September-October 2014 by Colorado Medical Society

September/October 2014

ALIGNING THE BIG PICTURE Colorado Medicine for September/October 2014

Volume 111, Number 5

Medicare incentives turn into penalties

Award-winning publication publication of the Colorado Award-winning Colorado Medical MedicalSociety Society

Colorado Medicine for September/October 2014

contents Sept./Oct. 2014, Volume 111, Number 5

Features. . .

Cover story

Cost commission kicks off–Colorado health policy leaders begin a herculean three-year task to produce recommendations to control cost and improve quality.

Check up on Colorado Medicaid–Colorado Medicine sits down with HCPF Director Sue Birch who explains her work in decentralizing Medicaid and other facets of the program.

COMPAC endorsements–Colorado Medical Political Action Committee chair David Ross, DO, announces this election cycle's endorsements for federal and state office.

Ready or not, the pieces of payment and delivery reform are rapidly moving into place in Colorado and elsewhere. Read complete coverage on how Medicare incentives are turning into penalties including a special two-page Medicare payment and delivery reform timeline followed by a column from Centers for Medicare & Medicaid Services Chief Medical Officer, Denver, Mark Levine, MD. Coverage starts on page 8.

Debunking workers' compensation myths–Colorado's workers' compensation system is a model for other states in part for its guidelines and favorable fee structure.

90-day grace period–The Colorado Division of Insurance has issued guidelines that helps physicians when patients are late making premium payments.

Inside CMS

Right to Try Act–Learn what physicians need to know as Colorado becomes the first state to give terminally ill patients options and access to investigational treatments.

Bridges to Excellence–Learn how the Colorado Business Group on Health Bridges to Excellence program gives physicians an opportunity to be recognized for quality.

Physician guidelines for death certificate completion– Leon Kelly, MD, El Paso County Coroner's Office deputy chief medical examiner tells physicians what they need to know.

Final Word–CMS past-president Michael Pramenko, MD, shares his Colorado experience at a Stanford national leadership seminar focused on health delivery reform.

5 7 44 45 46 48

President’s Letter Executive Office Update Annual Meeting Corporate Supporters/Member Benefits Reflections COPIC Comment

Departments 50 53

Medical News Classified Advertising

Colorado Medicine for September/October 2014

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

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OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2013/2014 Officers John L. Bender, MD, FAAFP President Tamaan Osbourne-Roberts, MD President-elect Kay D. Lozano, MD Treasurer M. Robert Yakely, MD Speaker of the House Brigitta J. Robinson, MD Vice-speaker of the House Alfred D. Gilchrist Chief Executive Officer Jan M. Kief, MD Immediate Past President

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

Allison Wood, MS Harold “Hap” Young, MD Lena Young, MS AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Mark Laitos, 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, 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 Shelley Rabern, Executive Legal Assistant, shelley_rabern@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;Medicine Chet Seward,for Assistant Editor. Colorado September/October Printed by Spectro Printing, Denver, Colorado

2014

Inside CMS

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

Telehealth – facilitating the next big thing Perhaps like me, you have not really seen telehealth live up to its promise here in Colorado. Although we have some telemedicine occurring in niche markets, like satellite hospital consultations, there is hardly a mainstream movement of consumer access to physician services online or by smart phone. Yet the trends are unmistakable: • The advent of accountable care organizations and other bundled payment reform systems will allow codes that were largely not paid for under fee for service, like telemedicine, to have a source of funding. • Regulators at the state and national level are continuing to modernize the law books around telehealth and telemedicine to encourage physicians to engage patients remotely within clear boundaries that are safe and have utility to consumers. • Patients will be empowered to decide when and with whom they will share critical information thanks to remote monitoring technologies such as Bluetooth-enabled biosensors that can communicate with smartphones and sync data to cloud-based health information exchanges. So what does Colorado need to do to participate more in the future? Well it turns out, according to the American Telemedicine Association (a reputable national leader in model language for state policy development for telemedicine rules and regulations) that Colorado is a little behind the rest of the nation. One important potential roadblock here at a mile high is that our state code only requires insurers to pay for telehealth if the patient lives in a county with a population of

under 150,000 people (C.R.S. 10-16123). The law itself seems to suggest that health care disparities and access problems only occur in rural and frontier Colorado. The reality is that telehealth could be used to meet the demands of many important access problems across suburban and urban Colorado as well. I am always amazed at how many patients may not have an automobile in this economy, but they will have a computer tablet and Internet access (and they use it right in the exam room!). Note that the Colorado law itself was written in 2001, long before Facebook, smart phones, and the widespread use of computer tablets by consumers. Estimates vary, but perhaps 20% of what physicians do on average in the office could be accomplished remotely. I would even go so far to say that much of what happens in a retail clinic could be performed as a telehealth visit. Now may be the right time to actively engage with other stakeholders to modernize Colorado’s approach to

telemedicine/telehealth in order to enhance access and improve the quality and cost-effectiveness of our care. At the upcoming annual meeting the House of Delegates will take action on a new policy for CMS on telemedicine. Taking that one step further, now may be the time to consider other potential roadblocks to expanded use of telehealth technologies, like requirements for physicians to document a barrier to an in-person visit for health benefit plan coverage of services provided via telemedicine, or requirements to utilize telemedicine when a physician has determined that it is not appropriate. Technology is rapidly changing the health care landscape and it is incumbent upon us to work with others to ask and answer these challenging questions in order for telehealth in Colorado to live up to its promise. It has been a great year, this is my final letter as your President – thank you for your membership in the Colorado Medical Society, and for all you do for the people of Colorado. n

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

Colorado Medicine for September/October 2014

Call 720-858-6310 for more information and to donate. 5

Colorado Medicine for September/October 2014

Inside CMS

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

Colorado cost commission begins work on lofty goals Although its first meeting was organizational, the Colorado Commission on Affordable Health Care conveyed a strong sense of commitment and purpose by the mere presence of some of the state’s most thoughtful and experienced health care policy leaders.

Created this spring by the Colorado General Assembly with a three-year life span, the commission includes members who are movers and shakers, veterans of Colorado’s lengthy record of successful collaborations in health care delivery innovations and reforms. Commission Interim Chairman Bill Lindsay also led the highly regarded 208 Commission, which produced a comprehensive, prescient set of health care system reform recommendations that predated the federal Affordable Care Act. More than a few of the commission members are practically household names, having collaborated

with CMS over the years and been recognized and honored by our physician leaders for their work on a wide range of initiatives.

The commission members bring their collective wisdom, drawn from long experience in the trenches of care delivery, financing and policy to produce recommendations that by design are intended to rinse the politics and urban myths out of the health care cost debate while building a consensus that reflects exam room-level realities. We are confident that the end products will be evidence-based – built from policies and methods that have a track record in other settings and states. At a time where partisan bickering and zero-sum politics have dominated national headlines, the commission will be a room full of serious, really intelligent experts working through some of the most complicated policy questions.

Given what is at stake, we don’t expect it will always be pretty. Cost outliers that cannot demonstrate their value will have no place to hide given the increasing online publication of cost and quality data. The commission will undoubtedly provoke spirited debates. Colorado has a well-earned reputation in the health care arena for fixing problems, not placing blame. We strongly supported senators Aguilar and Roberts’ development and enactment of the commission, and are pulling together our own internal work group to not only respond to the commission’s ideas, but to bring our own thoughts and recommendations to them. Our CMS boardroom discussions have centered on medicine’s duty to not only our patients, but also to society to be prudent stewards of health care expenditures. This will be tough work, and we are eager to step up. n

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

E-mail: Letters to the editor dean_holzkamp@cms.org

Colorado Medicine for September/October 2014

Cover Story

ALIGNING THE BIG PICTURE

Medicare incentives turn into penalties Marilyn Rissmiller, CMS Senior Director, Health Care Financing

Colorado Medicine for September/October 2014

Cover Story Editor’s note: This is the first in a series of articles Colorado Medicine will publish about Medicare’s approach to cost containment and quality improvement. Ready or not, the pieces of payment and delivery reform are rapidly moving into place in Colorado and elsewhere. And if you’re not among the physicians who are prepared for this significant change in health care, you’re already behind the curve. Since the approval of the Affordable Care Act in 2010, providers have heard the repeated clarion call to line up their operations for incentives (or carrots) that will await them if they comply, and penalties (or sticks) that will strike them if they don’t. Implemented by the Centers for Medicare and Medicaid Services (CMS), aligned programs like the Value-Based Payment Modifier (VBPM), Meaningful Use (MU) and the Physician-Quality Reporting System (PQRS) will soon shift in their effect – fundamentally altering how services are delivered and how physicians are compensated for these services. These programs aim to enhance value in health care by improving the quality of data reported by providers, refining how these services are purchased and delivered, and encouraging investment in technology. (See related sidebar: “A payment and delivery reform primer,” page 10). Some physicians might take false comfort knowing that the incentives and penalties from these programs don’t technically go into effect until January 2015. Unfortunately, even those who hop on the bandwagon now won’t savor the “carrots” until 2017, but the penalties will go into effect as early as next year. (See related breakout box: “Payment and delivery reform timeline,” pages 12-13). Though non-participants might not avoid the initial penalties, they could avert additional losses by taking a leadership role and paying closer attention to their billing, coding and exam room practices.

“These programs will inform the entire reporting environment of health care for years to come,” said John Bender, MD, president of the Colorado Medical Society. “Even if you choose to completely ignore all components of these programs, the ramifications of these reforms will be felt in all practices, since private payers take many of their standards and payment cues from the federally sponsored programs like Medicare and Medicaid.” Why change is afoot These reforms were designed to reduce waste, inefficiencies and runaway costs in the health care system – while providing incentives for getting on board and penalties for non-compliance. The programs operate under the Triple Aim goals of improving the patient experience of care, improving the health of populations and cutting costs. Because of the emphasis on finding new efficiencies, improving quality and reducing costs in health care, there might be a perception that the aforementioned programs effectively chastise physicians to nudge them into operating in a more cost-efficient manner. Furthermore, because information from PQRS feeds the Physician Compare website and potentially other “data dumps,” non-participating physicians could end up effectively “blacklisted” because they’re not included. The site could even hurt the reputations of participating physicians when the data aggregates information that is skewed because of circumstances beyond their control. But despite the potential downfalls, Bender maintains the programs intend to benefit all physicians – and the health care system – in both the shortterm and long run by providing a rich stream of data that will improve both the quality and efficiency of health care practices. “When viewed from a pragmatic lens, these programs could be seen as an opportunity to use data in a way that will make practices better,” Bender said.

Colorado Medicine for September/October 2014

“Not only do [the programs] gather data and provide incentives and penalties for physicians, many of them are encouraging new types of innovation to explore efficiencies and ways to aggregate meaningful data.” The big picture Reform proponents say these programs are a work in progress, but what is the overarching goal? In short, it’s the belief that better data and consistent standards will lead to better health care. Currently, a movement is afoot to establish a common set of standards that will create more consistency in the data collected among providers to enable them to produce and generate more relevant, apples-to-apples data from which to measure effectiveness and efficiencies. These programs operate from the premise that streamlining data will give providers more reliable and actionable information. While consistency is key in turning the tide, a regional approach will enable providers to make the best use of the data. And there’s no one right way to realize these efficiencies and improve health care. Though we are still in the early stages of knowing how to use data appropriately, much of the available data is vastly superior to previous statistics. Over time, all of these programs will mature and lead to different payment incentives or disincentives, and/or payment adjustments intended to hit the Triple Aim health care targets. To foster innovation in payment and delivery reform, CMS sponsors the Comprehensive Primary Care Initiative (CPCI), a collaboration between all major payers – including Medicaid and the largest insurance companies. The initiative, which has recruited four participating states including Colorado, is dedicated to developing new and more effective and efficient models of

Cover story (cont.) health care – and may be a bellwether for other states as the cost-containment measures take root. In Colorado, there are numerous examples of how CPCI works on a community level. One familiar example: Over the years, Mesa County has built a collaborative relationship between the area’s dominant physicians group, hospitals and health insurance carriers that has become a model for payment and delivery reform. The system works in Grand Junction and Mesa County because the region has a healthy sense of community, and a commitment to working together and helping one another – whereas the sense of community might get blurred in a larger metropolitan area. But the Western Slope provides an example every community and municipality can learn from. It’s important to note that the model didn’t exactly come together overnight, but rather evolved over many years thanks to dedicated physician attention and leadership. And while the Western Slope deserves credit for its foresight and innovation, Colorado physicians simply can’t afford to take a backseat in implementing these changes. A call for action Although it may be tempting for physicians to take a “wait-and-see” approach before getting on board with these reform models, those who decline to take part might end up being less adept at using information that can improve their practices, uncover new efficiencies, enhance safety and allow them to take advantage of the incentives that are coming to light every day. As the saying goes, “If you keep doing the same thing and expect a different result, that’s one definition of insanity.” Whether or not you agree with Medicare’s approach to improving quality and containing costs, truly transforming health care into a more sustainable system that avoids “insanity” and meets the needs of patients and providers will 10

not happen simply because we want it to. It will require forethought and planning in order to make these changes effective. Change is endothermic – it consumes

energy, and that energy must constantly be refreshed. Sitting by and waiting for the change to happen is not an appropriate strategy. If you’re going to improve, you need to take active steps to do so. n

