration between CMS and CSA that enabled the favorable ruling. It is extremely important that all in the house of medicine in Colorado continue to work together during this time of rapid change in health care. I applaud all of our partners who join us in championing patient safety now and in the future. n

Colorado Medicine for September/October 2015

Inside CMS

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

Chris Varani University of Colorado School of Medicine

Chris Varani is a third-year medical student at the University of Colorado. A Boulder native, he has earned degrees from the University of Michigan, Oklahoma State University and the University of Colorado. After a career as an officer in the U.S. Air Force, he is excited to become a physician involved both in individual patient care and in system administration.

Placing an IV Mr. K was a 48-year-old gentleman with a complicated medical history including immune suppression, prior transplants, bleeding disorders and a housemate who had recently been infected by clostridium difficile. His doctor sent him to our emergency room today upon hearing he now had diarrhea and fever. I enjoyed chatting with him as I ran through all of my questions. He understood that he might have a life-threatening illness. It wasn’t his first. He was mentally prepared to battle through it. The room was hopping. A nurse and a tech were helping Mr. K into his bed. Another nurse was charting. The attending checked in briefly. The team was running smoothly until I saw the tech set out the blood tubes. Since I couldn’t resist the extra practice, I asked, “would 36

you mind letting me draw the blood and set up the IV while you back me up?” The surprised tech grinned and agreed. The practiced patient smiled, shrugged and stuck out his arm. The rest of the team left the room so I could better focus. I examined his arm, looking for my target vein and trying to pinpoint the surrounding landmarks. It was just as an experienced instructor had taught me years ago while flying bombing patterns through the British fog. I cleaned the site, prepped the equipment and lined up the needle. “I’m going after this vein, left forearm and running at this angle.” I looked up at Mr. K to make sure he was still comfortable; “here we go…”. I sensed the tech lean in to watch, ready to take over if necessary but still encouraging me. Smooth! I fed in the catheter and pressed down on the vein to pinch it shut before retracting the needle. And then the blood started dripping out all over the place! My tamponade was failing and I scrambled to prevent a mess. The tech was already there, moving my thumb to the right location while moving the sheet under the arm to keep Mr. K’s pants clean. After so many years, she had anticipated the mistakes I might make. I finished collecting and cleaned up the blood that had escaped. Mr. K handed me another piece of gauze and pointed to some blood left on his hand. “If you leave that there, everyone else will think the medical student botched the blood draw!” Venipuncture is a basic skill but medical students do not get much practice. That was probably my ninth stick. My attending later told me that he might have done 40-100 in his career. The technician coaching me had probably done 40 IVs that morning. My attending explained that if a tech and nurse are unable to get an IV started in a patient, they ask the doctor to do it. When a person with years of experience and practice with literally Colorado Medicine for September/October 2015

Inside CMS thousands of IVs can’t get it, they go to the person who has done maybe a few dozen? It might make sense if the doctor then chooses to escalate the treatment with ultrasound or an arterial line. It doesn’t make sense when the doctor just removes the bandage and tries the same spot the nurse had attempted (exactly what I watched a resident do the day prior). The physicians have a higher license, but that does not mean they have more experience or skill in all tasks. I thought back again to my time dropping practice bombs at the bombing range. If I needed extra coaching or new techniques to hit the target, I went to the person with thousands of hours of experience or the instructor who was flying every day. I did not just go the next person with a higher rank. Becoming a general makes the person a General (and confers much greater authority). But it doesn’t magically make them a better pilot. While I was in the room I was the learner and the others were teachers. When we walked out my resident grinned and asked the tech how I’d done. “He got it, no problems. That’s my only chance to tell a doctor what to do!” The medical hierarchy was slammed back in place. The emergency department has hundreds of employees and relatively few are doctors. Some roles require a few weeks of training and some require a decade. Regardless, a person becomes an expert through effort and experience and that proficiency shouldn’t be discounted because of differences in title or rank. I received awesome IV training because I had an experienced tech and an experienced patient who guided me, let me spill a little blood, and showed me how to do it better next time. n

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Colorado Medicine for September/October 2015

