January-February 2018 Colorado Medicine

January/February 2018

Volume 115, Number 1

DRIVERS OF

CHANGE IN 2018

Award-winning publication of the Colorado Medical Society

contents Jan/Feb 2018, Volume 115, Number 1

Features. . .

10

Sound off–Members told CMS what they want and need from their medical society in a fall 2017 all-member survey.

12

Economic impact–A recent study by the American Medical Association shows the tremendous benefits physicians bring to the state’s economy.

13

AMA delegation report–The AMA is working on top

14

Legislative preview–The Colorado General Assembly is back in session for the first five months of 2018. See what issues you can expect them to address.

17

Physician payment–Medicare is reducing payment to physician practices owned by hospitals in an effort to level the playing field.

18

Opioid management–Kaiser Permanente Colorado is demonstrating best practices in pain management by engaging all members of the care team and the patient.

20

State Innovation Model–SIM is seeking applications for their third cohort and celebrating prior successes.

22

Medical TeleCommunications–CMS acquires telephone answering service to benefit member physicians.

24

Remembering a great leader–Renowned Denver heart

26

Colorado QPP Coalition–A collaboration in Colorado

Cover story The Colorado Health

Institute presented the 10 drivers of change Colorado physicians should expect to see in 2018 to the CMS board of directors for a strategic focus session in November. They range from changes in payment and quality metrics to consumer demand for increased technology and expensive pharmaceuticals. Read more about these drivers and the questions they raise for physicians and the Colorado Medical Society starting on page 6.

Inside CMS 5 President’s Letter 31 COPIC Comment 32 Reflections 34 Introspections

Departments 36 37 38 41

Member Benefits Spotlight Corporate Supporters Medical News Classified Advertising

Colorado Medicine for January/February 2018

issues of concern to physicians including health care reform, practice viability, wellness and medical education.

surgeon W. Gerald Rainer, MD, passed away in November.

brings tools and resources to physicians and practices complying with the Quality Payment Program.

28 Opinion/editorial–Longtime Colorado Medicine contributor Gary VanderArk, MD, gives his thoughts on artificial intelligence.

42

Final Word–Denver ophthalmologist Alan Kimura, MD, connects the 10 drivers of change in 2018 with the role of CMS and the importance of membership.

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF

2017-2018 Officers M. Robert Yakely, MD

President Debra J. Parsons, MD, FACP

President-elect David Markenson, MD

Treasurer Alfred D. Gilchrist

Chief Executive Officer

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

Katie Lozano, MD, FACR

Immediate Past President

AMA Delegates A. “Lee” Morgan, MD David Downs, MD Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD AMA Alternate Delegates Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Brigitta J. Robinson, MD Michael Volz, MD AMA Past President Jeremy Lazarus, MD

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

Division of Health Care Financing Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org Division of Information Technology/Membership Tim Roberts, Senior Director, Tim_Roberts@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Program Manager Adrienne_Abatemarco@cms.org Colorado Medical Society Foundation Colorado Medical Society Education Foundation Mike Campo, Staff Support, Mike_Campo@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office.

Subscriptions are available for $36 per year, paid in advance.

COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified.

Alfred D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor.

Printed by Hampden Press, Aurora, Colo.

Inside CMS

president’s letter M. Robert Yakely, MD President, Colorado Medical Society

Charting the future course CMS has served members over the years primarily as an advocacy organization that champions issues important to you and your patients. Over the past decade, we have led the fight to maintain Colorado’s stable liability climate, enacted managed care reforms and supported efforts that have reduced Colorado’s uninsured rate to the lowest in the state’s history.

To chart our future course, the board held a weekend retreat in mid-November 2017 designed to focus on the future of CMS. The process for taking a hard look at who we are, where we’ve been and where we are going is evidence-based because we are keeping you, our members, involved in this vital process. To accurately reflect our members’ goals, we will be asking for your input on how best to position the organization to deal with marketplace and public policy uncertainties. We will be taking your pulse on your levels of professional dissatisfaction that result from excessive regulation, burdensome paperwork, and EMRs that are designed mostly for billing and poorly designed for accurately documenting the problems your patients need you to address.

4. Reviewed and revised our purpose, values and vision.

At our January board meeting we will approve on a preliminary basis the revised purpose, values and vision along with a new set of goals. We will send these out for your review and comment as soon as the meeting adjourns, taking final action in March after your perspective is given full consideration.

the time to respond to the survey in advance of our weekend retreat, and I thank in advance those who will review and comment on the new set of goals. I think it is important for our members to know that you are the rudder that guides this ship. We can represent you best when you give us your perspectives in our surveys.

Feel free to reach out to me personally at any time by emailing me at president@cms.org. n

I am grateful to all members who took

To that end the board has: 1. Utilized recent literature to identify major drivers of change in the marketplace.

2. Considered your input from our recent surveys to identify problems we need to address.

3. Used email and text messaging to keep our members informed of where our advocacy has brought direct tangible benefits to all Colorado physicians.

Colorado Medicine for January/February 2018

Colorado Medical Society is pleased to announce Favorite Healthcare Staffing as our newest Member Benefit Partner.

For more than 30 years, Favorite Healthcare Staffing continues to set the standard for quality, service, and integrity in the Colorado healthcare community.

With preferred pricing for CMS members, Favorite’s comprehensive range of staffing and placement services can help physicians improve cost control, increase efficiency, and protect their revenue cycle. Call 720-2109409; email MedicalStaffing@FavoriteStaffing.com or visit www.favoritestaffing.com.

5

DRIVERS OF

CHANGE IN 2018

Kate Alfano, CMS Communications Coordinator

6

Colorado Medicine for January/February 2018

Cover Story Physicians are constantly aware that the practice of medicine is everchanging. This becomes even more apparent in the 10 drivers of change in 2018 that the nonpartisan Colorado Health Institute identified from a variety of sources including literature review, informant interviews and popular press. Each driver has and will continue to impact the health care delivery market and has strategic implications for Colorado physicians and the Colorado Medical Society.

President and CEO Michele Lueck and Paul Presken from CHI presented these drivers to the CMS board of directors during a strategic focus weekend in November 2017 to focus the board to determine a short-term and mid-term course of action.

CMS encourages members to explore the drivers that follow, consider the questions posed and engage with your medical society to position Colorado physicians at the forefront of health care transformation.

1. Public insurance is continuing to grow.

The newest CHI data on health coverage in Colorado shows that employer-sponsored health insurance has continually decreased over the past eight years – from 57.7 percent in 2009 to 49.4 percent in 2017 – while the number of Coloradans covered by Medicare, Medicaid or CHP+ has increased – from 20.1 percent combined in 2009 to 35.4 percent in 2017. The uninsured rate has decreased by more than half, from 13.5 percent in 2009 to 6.5 percent in 2017.

Driving Medicaid growth has been the expansion under the Affordable Care Act that opened the program in January 2014 to include more adults and former foster children up to age 26. In 2012-2013, 683,000 Coloradans were enrolled in Medicaid. The Colorado Department of Health Care Policy and Financing estimates that 1.4 million will be enrolled in Medicaid in 2017-2018. Enrollment in Medicare Advantage plans nationwide has steadily increased since 2014.

The increase of lives covered by public insurance raises questions: How do these changes impact administrative burden? Is Colorado accelerating toward capitation? How can practices anticipate and leverage bonuses, clinical measures and other financial incentives or financial penalties?

2. Payment reform is advancing.

Public insurance is leading the way in payment reform. On the federal level, there is bipartisan support for reform.

The Medicare and CHIP Reauthorization Act (MACRA) will impact most physician reimbursement for Medicare starting in 2019.

Colorado Medicaid will implement the second phase of its Accountable Care Collaborative (ACC), replacing Regional Care Collaborative Organizations (RCCOs) and Behavioral Health Organizations (BHOs) with Regional Accountable Entities (RAEs) in 2018. RAEs will be responsible for connecting Medicaid members with both primary care and behavioral health care. Primary care providers will be reimbursed for some behavioral health visits to encourage care integration. RAEs will be paid $15.50 per member per month and will contract with primary care providers for at least $2 per member per month.

Of the $15.50, HCPF will withhold $4 per member per month for the RAE to earn back if performance goals are met.

Additional incentive opportunities in ACC Phase Two will bring more financial risk to providers, a higher behavioral health capitation rate if RAEs hit performance goals and a pay-for-performance pool to encourage higher standards.

Questions raised by advancing payment reform: How do members prepare for downside risk? What are the sticks and carrots? How can members keep up with requirements for metrics?

What support can CMS provide? How can CMS train members to prepare for changes?

Colorado Medicine for January/February 2018

3. Consumers are demanding increased technology.

Technology is already part of the patient experience, with a Deloitte survey showing many consumers using the internet, apps or a device to refill a prescription; measure fitness and health improvement goals; pay a medical bill online; monitor health issues; track costs of care; receive health alerts or reminders; or measure, record or transmit data about a medication.

Deloitte also shows consumers are more likely to use telemedicine for post-surgical care, chronic disease monitoring, care while traveling and minor injuries.

Questions arising from a push for more technology: Will adopting new technologies lead to higher patient trust?

How will members ensure patient safety and confidentiality? How can members incorporate new technologies into a larger patient engagement strategy?

4. New models of care are emerging.

Physicians are witnessing a changing health care delivery landscape on the national, regional and local levels.