Medicare payment and delivery reform primer Major components of these payment and delivery reform programs, overseen by the Center for Medicaid and Medicare Services, are scheduled to go into effect in the fee-for-service program in 2015. Though each of these explores a different part of the health system “elephant,” they share the common intent of appropriately lowering costs by improving the process of care, making it more effective and more efficient. Physician Quality Reporting System – PQRS uses a combination of incentive payments and payment adjustments to report recording of quality information by eligible professionals. Beginning in 2015, the program will apply a payment reduction to providers who do not satisfactorily report data on quality measures for covered medical services. To participate in the 2014 PQRS program, individual eligible health care professionals may choose to report quality information through one of the following methods: 1) Medicare Part B claims; 2) Qualified PQRS registry; 3) Direct Electronic Health Record (EHR) using Certified EHR Technology (CEHRT); 4) CEHRT via Data Submission Vendor; 5) Qualified clinical data registry (QCDR). Physician Compare – This website, http://www.medicare.gov/physiciancompare, serves as the primary and authoritative source for all publicly available Medicare information. Physician Compare helps consumers find and choose health care professionals enrolled in Medicare so they can make informed decisions about the health care they get, as required by the ACA. Though still in its rudimentary phases, the website will evolve into a publicly accessible repository of information on physicians. Value-Based Payment Modifier – VBPM will support a physician value-based purchasing program that will track the quality and costs of large group practices of 100 or more physicians. The program provides comparative performance information to physicians and medical practice groups as part of Medicare’s efforts to improve the quality and efficiency of medical care. By providing meaningful and actionable information to physicians, CMS is moving toward physician reimbursement that rewards value rather than volume. VBPM contains two primary components: the Physician Quality and Resource Use Reports (QRURs) and the development and implementation for the Value-based Payment Modifier. Meaningful Use – The Medicare and Medicaid Electronic Health Records (EHR) programs provide incentive payments to eligible professionals, provider facilities and hospitals as they implement, upgrade or demonstrate meaningful use of EHR technology. Meaningful use is using certified electronic health record (EHR) technology to: improve quality, safety, care coordination, and population and public health; reduce health disparities; engage patients and families; and maintain privacy and security of patient health information. Ultimately, it is hoped that the meaningful use compliance will result in better clinical outcomes; improved population health outcomes; increased transparency and efficiency; empowered individuals; and more robust research data on health systems. Eligible professionals have until the end of 2014 to apply for the program incentives. Beginning in 2015 a payment reduction will apply to providers who have not achieved meaningful use. Source: Centers for Medicare and Medicaid Services

Colorado Medicine for September/October 2014

Cover Story

STICKS AND CARROTS: Program

2013 Note: 2013 data will determine 2015 payment adjustment

MEDICARE PAYMENT AND DELIVERY REFORM TIMELINE 2014 9/30/14 Last day for groups to register to participate in GPRO for 2014 PQRS program year via web interface, registry, EHR reporting or CAHPS reporting methods

PQRS

12/31/14 End of 2014 PQRS reporting period Note: 2014 PQRS data will determine 2016 PQRS payment adjustment

VBPM

Physician Quality Reporting System

10/15/13 Last day for groups > 100 to self-nominate/elect quality-tiering for VBPM Note: 2013 PQRS data will be used to determine 2015 VB modifier payment adjustment

5/1 to 9/30/14 Registration period for VBPM to avoid a 2% penalty in 2016 Third quarter 2014 Retrieve 2013 physician feedback reports (all groups and individuals) Note: 2014 PQRS data will be used to determine 2016 VB modifier payment adjustment

Value-Based Payment Modifier

2014 Last year to start and receive incentive payment 7/1/14 Last day to start meaningful use reporting period for first time attesters in order to avoid penalty

Meaningful Use

10/1/14 Must attest to meaningful use no later than this date to avoid penalty

Colorado Medicine for September/October 2014

Cover Story Though many of the Medicare-oriented programs intended to reduce costs and improve care have gone into effect, a number of implementation steps remain ahead in the years to come.

2016

2015

2017

1/1/15 Beginning of reporting period for 2015 PQRS program year for group and individuals

1/1/16 Beginning of reporting period for 2016 PQRS program year for group and individuals

1/1/17 2% penalty (per claim line) for group and individuals who did not satisfactorily report quality data in 2015

1/1/15 1.5% penalty (per claim line) for group and individuals who did not satisfactorily report quality data in 2013

1/1/16 2% penalty (per claim line) for group and individuals who did not satisfactorily report quality data in 2014

Note: The penalty will be 2% for subsequent years

2/28/15 Last day to submit 2014 PQRS data to determine the 2014 incentive payment and the 2016 payment adjustment

2/26/16 Last day that 2015 claims will be processed to be counted for PQRS reporting to determine the 2017 payment adjustment

2/28/15 Last day to submit 2014 quality measures for dual participation in PQRS and the Medicare EHR incentive program

2/28/16 Last day to submit 2015 quality measures for dual participation in PQRS and the Medicare EHR incentive program

12/31/15 End of 2015 PQRS reporting period

12/31/16 End of 2016 PQRS reporting period

Note: 2015 PQRS data will determine the 2017 PQRS payment adjustment

Note: 2016 data will determine 2018 payment adjustment

1/1/15 VBPM applied to physicians in groups of > 100, 1% penalty up to 2x% positive adjustment dependent upon quality and cost performance

1/1/16 VBPM applied to physicians in groups of >10, 2% penalty for groups of >10 and up to 2x% positive adjustment dependent upon quality and cost performance

Note: Based on 2013 PQRS data

Note: Based on 2014 PQRS data

First quarter 2015 Complete submission of 2014 PQRS information

1/1/17 VBPM applied to all physicians

To be determined 4% penalty proposed in Medicareâ&#x20AC;&#x2122;s notice of proposed rule for 2015 physician fee schedule update Note: Based on 2015 PQRS data

Third quarter 2015 Retrieve 2014 physician feedback reports (all groups and individuals) 1/1/2015 Eligible providers who have not achieved meaningful use subject to 1% penalty

1/1/2016 Eligible providers who have not achieved or maintained meaningful use subject to 2% penalty

Note: Based on 2013 attestation or hardship exemption

Caution 9% Cut

Colorado Medicine for September/October 2014

1/1/17 Eligible providers who have not achieved or maintained meaningful use subject to 3% penalty Note: There will be an additional 1% penalty per year for 2018 and 2019 (up to a maximum of 5%)

Physicians who ignore these programs now could face up to a 9% reimbursement cut by 2017 (some of it based upon 2015 performance). These cuts are separate from the planned 2% Medicare sequestration cuts and any potential SGR reductions.

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Colorado Medicine for September/October 2014

Cover Story

“I’m a good doctor.

Are you?”

Reporting quality measures to improve care

Mark A. Levine, MD, FACP, Chief Medical Officer, Denver Centers for Medicare & Medicaid Services

DISCLAIMER: The opinions expressed in this article are the author’s own and do not reflect the view of the Department of Health and Human Services or the Centers for Medicare & Medicaid Services.

while frequently active in quality improvement efforts in hospitals and other settings of care, were not often engaged in performance improvement activities focused on their own practices.

I’m frequently asked, “What kind of doctor are you?” I playfully respond, “Why a good one, of course!”

There has been significant progress in the last few years. Specialty societies are sponsoring registries that many physicians find useful in comparing outcomes for specific procedures.2 Specialties also have evolved programs for maintaining board certification that require performance improvement activity.3 Even standards for continuing profes-

That was easy to say a few years ago, as there was no way to tell. But today I shouldn’t be so cavalier. Anyone with internet access can soon find objective measures of my performance and can decide for themselves how good I really am.1

sional education are changing, placing increasing emphasis on active improvement activity, not simply attendance.4 Since 2007, Medicare has been contributing to this effort by collecting and reporting quality measures that inform on physician practice.5 The measures used are developed and vetted by peers and tested for reliability and validity.6 Quality measures today address a wide range of medical practice and are applicable to an expanding number of physicians.

Just as the public can access data on physician performance, so can physicians. Physicians can see a rapidly expanding set of data that provides insight into their practice in ways never before possible. Physicians need to embrace this newly available data and use it to better understand and improve their practice. Until recently, information available to physicians regarding their performance was more about productivity than it was about the product. The delivered product – quality health care – was difficult to assess. There were few reliable measures and imperfect mechanisms to collect and report them. A hospital or a health plan might provide some data, though the reported measures were not always well explained or understood. Opportunities for action to improve were not often recognized or acted upon. And, there was no easy way for physicians to compare their performance to that of others. No wonder that physicians, Colorado Medicine for September/October 2014

Cover story (cont.) More recently, Medicare has begun reporting measures of resource use.7 Starting in 2015, these measures, in conjunction with quality measures, will be used in adjusting the Medicare Feefor-Service (FFS) payment of physicians in large group practices for their performance.8 By 2017, all physicians who participate in Medicare FFS will be affected by this value modifier. The following is a list of suggestions and considerations that will help physicians understand the data being reported and use it to improve their practice: 1. Review your data. Consider the measures being used and their purpose and parameters, including inclusion and exclusion criteria. Learning cannot occur if the data is not reviewed and understood. 2. Look for variance. Does your data differ from that of your peers? 3. Identify opportunity. Where is there room for improvement? 4. Examine the process. Consider the

goal of your care and determine the best way to achieve a successful outcome. 5. Select a change that is likely to help. For improvement to occur, something must change. 6. Implement the change. Once the change has been selected, it takes conscious effort to avoid reverting back to old habits. 7. Track progress. You don’t have to wait for another report. It can be useful to maintain your own progress sheet on your improvement project. 8. Refine the change. If your change is not working, don’t be afraid to modify it. 9. Celebrate success. Continue to monitor for slippage. 10. Repeat the improvement process as needed. Understand that while not all variance will be within the physician’s direct control, it is likely to be within

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

the physician’s sphere of influence. It is important to work with colleagues to understand variance and collaborate in following the steps above. Sharing what you are learning with peers will promote a culture of improvement. Today’s data-driven health care environment provides opportunity for improving health care in ways not previously possible. Physician leadership in health care improvement is a necessary ingredient in the recipe for an effective, safe and efficient health care system. n References: http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/ physician-compare-initiative/ 2 Berwick D, Jain S, Porter M. Clinical registries: The opportunity for the nation. http:// healthaffairs.org/blog/2011/05/11/clinicalregistries-the-opportunity-for-the-nation/ 3 http://www.abms.org/maintenance_of_certification/ 4 http://www.accme.org/node/19546 5 http://www.cms.gov/pqrs 6 http://www.cms.gov/qualitymeasures 7 http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/PhysicianFeedbackProgram/index.html 8 http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html 1

Colorado Medicine for September/October 2014

Features

Cost commission kicks off Bob Mook, CMS contributing writer

Health policy leaders begin herculean three-year task Sixteen Colorado thought leaders convened at COPIC’s headquarters in Aurora on August 22 to take their first steps to understand and resolve what many regard as the “mother of all health policy problems.” Appointed by Governor John Hickenlooper and state legislators, the Colorado Commission on Affordable Health Care is charged with producing public policy recommendations to control costs and improve quality in health care.

During the first meeting, members of the commission unanimously voted Bill Lindsay the interim chair. Lindsay, the president of Lockton Employee Benefits Group, chaired the Colorado Blue Ribbon Commission for Health Care Reform. Better known as the 208 Commission, the group studied and established health care reform models for

expanding coverage – especially for the underinsured and uninsured – and to decrease health care costs for Colorado residents. That commission submitted a final report to the General Assembly in 2008, containing many policy recommendations that were either adopted

Members of the commission represent a diverse continuum of experts and stakeholders throughout Colorado’s health care system – from the government to the private sector, insurers and providers. (For a complete list of commissioners and their thoughts about their mission, see the accompanying breakout box). Created after the 2014 Colorado General Assembly approved Senate Bill 187, the three-year commission will analyze the causes of rising health costs with the goal of compiling recommendations for addressing cost and quality issues in Colorado. “I know that many of you realize that the task in front of us is herculean,” said Sen. Ellen Roberts, R-Durango, a cosponsor SB 187. Another co-sponsor of the bi-partisan bill, Rep. Amy Stephens, R-Manitou Springs, urged commissioners to strive for consensus and respectful dialogue to keep the commission from “devolving into a political exercise.”