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Inside CMS

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

COPIC and MagMutual form new alliance COPIC is always striving to improve the level of service we offer insureds; therefore, we are excited to announce that COPIC and MagMutual, the Southeast’s leading medical liability provider, are forming a new alliance to share industry knowledge and promote best practices. The arrangement is designed to reinforce a broader commitment to improve health care outcomes through patient safety and risk management education, and develop improved resources for the health care community. It will become effective in fall 2015. What are the benefits of this alliance? The alliance is focused on leveraging collective knowledge, experience and services to not only benefit policyholders, but also to better position COPIC to address the needs of a changing health care landscape. By maximizing the strengths of both companies, we anticipate the following benefits for insureds: • Enhanced insight and experience on patient safety and risk management issues that translates into knowledge passed on to insureds. • Improvements in technology platforms. • Development of new resources and tools to address current trends in health care. • Cost-sharing efforts designed to keep premiums affordable. Why was MagMutual selected as a partner? COPIC’s leadership team and board of directors determined that aligning with a like-minded medical liability carrier would better position us to address the future of health care and continue to deliver a high level of service. We are confident that MagMutual will serve as an excellent partner because we share many of the same values and history. Both companies were founded by physicians, have cultivated similar cultures, are recognized for their excellent customer service, and are committed to improving outcomes through patient safety and risk management education and resources. Will this alliance change how COPIC operates? We are not planning on consolidating business operations, but rather, sharing our knowledge and expertise with each other in a way that mutually benefits our policyholders. Rest 38

assured, we expect business to continue as usual for COPIC insureds. Under the terms of the agreement, both companies will invest in each other’s success. MagMutual will acquire a 25 percent minority interest in COPIC, and COPIC will act as a reinsurer for a portion of MagMutual’s written premium. Each company will retain its individual brand, trusted employees, and leadership and board of directors. Will policyholders see an increase in premiums as a result of this alliance? COPIC policyholders will not see premium increases due to this alliance, rather, we anticipate many added capabilities and efficiencies. Policyholders will continue to work with the same COPIC staff who serve them currently. Can you provide some more details about MagMutual? • The company was founded in 1982 and is based in Atlanta. • It is licensed to provide medical liability insurance in the following states: Ga., Ala., Ark., Fla., Ky., N.C., S.C., Tenn., Va., Ind., Md., Mich., Ohio, W.VA. • It insures more than 19,000 physicians and 272 hospitals and facilities. • There is no overlap in the states where MagMutual provides insurance and the states where COPIC does business. • MagMutual is rated A (Excellent) by A.M. Best, the leading insurance industry rating agency; this is the same rating that COPIC has maintained for more than 15 years. We are very excited about this alliance and the opportunities it will create. As always, we want to thank all of our insureds and partners for their ongoing commitment to COPIC and our mission. n Please note: The agreement is subject to approval by the Colorado Division of Insurance and the Georgia Department of Insurance. In addition, the agreement is subject to the consent of the Federal Trade Commission and Department of Justice. Pending those approvals, as well as finalizing closing documents, the agreement is expected to be operational this fall.

Colorado Medicine for September/October 2015

Inside CMS

CMS and COPIC staff report

Membership has its privileges When you are focused on taking care of patients, it’s nice to know that others are focused on taking care of you. Whether you are insured by COPIC or a CMS member (or both), there are many benefits each organization provides. We wanted to remind you of the resources available to support your efforts in health care. In addition to solid defense when you face a lawsuit or claim, COPIC insureds have access to the following: • Cyber liability coverage – Policies include coverage for cyber claims such as data breaches and cyber attacks; as health care is a key target for cybercrime, it is important to have reliable protection and support in this area. • An extensive list of education activities – There are more than 100 opportunities available through in-person seminars and online courses; these cover timely topics and allow you to earn points toward a premium discount. View a current listing at www. callcopic.com/education • Practice Quality (PQ) visits – On-site assessments designed to provide insight on best practices while addressing areas for improvement; these also help ensure that adequate internal systems (e.g. documentation, test tracking, patient follow up, etc.) are in place. • 24/7 hotline for advice – Problems don’t occur on a 9-5 schedule, so COPIC physician risk managers are always available to assist you and provide guidance through our hotline. • 3Rs Program – Recognized by The New England Journal of Medicine and Health Affairs, the 3Rs (Recognize, Respond and Resolve) Program attempts to preserve the physician-