Retail clinics have expanded dramatically, from 1,320 in 2010 to 3,000 in 2016, opening in grocery stores, pharmacies and big-box stores. These clinics have even developed their own advocacy group, the Convenient Care Association, which indicates they are not going away soon. This is affecting the health care workforce. Forbes reported in June 2017 that nurse practitioners are more in demand than most physicians as states allow them direct access to patients.

Questions for physicians regarding new models of care: How might practices align or partner with new care settings? What are the implications of new care settings for traditional offices? Hours? Convenience? With workforce patterns shifting, what steps can practices take to ensure quality and effectiveness?

7

Cover story (cont.)

5. Physician well-being is crucial.

Perform a quick online search on physician burnout and the number of studies, reports and articles is astounding. Medscape reports that physicians identify the leading causes of physician burnout as too many bureaucratic tasks, spending too many hours at work, feeling like “just a cog in a wheel,” the increasing computerization of practice, earning a lower income than desired, difficult patients, and insurance issues.

Stanford Medicine has demonstrated a reciprocal model where a culture of wellness, efficiency of practice and personal resilience combine for professional fulfillment.

Marti Schulte, president of Community Physician Consulting, suggests physician wellness can be improved by increased physician leadership in the workplace, cultivating commu-

nity among physicians, and surveying members to understand the extent of burnout in Colorado and its reasons.

Questions to answer regarding wellness: What approaches would make the biggest impact for members? Are there specific programs or services that would prevent physician burnout? How might CMS “cultivate community?”

6. Integration of behavioral and physical health is progressing.

Colorado has a number of programs supporting the move to integrate behavioral and physical health; addressing behavioral health has been shown to be key to overall health. The State Innovation Model (SIM) grant has supported 250 practices in two cohorts with a third cohort of 150 practices to be named in 2018. The Comprehensive Primary Care Initiative supports 71 practices, Comprehensive Primary

New member benefit, coming soon!

Know Your Rights database Physician practices have rights under Colorado law that can be exercised to mitigate health plan barriers to care. These rights are being summarized and incorporated into a members-only online database for easy access. The tool will be searchable, and help physicians and practice managers understand what those rights are.

Legal rights for physicians advocated for by CMS over more a decade include but are not limited to: physician profiling, prior authorization and referrals, telehealth, anti-retaliation, narrow networks, timely payment, contracting, and appeals.

Watch for more information in the coming months. The online database is scheduled for rollout by the end of March 2018.

8

Care Plus supports 203 practices, the Colorado Health Foundation Primary Care Practices number 20, and RAEs encompass 550 practices.

Questions from this movement to integrate behavioral and physical health: What kind of training and education would be valued for integration? How can CMS better equip physicians to integrate practices? What kind of programs would be valuable?

7. Population health and public health are converging.

The literature increasingly demonstrates that social and economic factors affect health outcomes and population outcomes over the course of a person’s life. Yet, health spending often dwarfs social spending. In the city and county of Denver, $4.5 billion is spent on medical care while just $41 million is spent on public health and prevention, according to the Colorado Health Institute. Population outcomes can be improved with a greater understanding of how to address social determinants of health like economic opportunity and physical environment; health factors such as health behaviors and conditions; mental health; access and quality care.

Questions arising from the convergence of population health and public health: How should CMS position physicians to participate in this issue? Should CMS advocate for “non-health” issues in population health? Where is the opportunity for physicians, especially thinking about this in combination with payment reform?

8. Consumers are facing higher spending.

The average individual deductible has increased dramatically, from around $500 in 2002 to upwards of $1,800 in 2016, according to the Medical Expenditure Panel Survey. A Kaiser Family Foundation report similarly found that the percentage of covered workers enrolled in a high-deductible health plan increased from 4 percent in 2006 to 28 percent in 2017. Con-

Colorado Medicine for January/February 2018

Cover Story sumers increasingly skip care because it costs too much. CHI found that in 2017, one of five Coloradans did not get needed care due to cost.

This leads to three questions for physicians: If consumers are more involved in paying for care, how will physician practices adapt? Is there specialized training or programs that could benefit practices? What are potential roles for CMS around pricing transparency?

9. Consumers are demanding new (and expensive) drugs.

A fast-rising percentage of pharmacy industry revenue comes from specialty drugs. At the same time, more hospital systems are adding specialty pharmacies. One in five hospital systems have internal specialty pharmacy capabilities and nearly two in five are considering adding them. Trends in prescription drug spending show 59 percent is due to drug composition changes or price increases, 23 percent is due to overall economic inflation, 10 percent is due to an increase in prescriptions per person and 8 percent is due to population growth.

Questions arising from this driver: What role do physicians have in offering alternatives or counter-arguments to consumer demand? How can CMS help prepare practices for the complex reimbursement associated with specialty pharmaceuticals? How do practices get involved?

10. Physicians can bring a strong voice to D.C. and Denver.

Physicians who choose to be involved politically can bring their real-world experience and illustrate real-world consequences to policymakers. The current administration seeks to encourage competition in health care, while gutting portions of the Affordable Care Act and relaxing federal oversight of the health care industry.

Questions arising from this driver: Where should CMS show up in these discussions? Is this a priority area for your membership? How can you best relay the specific interests of your membership to policymakers? n

Support the Colorado Medical Society Foundation The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans.

Consider giving a taxdeductible donation of $25, $50 or more to help CMSF continue its mission. Questions?

Call 720-858-6310.

Physicians bring economic health to our communities.

The 2018 AMA Economic Impact Study demonstrates how physicians contribute mightily to the health of Colorado’s economy.

175,246 JOBS

$31.1 billion IN ECONOMIC ACTIVITY

$1.1 billion

IN STATE & LOCAL TAX REVENUES

$14.9 billion IN WAGES & BENEFITS

Physicians’ impact is felt far beyond the exam room, reaching through local communities, producing a network of jobs and spurring local investment.

Learn more at PhysiciansEconomicImpact.org

© 2018 American Medical Association. All rights reserved. 17-1906041:1/18

Colorado Medicine for January/February 2018

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Features

SOUND OFF Kate Alfano, CMS Communications Coordinator

Members tell CMS what they want and need from their medical society in 2017 all-member survey The Colorado Medical Society, working with pollster Benjamin Kupersmit of Kupersmit Research, surveyed members in October and November 2017 to gauge perceptions of the Colorado Medical Society and physicians’ practice of medicine to help CMS better respond to physicians’ concerns and increase member engagement. Survey results, paired with an environmental scan compiled by the Colorado Health Institute, informed the strategic focus weekend conducted by the CMS Board of Directors in November.

REFLECTS MY PRIORITIES Applies 100% 2% 19%

Very Strongly

1%

2%

Somewhat 0%

17% 21% Communicates well with membership on the issues facing the medical profession

23%

Gives members like me a chance to provide input and suggestions 54%

Not Very Much 2%

Not At All

10%

2%

3%

6%

8%

12%

15%

4%

32%

35% Is having a positive impact on the health care system in Colorado

Has positive impact on my career as a physician in Colorado

38%

57%

30%

Reflects my priorities

32%

44%

COMMUNICATION Tracking shows clear improvement in ‘input’ and ‘communication,’ while other ratings have improved back to their 2008 levels since hitting low marks in the 2013 survey Gives members like me a chance to provide input and suggestions 2008

58%

Communicates well with membership on the issues facing the medical profession

Has a positive impact on my career as a physician in Colorado

2008 N/A

2008

44%

2008

42%

39%

2010

39%

Reflects my priorities

2010

44%

2010

67%

2010

2013

50%

2013

57%

2013

30%

2013

26%

2015

44%

2015

54%

2015

34%

2015

31%

2017

77%

2017

74%

2017

42%

2017

36%

INFORMATION AND ADVOCACY

IMPORTANT VALUES

‘Advocacy’ and ‘Information/Communication’ continue to be the top reasons members rely on CMS; physicians in large facilities are more likely to say ‘social/networking’

When asked to choose their most important value, members gravitated most toward ‘Fighter’ and ‘Collaborator’

Advocacy

72%

Information and communication

70%

Professional development

21%

Social opportunities/networking

21%

Community involvement

20%

Support with practice management

10%

Endorsed vendor discount programs

7%

None of the above

12%

10

Grassroots 4% Community 5% Caring 10%

Unsure 3% Collaborator 22%

Innovator 12%

Evidence-based 12%

Fighter 32%

Colorado Medicine for January/February 2018

Features

HOW SHOULD CMS PRIORITIZE WORK ON HEALTH CARE REFORM? Top-tier priorities are the liability/tort environment and advocacy as health reform continues to unfold As much attention as possible

A lot

1%

Some

None

3% 51%

14%

52%

18%

40%

19%

Health system reform, such as federal efforts to improve the ACA, or state efforts to provide affordable coverage for all Coloradans

Maintaining a stable medical liability/tort environment

3%

3%

3% 34%

23%

30% 27% Examining ways to reduce the cost of care with equal or better outcomes and quality

Helping physicians navigate payment reform and quality initiatives (MIPS, MACRA, etc.)