Jeff Cain, MD, CMS’ representative on the cost commission, emphasizes the critical need to identify systemic causes of excessive and unnecessary health care costs.

Colorado Medicine for September/October 2014

Cost commission (cont.) by the state or resembled provisions of what became the Affordable Care Act. Four members of the Colorado Commission on Affordable Health Care, including Lindsay, also served on the 208 Commission.

commissioners’ hopes and fears about the outcome of the commission, and appointing an interim chair, the commission appointed members of a planning committee who will begin the work of putting together the logistics of operating a three-year commission process.

Along with introductions, discussing

Members of the commission must meet

Who’s on board?

During their first-ever meeting on Aug. 22, members of the Colorado Commission on Affordable Health Care discussed what they hoped would come out of the three-year process.

“Part of our task is to build upon what we’ve already accomplished in the state of Colorado. We have a lot of opportunities to come forward with ideas in payment and delivery-system reforms.”

Elizabeth Arenales, JD

Director of Health Care Program, Colorado Center on Law & Policy

“In three years, I hope we will have a group that’s bipartisan, outcomes-based and evidence based. … If we don’t do this, the cost of health care is going to squeeze out things like education and roads and the things that are important to our lives.”

Jeffrey Cain, MD, FAAFP

Representing the Colorado Medical Society

“Thinking about affordable health care and how all the pieces come together is critical for Colorado. … If we come out of this in three years with some things we can really implement, I would consider this a success.”

Rebecca Cordes

Executive vice president, First Western Trust

“We need to understand the drivers of health care costs and why they exist. The quality of care really needs to be on the forefront.”

Greg D’Argonne

Chief financial officer, HCA-HealthONE and HCA Continental Division

“[Health costs] are an enormously complex issue. It’s important for us to focus on the best practices in reducing costs and improving care and not engage in debate.”

Steve ErkenBrack

President and CEO, Rocky Mountain Health Plans

“I’d like to come away with some bold recommendations. I think what will prevent our success is to try and sanitize things and not ask the hard questions.”

Ira Gorman, PT, PhD

Associate professor Rueckert-Hartman College for Health Professions, Regis University

“Three years from now, I hope we stop thinking of people as groups and start thinking of them as individuals.”

Linda Gorman

Director of the Health Care Policy Center at the Independence Institute

at least once a month, according to SB 187. For now information about the commission can be found on the Colorado Department of Health Care Policy and Finance’s website. n

“My perspective is that this is probably one of the most important opportunities that the state has and an opportunity to do a lot of good, but also to do a lot of damage if we are not thoughtful and careful.”

William Lindsay III

President of Lockton Employee Benefits Group

“I hope we can help the citizens of this state understand the importance of health insurance and why they need it.”

Marcy Morrison

Former commissioner of the Colorado Division of Insurance

“Health care is much bigger than treatment, medications, lab work and X-rays. It is truly a whole-person concept. And if we can’t break out of that narrow definition, then we’re not going to get a handle on costs.”

Dorothy Ann Perry

CEO, Spanish Peaks Behavioral Centers

“One year from today, I’d like to have some direction for the way forward. I’m very confident about making some positive change in health care.

Cindy Sovine-Miller

Political consultant, Sovine Miller & Co.

“We’re in a time of change and there really have been a lot of positive changes [in health care]. I think we need to evaluate those changes and also look forward ... to ensure the people of Colorado have the best health care possible."

Chris Tholen

Vice president of Financial Policy, Colorado Hospital Association

In addition, five ex-officio members will serve the commission: • Dee Martinez, director of public relations and marketing, Denver Health • Susan Birch, MBA, BSN, RN, executive director of the Colorado Department of Health Care Policy and Financing • Marguerite Salazar, commissioner of insurance, Colorado Department of Regulatory Agencies • Jay Want, MD, chief medical officer, the Center for Improving Value in Health Care (CIVHC) • Larry Wolk, MD, MPH, executive director of the Colorado Department of Public Health and Environment

Colorado Medicine for September/October 2014

Features

Check up on Colorado Medicaid

Susan Birch, MBA, BSN, RN, Executive Director Colorado Department of Health Care Policy and Financing

Bob Mook, CMS contributing writer

Colorado Medicine sits down with HCPF Director Sue Birch As a former nurse and executive director of the Colorado Department of Health Care Policy and Financing (HCPF) since 2011, Sue Birch understands health care from both a clinical and administrative perspective.

Colorado Medicine: How did the idea of decentralizing Medicaid come together?

During her time with HCPF, Birch has overseen the restructuring of the state’s Medicaid system into seven Regional Care Collaborative Organizations. By providing a home base of coordinated care for Medicaid recipients, RCCOs are intended to realize efficiencies of health information technology while meeting the unique health needs of Colorado’s diverse populations at the individual and population health levels.

Sue Birch: Colorado under the Ritter administration moved forward on health reforms. The Affordable Care Act allowed us a really strong start, getting everybody covered at the right price and in the right model of accountable care. We pushed forward with the vision for health, wellness and prevention. We have really anchored our state with leveling out regional care collaborative organizations. I am proud we have delivered on the vision, implementing a lot of change and incenting accountable care here in Colorado.

To put the reforms of the past four years in perspective, Colorado Medicine asked Birch to explain HCPF’s work in decentralizing Medicaid, the increased role of Medicaid in the state’s health care system, making payments more attractive to primary care physicians, and how Colorado health care services will be funded in the future.

We have seven regions that are coordinated care entities. They have come together to focus on cost containment, establish a standardized level of primary care through the medical home model and use a new statewide data analytics contractor infrastructure. With the fundamental pieces in place, these regional collaborations have helped us lay the

Medicaid reimbursements: A specialist’s view While much has been done to bridge the disparities in Medicaid reimbursements, advocacy groups and lobbyists representing Colorado physicians aren’t resting on their laurels, said Murray Willis, MD, president of the Colorado Society of Anesthesiology. “Physician specialty societies have met monthly with Medicaid department staff to engage in candid discussions about the low reimbursement rates in Medicaid for specialty areas. We have exchanged quite a few interesting ideas. The department updated us on potential plans to improve ’access to care’ for their clients where there is difficulty in finding specialty physicians. While no solutions are tied to direct reimbursement, we are glad the conduit is there. In future conversations, it is our goal to ensure that serious consideration is given to potential changes in delivery of service models and reimbursement increases.” 22

base for the health care transformation in the public sector. One of the first things that the Hickenlooper administration did was to execute contracts in service delivery redesign. This was really a prioritization toward our valued primary care providers – the doctors, nurse practitioners and PAs who do the lion’s share of the primary care work. We will be rebidding and reworking this proposal in the coming months and years to make the Accountable Care Collaborative more robust with specialty care and public and behavioral health integration. We have implemented the Accountable Care Collaborative (ACC) and are fully loading our Medicaid clients into RCCO and PCMHs. As of today, we have about 688,000 of our nearly 1.1 million patients in the RCCO pipeline. More care coordination work with chronic conditions and life span approaches are connecting clients and their providers. We want to assure the relationships with providers are supported so that clients don’t go to the emergency room unnecessarily. Providers are more mindful of reducing unnecessary high-cost imaging – CT scans, etc. – and reducing hospital readmissions. We are very excited about the results and progress we are making. We also successfully executed what we call the dual contracts (clients covered by both Medicaid and Medicare). CMS had to approve how we handle and manage the chronic complex clients that comprise 17% of our population. After extensive negotiations, our team advanced Colorado as the tenth site in the

Colorado Medicine for September/October 2014

Features nation to improve services with a valuebased and shared savings approach. In our third year, we will improve specialty care with the use of health infrastructure investments like Project ECHO. In November, we’ll release more data and statistics demonstrating successes and savings. The near future holds a partnership with the foundations on vigorous evaluation methods so that our work can be replicated nationally. It’s my hope that by continuing to invest in the primary care side of our work together, we’ll see greater value and transformation in the Colorado health care system. What sort of success stories do you think that Colorado Medical Society members will want to hear about? CMS members have been our biggest supporters and partners. I have heard accolades for the tools and service delivery redesign that is allowing doctors to provide medicine in its pure form. Having the right tools in place in reviewing their primary care work at the individual, practice and regional levels is harmonizing our efforts. I have also heard a lot of positive feedback for the increased reimbursement and new way of moving toward incentivizing performances and valued-based payments.

performance by improving the patient experience while improving the health of populations and reducing the percapita costs of health care), and I can’t tell you how many people have said, “Can’t you just do one thing at a time?” But we really can’t say, “We’re just going to worry about access and coverage.” We also have to be transforming quality, moving to value-based payments and pushing wellness, prevention and health education.

cal and individualized, so I think this regional decentralized approach will continue to deliver results. We have a push toward life span metrics and quality outcomes, using three metrics – emergency room use, high cost imaging and readmission rates. In our next phase we are focusing on integrating physical and mental health. We want to forge more understanding of how mind and body are working together or working against a person’s health status.

The department is moving forward on pushing person-centered care. That’s going to help clients better understand their role when they go into their docs and primary care homes. We think that driving more care coordination will help docs practice better medicine and assist clients with achieving their health goals.

We want to use our RCCO platforms to drive toward better health and social well-being where it shows us savings.

How do you see this decentralized approach to Medicaid looking in four years?

Can you give us an idea of how the regional approach plays out? We have some good case studies happening in Colorado. Our Colorado Springs community is really a leader in aging services. We have our Western Slope folks who are pioneers in payment reform. We have some great work that

I am a firm believer that all health is lo-

Are there any statistics you’d use for how the programs are working? Colorado is fifth best in the nation for reducing our uninsured rate from 18% down to 11% statewide, with both private and public insurance. We have almost 60% of clients in tighter care coordinated systems. More than 40,000 providers statewide see our clients in partnership with this transformation work. How do these policies advance the Triple Aim? It’s maybe a little difficult for the public and our politicians to understand the notion of our Triple Aim (Editor’s note: Developed by the Institute for Health Care Improvement, the Triple Aim concept aspires to optimize health system Colorado Medicine for September/October 2014

Medicaid (cont.) is emerging in north Denver. They’re all unique and specialized. But they are all advancing this health care transformation. We want these systems of care to play to their strengths and for them to keep building this team-based care model. For example, we have partnered with the health departments to deliver on public policy about putting more teenagers on long acting, reversible contraceptives. We have seen tremendous drops in the teen pregnancy statewide.

Colorado has taken steps to increase Medicaid reimbursements and make it more palatable for primary care physicians to participate. Are you pleased with the progress of payment reform so far? We have started the process with our West Slope partners. Getting federal approval has taken time but we are making significant headway. We have to come to grips with the notion that there aren’t really going to be new dollars, but that there should be redistrib-

uted dollars. I am very pleased with how we are progressing payment reforms. We don’t want to do things so quickly that we would cause unintended financial consequences. That being said, it’s definitely a pushpull system with our federal partners, because we only control half of this equation with state money. We have to get federal buy-in with how we are maturing payments for our docs. We have made a complete and total commitment to the 18-month primary care rate bump extension. But we also need to understand how the savings we create are going to be sustainable. Because I don’t see huge new dollars coming into the system as we continue to move through health care reform. I think that getting people healthier and getting them working at their maximum productivity will ultimately bear some results with our clients. We also are trying to decrease the wasteful spending that goes on. Nationally, one-third of health care spending is a complete and total waste. We’re trying to ensure that as we’re overhauling into a new system, we simplify our processes. So, you are really hoping that the savings that you’re seeing as a result of these reforms will make the increased fees sustainable in the future? I think we as health professionals and policymakers need to decide if we shift more resources into population health and prevention. How do we start to use the dollars in a more accountable way, so that we are only paying for evidencebased services, and that we have more quality ratings for our providers? For example, with NICU – the new neonatal intensive care units – we want to make sure that those types of units and services are delivering the right services to the right people. We want to reduce the variation of pricing. So all of those things lead me to believe that with redistribution and accountability, paying attention to the data we have, we’ll be able to move the resources around toward the right configuration of care providers.