patient relationship after an adverse outcome and reimburse the patient for medical-related expenses. • Legal department assistance – Attorneys and paralegals can assist in answering legal-related questions or to point you in the right direction for legal help. When asked how they utilize COPIC, some insureds pointed to these examples: • “Clinic visits to identify weaknesses in the practice and the ability to call at any time and get advice about a possible risk.” • “[COPIC] provides proactive physician risk management education...essentially ‘preventive medicine’ against lawsuits.” • “When I was a resident, I was able to watch the 3Rs Program in action and see how much all the ‘grown up’ doctors trusted COPIC.” The Colorado Medical Society is the largest professional membership organization in the state speaking on physicians’ behalf in the legislature, the courtroom and the boardroom. There are numerous ways to be engaged in such fundamental issues as improving the quality and cost effectiveness of care delivered in our state, the economic viability of physician practices, and bolstering professionalism. • Advocacy – CMS aggressively advocates at the state Capitol with its lobby team and through its political action committee, COMPAC, by supporting pro-physician and pro-patient legislators. Physicians across the state participate by interviewing candidates and making recommendations for endorsement. Members also testify for or against legislation during session.

Colorado Medicine for September/October 2015

• Leadership – CMS provides leadership training like the Advanced Physician Leadership Program and involvement opportunities on its Board of Directors and committees and commissions that develop policies on the most important topics in medicine. CMS also recommends physicians to serve on outside task forces, commissions, and working groups. • Practice support and discounts – CMS provides practice support and negotiates discounts on your behalf with member benefit partners that offer special deals and services at reduced rates. Need a HIPAA-compliant mobile app for medical communication? How about financial planning services from firms that know physicians’ priorities? CMS partners cover a broad range of services. • Practice simplification – CMS advocates for quality patient care and reduced administrative hassle. As a central organizer of the Clean Claims Task Force, CMS is working to develop a standardized set of payment rules and claim edits to be used by payers and health care providers in Colorado that will ultimately save millions. CMS and COPIC help physicians and practices endure the challenging and constantly evolving medical environment by having your back. We provide the unity to keep you connected while also providing the tools to help your bottom line, help you navigate the legal environment, help you succeed with new quality and reporting requirements, and help you transform your practice to increase your career satisfaction. With physicians, by physicians and for physicians – COPIC and CMS are here for you. n 39

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medical news AMA statement: Insurance mergers will reduce competition and choice Steven J. Stack, MD, president of the American Medical Association, issued the following statement on July 24, 2015. “The American Medical Association believes patients are better served in a health care system that promotes competition and choice. We have long cautioned about the negative consequences of large health insurers pursuing merger strategies to assume dominant positions in local markets. Recently proposed mergers threaten to increase health insurer concentration, reduce competition and decrease choice. “The AMA’s own study shows that there has been a serious decline in competition among health insurers with nearly 3 out of 4 metropolitan areas rated as ‘highly concentrated’ according to federal guidelines used to assess market competition. In fact, 41 percent of metropolitan areas had a single health insurer with a commercial market share of 50 percent or more. “Further AMA analysis shows that based on federal guidelines, the proposed Anthem-Cigna merger would

be presumed to be anticompetitive in the commercial, combined (HMO+PPO+POS) markets in nine of the 14 states (N.H., Maine, Ind., Conn., Va., Colo., Ga., Nev., Ky.) in which Anthem is licensed to provide coverage. “The lack of a competitive health insurance market allows the few remaining companies to exploit their market power, dictate premium increases and pursue corporate policies that are contrary to patient interests. Health insurers have been unable to demonstrate that mergers create efficiency and lower health insurance premiums. An AMA study of the 2008 merger involving UnitedHealth Group and Sierra Health Services found that premiums increased after the merger by almost 14 percent relative to a control group. “To give commercial health insurers virtually unlimited power to exert control over an issue as significant and sensitive as patient health care is bad for patients and not good for the nation’s health care system. The U.S. Department of Justice has recognized that

patient interests can be harmed when a big insurer has a stranglehold on a local market. “Given the troubling trends in the health insurance market, the AMA believes federal and state regulators must take a hard look at proposed health insurer mergers. Antitrust laws that prohibit harmful mergers must be enforced and anticompetitive conduct by insurers must be stopped.” n Editor’s Note: The findings on health insurer consolidation come from the 2014 edition of AMA’s Competition in Health Insurance: A Comprehensive Study of U.S. Markets, which offers the largest and most complete picture of competition in health insurance markets for 388 metropolitan areas, as well as all 50 states and the District of Columbia. The study is based on 2012 data captured from commercial enrollment in fully and selfinsured plans, and includes participation in consumer-driven health plans.