Physician morale and wellness

26%

34%

36%

40%

38%

HOW SHOULD CMS PRIORITIZE WORK TO HELP PHYSICIANS IN PRACTICE? We also see great importance placed on reducing administrative burdens on physicians As much attention as possible

A lot

Some

1%

2% 40%

19%

None 7%

1% 40%

24%

40%

22%

23% 35%

Reducing administrative burdens from private insurance payers

Reducing administrative burdens from Medicare

Reducing administrative burdens from Medicaid

23%

30%

34%

Reducing administrative burdens from your employer/hospital administration

31%

ORGANIZATION VALUES

Members reacted positively to a range of values that CMS tries to espouse as an organization Very strongly

Should espouse this value 2%

0%

Somewhat 2%

40% 7% Evidence-based, grounding policy decisions in the latest available peer-reviewed data whenever possible

Not very much

0%

4%

35%

18%

6%

44%

1% 35%

23%

Caring, honoring the unique role that physicians play as healers and their dedication to patients

34%

4%

1% 40%

20%

3% 29%

33%

1% 25%

Grassroots, with creative, direct physician engagement to help drive policy 41%

0% 31%

20%

Innovator, on the leading edge of state societies driving policy on the issues physicians face

Fighter, for a profession on the ropes that needs a strong advocate in tough times

Collaborator, brings stakeholders together to find common ground

40%

Not at all

7% 38%

42%

1% 20%

Community, a way for physicians to connect with their peers, whether in person or virtually 33%

Engage with your medical society through Central Line at www.cms.org/central-line or by emailing Engage with your medical society through Central Line at www.cms.org/central-line or by emailing president@cms.org

Colorado Medicine for January/February 2018

11

Features

Economic impact American Medical Association

Colorado physicians boost the state’s economy, supporting 175,000 jobs, generating $31.1 billion in economic activity Study highlights • With the strongest economy in the nation, Colorado physicians help the state stay on top.

• But rural health care access in Colorado is a major issue.

Colorado needs to invest more in its doctors and recruit more physicians to serve residents. And the state needs to continue its investment in virtual, e-health infrastructure to help bridge this health care divide.

• As the market for health insurance has expanded, more Coloradans are insured than ever before. More doctors are needed to serve residents in the state.

Physicians are a critical component of the health care system, providing care to patients across a variety of settings and within a multitude of specialties and subspecialties. Through the care provided to their patients, physicians can have a positive and lasting impact on the health of their patients and the community as a whole. However, the breadth of a physician’s impact reaches far beyond just the provision of patient care. Physicians also play a vital role in the state and local economies by creating jobs, purchasing goods and services, and supporting state and community public programs through generated tax revenues.

A new report, The Economic Impact 12

of Physicians in Colorado, released by the Colorado Medical Society and the American Medical Association (AMA), provides estimates of the total economic impact of patient care physicians on the economy of Colorado, across four vital economic barometers: output, jobs, wages and benefits, and state and local tax revenue. As of December 2015, there were 736,873 patient care physicians within the 50 states and the District of Columbia. Of these, 12,840 physicians practiced in the state of Colorado.

The overall findings in the state of Colorado are as follows: • Total output: In Colorado, physicians created a total of $31.1 billion in direct and indirect economic output (i.e., sales revenues) in 2015. On average, each physician supported $2,422,969 in output.

• Jobs: In 2015, physicians supported 175,246 jobs (including their own), the total of direct and indirect positions. On average, each physician supported 13.65 jobs.

• Wages and benefits: Physicians contributed $14,922.4 million in direct and indirect wages and benefits for all supported jobs in 2015. On average, each physician supported $1,162,177 in total wages and benefits.

• Tax revenues: Physicians supported $1,141.1 million in local and state tax revenues in 2015. On average, each physician supported $88,867 in local and state tax revenues.

Given the rapidly changing health care environment, it is critical to quantify the economic impact physicians have on society. This report provides data that demonstrates how physician prac-

tices both ensure the health and wellbeing of communities as well as support local economies and enable jobs, growth and prosperity. It focuses on physicians (MDs and DOs) who primarily engaged in the practice of medicine (i.e., patient care activities as compared to those who focus on research or teaching), regardless of whether they are office- or hospital-based.

The report found that every dollar applied to physician services in Colorado supports an additional $2.17 in other business activity. An additional 7.92 jobs, above and beyond the clinical and administrative personnel that work inside the physician practices, are supported for each $1 million of revenue generated by a physician’s practice. In addition, Colorado physicians generate more economic output, produce more jobs and pay more in wages and benefits than higher education, nursing and community care facilities, legal services and home health.

Across the country, physicians add $2.3 trillion to the U.S. economy, support more than 12.6 million jobs nationwide, contribute $1 trillion in total wages and benefits paid to U.S. workers, and generate $92.9 billion in state and local tax revenue.

To view the full report and an interactive map, visit www.

PhysiciansEconomicImpact.org. n

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

Colorado Medicine for January/February 2018

Features

AMA working for you Lynn Parry, MD, Colorado Delegate to the American Medical Association

AMA making gains on health care reform, practice viability, wellness, medical education and more Congratulations to our CMS members who have joined the American Medical Association: We have a terrific delegation representing you. The AMA Interim Meeting was held in November 2017, attended by your leadership and Colorado delegates as well as the delegates representing Colorado specialty societies. I want to extend special congratulations and gratitude to M. Ray Painter Jr, MD, who has retired from the Colorado delegation after 32 years of service, many of those as chair.

So, what is the AMA doing for you? The AMA has been sending a consistent message that any health care reform cannot decrease the number of people covered or remove current protections.

Visit www.patientsbeforepolitics.org for more.

AMA Executive Vice President and CEO James L. Madera, MD, introduced IHMI, the Integrated Health Model Initiative – a collaboration with IBM Watson, Intermountain Healthcare, Cerner and the American Heart Association directed at creating a single standard to share meaningful patient-centric data. It will capture patient goals and assemble data elements into meaningful conceptualization of the patient’s state. Combined with SWITCH, a subscriber network that enables secure permissions-based sharing of health data among patients, physicians, payers and others in health care and technology, IHMI has the potential to make the access to data for physicians more clinically relevant and more efficient.

The AMA has been working to develop tools for assessment of and solutions

The Colorado delegation honored M. Ray Painter Jr, MD, with a reception during the AMA Interim Meeting in Honolulu, Hawaii. Painter (back row, center) poses with Colorado medical students who attended the meeting. to physician burnout, emphasizing the need for a systems approach as we move to larger and larger systems. Visit the professional well-being section of www. stepsforward.org.

Medical education remains an area of need. Medical school debt contributes significantly to career decisions and to physician burnout. The AMA is involved in working with transformation in medical education, both at the preand post-MD degree level.

The AMA Council on Ethical and Judicial Affairs (CEJA) has continued to solicit input on physician aid in dying – an issue that continues to polarize physicians. The AMA House of Delegates asked CEJA to reexamine its policy that opposes physician participation in aiding a patient actively terminating his or her own life. There are now six states plus Washington, DC that have legalized the practice. How should medical

Colorado Medicine for January/February 2018

ethics guide physicians in this conflict between “do no harm” and “patient autonomy”?

The AMA is your national advocate. It worked with states to block the megamergers that insurers were contemplating. Although it was an incredible heavy lift, it likely occurred without many physicians recognizing that preventing those mergers meant preventing profound cuts in reimbursement. Providing help with managing shifting payment systems and providing physicians with tools to navigate new regulations is an ongoing commitment of the AMA. This only covers a small part of the activity of the AMA. The Interim Meeting was another opportunity to hear from physicians from disparate geographic areas, and all career stages and practice settings. The AMA remains a place where we have to understand each other in order to help our patients. n 13

Features

Legislative preview Susan Koontz, JD, General Counsel, Senior Director of Government Relations

Issues to watch in the 2018 Colorado General Assembly The Second Regular Session of the 71st Colorado General Assembly convened on Wednesday, Jan. 10, 2018, and will run through May. The Colorado Medical Political Action Committee (COMPAC)

“The 2018 General Assembly will be focused on the opioid crisis, the budget, divergent views about how to fix PERA and highway funding, with each side positioning its approach to best serve the reelection of its members and respond to the needs of their constituents. ” - Jerry Johnson, CMS lobbyist has already begun working to address issues sure to arise this legislative session including engaging legislators in the interim and working through the lobby team to maintain open communications.

For the benefit of Colorado physicians, all elements of the CMS public affairs program will be engaged, including professional direct advocacy, message development and communications, legal research and bill drafting, policy development and research, witness preparation, 14

and member updates and calls to action.

Jerry Johnson of Johnson Consulting, a longtime and decorated lobbyist for CMS, gives his analysis of what to expect in 2018. “The 2018 General Assembly will be focused on the opioid crisis, the budget, divergent views about how to fix PERA [Colorado Public Employees’ Retirement Association] and highway funding, with each side positioning its approach to best serve the reelection of its members and respond to the needs of their constituents. Now that Congress has passed the tax bill and nothing is forcing the hand of states in the shortterm, coupled with 2018 being an election year, it is highly unlikely that a new coverage scheme will emerge or be politically viable if it does.”

Though the individual mandate of the Affordable Care Act was repealed by Congress’s tax bill, Gov. John Hickenlooper strongly supports Medicaid expansion, the sale of subsidized health insurance tied to a consumer mandate to purchase such insurance, and preservation of employer-sponsored health insurance, and it is almost certain that his administration will not transition to a different coverage scheme during the remainder of his term in 2018, Johnson said.