Colorado Medicine for September/October 2014

Features It sounds like the funding of the Medicaid fee bump and keeping it sustainable is a one-year-at-a-time proposition that will need to be continually tweaked as the other variables in health care play out. Is this correct? Absolutely. As we drive more success with information systems and new health information technology, there’s so much development around simplifying rules and stripping down bureaucratic processes. We’ll be modernizing our provider enrollment processes next year, and that is going to make it so much easier for providers to work with us. There have been some concerns about the hospital provider fee – created to fund Medicaid expansions before the ACA went into effect – and whether the dollars are being used as intended or as they could be best used. What are your thoughts? We are so lucky in Colorado that we created a hospital provider fee scenario that pays for Medicaid expansion and is driving the uninsured rate down. We feel the hospital provider fee absolutely fulfills its intent. We are hopeful that efficiencies and transformation will drive premiums down even further. As we have more people insured, and as the federal government changes the parameters around the hospital provider fee, we have to watch that closely. As we have more technological advances, fewer people going to hospitals, more care at home, or in primary care ambulatory settings, we have to look at how we mature the idea of a hospital provider fee as well. What are your ideas for making Medicaid more palatable for specialists? There was a bump in reimbursements for primary care codes, but not specialty care. What’s currently being done to address this disconnect? I am really excited about where we are headed with Project Echo and the Docto-Doc program. I think we’ll be seeing lots of movement and improvements around getting the next layer of specialty service provision in place for our Medicaid clients. n Colorado Medicine for September/October 2014

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Colorado Medicine for September/October 2014

Features

David Ross, DO, Chair Colorado Medical Political Action Committee

In politics, not knowing your right from left is a good thing While none of us were trained as political activists in medical school or residency, and for many of us it’s probably not even in our DNA, one need look no further than our almost annual clashes with the trial lawyers or the SGR debacle to embrace the political engagement imperative. Politicians are making calls that impact our patients and practices in a tribalized partisan environment. Otherwise thoughtful public officials can face the unrelenting demands of party leaders and major donors. Absent our presence in the political arena, others have, and will continue to, take up our slack. The rules of engagement require us to have working, sustainable relationships with the public officials on both sides of the aisle who are responsible for setting the course of health policy. Adhering to this rule is an imperative during this time of rapid transformation and upheaval in our profession. At CMS we, like other medical societies, struggle with political crosscurrents that sharply diverge between the more traditional conservative policy options, such as medical liability, and the decidedly center-left polices that drive health care spending, like Medicaid reimbursement, coverage and eligibility. The basis of medicine’s support of a candidate or incumbent takes into careful consideration the balance of those views – respecting their constitutional duty to make choices that can’t possibly please every constituency or interest group. Whatever our personal beliefs, COMPAC simply does not have the luxury of accommodating all of our individual views in determining CMS’ political

course if we want to achieve “the art of the possible,” as past CMS president Lynn Parry, MD, puts it. Physician advocacy in the public policy space requires a level of pragmatism and partisan agnostics that will make some of us uncomfortable on any given position. This is because our policy agenda spans such a wide range of issues, from liability reform one day, to Medicaid reimbursement the next. When I meet with national and state legislators, I am sometimes asked why CMS’ official policy may differ from that politician’s view on an issue. I always preface my reply by stating that CMS is a politically pragmatic organization that advocates for what works in the real world of medicine. This has less to do with doctrine and more to do with the pursuit of evidence-based policies. We know from experience as clinicians, the conventional scientific wisdom will evolve and require revision – and it has to be that way. But that certainly doesn’t mean we don’t listen to the political views of our members. They are vitally important. Based directly on our members’ local review and recommendations, we have defended our legislative champions not just at election time but also from those in their own party in their primaries. And, when we have encountered legislators whose views are sufficiently and unrelentingly anti-physician, right or left, we have staunchly opposed them. We have taken these positions regardless of payback risk or our prospects of winning. The choices COMPAC makes to sup-

Colorado Medicine for September/October 2014

port, or oppose, are homegrown and locally-owned by our participating members and drawn from the legislator’s voting and non-voting record – actual or anticipated. There are no wrong choices, merely consequences for each fight we pick, or avoid. We look for a pattern of support for medicine and patients – right and left. Our choices are never drawn from a purely partisan or ideological well. Whether you want to participate individually or join our movement, there is a graduated scale of political activism: 1. Join our movement financially. A modest contribution to COMPAC and the special Small Donor Committee (used exclusively to support candidates that protect Colorado's stable tort enviornment). They are vital to the success of our friends at the ballot box. 2. Join your local “Breakfast Club” by contacting CMS. You will be surprised how much more you have in common with your area legislators, well beyond being carbon-based organisms. 3. Host or co-host local support events for the legislator of your choice (even if we haven’t taken sides). Receptions, coffees, block walks, mini-internships, and all the varied means of engaging your legislator/candidate in the face-to-face interactions during the election season strengthen those relationships and the mutual understanding that follows. At COMPAC, your perspective and participation are critical to us. Thanks for all that you do and be sure to vote in the 2014 general election. n 27

Features

COMPAC announces candidate endorsements

CMS staff report

Physicians urged to consider recommendations Unless you have cancelled your cable network and thrown your TV out the window, you are painfully aware that this is an election year. This means that physicians across the state have been hard at work interviewing candidates and helping the Colorado Medical Political Action Committee, (COMPAC), make decisions on what candidates to support in the upcoming election. Through September 10, 2014, COMPAC has endorsed 76 candidates for state and federal office this year. Physicians and all friends of medicine are encouraged to consider the recommendations that follow and, above all, to be sure to vote. This list represents endorsements made by press time – more will have been selected before the election. For an updated list, visit www.cms.org. For help identifying the candidates running in your district, visit http://www.cms.org/advocacy/findyour-legislators. COMPAC does not endorse based on political party. Instead, endorsements are made following a screening process that takes into account the views of the local medical community, the position of a candidate or incumbent on medical issues important to the medical society, the demographics of the district and a candidate’s ability to win. COMPAC instituted the local physician screening process

in the 2006 election cycle and hundreds of physicians have participated in the process since then. This has proven instrumental in developing relationships between local constituent physicians and members of the Colorado Legislature. Colorado Medical Society has nearly 8,000 members with passionate beliefs from across the political spectrum. Alfred Gilchrist, CMS CEO, has seen first-hand the challenge medical society members often experience trying to separate personal politics from professional pragmatism. “In my three-decade tenure as a physician advocate, I have found that physicians consistently and understandably struggle with separating their personal political beliefs from the more hard-nosed pragmatism that dictates medicine’s support of an elected official (or candidate) whose track record or predisposition is demonstrably pro-medicine even when at odds with local doctors’ own partisan or ideological leanings,” said Gilchrist. On page 27 of this issue, be sure to read a column by COMPAC Chairman Dave Ross, DO, that provides more background on the strategy behind COMPAC endorsements that emphasizes not only the inherent value of physician engagement in the political process, but also one of the most fundamental rules of political engagement: ideological agnosticism. n

All friends of medicine are eligible to participate. Call 720-859-1001, ext. 6327 or 800-654-5653, ext. 6327 28

Colorado Medicine for September/October 2014

Features

COMPAC COLORADO LEGISLATURE ENDORSEMENTS COLORADO SENATE DISTRICTS COLORADO HOUSE DISTRICTS (cont.) SD 2 Kevin Grantham (R) El Paso/Clear Creek HD 28 Brittany Pettersen (D) Jefferson SD 3 Leroy Garcia (D) Pueblo HD 29 Tracy Kraft-Tharp (D) Jefferson SD 6 Ellen Roberts (R) Montrose/Montezuma/ HD 30 Jenise May (D) Adams Ouray/San Juan HD 31 Joseph Salazar (D) Adams SD 7 Ray Scott (R) Mesa HD 32 Dominick Moreno (D) Adams SD 9 Kent Lambert (R) El Paso HD 33 Dianne Primavera (D) Boulder/Broomfield SD 15 Kevin Lundberg (R) Larimer HD 34 Steve Lebsock (D) Adams SD 16 Jeanne Nicholson (D) Boulder/Denver/ HD 36 Su Ryden (D) Arapahoe Jefferson HD 37 Jack Tate (R) Arapahoe SD 19 Rachel Zenzinger (D) Jefferson HD 38 Kathleen Conti (R) Arapahoe SD 20 Cheri Jahn (D) Jefferson HD 39 Polly Lawrence (R) Douglas/Teller SD 22 Andy Kerr (D) Jefferson HD 40 John Buckner (D) Arapahoe SD 24 Judy Solano (D) Adams HD 41 Jovan Melton (D) Arapahoe SD 30 Chris Holbert (R) Douglas HD 42 Rhonda Fields (D) Arapahoe SD 32 Irene Aguilar (D) Denver HD 43 Kevin VanWinkle (R) Douglas SD 34 Lucia Guzman (D) Denver HD 46 Daneya Esgar (D) Pueblo HD 47 Clarice Navarro-Ratzlaff (R) Pueblo/Fremont/Otero COLORADO HOUSE DISTRICTS HD 48 Steve Humphrey (R) Weld HD 1 Susan Lontine (D) Denver/Jefferson HD 49 Perry Buck (R) Larimer/Weld HD 2 Alec Garnett (D) Denver HD 50 Dave Young (D) Weld HD 4 Dan Pabon (D) Denver HD 51 Brian Del Grosso (R) Larimer HD 5 Crisanta Duran (D) Denver HD 52 Joann Ginal (D) Larimer HD 7 Angela Williams (D) Denver HD 54 Yeulin Willett (R) Delta/Mesa HD 8 Beth McCann (D) Denver HD 55 Daniel Thurlow (R) Mesa HD 9 Paul Rosenthal (D) Arapahoe/Denver HD 56 Kevin Priola (R) Adams/Araphaoe HD 10 Dickey Lee Hullinghorst (D) Boulder HD 57 Bob Rankin (R) Garfield/Moffat/ HD 11 Jonathan Singer (D) Boulder Rio Blanco HD 12 Mike Foote (D) Boulder HD 58 Don Coram (R) Delores/Montezuma/ HD 13 KC Becker (D) Boulder/Clear Creek/ Montrose Grand/Gilpin HD 59 J. Paul Brown (R) Archuleta/Gunnison/ HD 14 Dan Nordberg (R) El Paso Ouray/La Plata HD 16 Janek Joshi (R) El Paso HD 60 Jim Wilson (R) Chaffee/Custer/Fremont HD 19 Paul Lundeen (R) El Paso HD 61 Millie Hammer (D) Delta/Gunnison/Lake/ HD 21 Lois Landgraf (R) El Paso Pitkin HD 22 Justin Everett (R) Jefferson HD 62 Ed Vigil (D) South Central Colo HD 23 Max Tyler (D) Jefferson HD 63 Lori Saine (R) Weld HD 24 Jessie Danielson (D) Jefferson HD 64 Timothy Dore (R) Eastern/ HD 25 Jon Keyser (R) Jefferson Southeastern Colo HD 26 Diane Mitsch Bush (D) Eagle/Routt HD 65 Jon Becker (R) Northeastern Colo HD 27 Libby Szabo (R) Jefferson

COMPAC FEDERAL CONGRESSIONAL DELEGATION ENDORSEMENTS U.S. SENATE Mark Udall (D) D-1 D-3

D-4

U.S. HOUSE OF REPRESENTATIVES Diana DeGette (D) (Denver, Arapahoe, Jefferson) D-4 Elbert, Douglas, Lincoln, Kit Carson, Cheyenne, Scott Tipton (R) (Moffat, Routt, Pueblo, Jackson, (cont.) Kiowa, Crowley, Otero, Bent, Prowers, Baca) Rio Blanco, Garfield, Montrose, San Miguel, Dolores, D-5 Doug Lamborn (R) (El Paso, Park, Chaffee, Teller, Montezuma, La Plata, Rio Grande, Alamosa, Conejos, Fremont) Costilla, Huerfano, Custer) D-6 Mike Coffman (R) (Adams, Arapahoe, Douglas) Ken Buck (R) (Weld, Logan, Sedgwick, Phillips, D-7 Ed Perlmutter (D) (Arapahoe, Jefferson, Adams) Morgan, Washington, Yuma, Adams, Arapahoe,

Colorado Medicine for September/October 2014

Features

Workers’ compensation Bob Mook, CMS contributing writer

Debunking the myths about Colorado’s system Colorado’s workers’ compensation system is considered a model for other states because of its comprehensive and frequently updated guidelines, accessibility and a fee structure that pays more than Medicare and private insurers.