SCL Health-Front Range receives accreditation with commendation The Colorado Medical Society Committee on Professional Education and Accreditation has awarded accreditation with commendation, the highest level of CME accreditation, to SCL Health-Front Range. SCL Health-Front Range, formerly Exempla Healthcare, represents three hospitals within a system – St. Joseph’s Hospital in Denver, Good Samaritan Hospital in Lafayette, and Lutheran Hospital in Wheat Ridge. All three hospitals have collaboratively formed a central CME committee consisting of physician 40

chairs, quality representatives, and other key health care professionals. They meet regularly to identify systemwide gaps and utilize their CME program to address the educational needs through organizational initiatives and team-based courses. This honor, accreditation with commendation, is awarded to CME institutions that adhere to all 22 CME criteria of the Accreditation Council for Continuing Medical Education, or ACCME, the main accreditation body

for CME. CMS is recognized by the ACCME to accredit CME providers in Colorado and the surrounding states. To receive commendation, organizations must demonstrate that they use CME as a tool to improve quality performance, and that they collaborate with internal or external stakeholders to further improve quality. SCL Health-Front Range has received a sixyear term of accreditation rather than the standard four-year term. n

Colorado Medicine for September/October 2015

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medical news Physicians needed to become preceptors through the Foundations of Doctoring curriculum at University of Colorado School of Medicine The University of Colorado School of Medicine is in need of physicians to volunteer as preceptors. Students attend about one preceptor session (four hours) two to three times per month in their preceptor’s place of practice while school is in session. Students are focused on practicing physical exam and communication skills that they have learned in the classroom. This early clinical exposure allows students to apply some of the basic science knowledge they are acquiring in the classroom, helps them to feel comfortable interacting with patients, and most importantly provides them with the opportunity to gain

exposure to a practicing physician who can serve as a role model and mentor in their training. As a preceptor, a physician will have access to teaching material through the UCSOM website including access to the Academy of Medical Educators and their educational development programs and access to the Office of Community Based Medical Education website, which includes benefits for preceptors: www.medschool.ucdenver. edu/ocbme. UCSOM will also maintain a record of each physician’s Foundations of Doctoring teaching service and related evaluations and provide preceptors with a plaque to display as

recognition of this commitment to medical education. Having a student in the practice setting can be challenging to balance but also rewarding and refreshing to a physician’s career. Preceptors have the potential to leave a lasting impact on a young physician in training and have a positive influence on the way they interact with every patient they encounter for the rest of their career. If you are interested in becoming a preceptor this year or in the future, please email Foundations.Doctoring@ucdenver.edu. Go to www.medschool.ucdenver.edu/fdc for further information. n

CMS Regional Innovation Day: Innovation to Transform Care

Sept. 29, 8 a.m. - 3:30 p.m., Byron Rogers Federal Office Building, Denver, Colo. Join the Centers for Medicare and Medicaid Services Denver Regional Office for a Regional Innovation Day on Sept. 29, 2015, 8 a.m. - 3:30 p.m., at the Byron Rogers Federal Office Building, 2nd Floor Conference Room, 1961 Stout St., Denver, Colo. Health care professionals, payers, health care organizations, and state and federal government officials will convene to discuss innovations to transform health care. Agenda topics include: • Transforming Primary Care. • Transforming Specialty Care. • Healthcare Organizational Reform. • The Role of Community in Innovation. Each of these sessions will highlight both federal and non-federal innova-

tions in health service delivery. • Reactor Panel - experts will share their perspectives on the day’s topics and discussions with audience interaction. • Next Steps - Where do we go from here and how do we maintain momentum in innovation? There is no fee to attend, but seating is limited!Register today by visiting: http://cms-regional-innovationday. eventbrite.com. For questions, please contact Dennis DelPizzo at 303-844-1994, dennis.delpizzo@cms.hhs.gov. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for