“Because CMS actively supported both the Medicaid expansion and legislation that created Connect for Health Colorado, the state’s health insurance exchange, the governor might be open to strategies to further close the coverage gap, though any tax bill in the 2018 legislature would be dead on arrival in the state Senate.”

The economic pressures on physicians to control costs, coupled with the continued realignment of payment models in both public and private sectors, have generated significant partitioning of medical practice settings and placed further limits on practice choices that assure economic security and viability. The political uncertainties and interdependence of federal and state health care financing, and sharp differences among leaders and influencers regarding those policy options, will continue to exacerbate the business relationships between payers, physicians and other providers, as well as hospitals and medical staffs. Market responses will likely be antagonistic or predatory more than collaborative.

The stakes are clear for the 2018 election cycle: Partisan control of the executive and legislative branches of state government and the Office of the Attorney General. “Led by COMPAC, CMS and component societies, physicians are already heavily engaged in the process of interviewing candidates for open seats and developing relationships that will pay dividends however control of the Executive and Legislative Branches emerges,” Johnson says.

Physicians can stand up and make a difference. Stay involved during the session by joining COMPAC with a contribution at www.cms.org/contribute, volunteering to interview your local candidates for election, or testifying in support of bills as needed. Email adrienne_abatemarco@ cms.org or call 720-858-6322 to express your interest in testifying. Watch for emails from COMPAC calling physicians to action on bills as they arise. n

Colorado Medicine for January/February 2018

Features Issues to watch in 2018 General Assembly Opioid crisis: More than 63,600 lives were lost to drug overdose in 2016, the most lethal year yet of the drug overdose epidemic, according to a new report from the National Center for Health Statistics. This already high-profile issue has been on the radar of top advocacy groups and elected officials for years and at least six bills will be introduced this session stemming from the work of an interim legislative committee.

“I am incredibly proud of the bipartisan work we have done through this interim committee to lay a foundation for addressing this epidemic, and begin to close the gaps people face in our system to move towards treatment and recovery. I look forward to continuing to work with the providers who are on the front lines and appreciate your involvement and feedback through this process.”

- Rep. Brittany Pettersen, chair of the Opioid and Other Substance Use Disorders Interim Study Committee

Colorado Medicine for January/February 2018

Budget: Colorado’s economy continues to be among the best in the nation and will continue to grow at a moderate pace through 2019. Gov. Hickenlooper submitted his FY 2018-19 budget request on Nov. 1, 2017. The key components of the request are full funding for K-12 education for inflation and enrollment, an increased appropriation for Medicaid and a salary increase for direct care staff, increased funding for corrections, and an increase in the state’s reserve.

Medical liability: The legislature may see another attempt at tort reform from insurance carriers through the elimination of “phantom damages,” or the difference between the medical expenses paid versus billed.

Scope of practice: The chiropractors’ association is interested in supporting legislation to allow chiropractors to be considered treating physicians for workers’ compensation cases.

Join Now! Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or email susan_ koontz@cms.org

Thank you!

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Doctors and medical students as lobbyists: How hard could it be?

CMS CPMG Section, Medical Student Component and COPIC invite physicians and medical students to attend Public Policy Leadership Forum on Saturday, Feb. 3, 2018 Advocacy in the public policy realm can be a powerful tool to effect positive change – if you understand the nuances of a powerful short game and strategic long game. The CMS CPMG Section, Medical Student Component and COPIC invite physicians and medical students to attend a Public Policy Leadership Forum on Saturday, Feb. 3, 2018.

You advocate for your patients every day. Take that advocacy to the next level by learning from some of the best in the business, getting the information you need and practicing the key skills for success in public policy advocacy. The interactive and action-packed program will cover the basics on the legislative and rule-making process, how to approach hot-button issues, the importance of knowing your elected officials and candidates, the mechanics of lobbying and real-world opportunities to get involved now.

Learning objectives • How to frame and pitch issues to elected officials, adjusting the pitch to the political environment and your audience • How to distinguish the meanings and obfuscations of an elected official’s response and intuit the motives and weaknesses of an adversary • How to identify the remarkably easy, user-friendly entry points into their world and how to capitalize on those opportunities • How to convert ideas into real-world public policy consequences, whether to advance policy or redirect it Speakers We are honored to feature an all-star faculty of health policy experts, legislators and physician leaders who will focus on the current public health crisis caused by opioid abuse and misuse to give participants the insider’s perspective.

• The Honorable Mike Coffman (R-Aurora), member, Congress • The Honorable Brittany Pettersen (D-Lakewood), chair, interim legislative committee on opioid abuse • The Honorable Jack Tate (R-Aurora), member of the interim legislative committee on opioid abuse • Joe Gagen, JD, renowned legislative trainer • Jandel Allen-Davis, MD, vice president of government, external relations and research, Kaiser Permanente Colorado Region • Robert Valuck, PhD, RPh, chair, Colorado Consortium for Prescription Drug Abuse Prevention

• Joe Hanel, manager of public policy outreach, Colorado Health Institute • Benjamin Kupersmit, president, Kupersmit Research • Jan Kief, MD, CMS past president • Donald Stader, MD, CO-ACEP board member and CMS liaison to the interim legislative committee on opioid abuse Who should attend?

• Emerging and current physician and medical student leaders • Practicing physicians who want to have a broader impact for the profession and their patients • Physicians and medical students who have questions about how the public policy process works and how to engage elected officials face to face • Physicians and medical students who are frustrated with the current system and want to help make a change in health policy • Physicians and medical students who want to overcome the cynical belief that politics is futile The event will be held at CMS/COPIC headquarters.

Seating is limited to 85 participants divided between physicians and students. The first five Western Slope registrants receive a complimentary overnight stay in Denver. Watch your email in late November for registration instructions. Questions? Contact Dianna_ Fetter@cms.org.

Features

Physician payment Kate Alfano, CMS Communications Coordinator

Trends in physician employment increase costs, spur Medicare to take action The Centers for Medicare and Medicaid Services has taken note of a trend indicating that when hospital employment of physicians increases, costs to Medicare also rise. The government is taking action through a proposed rule for “offcampus departments.”

Starting in 2018, the federal CMS proposes to reduce current fee schedule payment rates for non-excepted items and services furnished by off-campus hospital outpatient provider-based departments by 50 percent, changing the payment rate from 50 percent of the Hospital Outpatient Prospective Payment System payment rate to 25 percent of the OPPS rate.

“CMS believes that this adjustment will encourage fairer competition between hospitals and physician practices by promoting greater payment alignment,” the agency said in a July 13, 2017 fact sheet.

As stated in the proposed rule published in the Federal Register on July 21, 2017, “for CY 2019 and for future years, we intend to examine the claims data in order to determine not only the appropriate PFS [physician fee schedule] Relativity Adjuster(s), but also to determine whether additional adjustments to the methodology are appropriate – especially with the goal of attaining site-neutral payments to promote a level playing field under Medicare between physician office settings and non-excepted off-campus PBD [provider-based department] settings, without regard to the kinds of services furnished by particular off-campus PBDs.”

practice, agrees with Medicare’s proposed rule, calling it “unfair” when employed physicians bill a hospital fee. Her practice is in the process of being acquired by a hospital system in early 2018. “I just think it isn’t in the spirit of true billing,” she said. “Just because you’re employed by a hospital doesn’t mean you’re in the hospital system. It doesn’t mean you can bend the rules.”

While it does cost more to run a hospital than a physician practice, she said the increased billing for off-campus departments was a loophole that the hospital systems used that will now be closed.

The difference in payment between independent physicians and employed physicians is stark. A study by the Physicians Advocacy Institute conducted by Avalere Health found that for four specific cardiology, orthopedic and gastroenterology services, physician employment has resulted in more than $3.1 billion in increased costs from 2012-2015. The Medicare program paid $2.7 billion more for these services in employed settings

and Medicare beneficiaries faced $411 million more in financial responsibility for these services in these settings.

The authors concluded that when physicians are employed by hospitals or health systems they perform more services in a hospital outpatient department (HOPD) setting than independent physicians for a variety of reasons, including enhanced care coordination, reimbursement incentives, network access and specific HOPD assets. A higher proportion of services performed in a HOPD setting brings increased costs to the Medicare program and patients.

Between 2012 and 2015, the number of physicians employed by hospitals grew by 46,000 (49 percent) nationwide, and the number of physician practices employed by hospitals increased by 31,000 practices (86 percent). As the trends of employment continually increase, cost implications on Medicare and patients will continue to keep this issue in the spotlight. n

Jennifer Souders, FACMPE, CPC, practice administrator for a family medicine Colorado Medicine for January/February 2018

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Features

Teamwork for positive results Kate Alfano, CMS Communications Coordinator

Michael Evers, DO CPMG

Heidi Clune, MD CPMG

Kaiser Permanente Colorado: Demonstrating best practices in pain management In the face of sobering statistics on prescription drug abuse and misuse, particularly concerning certain pain medications, Kaiser Permanente Colorado and Colorado Permanente Medical Group (CPMG) are making proactive changes to how their care teams manage patients who need opioids and, as a result, are achieving high patient and provider satisfaction. CPMG is one of the state’s largest multispecialty medical groups and serves the 680,000 members of Kaiser Permanente Colorado.

These changes require the teamwork of primary care and specialty care physicians throughout CPMG, and other health care professionals who are aided

by Kaiser Permanente Colorado’s integrated electronic medical record (EMR).