“It’s an unknown fact that workers’ compensation and occupational medicine can be very profitable practice for medical providers.” – Edward Leary, MD, medical director, Pinnacol Assurance Yet despite many benefits, a recent survey among Colorado Medical Society members revealed a number of misperceptions from providers who don’t participate in the system. Conducted by Kupersmit Research, the survey showed a vast majority of nonparticipating physicians believe the system inflicts a heavy administrative burden on participants and pays too

little for workers’ compensation services. The survey showed that 77% of CMS members who don’t participate in workers’ compensation are not open to doing so. To change those perceptions, Colorado’s Division of Workers’ Compensation is encouraging health care professionals throughout the state to consider an accreditation program intended to help providers better understand the system, enabling them to help patients recover from work-related injuries while getting fairly compensated for their efforts. “We’re educating providers on what the workers’ comp system is really like,” said Dan Sung, manager of medical policy for Colorado’s Division of Workers’ Compensation. “Our programs are truly great and the investment of time and money is nominal when compared to the benefits of learning how to effectively navigate the system.” The division offers two types of accreditation courses to help providers better understand the system: A one-day (Level One) course gives a basic overview of the system and its administrative criteria and a two-day (Level Two) course offers an emphasis on medical impairment rating. Costs for accreditation range from $200 to $400, with re-certification required every three years.

Workers’ compensation resources • For more information about Colorado’s workers’ compensation system, visit www.colorado.gov/cdle/dwc • Information about Pinnacol Assurance can be found at http://www.pinnacol.com • To learn more about Colorado’s workers’ compensation accreditation program, contact Ellen Oakes at 303-318-8752.  30

A Level Two course will be available Oct. 10-11 and the next Level One course will be conducted in May 2015. Ideally, the division would like to offer more classes so that more health care professionals understand the system and are fairly reimbursed for their services, Sung said. “Getting accreditation shows insurers and employers that you understand the system, so you are more likely to be chosen by employers as an authorized provider and thus reimbursement may be more efficient,” said Kathryn L. Mueller, MD, MPH, FACOEM. Mueller is the medical director of the Division of Workers’ Compensation and a professor of the Department of Physiatry and the School of Public Health at the University of Colorado Anschutz Medical Campus. She was recently named among the 50 most influential people in workers’ compensation by SEAK Inc., a training and professionaldevelopment organization representing individuals in the workers’ compensation arena. While Mueller acknowledges that there are key differences in how workers’ compensation services are reimbursed compared to “regular health care,” she maintains that Colorado’s system offers strong support services to help providers fill out and submit the required paperwork and give clarification when needed. “Billing systems are always challenging,” Sung said. “But we’ve put in a medical billing dispute-resolution process to

Colorado Medicine for September/October 2014

Features make sure that payers and providers can resolve their disputes as quickly as possible.” Compared to other states, Colorado’s workers’ compensation system is quite user-friendly, said Edward Leary, MD, medical director of Pinnacol Assurance, Colorado’s largest workers’ compensation insurer representing more than 55,000 employers in the state. All employers in Colorado are required by law to carry workers’ compensation insurance. Established more than 100 years ago, Leary says Pinnacol has laid much of the groundwork for workers’ compensation throughout the country. Pinnacol works closely with policyholders and health care providers to help staff navigate through paperwork associated with workers’ injuries. Leary said there are misconceptions on how much paperwork is required from practice managers dealing with workers’ compensation patients. “Once we have one of our provider relations specialists interacting with these administrators, many of these misconceptions go away,” he said, adding that Colorado’s workers compensation system has done much to ease the administrative burden for physicians so they can focus on patients and draw revenue from treating them.

levels, Leary points out that physicians play a critical role in patients’ lives and the state’s economy by participating in the system. “They are caring for these people at a very important juncture in their lives –

particularly in terms of their ability to provide for their families,” Leary said. “It’s also an important service to the companies of Colorado who rely on a system that cares for their injured workers and brings them back to work.” n

Seeking Primary Care Physicians/Practices in the Denver Metro Area

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

“It’s an unknown fact that workers’ compensation and occupational medicine can be very profitable practice for medical providers,” Leary said. Compared with other states, Colorado’s workers’ compensation guidelines are “very easy to understand,” said David Hansen, Pinnacol’s SelectNet network operations lead. “Physicians are given a lot of leeway to treat injured workers. They don’t have to pick up the phone and ask for authorizations every step of the way,” Hansen said. “Some states micromanage every step and make it very difficult.” In addition to favorable compensation Colorado Medicine for September/October 2014

Features

90-day grace period Marilyn Rissmiller, CMS Senior Director, Health Care Financing Kate Alfano, CMS contributing writer

DOI guidance helps physicians when patients are late making premium payments Earlier this year the Colorado Division of Insurance (DOI) issued proposed regulations concerning grace periods for policyholders receiving federal advance premium tax credits (APTC) per the Affordable Care Act (ACA). The purpose of the regulation is to establish the requirements for grace periods when a policyholder is delinquent in the payment of monthly premiums for health benefit plans offered on the state’s health insurance exchange (Connect for Health Colorado).

By issuing this regulation the DOI had an opportunity to provide additional clarity to the 90-day grace period that was not addressed in ACA. However, the rule fell short. Neither the ACA nor the proposed regulation provided carriers with specific direction about the type and notification timing of critical information sent to providers regarding a patient’s eligibility status. Physicians, and the provider community as a whole, expressed concerns regard-

ing the potential financial burden they face when they do not receive timely notification about when a patient enters the second and third month of the grace period. This uncertainty could become a disincentive for physicians to participate in the health plans offered through Connect for Health Colorado. Colorado Medical Society (CMS) has supported the insurance exchange because of the expanded access to coverage it offers to patients. We thought that the proposed regulation offered a means to mitigate these concerns. CMS and 10 other organizations submitted detailed comments regarding when the notice should be provided and what information needed to be included. CMS Past-president Jan Kief, MD, also testified at the public hearing in May. While Insurance Commissioner Marguerite Salazar concluded that the DOI does not have the authority under current statute to incorporate the changes requested, she did issue an August bulletin to carriers that provides additional direction. Specifically, we are pleased to report that many of the CMS’ suggestions were accepted concerning what information is reported about a patient’s eligibility status within the 90day grace period and when physicians are alerted. The bulletin also clarifies the relationship between the grace period and the existing statute on eligibility verification. The bulletin, B-4.77, will go a long way to ensuring that physicians and others receive consistent and timely

Colorado Medicine for September/October 2014

Features information from carriers concerning their patients’ eligibility status. CMS has developed a fact sheet that can be found on the CMS website, along with a copy of the bulletin. The major points are outlined on the next page. The key to these protections lies in the physician practice’s hands. It is important to check the patient’s eligibility status prior to services being provided so that financial arrangements can be made in advance of potential problems later related to unpaid patient premiums.

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

Colorado Medicine for September/October 2014

90-day grace period (cont.)

90-day grace period facts for Colorado Under the Affordable Care Act (ACA), if a patient who receives an advance premium tax credit does not pay his or her health insurance premiums in full, he or she enters a 90-day "grace period." During the first month of the grace period, the patient continues to have health insurance coverage, and the patient’s health insurer will pay claims for health care services provided to the patient during that time. However, if the patient enters the second or third month of the grace period, the health insurer may pend claims for services provided to the patient during that time. If the patient pays his or her premiums in full before the end of the grace period, the patient retains health insurance coverage for the second and third months of the grace period, and the insurer will pay the pended claims. But if the patient does not pay his or her health insurance premiums in full before the end of the grace period, the health insurer will not extend coverage for the second or third months of the grace period and will deny claims for services provided during that time. In this case, a patient is then responsible for paying the entire bill for services rendered during the second and third months. Current statutes do provide some protections when patients are in the second and third month of the grace period, as long as you use them proactively and within the timeframes laid out within each section. Eligibility verification is the key • Each carrier must have one or more mechanisms in place for eligibility verification at the time services are provided, and regardless of the mechanism shall issue an eligibility verification code. C.R.S. 10-16-705(12)(a)(b) • If you verify the patient’s eligibility within two business days prior to the delivery of services and the claim is paid, the carrier cannot take the money back. C.R.S. 10-16-704(4.5)(f) • If at the time you verify eligibility, the carrier determines that the patient is in the grace period and a premium has not been received they may report that eligibility is contingent on payment of the premium due. o At the time you verify eligibility, the carrier should be able to provide you with information concerning when the patient/policyholder entered into a grace period; the length of the grace period; which month of the grace period the policyholder is currently in; and the date upon which the grace period will expire and the policy will be cancelled. • If you receive information from the carrier that coverage is contingent upon receipt of a premium, the hold harmless requirements of C.R.S. 10-16-705(3) do not apply and you may collect payment from the patient. C.R.S. 10-16-704(4.5) (g)(II) o This means that you may make arrangements with the consumer, prior to delivering services, to collect partial or full payment from the patient/policyholder. (If the policyholder pays all past-due premiums and the carrier pays the pended claims, you must refund all payments received from the consumer that exceed the patient’s responsibility, i.e. copayments, deductibles, and/or coinsurance amounts.) Notification Once a carrier receives a claim from a provider for a policyholder who is currently within a grace period, the carrier must send a letter to the provider no more than five business days after the receipt of the claim for services incurred during the grace period. The notice should contain the same level of detail as noted above concerning where the patient is within the grace period and when it will expire. Note: Plans that are subject to Colorado insurance laws and regulations have “CO-DOI” noted on the insurance card. n

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member

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

Colorado Medicine for September/October 2014

Features

Right to Try Act Susan Koontz, JD, CMS General Counsel Jean Martin, MD, JD, COPIC Legal Counsel

Colorado becomes first state to give terminally ill patients options and access to investigational treatments Colorado recently became the first state to enact legislation intended to allow terminally ill patients access to investigational drugs, biological products and devices (“investigational treatments”)

“Physicians prescribing experimental treatment under the new law will want to strictly comply with the law’s requirements and be aware that a reasonableness standard applies.” – John L. Conklin, JD that have not yet completed clinical trial and been approved for general use by the U.S. Food and Drug Administration. Colorado House Bill 14-1281, titled “Access to Treatments for Terminally Ill Patients” and known as the “Right To Try Act,” was passed unanimously by the Colorado legislature and signed into law by Governor John Hickenlooper on May 17, 2014. One of the co-sponsors of the bill, Representative Joann Ginal, (D-Fort Collins), described the bill in this way: “The Right to Try bill is a choice that terminally ill patients may be able to qualify for when all other methods to help are exhausted. It is an option other than death. It is a bill of hope, when all else has failed.” 36

Despite the passage of this new state law, its interaction with matters subject to federal jurisdiction and the potential consequences for physicians who seek to act under its provisions are currently unclear. The Right To Try Act applies to treatments that have successfully completed Phase 1 of a clinical trial but have not been approved by the FDA for general use and remain under investigation in a FDA-approved clinical trial. Although current federal law permits the FDA to allow manufacturers to provide investigational treatments to terminally ill patients outside of clinical trials on a case-by-case basis, supporters of Colorado’s Right To Try Act maintain the FDA’s approval process is too lengthy and complex, with only a small number of patients (under 600 in 2013) successfully gaining access to investigational treatments through the FDA. At the outset, it is important to understand that the Right To Try Act does not require a physician to recommend an investigational treatment not yet approved by the FDA for general use. A physician should always exercise his or her independent medical judgment in recommending any treatment for a patient, whether investigational or not. Rather, the Act provides authorization under Colorado law for a physician to recommend an investigational treatment to 1) a terminally ill patient 2) who has considered all other treatment options currently approved by the FDA and 3) is unable to participate in a clinical trial located within 100 miles of their home.

Inpatients at Colorado licensed hospitals are excluded from eligibility for investigational treatments under the Right To Try Act. The Right To Try Act “authorizes” physicians to recommend investigational treatments pursuant to Colorado law in three ways. The Act 1) precludes a state licensing board from taking action against the physician solely for recommending an investigational treatment, 2) precludes action against a physician’s Medicare certification solely for recommending an investigational treatment, and 3) states that the Act does not create a private right of action against a physician for harm caused to a patient as a result of the use of an investigational treatment. However, the Act is clear that physicians are still bound to act reasonably and in accordance with accepted medical standards of care. This begs the question: What are the accepted medical standards of care regarding the use of an investigational treatment not approved for general use by the FDA? One can imagine a patient’s family contending that a physician’s knowing recommendation of an investigational treatment in contravention of current federal laws and regulations is per se unreasonable and not in accord with accepted medical standards of care. Such a question may ultimately be left to a civil jury to resolve. “Physicians prescribing experimental treatment under the new law will want to strictly comply with the law’s requirements and be aware that a reasonableness standard applies,” said CMS outside counsel John L. Conklin, JD.