Colorado Medicine for September/October 2015

Continuing Medical Education (ACCME) through the joint providership of the Colorado Medical Society and Centers for Medicare and Medicaid Services. The Colorado Medical Society is accredited by the ACCME to provide continuing medical education for physicians. The Colorado Medical Society designates this live activity for a maximum of 5.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. n

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

Colorado Medicine for September/October 2015

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medical news 2015 Colorado Health Access Survey: Number of Coloradans with health insurance reaches record high The 2015 Colorado Health Access Survey (CHAS), released Sept. 1, provides an in-depth look at the impact of the Affordable Care Act in Colorado, tracking the full implementation of the health reform law over two open enrollment periods. The CHAS is funded by The Colorado Trust, a health foundation dedicated to ending health inequalities, and is administered by the Colorado Health Institute (CHI), a nonprofit health policy research institute. Here are CHI’s top 10 takeaways from the survey: 1) Health insurance: Setting records in Colorado The percentage of Coloradans without health insurance fell to a record low – 6.7 percent – from 14.3 percent in 2013, before the ACA. The number of uninsured dropped to 353,000 from 741,000 in 2013. 4.9 million Coloradans now have health insurance, an all-time high.

4) Who got covered: Kids, lowest earners Only 2.5 percent of Colorado children under 19 remain uninsured, down from 7.0 percent. The uninsured rate for those earning at or below 300 percent of the federal poverty level (FPL) fell to 8.3 percent from 20.5 percent. 5) Who still isn’t covered: Young invincibles, Hispanics, Western Slope residents The “young invincibles” between 19 and 29 were targeted for enrollment, but still have the second-highest uninsured rate at 12.9 percent, trailing only the thirty-somethings. The uninsured rate for Hispanics fell to 11.8 percent from 21.8 percent, but they remain the least likely to have insurance. The four-county region around Steamboat Springs retains the No. 1 spot with an uninsured rate of 13.0 percent.

2) Medicaid expansion: Higher-than-expected enrollment Medicaid enrollment soared by 450,000 between 2013 and 2015. The data show that despite concerns that the influx would make it a lot harder for enrollees to get care, that didn’t happen.

6) Uninsurance is down, but underinsurance is up Colorado also saw a rise in “underinsurance” to 16.4 percent from 13.9 percent. This is when people have insurance that doesn’t adequately cover their medical expenses. Often, these are plans with low premiums but high deductibles or high co-pay requirements.

3) Types of coverage: A changing landscape More Coloradans are covered by employer-sponsored insurance (50.9 percent) than any other type, but it dropped slightly from 52.6 percent in 2013. Levels of individual insurance, including Connect for Health Colorado, stayed flat. One in three Coloradans (34.2 percent) is now covered by public insurance – Medicaid, Medicare or Child Health Plan Plus (CHP+) – up from 24.2 percent.

7) Cost: Still the No. 1 reason for lack of insurance Among the 353,000 Coloradans who still don’t have coverage, cost is still the top reason. While that hasn’t changed since 2009, it is showing a downward trajectory. The percentage of uninsured Coloradans who say they don’t need coverage has leveled off after a surge in 2013, falling to 20.8 percent from 24.9 percent. About 45 percent of Colorado’s uninsured are only willing to pay up to $99 a month for insurance premiums.