When a patient requires opioids, his or her primary care physician creates a pain management plan that can be easily accessed by other care providers in real time, ensuring all can communicate a consistent message to the patient. Physicians can also “staff message” within the EMR to colleagues who will be seeing the patient to alert them to changes in medication management.

When prescribing, the EMR setting for all narcotics is to dispense 14 tablets as a defaulted standard. Kaiser Permanente Colorado pharmacists have a fully implemented corresponding responsibility for patients who appear to be at higher risk for an adverse event. Pharmacists will alert primary care physicians when an opioid dose is flagged as high, written 18

prior to the expected fill date or includes a high quantity of tablets/capsules.

Clinical pharmacy specialists – who are informed about the current research around elective pain management – are available to review medication regimens and provide recommendations for safe prescribing when contacted by primary care physicians.

As an additional safeguard, Kaiser Permanente Colorado built a comprehensive opioid registry to track opioid use for all members who are prescribed chronic opioid therapy. Standard patient/physician opioid agreements and monthly fill calendars are used for any patients receiving a monthly opiate prescription in primary care.

Licensed practical nurses (LPNs) have a color-coded calendar that helps track all monthly opiate fills (28-day prescriptions). They ensure the urine drug screens are completed at the correct intervals, the Prescription Drug Monitoring Program is checked and the prescription is ready for cosign before the patient’s fill day arrives.

“We are learning that improving patient safety when it comes to chronic pain and opioids is most successful when all parties commit to working toward the common goal at the system, provider and patient levels. Our multidisciplinary pain management team works collaboratively with primary care physicians not only on opioid dose changes and care plans, but also on strategies to fully engage patients

in the process to help them understand their non-opioid pain management options,” says Michael Evers, DO, CPMG pain medicine physician.

“We know that some patients with chronic pain benefit from opioid prescriptions, but whenever possible, we prefer to use adjuvant agents including over-the-counter creams and medications, as well as non-pharmacological treatments,” says Heidi Clune, MD, CPMG family medicine physician. “Kaiser Permanente Centers for Complementary Medicine provide acupuncture, massage and chiropractic care, and we will often recommend these services as the primary focus of the pain treatment even if opioids are still necessary. We are also strong proponents of cognitive behavioral therapy, which has been shown to improve pain better than opioids.”

In the specialty of anesthesia, there is a movement to use “multi-modal” pain management in the preoperative, intraoperative and postoperative settings.

This includes use of NSAIDs, gabapentin and acetaminophen to decrease the use of narcotics in the postoperative setting.

In obstetrics for cesarean deliveries, patients are given preoperative NSAIDs, Celebrex and acetaminophen. Postoperative ibuprofen and acetaminophen are scheduled every six hours. Oxycodone is given on an as-needed basis. Patients are sent home with 20 tablets of oxycodone, if needed. They may have one refill of 10

Colorado Medicine for January/February 2018

Features tablets and must have a follow-up visit if they request a second refill.

In palliative care, physicians often see the complicated side of opioid addiction as it can interfere with optimal pain control at the end of life. Sometimes this means that patients with current or past addiction require very high doses of opioids to manage their pain. Conversely, some patients who have heard about opioid abuse in the media or have personally experienced opioid abuse, overdoses or deaths of their family members are reluctant to use these medications at all.

As a result, Kaiser Permanente Colorado has instituted a comprehensive plan to assess, educate and follow patients with serious illness to keep them as comfortable and as safe as possible.

This protocol involves the following: 1. Initial opioid risk assessment as standard practice for all patients for whom CPMG physicians prescribe opioids.

2. Standard education regarding opioid risk for all patients for whom CPMG physicians prescribe opioids.

3. Routine RN follow-up calls within a few days of medication initiation to ensure safety and efficacy.

4. Telephone calls required for patients to request refills and to discuss their plan of care with the RN to maximize the efficacy of medications and ensure that the medications sent home (often in large quantities) are being used according to plan. No automatic refills allowed for patients because their care needs often change as they move through treatment.

5. Routine, face-to-face follow-up visits every three months (at a minimum) to ensure the pain plan is still appropriate.

6. Careful attention to adjuvant agents and non-pharmacologic treatment modalities based on the nature of the pain (e.g. if bone pain, using antiinflammatories as adjuncts).

clinical pharmacists, physical therapists and social workers. This integrated eight-week course is designed to educate high-risk opioid use patients about pain management and alternatives to opioid use through exercise, meditation, acupuncture and mindfulness.

Robert Kerley, a Kaiser Permanente member since 2015, sustained a serious back injury in 2010 and spent years fighting the pain with medication after medication, rarely leaving his couch, unable to work or participate in family activities.

“It disrupted our lives so much. You feel less than human. Life changed for me when I went to Kaiser Permanente and actually got a doctor that cared,” says Kerley. “Going to the classes and talking to other people there that had been weaned down off of their doses helped me. Life now is great because I’m able to be a father again. I got my life and my family back.”

perience in Kaiser Permanente Colorado’s Integrated Pain Service program at https://kp.qumucloud.com/view/ orzN8PAp2Ez. The program has shown results in addition to the personal recovery of participants. A 12-month quality improvement cohort study of program effectiveness demonstrated a 25 percent decrease in emergency department visits and a 40 percent decrease in total opioid doses across the 80-patient cohort.

“It boils down to a culture shift for both providers and patients,” Evers says. “Integrating data and analytic capabilities allows us to target opportunities for improvement in a compassionate, patientcentered manner, while simultaneously pursuing a broader prevention-oriented population management model.” n

You can learn more about Kerley’s ex-

Finally, patient education is an important part of the program. One of Kaiser Permanente Colorado’s main locations provides a multidisciplinary pain management program run by CPMG physicians, along with clinical psychologists, Colorado Medicine for January/February 2018

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Features

State Innovation Model Heather Grimshaw, Communications Manager, SIM

SIM helps providers move beyond the theory of health reform The Colorado State Innovation Model (SIM) closes its third and final application (bit.ly/sim3application) for cohort 3 on Jan. 19. This governor’s office initiative, which is funded by the Centers for Medicare and Medicaid Services, helps Colorado primary care practices integrate behavioral and physical health, and test alternative payment models.

The initiative launched with 100 practice sites and four community mental health centers in 2016, expanded in 2017 with 155 practices in cohort 2 and will help a total of 400 primary care sites and four community mental health centers deliver whole-person care by the end of its four-year time frame in July 2019. These three cohorts will integrate physical and behavioral health with support from SIM; they represent about 25 percent of the primary care practice sites in the state. The work the first two cohorts and the community mental health centers are doing to integrate behavioral and physical health affects close to 700,000 patients.

“Our SIM initiative enables providers to move beyond the theory of health care reform and implement meaningful change that improves patients’ lives and avoids unnecessary costs,” said Gov. John Hickenlooper.

Perhaps one of the greatest benefits to SIM participation is the knowledge that addressing the whole patient is the right way to deliver primary care.

“It’s energizing to give the kind of care you envision instead of being frustrated every day,” said a SIM cohort 20

1 physician. “Somewhere in your gut you feel like, ‘God, I could do better.’”

negotiate contracts that reward the value (not volume) of care delivered.”

A few successes from cohort 1 practices: • Increased mental health screenings: Practices screened 215,659 eligible patients for depression; followed-up on positive results • Decreased burnout • Improved ability to report and confidence in clinical quality measures (CQM), data that can help providers articulate a unique value and negotiate more effectively with health plans • Example: In the second quarter of 2017, 100 percent of SIM practices reported on at least one CQM • Improved integration: Of 92 cohort 1 practices, 39 moved to a higher level on the Integrated Practice Assessment Tool after a year of SIM participation (42.4 percent): http:// bit.ly/2ijUWai

Articulating unique value The shift from fee-for-service to valuebased contracting is still new for a lot of providers, which is why the coaching and guidance provided with SIM funding is so valuable.

SIM will provide cohort 3 practices with a year of on-site coaching from clinical health information technology advisors and practice facilitators ($25,000 value), financial support that includes a $40,000 small grant opportunity, and access to a data aggregation tool that helps health care teams evaluate and improve processes using cost and utilization data. Get a full list of benefits: http://bit.ly/2zVdaVl. “The goal of SIM is to help providers gain valuable skills to help them collect, report and use data more effectively,” said Lt. Gov. Donna Lynne and SIM chief operating officer. “This information helps them provide improved patient care and successfully

One illustration of how SIM prepares practices for success with alternative payment models: SIM practices designated as primary care medical providers in the Health First Colorado (Medicaid) Accountable Care Collaborative will have a “glide path” to participate in the new alternative payment model (APM): http://bit. ly/2krl0AY. SIM practices will not have to submit quality measures for the first performance year (2019) of the Health First Colorado APM and will receive full credit on the APM point scale for their participation in SIM. Health First Colorado is one of seven payers that support SIM practices with APMs that are negotiated directly between practices and payers. Read more about payment support: http:// bit.ly/2CE9b4p.

Whole-patient health The SIM initiative helps providers progress along an integrated care path continuum that might start with referrals and could lead to co-location of behavioral and physical health professionals in primary care settings.

Integrated care improves patient outcomes, reduces health care costs and enhances provider morale. About 1,847 SIM providers in cohorts 1 and

Colorado Medicine for January/February 2018

Features 2 are delivering integrated care during approximately 3,342,018 annual patient visits.