Colorado Medicine for September/October 2014

Features Potential professional liability Under the Supremacy Clause of the U.S. Constitution, state laws are void if they conflict with valid federal statutes and stand in obstacle to the accomplishment and execution of Congress’s full purposes and objectives. Colorado’s Right To Try Act does not set aside federal law and regulations regarding access to investigational treatments or limit the FDA’s exclusive jurisdiction to regulate drugs and biological products and devices. Thus the Right To Try Act does not insulate physicians from potential repercussions at the federal level. Furthermore, the Right To Try Act may be subject to a future constitutional challenge on the grounds that it conflicts with a matter of exclusive federal regulation in contravention of the Supremacy Clause. Although the validity of Colorado’s Right To Try Act has not yet been challenged in the legal system, the FDA has issued a statement expressing concern about state efforts that may undermine its “Congressionally mandated authority and agency mission to protect the public from therapies that are not safe and effective.”

ments for eligibility of the Act. The Act also requires that a physician obtain written informed consent from the patient that includes: 1) an explanation of the currently approved treatments; 2) an attestation that the patient agrees with the physician that currently approved treatments are unlikely to prolong the patient’s life; 3) a clear identification of the specific proposed investigational treatment; 4) a description of the best, worst and most likely outcomes of the proposed investigational treatment, including the possibility that new, unanticipated, different or worse symptoms could arise and death could be hastened; 5) an explanation that a health insurer is not obligated to pay for care and treatment subsequent to an investigational treatment; 6) a statement that the patient’s eligibility for hospice care can be withdrawn if the patient begins an investigational treatment; 7) a statement that in-home health care may be denied if the patient begins an investigational treatment; and 8) a statement that the patient and his or her estate are liable for health care expenses consequent to the use of an investigational treatment.

Given the uncertain legal landscape and concurrent but differing state and federal laws and regulations, prudence dictates physicians adhere to both state and federal requirements concerning access to investigational treatments. Physicians considering treating a patient with an investigational drug outside of an approved protocol should discuss this with their malpractice insurance carrier. The professional liability policy may have an exclusion for using a drug that is not approved by the FDA for any purpose. Physicians should also be aware that this issue is subject to further legal developments. Possible examples would include Colorado’s Medical Board or Department of Health issuing rules or adopting policies concerning the implementation of the Right To Try Act; Colorado enacting additional state laws clarifying the Right To Try Act; or the FDA or other federal agencies issuing regulations concerning investigational treatments.

The Right To Try Act expressly allows health insurers to discontinue coverage of benefits related to the investigational treatment from the time the patient starts an investigational treatment until six months after the end of the investigational treatment. Although the Act does not require a health insurer to deny coverage and requires the maintenance of coverage for pre-existing conditions, the potential financial ramifications of instituting an investigational treatment suggest that a physician exercise caution and spend considerable time counseling the patient to ensure the patient is aware and informed about the financial risks.

To make a recommendation of an investigational treatment, the Right To Try Act requires a physician certify in writing that the patient meets the require-

Although the Right To Try Act is silent with regard to the specialization of a recommending physician, the

Colorado Medicine for September/October 2014

requirement that written informed consent contains a description of the worst, best and most likely outcomes suggests that appropriate specialist consultation and participation is a necessary part of obtaining the required informed consent. Finally, the Act does not require manufacturers to provide patients access to investigational treatments upon a physician’s recommendation. A physician should be aware that a manufacturer may not be incentivized to endanger their investment in the FDA approval process by distributing an investigational treatment that is still undergoing clinical trial and has not yet received final approved from the FDA. Colorado’s Right To Try Act stands at the forefront of a novel state law movement seeking to expand patient access to investigational treatments. Accordingly, physicians must act cautiously and give due consideration to the potential risks of recommending an investigational treatment. At a minimum, CMS urges its members to ensure they comply with all applicable state and federal laws and regulations in considering recommending an investigational treatment. n

To register online for this event, visit www.cha.com, click on “View All Events” on the website home page, then the Patient Safety Leadership Congress link.

Features

Bridges to Excellence Robert J. Smith, MBA, Colorado Business Group on Health

Opportunity for physicians to be recognized for quality Kate Alfano, CMS contributing writer As the Colorado Business Group on Health engages physicians on behalf of employers in an effort to improve the value of their health care spending, we find that many physicians resist two of the more common methods of payment reform: capitation and pay-for-performance. We think they do so with good reason. Capitation poses several problems, not the least of which is the large number of patients required to achieve statistical reliability and payment fairness. That number far exceeds what the vast majority of Colorado practices are likely to realize from any given purchaser. Pay-for-performance measures, meanwhile, are typically insurer-specific (and often insurer-centric) and seem to benefit the specific insurer rather than the individual physician. Even worse, because the measures are peculiar to each insurer, physician practices get pulled in multiple directions – further fragmenting efforts at performance improvement. As an alternative to many of the current payment strategies, we propose that the nationally recognized Bridges to Excellence (BTE) program represents the best approach to focusing on what really matters in health care: intermediate measures of patient outcomes. BTE recognizes physicians who perform well against a collection of nationally endorsed, standardized outcomes measures and/or guidelines adopted to delineate high quality care delivery for patients. These measures have the greatest clinical and financial impact. Perhaps most importantly, these guidelines were developed in collaboration with physician experts and leading health care organizations. Non-prescriptive in nature, BTE guidelines focus on quality accountability: the 38

improvement of intermediate outcomes and better adherence to good processes as a means to measure the effects of proper management of patients and the delivery of good results. BTE rests on principles developed and supported by the American Medical Association, such as: • A focus on quality. BTE uses, and the AMA recommends, “evidence-based quality of care measures, created by physicians across appropriate specialties.” Rather than first focusing on cost, BTE standards represent those intermediate clinical outcomes that promote the best patient care. Costs actually end up being lower for BTErecognized physicians because of the emphasis on quality and patient benefit. • Fostering the physician-patient relationship. BTE respects that physicians are “ethically required to use sound medical judgment, holding the best interests of the patient as paramount.” Concerned only with the patient, and not the payer, BTE standards are designed to acknowledge outcomes limitations in the most severe patients. BTE asks the clinician to supply a statistically valid sample of patients or a full patient panel and then requires a proportion of these patients meet a criterion such as blood pressure or cholesterol levels. • Fair reporting using accurate data. By including statistically valid data directly from the practice’s patient records, and NOT from the insurer’s claims, BTE ensures that the data accurately reflect patient results. And by including data across all payers, BTE reports

fairly reflect physician practice patterns, regardless of payer source or type. By seeking BTE recognition, clinicians endorse these physician-sponsored, transparent standards. But there are three more immediate and concrete reasons why a physician would seek recognition: 1. Network designation and performance rewards. Clinicians who join the BTE program can establish eligibility for pay-for-performance bonuses, differential reimbursement or other incentives from participating payers and health plans. In Colorado, selected health plans and employers use BTE recognition to provide annual incentives for each patient seen. Nationally, BTE recognitions are used by several major insurers as part of their network designations. 2. Demonstration of outcomes. Recognized clinicians demonstrate to the public, health plans and peers their dedication to delivering high quality patient care. Overall, patients who have diabetes and are being seen by BTE-recognized physicians have: o 49 fewer ED visits per thousand visits o 16 fewer inpatient admissions per thousand admissions, and o 356 days spent in a hospital, compared to 436 days as an inpatient per thousand patients, or 80 fewer hospital days 3. Performance benchmarking. Clinicians can identify aspects of their practice that vary from the performance requirements and take steps to improve quality of care. For HbA1c, blood pressure, LDL levels and other metrics, clinicians can see where they

Colorado Medicine for September/October 2014

Features stand relative to threshold as well as minimum/maximum levels. (It should be noted that in Colorado BTE recognitions are awarded only to individuals, not to practices.) The CBGH has worked with member employers and various insurers to adopt BTE for diabetes and cardiac care – two of the chronic disease states that have the greatest impacts on Colorado employees’ health status and on employers’ costs – both in terms of direct medical costs and indirect costs due to increased absenteeism/presenteeism. For instance, with regard to diabetes, according the Colorado Department of Public Health and Environment (CDPHE): • The adult prevalence of diagnosed diabetes increased 157% over the past decade, from 4.7% to 7.4%. • One in four Coloradans with diabetes is undiagnosed. • Even more alarming, an estimated one in three U.S. adults is pre-diabetic. Unfortunately, only 6% of adult Coloradans were aware of having pre-diabetes in 2012. • Two in three people with prediabetes will likely develop diabetes within 6 years. With regard to cardiovascular disease, CDPHE cites this diagnostic category as the leading cause of death in Colorado. On average one Coloradan dies every hour due to cardiovascular disease. Nationally, BTE programs have also been developed for hypertension, coronary artery disease, congestive heart failure, spine, asthma, congestive-obstructive pulmonary disease, depression and medical home. Although these BTE programs have not been implemented in Colorado, some national carriers – including Aetna, Anthem, and UnitedHealthcare – either incorporate them into or use them as part of their national network contracts terms. As noted above, pulling physicians in multiple directions compromises both practice efficiency and practitioner effectiveness. BTE measures and guidelines are

Colorado Medicine for September/October 2014

BTE (cont.) designed to align with the Physician Quality Reporting System (PQRS), a Medicare reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. Clinicians can achieve BTE recognition in one of two ways: • Electronic data submission. Depending upon the type of electronic medical record in place, clinicians can electronically submit data. Electronic submissions: o Are transmitted and reviewed quarterly. o Include all patients seen with diabetes during a period. In addition to ease of submission, this method provides access to reports that are available for real time population management and patient level management. Moreover, submitted data extends patient impact through all BTE chronic care programs. • Manual chart review and extraction. Alternatively, data can be submitted manually through a point in time audit. Such chart audits must be completed at least once every two years. The

submitted data will reflect care of 25 patients per clinician. Data can be submitted either directly to BTE through CECity’s “MedConcert” protocol (see https://bte.medconcert.com) or through the National Committee for Quality Assurance (NCQA) (see www. ncqa.org/Programs/Recognition/BridgestoExcellence.aspx). Data submitted electronically via your EMR is a very nominal cost, and many EMR vendors are already capable of interfacing at this time. Pricing is available on the respective websites. Through the efforts of the Colorado Business Group on Health, BTE programs in Colorado bring key practical advantages to recognized physicians. CBGH promotes these physicians in their annual Health Matters Quality Report: Physicians, published annually. Other advantages include the opportunity to differentiate themselves, to benchmark their performance as part of their internal efforts at improvement, to attain health plan recognition and to achieve some financial remediation.

Physicians and practices seeking greater continuity across health plans’ standards as well as increased emphasis on clinical, rather than financial or simple, utilization measures can advance their own interest by first pursuing BTE recognition themselves and then by insisting during contract negotiations that nationally recognized BTE standards replace esoteric, plan-specific targets. No other programmatic opportunity exists for physicians to assert themselves and advocate for patientcentered targets. In a time of increasing demands for transparency and accountability on the part of health care purchasers and consumers, Colorado physicians will be best served by endorsing the sort of outcomes-based measures of quality that the Bridges to Excellence program represents. For more information about BTE in Colorado, visit the CBGH website at http://www.cbghealth.org/projects/improving-quality/bridges-to-excellence/ or call Donna Marshall or Robert Smith at 303.922-0939. For information about BTE nationally, go to http://www.hci3.org/ node/1. n

Colorado Medicine for September/October 2014

CMS Education Foundation Help send a student through school

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

Call 720-858-6310 for more information and to donate Colorado Medicine for September/October 2014

Features

Death certificates Leon Kelly, MD, Deputy Chief Medical Examiner El Paso County Coroner’s Office

Physician guidelines for death certificate completion In Colorado, death certificates can be completed only by physicians or coroners. Despite the fact that every single patient we care for will eventually require a death certificate, almost no time is spent during medical school or postgraduate training teaching physicians how to complete this task. For many of us, completing the death certificate will be the final act in the care of our patient. The caring physician will be asked to complete a death certificate on cases not reportable to the coroner or cases where the coroner has performed an investigation and deemed it not to require a forensic autopsy. Ideally, the clinician who has the most first-hand knowledge of the patient will be available, but statute allows for any physician with facts concerning the decedent’s health and the circumstances of the death to complete the death certificate. This may be a practice partner, sub-specialist or the chief medical officer of the facility.