Colorado Medicine for September/October 2015

8) More insurance isn’t making it harder to get care Coloradans aren’t finding it much harder to get health care. There’s been an increase in the percentage of people who can’t get an appointment when one is needed, to 18.7 percent from 15.0 percent. This may change as the newly insured develop new health care habits. One good sign: the percentage reporting a preventive care visit in the past year rose to 66.1 percent from 61.9 percent. 9) Affordability: Health care still costs too much for many The percentage who didn’t see a doctor because of cost declined only slightly, to 10.4 percent from 12.3 percent. The percentage who didn’t fill a prescription because it cost too much dropped a bit to 9.8 percent from 11.2 percent. 10) Coloradans are happier about health care Coloradans give the health care system higher marks than two years ago. Nearly three of four (74.6 percent) say it meets the needs of their family, up from 69.1 percent. More than half (51.2 percent) say that it meets the needs of most Coloradans, an increase from 44.1 percent. The 2015 CHAS was a telephone survey of 10,136 randomly selected households in Colorado, both landlines and cell phones, administered between March 2 and June 26. The margin of error for the uninsured rate of 6.7 percent is plus or minus 0.93 points, a range from 5.8 percent to 7.6 percent. The CHAS is based on a non-institutionalized population estimate of 5,294,229. Detailed information, including data broken down by region and topic area as well as interactive graphics, is available at coloradohealthinstitute.org. n 43

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

➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES ➤ PROPERTIES PAIN MANAGEMENT SPECIALIST NEEDED to provide consultations, develop pain related practice protocols, and advise on medical management for inpatient psychiatric patients with chronic pain issues. This is a part-time, low-risk, flexible opportunity to practice good medicine, have the time needed to assess patients properly, experience camaraderie, and be well compensated for your time. Malpractice provided. If interested, a PM&R physician could also provide musculoskeletal medicine consults. Contact our practice administrator, Debora Din at 303-8667050 Debora.Din@state.co.us or Lisa Lucas, MD at lisa.lucas@state.co.us. Our facility is located in Southwest Denver near Hampden and Federal.

WANTED: A PROFESSIONAL ADVISOR FOR M.D. CLUB at Fairview High School, Boulder, CO; arrange visits to med. centers & provide guest speakers in various specialties. Contact Jessie Bolger, President, at jessiebolger@gmail.com or 610-400-7426 SEEKING A DYNAMIC TEAMORIENTED CHIEF MEDICAL OFFICER for growing non-profit with 4 primary lines of business. Half-time position. Information and details at www.rmhcare.org. Submit resume and application to careers@rmhcare.org. RMHCS is an EOE.

OFFICE SPACE AVAILABLE for family medicine or pain management in Centennial, CO (near C-470 and University Blvd). There are two exam rooms and an X-Ray room on site. Email: milehighspineandpain@gmail.com; Tel: 720-401-8156 MEDICAL OFFICES FOR SUBLEASE LOVELAND/GREELEY - A fully furnished Medical office (1300 Sq ft) in Loveland for sublease on Friday located opposite McKee Med Ctr. A fully furnished Medical office (2750 Sq ft) in Greeley for sublease on Wednesday located just off 10th street. Contact: Karen 970-221-2370/ kmmasterson@allergypartners.com

RADIOLOGIST NEEDED PARTTIME to advise general radiography department in small facility in SW Denver. Excellent part-time opportunity. Very flexible. Please contact Debora Din, 303-866-7050.

SEEKING PRIMARY CARE PHYSICIANS OR CLINICS IN THE DENVER METRO AREA If you are considering: CHIEF MEDICAL OFFICER This is an exceptional opportunity to serve as the executive champion for clinical quality and outcomes for an organization renowned for quality and patient safety. See information and application details at http://www. msasearch.com/featured_ searches_view.aspx?opening_ id=11257. 44

• A new practice opportunity, • Integrating your current practice into a progressive group, • The sale of your practice, or • A change of employment. We offer a unique opportunity: • To be part of a progressive primary care group that has been a Level 3, Patient Centered Medical Home since 2009, • With a competitive compensation package, • Achieve a work/life balance, and • Care for patients without administrative headaches. If interested, contact us at (303) 493-5276. All inquiries will be kept in strict confidence and will receive a prompt response. Colorado Medicine for September/October 2015

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➤ PROPERTIES MEDICAL PRACTICE FOR SALE: NEAR DENVER, CO - This turnkey practice is located a charming ski resort town well known to skiers around the world! It is grossing over $1M and is steadily growing year over year. Located in a newer medical center with room for expansion. The practice focus is on customized medical aesthetics and laser treatments. This is a 100% cash business that is well-equipped with state of the art equipment. The practice has a great reputation and is well known in the community. For more info, please contact Scott Daniels at Practice Concepts at 877-778-2020 or email scott@ practiceconcepts.com. (ID #76579)

➤ MISCELLANEOUS BUSINESS ATTORNEY Spending too much time trying to run a business rather than practicing medicine? I can help the business side of your medical practice focus on business, allowing you to increase focus on practicing medicine while still maintaining control of your business. Strategic planning, operational execution, vendor management, are a few of the necessary business matters distracting from the practice of medicine. Minimize those distractions. Helping businesses and business people achieve their business goals as a business consultant and General Counsel is my passion. David Silverman, Attorney & Counselor At Law, LLC david@dsilvermanlaw. com; 303-858-9850.