Colorado was one of 11 states selected for the SIM model test awards, and the only state to focus on integrated care supported by public and private payers as its primary goal. The state will receive $65 million from the federal CMS to implement and test its model for health care innovation. It is expected to save or avoid $126.6 million in health care costs for the agency with a 1.95 return on investment during its four-year timeline.

Learn more: • Benefits to participating in SIM: http://bit.ly/2zVdaVl • Integrated care continuum: http://bit.ly/2lVjk2l • Practice transformation articles: https://www.colorado.gov/pacific/ healthinnovation/ptseries3 • Glenn Madrid, MD, talks about his involvement in SIM: https://youtu.be/ol6NbNLp0tQ • Cohort 3 information: http://bit.ly/2j3hA6j n

Owned and operated by the Colorado Medical Society and backed by a 50-year history of physician ownership, MTC is uniquely focused on the needs of its clients.

Serving medical professionals is all we do.

MTC's management team has over 50 years of experience in medical answering services. Our operators are professional, friendly and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule.

MTC proudly received the prestigious 2009 Award of Excellence for the fourth year from ATSI (Association of TeleServices, Intl.), a service-quality award based on test calls placed over a six-month period. MTC is a member of the Denver/Boulder Bettter Business Bureau, ATSI and Telescan Users Network (TUNe).

MTC particpates in the Colorado Medical Society's Disaster Preparedness Program by contacting volunteer providers in the event of a large scale disaster. In addition we collaborate with CMS every six month in testing the response time of the volunteer providers.

Plug into your reinvented medical society!

Log on today to choose Interest areas, submit policy proposals, and more. www.cms.org/ central-line

Colorado Medicine for January/February 2018

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Features

Medical TeleCommunications Staff report

CMS acquires answering service to benefit member physicians The Colorado Medical Society is excited to announce that it has recently become the majority shareholder of Medical TeleCommunications, the telephone answering service primarily focused on serving the Colorado medical office market.

MTC has been in business since 1975.

It was started by the Arapahoe-DouglasElbert Medical Society when there was an acute need for an answering service to specialize in helping medical offices and their providers take after-hours calls.

Today, MTC provides service to more than 300 practices with a geographic footprint spanning much of Colorado.

MTC will continue to be managed by Casey Davis, its long-time CEO, on a day-to-day basis. Casey has been with the company for 22 years, starting as an operator in high school and becoming its executive director in 2004. Additionally, Casey and his wife Jennifer are now also minority shareholders of the company. The board of directors of the company will be comprised of Dean Holzkamp, CMS COO; Mike Campo, PhD, CMS director of business development and member benefits; Katie Lozano, MD, FACR; and Casey and Jennifer Davis.

Along with MTC’s management team

and employees, Casey is excited about the future possibilities of the company as well as the current services it offers.

MTC will continue to focus on its core business of providing answering services for physician offices, along with pager rental, and its secure messaging app. Along with those services, MTC is excited to offer automated patient messages and other custom applications.

Our upcoming automated patient messages service will include appointment reminders, billing reminders, annual visit reminders, or any other custom message campaign. These messages can come by voice, email or text message.

In an age where much is automated, MTC maintains personal connections by providing live operators to callers and clients. MTC provides ongoing training and support for staff, including HIPAA and customer service education. The staff participates annually in the Association of TeleServices International’s (www.atsi.org) Award of Excellence program to evaluate answering services and call-taker performance across several different performance metrics.

MTC has had a longstanding relationship with CMS as a Member Benefit Partner. Additionally, for the past decade, CMS members who are MTC clients have received a monthly discount.

Together, they are excited to grow and expand services to support clients and the communities they serve.

MTC can be contacted by visiting the website at www.medteleco.com, e-mail at info@medteleco.com or phone at 303761-6594. If you wish to contact Casey directly, please e-mail cdavis@medteleo. com. MTC is headquartered in Denver. n

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Colorado Medicine for January/February 2018

Colorado Medicine for January/February 2018

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Features

Remembering a great leader Kate Alfano, CMS Communications Coordinator

W. Gerald Rainer, MD

W. Gerald Rainer, MD, Nov. 13, 1927 - Nov. 14, 2017 William Gerald Rainer, MD, a renowned Denver heart surgeon and longtime leader in the Colorado Medical Society, died suddenly of natural causes on Nov. 14, 2017, one day after his 90th birthday. Those who knew him admired him as a pioneer, innovator, teacher and philanthropist, and those who didn’t know him certainly benefited from his tremendous contributions to organized medicine and research.

“Dad was a caring physician,” said William Rainer Jr., MD. “He enjoyed talking to and, indeed, befriending many of his patients. He was an accomplished and adept surgeon and was proud of his excellent results. Although he practiced in a private hospital setting throughout his career, he was a dedicated academician. He was always involved in multiple clinical and laboratory research projects. In the latter half of his career, he became deeply involved with the University of Colorado providing his expertise working with multiple committees, easily earning his title of ‘distinguished clinical professor.’”

“He taught me a lot, as he taught everybody, about having respect for the privilege of practicing medicine,” said Gerald Zarlengo, MD, a Denver obstetrician-gynecologist who first met Rainer at Saint Joseph Hospital as a third-year medical student and continued interacting with him through residency and his career. “It’s difficult to find the right words. It was more a lesson about not ever taking for granted what this privilege means: You were fortunate enough to get selected to go to medical school and to get a degree in medicine; respect that.”

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“He was a consummate teacher; he usually had a fellow, often from a foreign country, and was highly respected by the Saint Joseph surgery residents,” Rainer Jr. said. “He was heavily influenced by and a devout follower of his mentor, Dr. Ben Eiseman. His partnership of 17 years with Dr. Ted Sadler was known by all as a model of excellence.”

Rainer would continually challenge the residents, fellows and even colleagues who came through his operating room or were with him in meetings. To some, he came across as intimidating, but Carl Unrein, who worked with him through the Saint Joseph Hospital Foundation, said it was because he was a natural teacher who demanded excellence. “He had the gentlest personality and if he corrected you it’s so you could become a better person. He was always teaching.

He had a love for residents, a love for medicine, and an undying support and love for philanthropy,” Unrein said.

Rainer was born in 1927 as the fourth child in a family of five children in rural Gordo, Ala. According to a biography by the Saint Joseph Hospital Foundation, “The Legacy of Dr. W. Gerald Rainer,” his mother recognized his extraordinary potential and gave him every opportunity she could to flourish.

When the other five-year-olds in town were starting kindergarten, he was enrolled directly into third grade where his gift for quick learning kept him at a pace at or beyond his older peers. He graduated high school at the age of 15 and enrolled at Emory University in Atlanta on a full scholarship. He transferred almost immediately to the Uni-

versity of Alabama School of Medicine to study pre-medicine alongside medical students 10 years his senior. Within two years he completed his undergraduate training and entered medical school at the University of Tennessee School of Medicine at age 17.

During his internship at Wesley Memorial Hospital in Chicago he met a nurse, Lois Sayre, who in 1950 would become his wife and partner, every step of the way. He maintained a successful general medical practice in Blue Island, Ill., and the couple raised four children: Vickie, Julia, William Jr. (Bill) and Leslie.

In response to the Korean War, he volunteered for the U.S. Army Medical Corps as first lieutenant. He served as a battalion surgeon with the Third Infantry in theater from 1952 to 1953 and was awarded the Bronze Star Award and the Combat Medical Badge for his meritorious and brave service in a field of combat.

Returning to the United States, he was posted at the U.S. Army Hospital at Fort Carson in Colorado Springs, Colo.

He and Lois chose to stay in Colorado and he completed his service to the U.S. Army with a residency in general surgery at Fitzsimons Army Medical Center in Denver. In 1959, he was the first to complete a fellowship in thoracic and cardiovascular surgery at the University of Colorado. He practiced thoracic and cardiovascular surgery for 50 years with St. Joseph Hospital in Denver as his professional home, and made significant contributions in research and the development of the field of cardiac surgery.

Colorado Medicine for January/February 2018

Features “He did so many things behind the scenes that no one was aware of in terms of steering the mothership of Saint Joe’s, not just in cardiovascular surgery but just the constant push for evidence-based medicine, patient safety and the patient standard – long before they became norms in medicine,” Zarlengo said. “He always, always, always had the concern of the betterment of Saint Joe’s at heart.”

“He was very, very competent,” said Sister Marianna Bauder, who was president and CEO of the hospital for a period in the 1990s. “He knew his work very well.

When I was there they used to tease him a little bit that he thought he was the fourth person of the Blessed Trinity but he really cared about the hospital, and he cared especially about the residency programs.” He used his influence to save the residency programs from being shut down by a “short-sighted” administrator and he and Lois donated the Rainer Auditorium in the Russell Pavilion where experts are invited to lecture to medical students and residents, she said.

“He could make things happen behind the scenes because he had been there for so long and he cared about the institution so much,” Bauder said. “I cannot speak highly enough of this wonderful, sincere person who cared a lot about the patients, and that included the patients of the whole hospital. He wanted to make sure we practiced good medicine.”