The burden of proof for the information on the death certificate is “a reasonable degree of medical probability” or, in other words, “more likely than not.” In many cases, it will be impossible to know why a person has died, but our understanding of pathophysiology and pure common sense will allow us to reasonably surmise the underlying disease state or states that led to death. For cases where one can reasonably conclude a cause of death but medical investigation was limited or incomplete the term “probable” is appropriate. Cause of death statement The cause of death – defined as the pathophysiologic derangement or disease/injury state that led to death – is recorded in part one of the death certificate. There may be an identifiable “immediate cause of death,” which is the final disease process that ends life. But perhaps more importantly, there may also be an “underlying cause of death” – the disease or injury states that

Key elements to death certificate completion The death certificate is a critical public health tool with a value limited to the clarity and completeness of the information recorded on it. Here is a summary of key elements:

• Record the cause of death as etiologically specific as possible. • Use a sequential description of the chain of physiological disturbances. • Be as descriptive as possible. • Do not report mechanistic terminal events. • Do not use abbreviations. • Have a low threshold for the inclusion of non-natural events. • Call your coroner if considering a non-natural event causing or contributing to death.

initiated the physiologic derangement and downward spiral that ultimately resulted in death. The goal is to be as etiologically specific as to both the immediate and underlying causes of death. The statements can be recorded as a single disease state on the first line or a series of disease states with the most immediate on the first line and the preceding disease states below it. The underlying disease state will be listed last, as it is the derangement that began the process. This is known as the “but for” principle, as in “but for this event all subsequent chain of events would not have occurred and the individual would not have died at the time and place they did.” In most cases the underlying cause of death will determine the manner. Mechanistic terminal events add little value to the cause of death statement. These include cardiac arrest, asystole, cardiopulmonary arrest, multi-organ system failure and hyperkalemia. These events have a multitude of underlying causes and give no hint as to the etiology of the cause of death. Manner of death If the cause of death is the “why” are they dead (e.g. gunshot wound), then the manner of death is the “how” are they dead (e.g. suicide). The manner is a checkbox that informs the reader of the circumstances surrounding the death and consists of natural (disease or aging process), accident (sudden, unexpected external event), homicide (volitional act by another meant to cause harm or fear), suicide (volitional self-inflicted act meant to cause harm), or undetermined (unknown cause of death or more than

Colorado Medicine for September/October 2014

Features one possible manner). Any non-natural event or injury including drug intoxication causing or contributing to death will result in a non-natural manner selection. Non-forensic pathologists should never sign a death certificate with any manner other than “natural” unless instructed to do so by the coroner. Part two of the death certificate references other significant conditions that may have contributed to the disease state or caused worsening of the health of the individual while not directly in the chain of events listed in Part 1. It’s important to list any and all factors that you feel may have hastened the decline of the patient. Any non-natural events placed in Part 2 should result in a nonnatural manner determination and should be reported to the coroner.

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

The “interval between onset and death” is to be recorded as accurately as possible, but if an exact duration is unknown this can be listed in a general terms such as seconds, days or years. n

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

Colorado Medicine for September/October 2014

Inside CMS

September 19–21, 2014 • Vail Cascade Resort

Good friends, good food and good music:

CMS is bringing the best of Carnival to the mountains

CMS thanks the following sponsors and exhibitors for their support of this year’s annual meeting Presenting Level Sponsor COPIC Gold Level Sponsors CIGNA HealthCare Colorado Drug Card Purdue Pharma L.P. UnitedHealthcare Wells Fargo Silver Level Sponsor Air Force Health Professions Exhibitors

athenahealth Bluestein Law Firm, PC Carr Healthcare Realty Center for Dependency, Addiction and Rehabilitation Center for Personalized Education for Physicians Colorado Physician Health Program CORHIO Donor Alliance GL Advisor 44

Harmony Foundation InBody Life Care Centers of America Medical TeleCommunications ReachLocal Sharkey, Howes & Javer TransFirst United Allergy Services University of Colorado Hospital/CeDAR Colorado Medicine for September/October 2014

Inside CMS

CMS Corporate Supporters and Member Benefit Partners

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

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

PRACTICE VIABILITY (cont.) athenahealth 888-402-6942 or visit www.athenahealth.com/cms. *CMS Member Benefit Partner

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

Bluestein Law Firm, PC 720-420-1777 or visit www.bluesteinlaw.com

Sharkey, Howes & Javer 303-639-5100 or visit www.shwj.com. * CMS Member Benefit Partner Wells Fargo 303-863-6014 or visit www.wellsfargo.com * CMS Member Benefit Partner INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit www.callcopic.com *CMS Member Benefit Partner UnitedHealthcare 877-842-3210 or visit www.UnitedhealthcareOnline.com MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or visit www.coloradodrugcard.com *CMS Member Benefit Partner

Carr Healthcare Realty 303-817-6654 or visit www.carrhr.com Diagonal Medical Billing 303-551-7944 or visit www.diagonalmedicalbilling.com First Healthare ComplianceTM 888-54-FIRST or visit www.1sthcc.com *CMS Member Benefit Partner GL Advisor 877-552-9907 or visit www.gladvisor.com/cms * CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251 or 303-761-6594 or visit www.medteleco.com * CMS Member Benefit Partner

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

Solve IT 303-800-9300 or visit www.solveit.us *CMS Member Benefit Partner

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

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

University of Colorado Hospital/CeDAR 877-999-0538 or visit www.CeDARColorado.org PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit www.alnmm.com Colorado Medicine for September/October 2014

Transcription Outsourcing 720-287-3710 or visit www.transcriptionoutsourcing.net Transworld Systems 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner 45

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.

Jonathon J. Parker MSIV, PhD University of Colorado SOM

Jonathon Parker is a fourth-year medical student at the University of Colorado School of Medicine. He recently completed his Ph.D. in Cancer Biology as part of the NIH-funded, Medical Scientist (MD/PhD) Training Program, studying the malignant brain tumor, glioblastoma. Jonathon and his wife, Danielle Marck, a patient navigator at Denver Health, enjoy exploring Colorado with their two pets, Eloy and Milo. In their free time, Jonathon and Danielle volunteer at Brent’s Place, a safe, clean home for children and their families to stay while undergoing bonemarrow transplant and chemotherapy. This year Jonathon will be applying to residency programs in Neurological Surgery with a plan to remain in Academic Neurosurgery.

Transplant

Late Friday evening, my team received a call that donor organs had become available. The student in me was uncomfortably excited; I had waited all week to participate in a transplant, and I had become convinced I would leave the rotation without that privilege. Despite feeling hardened to tragedy through witnessing suffering and death over my year in the hospital, I was unprepared for the events that followed. Unfortunately, when we received the call, we learned that the donor was a 12-year-old boy, who had suffered a hypoxic arrest after an RSV infection, resulting in brain death. I could only image the parents’ devastation at their loss and how they would possibly come to terms with this horrible re 46

ality. Simultaneously, the budding physician in me refocused on the life his organs would bring to perhaps three or more desperate individuals waiting for a transplant. Upon their arrival at Children’s Hospital, the transplant team and I entered the all-too-quiet operating room. The child lay intubated on the table, bright OR lights focused on his exposed belly. His chest rose and fell with the beat of the ventilator. However, a palpably different mood draped the room I had entered many times before. The child would not leave the room with a beating heart. Despite my medical training and profound interest in the brain, I struggled to come to terms with the concept of “brain death.” Was the child still alive? I overheard the nurses retelling how the mother collapsed at her son’s beside as he was wheeled back to the OR. Somberly, as we began the harvest, a nurse read aloud a message from the patient’s mother, providing us just a small glimpse into his story. It was a wholly inadequate introduction to the all-too-short life of the child. Trying to both recognize and suppress the emotions welling up, a race of thoughts went through my head. I had been convinced, naively, that I had figured out all the ethical ramifications of transplant. I was completely mistaken. As the scalpel sliced through the patient’s skin from sternum to pubic symphysis, I tried to focus on the goal: to remove the organs as quickly as possible, in an effort to save the lives of three lucky individuals, who would ironically never know the story of this boy. After the squeal of the saw subsided, his chest lay open, his heart still beating. Still amazed by the beauty of the human body, I stared; it was the first beating human heart I had laid eyes on. Irrationally, I thought to myself that he was still alive. Shouldn’t we do something to help him? Colorado Medicine for September/October 2014

Inside CMS We next turned our attention to the liver; its pink, brightly glistening surface was a stark contrast to the fatty and often cirrhotic livers I was accustomed to. Cross-clamp the inferior vena cava. I found my hands feverishly packing the abdomen with ice. Perfuse the liver. All of a sudden, his blood was draining, and the heart went into v-fib. Instead of a distant tracing on a screen, I watched as the heart fruitlessly vibrated, heralding the demise of our patient. I found myself being handed the kidneys, tethered together through the IVC, like two beans. I held in my hands two delicate organs destined to save the lives of two patients, now rushing to the hospital. Turning to the back table, I placed the organs into the bath of ice, urging the cells to forget their taste for glucose and oxygen. The tenuous thread of human life was suspended in ice. Back to the table, I stared into an empty abdomen, a striking sight. I recognized at this point that the patient had passed away. Had he died earlier? Had his soul left before that? These questions weighed on me. The resident handed me the 0-nylon, giving me the privilege of closing the gaping hole in the body. Was this still a boy? Or just a body? I could close the incision, but what I couldnâ&#x20AC;&#x2122;t express was the depth of sorrow and sadness I felt for the boy and his family. Silently working, I gingerly manipulated the tissue, taking care to make the skin closure look as seamless as possible. It was the least I could do, the only part I felt capable of doing, to honor the boy and his family. As I returned home that night, I thought again of the boy and his family, of all the experiences he would not experience. I had to rest. Exhausted from the day, I knew we would transplant two kidneys in the morning. The best way to honor the ultimate selflessness of the family was to ensure that all the organs made it safely into their recipients. n

Colorado Medicine for September/October 2014

Inside CMS

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

COPIC celebrates 30 years

A strong foundation that supports improved medicine I first became insured by COPIC in 1996 as a young orthopedic surgeon. Back then, I viewed my coverage as a “necessary expense” and had little knowledge about it. I was focused on my medical practice without fully recognizing the ways medical liability issues could influence how I practiced medicine. As my involvement with COPIC grew, so did my appreciation for its history. I came to understand how the company emerged out of a crisis that threatened health care in Colorado, how the courage of a few led to a better option for many, and how a noble mission paved a path that others would follow. In the early 1980s, national insurance carriers decided to leave Colorado or imposed substantial price increases on existing insureds. The business decisions of carriers were impacting the delivery of care in a negative way and something had to be done. Under a shared affiliation with the Colorado Medical Society, a group of physicians came together to address the problem. They realized that the best way to predict the future was to create it, and set forth to build a company that redefined the medical liability landscape in Colorado. When COPIC became a fully licensed and regulated Colorado insurance company in 1984, it was an invention out of necessity. The founders had a vision to create an entity that would ensure a stable medical liability environment, embrace a physician-directed approach, and put the interests of improving health care before financial profits. As the years passed, COPIC continued its focus on rate stability and expanded into a company that emphasizes and invests in patient safety and risk management. Some of our milestones in the last 30 years include: • 1985 – COPIC Financial Service Group was formed to provide a broad range of personal and professional insurance and financial products for the health care community. • Early 1990s – COPIC begins to offer educational seminars and workshops designed to improve communication and workflow among medical teams, and our Practice Quality nurse reviewers launch a program to visit all of our insured, office-based practices every two years. • 2002 – COPIC develops Level One Guidelines designed to reduce systems failures, improve documentation, and 48

ultimately reduce avoidable adverse outcomes. • 2007 – COPIC’s 3Rs Program (Recognize, Respond and Resolve) is recognized by The New England Journal of Medicine as part of the national transformation in how health care providers communicate with patients about unexpected outcomes. • 2014 – COPIC receives initial accreditation by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. In addition to COPIC’s commitment to insureds, we also realized our role in health care allowed us to contribute on a larger level. Whether it is funding grants that improve patient safety or removing financial burdens for volunteer physicians, COPIC has embraced opportunities to make a difference in several ways: • 1992 – COPIC Medical Foundation was created to provide grant funding for programs and initiatives that improve patient safety and quality of care. • 1996 – COPIC begins offering medical professional liability insurance at no charge to eligible physicians who provide uncompensated medical care. • 2010 – COPIC’s weeklong residency program for medical students surpasses more than 160 annual participants who attend sessions focused on patient safety and medical liability issues. Another key factor in COPIC’s success and longevity is the partnership we have with CMS. From the beginning, CMS was an integral part of our formation and provided much-needed support. The benefits of the COPIC and CMS partnership are evident today in the public policy and advocacy work that occurs year-round to protect tort reform and monitor legislative issues that impact health care in Colorado. As I look back over the last 30 years, there is a sense of pride in knowing that COPIC’s original ideals remain strong to this day. We owe much to the group of individuals who founded the company, and there is a responsibility to carry on the legacy they started. COPIC has become more than just an insurance company – we are a critical partner in serving and protecting health care professionals in the delivery of better medicine. n

Colorado Medicine for September/October 2014

Colorado Medical Society is pleased to announce First Healthcare Compliance as our newest Member Benefit Partner. TM

First Healthcare Compliance provides a comprehensive compliance solution that saves time and money and mitigates risks for physicians and other healthcare providers in private or small group practices, and for hospital provider networks and health systems. The seamlessly integrated, turnkey solution makes it easy to comply with every federal regulation that applies to health care practices, including HIPAA/HITECH, OSHA, the False Claims Act, the Anti-Kickback Statute and Stark, all in one place. It includes: • A fully secure, cloud-based online management tool • Anonymous hotline for whistleblowers • Online training (24/7/365) • Sample document library for customizing Policies & Procedures • Organizational tools and resources for ongoing compliance management • Ist Defense File™ for storing information and records with time • Toll-free, personalized live support each business day and date stamps as proof of an established compliance program Contact First Healthcare Compliance TODAY at 888-54-FIRST or info@1sthcc.com.