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Colorado Medicine for September/October 2015

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Serving the CME 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 45

Features

the final word Gregory Dean Smith, DO, PhD, MDiv, ACOFP-dist CMS WCPIC chair

Physician advocacy assures access to care for injured workers It has been a busy year for the members of the CMS Workers’ Compensation and Personal Injury Committee (WCPIC). The committee worked feverishly to be ready to present our initial thoughts to the Division of Workers’ Compensation (DOWC) by June 1 as they changed to an RBRVS (resource-based relative value scale) system. The committee only had one month of preparatory time to present our thoughts and ideas for the division’s stakeholders meeting the beginning of August. With that in mind, I appointed a subcommittee to meet as often as needed to have our report ready in time to present to the shareholders. I would like to thank all members of the committee for their work, with Lynn Perry, MD, Joseph Ramos, MD, Tashof Bernton, MD, and Kathryn Mueller, MD, putting in additional time and effort as the subcommittee worked hard to allow us the needed time to finish the report and submit the document in a professional fashion to present to the stakeholders meeting. At the beginning of the year we realized that we needed to condense our yearlong agenda into three manageable parts to allow us to be prepared and focused for the work ahead. We wanted to take time to: 1. Consider the requests of CMS members as we proceeded throughout the year, 2. Work on completing all projects regarding rules and regulations, as well as developing a budget request, and 3. Work on developing a new webpage on CMS.org to aid in increas 46

ing membership both for CMS, as well as assisting in recruiting physicians to consider treating more patients in the workers compensation arena. We realized that the pool of workers’ compensation physicians is shrinking in Colorado with respect to those physicians who are seeing workers’ compensation patients. We are also down to approximately 60 physicians who are willing to perform Division IMEs, which is placing a strain on those now doing them, and putting a strain on the system to have these reports completed in a timely fashion for both the patients and their legal counsel. In the coming year(s) we want to use the new webpage to offer advice, begin offering webinars to assist the physicians here in Colorado, and distribute information to those physicians out of state doing IMEs and medical reviews. One recommendation is that all physicians participating in the workers’ comp system should be at least level one accredited in order that they might know the basic rules of the Colorado system. With the rules and regulation subcommittee submitting their final report, we went before the DOWC director’s hearing and left them a seven-page packet that contained recommendations that the committee felt would benefit all physicians involved in workers’ comp – both primary care physicians and specialists. There were concerns that many procedures were going to take major reimbursement hits: Physicians using the QSART test, as an example, with initial budget submission taking the test from approximately

$1,000 to $295 based on changing to RBRVS system. By working with DOWC staff, we were able to return it to its previous level of reimbursement. We were concerned that many procedures were going to take major hits, but after working out the budget process we feel we obtained a fair market value for all procedures with no one procedure taking a major hit. The committee recommended that overall procedures should see a modest increase in the coming year of 5 percent to offset inflationary expenses in physicians’ offices. Finally, although we only had four minutes to present to the DOWC director (as did all groups), we discussed the amount of time that was being wasted by physicians having to deal with physician reviewers and adjustors not being fully informed of medical procedures we requested. Many physicians are being denied care for their patients that in the past would have never been a problem. Personally, I would like to thank the WCPIC committee, CEO Alfred Gilchrist for his oversight and insight, Terry Boucher who serves as our DOWC liaison, and Marilyn Rissmiller for all her hard work crunching numbers and having all of the information we needed at a moment’s notice. I would be remiss not to thank our CMS President, Tamaan OsbourneRoberts, MD, for his faith in us, and for attending meetings when he had time to give us his thoughts and ideas of where we should lead this year. n

Colorado Medicine for September/October 2015

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