In addition to his lengthy service as a surgeon, department leader and faculty physician, he held leadership positions with the University of Colorado Health Sciences Center, Fitzsimons Army Medical Center, the Society of Thoracic Surgeons, the American College of Chest Physicians, the Colorado Medical Society, the Denver Medical Society, the Denver Academy of Surgery, the Rocky Mountain Cardiac Surgical Society and the American Board of Thoracic Surgery.

Rainer’s grandsons, William Rainer III, who had a special relationship with his grandfather, is in his second year of residency in orthopaedics at Mayo Clinic in Rochester, Minn.

Rainer Jr. said his father’s legacy is “definitely the quality of surgical education at Saint Joseph Hospital. Definitely bringing the Colorado Medical Society through some difficult times; similarly for the Colorado Symphony Orchestra.

No question, he has always been generous and charitable. He was a reliable and strong provider for our family, ensuring that each of us children had special opportunities contributing to and shaping our future pathways.”

“He just was a larger-than-life individual who did so much,” Zarlengo said.

“And he will be greatly missed.” n

He is survived by his wife, sister Gypsy Richards, children, eight grandchildren and three great-grandchildren. One of

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Features

Colorado QPP Coalition Courtnay Ryan, Quality Improvement Facilitator, Telligen

Prepare for QPP success With a renewed sense of energy in the new year, health care professionals are setting goals and strategies for success in the months to come. With that in mind, there is no better time to focus on the Quality Payment Program (QPP). The year 2018 marks phase 2 of the QPP and the second year of the transitional period for eligible clinicians to participate in it.

The QPP was established as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and began in 2017. Clinicians will continue to participate via one of two tracks: the Advanced Alternative Payment Models (APMs) or Merit-based Incentive Payment System (MIPS). While requirements for the 2018 performance year have increased, the intent of the program and focus on cost and quality remain the same.

The goal is to help patients and clinicians make decisions about health care using data-driven insights, aligned and meaningful quality measures, and innovative technology. The program is designed to be flexible, transparent, and structured to reflect input from clinicians, patients and other stakeholders.

Changes outlined in the QPP 2018 final rule allow for diversity in physician practice experiences with quality reporting, payment reform and the expectation that the QPP will evolve.

Colorado is known for its strong collaborative efforts and the ability to leverage resources, and the Colorado Quality Payment Program Coalition (COQPPC) is a perfect example of that.

The COQPPC is a group of 25 member organizations from across the state that 26

are committed to helping clinicians successfully navigate payment reform. As health care professionals, we recognize that the responsibility for this work is shouldered by physicians and administrative staff, which is why the COQPPC provides support and guidance to help alleviate some of that burden. The group provides streamlined communication efforts, monthly educational webinars, monthly fast facts and other resources developed by subject matter experts in the field to help groups succeed.

technical assistance support and all resources, please visit www.cms.org/coqpp.

We welcome any organization that would like to join COQPPC and further support the clinicians across Colorado.

For more information on the resources available or to join COQPPC, please contact Courtnay Ryan at courtnay. ryan@area-d.hcqis.org. n

Monthly webinars, such as “Understanding your QRUR report” (www.cms. org/coqpp/webinars) provide a forum for 30 minutes of education on a topic related to QPP, with 30 minutes for open discussion and information sharing as well as questions and answers.

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

Fast facts (www.cms.org/coqpp/fastfacts) such as “What is an alternative payment model?” provide five resources that take five minutes to read and will help clinicians stay on track.

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

COQPPC partners and stakeholders share a vision to reach all clinicians across Colorado through increased awareness of the QPP and its effects on physician practices. COQPPC is comprised of organizations that provide no-cost technical assistance and health information technology as well as professional societies and others who can advocate on behalf of providers in the state. The group has strong support and engagement from the Centers for Medicare and Medicaid Services, and has been recognized nationally for its work in Colorado.

For more information, call Tim at 720-858-6306 or email tim_yanetta@cms.org

For a full list of COQPPC members, Colorado Medicine for January/February 2018

Features

Compliments of:

Free Statewide Prescription Assistance Program The exclusive Rx program of the Colorado Medical Society

Attention!

New Higher Discounts!

RETAIL PRICE

MEMBER PRICE

MEMBER SAVINGS

MEDICATION

QTY

Azithromycin 250mg Tab

6

$29.29

$15.86

46%

Lamotrigine 100mg Tab

30

$54.79

$14.65

73%

Topiramate 100mg Tab

30

$87.60

$8.98

90%

Levofloxacin 500mg Tab

10

$114.79

$11.15

90%

Losartan 100mg Tab

30

$57.06

$13.82

76%

Rosuvastatin 40mg Tab

30

$226.56

$17.46

92%

Pantoprazole DR 40mg Tab

30

$69.81

$12.42

82%

NOTE: Our price is the average price members paid on that prescription during the month of January, 2017.

Retail price was obtained by calling CVS/pharmacy. Pricing varies by pharmacy and by region. Prices are subject to change.

You can help by encouraging your patients to print a free Colorado Drug Card at:

www.coloradodrugcard.com

Customize the Colorado Drug Card for your practice!

Program Highlights: Free to all patients.

Cards are pre-activated, no sign-up forms needed.

Discounts on brand and generic medications.

Helps patients that have high deductible plans or are uninsured.

Reduces patient callbacks.

Enhances physicians’ ability to treat patients with drugs that may not otherwise be affordable.

HIPAA Compliant

For more information or to order your free personalized Colorado Drug Card please contact:

Milton Perkins - Program Director mperkins@coloradodrugcard.com

Colorado Medicine for January/February 2018

27 Card Colorado Drug

Features

Opinion/ editorial Gary VanderArk, MD

Artificial intelligence will transform health care Editor’s note: Colorado Medicine occasionally accepts and publishes opinion/ editorial columns on topics of interest to Colorado physicians and consistent with topics associated with the Colorado Medical Society operational plan. The opinions expressed in all guest opinion/editorials are those of the author and do not necessarily reflect the views of the Colorado Medical Society.

Artificial Intelligence (AI) is on the way, and it will make us better doctors.

By 2018 30 percent of providers will use cognitive analytics with patient data.

We will be able to predict outcomes and improve diagnostics. It will drastically reduce errors. AI can tap huge databases from around the world. It can consume millions of pages of medical journals to show us best practices, stratification of risk and treatment suggestions. By focusing on preventive and predictive medicine, AI can avoid injury and disease altogether. It will reduce the burden of documentation, help triage patients and communicate with our patients.

Wow! Help is on the way and we need to get ready. All medical professionals must acquire basic knowledge about how AI works and patients need to know how AI can benefit them. Machine learning will improve the process and allow better coordination of care.

AI has the potential to redesign health care completely. Computers can already develop better treatment plans, analyze images and read pathology slides better than doctors.

Virtual reality is already being used to effectively reduce postoperative pain, treat phobias, and handle depression 28

and anxiety. It can be used to enhance medical training and it is an aid to rehabilitation. Augmented reality can provide information about drugs and is a fantastic aid in preparing for surgery.

In neurosurgery it can show the way to approach a tumor and it makes surgery safer and produces better outcomes.

Health care trackers, wearables and sensors are great devices to teach us more about our bodies. They can help patients retake control over their lives.

We can now have immediate feedback on daily activities, sleep quality, blood pressure, blood oxygen levels, cardiac fitness, heart rate, temperature, electrocardiogram, cognitive skills, brain activity and productivity. We now have medical tricorders with which you can diagnose and analyze every disease. We will soon have microscopes with smartphones.

3D printing, which has the potential to eradicate transplantation waiting lists.

AI will change things for patients. If they feel sick or need medical advice, they can dial into a telehealth service.

Patients who are really sick will have medical records immediately available for providers. Patients needing hospitalization will be surrounded by screens which will deliver tailored education and be responsive to their requests. Patient alerts will be calibrated to clearly distinguish life-threatening issues.

Yes, AI will make us better doctors. It will eradicate waiting time, prioritize my emails, find the information I need, keep me up-to-date, work when I don’t, help me make hard decisions, help me collaborate more and do administrative work. Hallelujah! n

Although it took years and billions of dollars to complete the Human Genome Project, soon we will be able to get your whole genome for less than $100. Genomics will help detect sensitivity to drugs, risk for diseases, identify microbiomes, and suggest what we should eat.

AI will revolutionize drug development.

Nanotechnology will soon deliver drugs to cancerous tissue, swim through our bloodstream, and perform microsurgery.

Robotics is one of the most exciting and fastest growing fields in health care.

Robotics will complement doctors, not replace us. They already can disinfect a hospital room, take blood samples, reduce stress for elderly patients and let paralyzed patients walk again. Then there is the wonderful technology of

Join Now! Colorado Medical Political Action Committee www.cms.org/ contribute

Colorado Medicine for January/February 2018

Colorado Medicine for January/February 2018

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Colorado Medicine for January/February 2018

Inside CMS

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

Physician involvement is critical to our mission The notion of “physician involvement” has been embedded in COPIC since the day we were founded. It’s a guiding principle that is visible through the expertise of our physician risk managers, and it extends into relationships we have cultivated throughout the health care community. In particular, physician leadership that drives COPIC is evident in two key areas: the faculty consultants we work with and members of our board of directors.

Faculty consultants Overview: A network of physicians who serve as outside consultants to COPIC. Areas of involvement: • Consultants are called upon to help review cases related to their specialty.

• They attend at least two COPIC Claims Committee meetings per year.