Colorado Medicine for September/October 2014

Departments

medical news CHA reports Colorado hospitals seeing more, and sicker, Medicaid patients Hospitals in states that chose to expand Medicaid under the Affordable Care Act (ACA) reported sustained growth in Medicaid patient volumes during-second quarter 2014 – and three times the increase of emergency department (ED) visits than hospitals in non-expansion states in second-quarter 2014 compared to the same time last year, according to a new study from the Colorado Hospital Association (CHA). The national study includes several observations: • The average number of ED visits to hospitals in expansion states increased 5.6% from second-quarter

2013 to second-quarter 2014. This change was greater than expected from the variation over the last two years. In comparison, hospitals in non-expansion states reported a 1.8% increase in ED visits between the second quarters of 2013 and 2014. • Hospitals continued to see a surge of new enrollees seeking care. Medicaid volumes at hospitals in expansion states continued to increase in the second quarter of 2014 at a rate of almost 9%, but at a slower rate than the first-quarter rate of almost 24%. • Data from second-quarter 2014 shows growth in the proportion of Medicaid charges and a decline in the

self-pay proportion seen in hospitals in non-expansion states. This unexpected Medicaid growth in hospitals in non-expansion states did not appear in first-quarter 2014 and is likely due to the “woodwork effect,” where previously unenrolled but eligible individuals discover they are eligible for Medicaid. In addition to the national study, CHA conducted a Colorado-specific analysis and identified several emerging trends. Among them, Medicaid patients now arriving at Colorado hospitals have more complex conditions than the average Medicaid patient seen previ-

Colorado Medicine for September/October 2014

Departments ously and EDs are seeing more Medicaid patients than before. Case mix index, which measures complexity and resource needs, increased 10% for Medicaid patients in the first quarter of 2014 as compared to first-quarter 2013; additionally, the number of Medicaidcovered ED visits increased 38% in firstquarter 2014 as compared to the previous year. “Hospitals located in expansion states are serving greater numbers of Medicaid patients, many needing care for advanced chronic health conditions that were previously left untreated,” said Steven J. Summer, CHA president and CEO. “These findings confirm that individuals who previously had no insurance coverage are now seeking and receiving health care services – and their needs are great.”

Oregon; and a local, in-depth examination of Colorado trends using additional datasets. The national analysis is based on data from 450 hospitals across 25 states, 13 of which expanded and 12 of which did not. The reports were conducted by CHA’s Center for Health Information and

Data Analytics using data from the CHA Discharge Data Program database and CHA’s DATABANK program, which has been working with hospitals throughout the country since 1985. The full report, Impact of Medicaid Expansion on Hospitals: Updated for SecondQuarter 2014, is available at www.cha. com. n

Call for nominations The Colorado Medical Society is issuing a call for nominations for the following elected offices at its upcoming annual meeting September 19 - 21 at the Vail Cascade Resort. Visit www.cms.org to view qualification and application requirements. To date, the following physicians have announced their candidacy. President-elect (one-year term) Michael Volz, MD Speaker of the House (two-year term) Bob Yakely, MD, incumbent

The Medicaid volume increases at hospitals demonstrate a considerable existing – and previously unmet – demand for health care services in communities. Additionally, volume and ED trends identified in expansion and non-expansion states respectively, aren’t simply national averages, but rather, are consistent throughout each state, respectively. This affirms that the choice between expansion and non-expansion has consistent and predictable outcomes.

Vice-Speaker of the House (two-year term) Brigitta Robinson, MD, incumbent CMS Historian (one-year term) W. Gerald Rainer, MD, incumbent

AMA Delegate (elect one) (One, two-year term beginning Jan. 1, 2015, ending Dec. 31, 2016) A. “Lee” Morgan, MD, incumbent AMA Alternate Delegate (elect one) (One, two-year term beginning Jan. 1, 2015, ending Dec. 31, 2016) Kay Lozano, MD Daniel Perlman, MD

“Many states have chosen to create a healthier population and stronger health care provider safety net through expansion,” said Chris Tholen, CHA vice president of financial policy. “The true measure of success is finally knowing whether the people who need health care are actually receiving it. An insured community is a healthier community.” In July 2014, CHA released a preliminary analysis of first-quarter 2014 data regarding the impact of the ACA Medicaid expansion. This report is an updated analysis that examines how the trends shown in the previous study progressed into the second quarter of the year, as well as additional information about the Medicaid population. It presents a national review; a regional comparison of Montana, Washington and Colorado Medicine for September/October 2014

The Jane Nugent Cochems Trust

eed n n i s Financial h n a i c elp for physi

Application deadline: October 15, 2014 The Colorado Medical Society administers grants from the Jane Nugent Cochemâ&#x20AC;&#x2122;s Charitable Trust to offer short-term financial help to physicians in need. The average grant to approved applicants ranges from $5,000 to $10,000 although larger amounts can be approved. 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 http://www.cms.org/about/cochems-trust/ to download an application form. 52

Colorado Medicine for September/October 2014

Departments

classified advertising ➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES FAMILY MEDICINE PHYSICIAN – Longmont Clinic, a 49-physician multispecialty group serving Boulder & Weld Counties since 1906, is seeking a fulltime family medicine physician to join our Carbon Valley Medical Center practice in Firestone, CO. Active CO and DEA licenses required. Compensation package includes competitive base salary plus incentive plan, comprehensive benefit program and future partnership opportunity. Please forward CV and inquiries to klightfoot@longmontclinic.com LITTLETON PEDIATRIC MEDICAL CENTER – is seeking a part time or full time board certified pediatrician for its Highlands Ranch or Ken Caryl offices both in metropolitan Denver. Please call Nita O’Brien, R.N. @ 303791-9999 or email address: nita-littlepeds@qwestoffice.net

SEEKING FULL OR PART-TIME EMERGENCY MEDICINE PHYSICIANS – Innova Emergency Medical Associates is a completely different type of emergency medicine group in the intermountain west. We fully employ all physicians and allied health professionals, and employees enjoy an incredible benefits package. We specialize in rural emergency medicine and allow you the ability to work where your services are highly needed and appreciated. Additionally, given our innovative scheduling matrix, you can live where you’d like and enjoy our beautiful region. We are experiencing tremendous growth and are looking for emergency medicine physicians, physician assistants, and nurse practitioners to be part of our team in a variety of facilities in

Colorado and New Mexico. Please check out our website and apply online: www.innovaem.com/join-our-team/apply/. Feel free to forward your CV, as well, to ashley@innovaem.com.

➤ PROPERTIES FOR SALE OR LEASE MEDICAL OFFICE SPACE – It’s a medical office space sharing with owner’s suite but separate spaces. Available 2-4 exam rooms-waiting areas-reception desk-Restroom-Kitchen/break room. It is about 1800 sq. feet space, and $2500/ month. Space is conveniently located on University Blvd and I-470. It is a medical building, and space is for Medical or Health Care offices - Primary Care, Orthopedist, rehabilitation physicians, etc. 7940 S. University Blvd, ste100 Centennial, CO 80122. Call 303-564-5008

Colorado ICD-10 Coalition helping physicians prepare for coding switch The Colorado ICD-10 Coalition, a statewide organization of interested educators, consultants, physician and practice representatives, continues to help Colorado physicians prepare their offices for the scheduled implementation of the ICD-10 diagnosis codes in advance of the deadline that has recently been extended to at least Oct. 1, 2015. "Despite the recent delay in the implementation of ICD-10, physicians and their staffs would be wise to continue their preparations so they don’t feel overwhelmed when it eventually goes into effect," said Marilyn Rissmiller, CMS senior director of the Colorado Medical Society Division of Health Care Financing. The coalition’s resources include a series of webinars, educational events, worksheets, task lists and apps that are available on the group’s website, www.cms.org/icd-10. The two most recent webinars, Project Planning Phase 1 and 2, provide viewers with information on how to jumpstart this transition. To learn more and to access resources to help you navigate the ICD-10 maze, go to www.cms.org/icd-10. Colorado Medicine for September/October 2014

Features

the final word Michael J. Pramenko, MD, Executive Director Primary Care Partners, Grand Junction Colorado Medical Society Past President

CMS physicians share experience at national leadership seminar Knowing is not enough; we must apply. Willing is not enough; we must do. -Johann Wolfgang Von Goethe I was invited by the Center for Improving Health Care (CIVHC) to join CMS president-elect Tamaan Osbourne-Roberts, MD, at a leadership seminar at Stanford University in August. The seminar was sponsored by the Network for Regional Healthcare Improvement, funded by the Robert Wood Johnson Foundation, and highlighted efforts in health delivery reform from several states. Featured speakers included CIVHC’s Jay Want, MD and Arnold Milstein, MD, who directs the Stanford Clinical Excellence Research Center and serves as the medical director for the Pacific Business Group on Health. National trends The program’s overall theme centered around the concept that inflation rates of public and private health care spending in the United States must effectively be addressed so that our society can properly fund other essential priorities like education and infrastructure. Indeed, health care spending has a chokehold on our economy, and on our competitive status in the world marketplace. As we move farther into the journey on health system reform, more research is being done on delivery models that both lower per capita health care spending and improve clinical outcomes. We must improve on both variables as research indicates that focusing on quality does not always directly lead to lower cost. 54

With respect to cost, transparency stands to reshape the world of health care. The All Payer Claims Database here in Colorado is just beginning to influence how prices are set. And, of course, the days of fee-for-service reimbursement as the sole payment model for providers are certainly numbered. Right now public and private payers are testing value-based payment models that will de-emphasize its role. For physicians, our biggest challenge will be to improve the quality of care we deliver. We must avoid the temptation to measure this by each individual we treat. On the contrary, the measure of our success will relate to our role in improving the health of a whole population. This is done one patient at a time, with the recognition that we are dealing with a scarce resource. Certainly treating each individual without any respect to cost ignores the health of the population. Local implementation Here at Primary Care Partners in Grand Junction, we are busy navigating the changes necessary to deliver on this value proposition while maintaining our autonomy as a private practice. As we are all experiencing, this change is stressful and the urge to maintain the status quo or sell the practice can be strong. We are fortunate to have partners in this endeavor. Locally we have a robust health information exchange via Quality Health Network (QHN). Rocky Mountain Health Plans continues to lead the insurance company pack by stressing the Triple Aim here in Western Colorado, and is currently helping us with a new embedded IT tool to

assess risk in our patient population. Hospital engagement with partnering on value-based projects shows promise. And some of our local employers are organizing to help leverage some of the needed changes here in Mesa County. State pilots From the state level, Colorado Medicaid is piloting a new payment model with RMHP and local providers. Under HB 1281, we are testing a new global payment for a segment of the Medicaid population. This new model will incentivize providers to focus on the sickest patients and emphasize the importance of physical and mental health. From the federal level, the Affordable Care Act’s Center for Medicare and Medicaid Innovation has delivered on a payment model to support advanced patient-centered medical homes. Four practices here in Mesa County join over 70 in Colorado within this project. The Comprehensive Primary Care Initiative has funded care coordinators, behavioralists, a patient portal, an embedded pharmacist, and shared decision-making advances here at our large practice. I agree with Dr. Milstein when he says, “physicians are the single most influential force in health care.” As we go about helping to guide health reform along the proper path, we simply must be willing to lead change. Our patients, our communities and our economy depend upon it. n

Colorado Medicine for September/October 2014