• They participate in sessions to learn about operational issues such as premium rate determination, financial management and public affairs.

• They also assist in specialty-specific tasks that may include claim evaluations, underwriting, risk management and grant funding by the COPIC Medical Foundation.

Term: Three-year commitment Candidate qualifications: Physicians who are active in a medical or health care practice and insured by COPIC. Generally, candidates are at midpoints in their medical careers.

Board of directors Overview: Leadership team that oversees the management and strategic direction of the company.

Areas of involvement: • Members attend quarterly board meetings.

• They serve on various committees related to the different business aspects of the company.

• They engage in actuarial and corporate management courses during their first year of tenure.

• They work closely with the management team to develop the company’s overall strategic plan.

an interest/experience in the business side of health care and leadership management. In the past, several board members were faculty consultants before becoming part of the board.

Dual roles as advisors and advocates The physicians who are part of these groups serve dual roles as advisors and advocates. They allow COPIC to stay closely connected to different perspectives within health care and help identify emerging challenges.

In addition, we consider faculty consultants and board members as our first level of patient safety and risk management outreach. As recognized leaders who have a strong voice in their professional networks, they help COPIC “spread the lessons learned” and disseminate information as real-time risk managers. They also provide direct feedback that is essential in developing our programs and resources.

How does COPIC select physicians for these two areas? We proactively look for different candidates and many physicians come to us by way of referrals. The selection process is designed to identify a mix of physicians with various backgrounds and experiences so there is diverse representation.

This entails selecting physicians from different geographic locations (urban and rural settings), medical specialties and practice size. Most importantly, we try to find physicians who will fit in with COPIC’s culture and possess a commitment to patient safety and risk management.

“I liked the way COPIC seemed to focus on both helping keep physicians out of medical liability claims through risk management programs and supporting physicians who wind up facing a claim. I wanted to learn more about these processes and contribute to improving the environment for my fellow physicians,” said Eric Zacharias, MD, a faculty consultant alumni.

COPIC’s investment in physician involvement remains a vital factor in our success. We recognize that those on the frontlines of medicine offer the most valuable insight, and our ability to tap into this will always lead to improvements in health care. n

Term: 12-year term Candidate qualifications: Physician leaders who also have Colorado Medicine for January/February 2018

31

Inside CMS

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

Nikki Bloch University of Colorado School of Medicine

Nikki Dyan Bloch, MS1, was raised in Woodbridge, Conn.

She obtained a BA in Classics at the University of ColoradoBoulder and spent three years working – two at Children’s Hospital Colorado in Pediatric Orthopedic Spine research – prior to entering the University of Colorado School of Medicine. Her interests in the fields of Classics and medicine derive from her desire to understand the human condition. From her experience as a health center volunteer through Planned Parenthood and sexual assault advocate-counsel through Moving to End Sexual Assault (MESA), Nikki found a passion for social justice and underserved populations which she plans to incorporate in her future practice.

Encountering the body

I Moses asks to see God’s face and God shows him his back.

This was the Torah portion my brother read at our B’nai Mitzvah and it’s the first thing that comes to mind when I meet you. When I meet your back. I’m not religious or anything. I haven’t even thought about it since listening to my twin brother chant it in Hebrew before a strange array of familiar and unfamiliar faces, except in rare reminiscence to complain about how easily one could give a d’var on his portion compared to my own archaic passage on ritual

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animal sacrifices in the now twice-destroyed temple. But this unfitting analogy strangely keeps returning to me. Face down with head, hands, and feet fully covered, I’m bothered by how impersonal it feels. And I’m starkly uncomfortable identifying my cadaver only by a number.

IIA The first cut is hardly tentative. I was expecting something more. Something powerful and memorable. Explosive.

Instead, I am both unbothered by the smells, sights, sounds of dissection and unmoved to exhilaration. I feel I’m experiencing it wrong. I don’t feel enough.

IIB I’m trying desperately, desperately to be present To experience this gift fully But the thing is the cadaver lab doesn’t exist in a vacuum And neo-Nazis are flooding our streets And I don’t know your name Only a number And how many of us were just numbers?

III Haphazardly slashing through fascia in search of the inguinal ligament, I suddenly spot the jagged cut I’ve created in your skin, a literal delineation of haste and carelessness. There’s something about this crude incision that feels insulting, inhuman. How long have I been cutting without consciously aware you are a person? I look toward your face, an attempt to ground myself, and am dismayed again to find that it is covered. How easily we dissociate when we don’t have our human reminders. I’m afraid of this in myself. And maybe that’s why I’m so uncomfortable with numbers for names and covered extremities. I need the reminders.

Colorado Medicine for January/February 2018

Inside CMS IV When God shows Moses his back, Moses is ungrateful.

It isn’t enough.

He wants to see his face.

His Hands.

His Feet.

To know his name.

But I was given a body.

Not an identity.

And it’s enough. n

Plug in to your reinvented medical society! www.cms.org/central-line

Colorado Medicine for January/February 2018

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Departments Inside CMS

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

Charles Haverty Rocky Vista University College of Osteopathic Medicine

Charles Haverty, OMS III, grew up in Strasburg, Ohio, and obtained his Bachelor of Science in Biology from the University of Akron. Upon graduation, he took a gap year to work in the yachting industry in Fort Lauderdale, Fla., before moving to Colorado to begin his medical education at Rocky Vista University. He is currently living in Colorado Springs and enjoys hiking, golfing, live music and snowboarding.

Emotions of medical practice The third year of medical school is an enormous transition from the first two years, as students move from bookwork to hands-on learning. I tend to remember things when I experience them, and I anticipate retaining much more information from third year than from the first two years when I simply read about procedures and illnesses. Talking with a patient with COPD and noticing their trouble breathing will help me remember the pathophysiology behind the disease and allow me to manage their disease effectively.

While I was excited for the hands-on, patient interaction style of learning for third year, I was apprehensive about one particular aspect of this style of learning: my emotional reaction to the patient. That patient with COPD isn’t just a disease to be managed; they may have kids and grandkids, dreams, aspirations, and regrets about life that they have a longing to fulfill but are limited in their ability 34

to address because of their illness. A concern of mine for third year and beyond is rooted in my tendency to become emotionally involved with people, how I handle those emotions, and the effect that they have on my ability to concentrate and think logically so that I can make the best decisions possible for my patients.

When I become emotional, I don’t display it with tears, but instead become frustrated, easily irritable and distractible.

In a recent conversation with a mentor, he asked if it was okay to cry in front of patients during the delivery of bad news. I explained physicians must be in control of their emotions when delivering bad news to a patient. If the patient started crying, isn’t it bad to have their physician, their last possible ray of hope in this terrible situation, also start crying, only confirming the patient’s worst fears?

However, displaying emotions in front of patients may not be as harmful as I previously thought. Studies have shown that choking up/crying, touching and smiling were associated with a positive impact on the physician-patient relationship, not only in that specific interaction but also in future interactions. On the other hand, withdrawing from the situation and defending oneself, both mechanisms that I have employed in emotionally charged situations, have immediate negative impacts on the relationship.

During the first two years of my medical education, if something happened that resulted in me having a distracted state of mind, it was easy to remove myself from the situation and take the time to calm down. In third year, these kinds of breaks aren’t always available; I am expected to continue working regardless of my emotional state.

I was apprehensive that my distracted state after experiencing emotionally draining situations might lead to me making poor decisions for my patients; however, my experience in my family medicine clinical rotation has only been positive. While I have been faced with difficult situations, my preceptors have been supportive and encouragColorado Medicine for January/February 2018

Inside CMS ing, pushing me to challenge myself but always understanding of my limited experience. In some cases, patients have trusted me enough to confide in me aspects of their lives seldom shared with anyone, often finding it difficult to express themselves without strong emotions and tears. I was surprised at my own reaction in these experiences; instead of becoming irritated that I can’t help them in every aspect of their life or frustrated that I can’t spend more time with them because there are more patients to see, I have learned to strive for little victories in the patient’s life.

While the patient appreciates that I acknowledge their entire story and treat them as a whole human, helping them with one or two small problems makes all the difference. It is impossible to change someone’s life in just one office visit, and that is the beauty of family medicine: building lifelong relationships with generations of patients so that over time you can help them find health in all aspects of their life. n

Colorado Medicine for January/February 2018

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Departments

Member Benefits

Spotlight Renewing your lease: Five important things to know of these terms are negotiable and play a large role in the financial structure of a lease renewal.

Renewal negotiations are most effective when conducted in the proper timeframe, by having multiple viable relocation options, and creating a strong posture to maintain the upper hand.

Perry Bacalis, Carr Healthcare Realty Leases and lease renewals are not typically conducted on a level playing field. After all, the landlord is in the real estate business and most doctors are not. By planning ahead and having professional representation, it is possible to negotiate a lower lease rate and receive a substantial tenant improvement allowance and free rent.

How does the lease renewal process work?

An important clause found in a standard lease is the renewal option. This allows you to extend your lease for a predetermined amount of time by giving your landlord advance written notice. Renewal options include terms for specific lease rates, concessions such as free rent and tenant improvement allowance, and whether a new base year for operating expenses will be granted. Whether or not a renewal clause exists in the original lease, all 36

When should the process begin?

As a rule of thumb, you should begin to consider the renewal process 1218 months in advance of your lease’s expiration. This is recommended so that you can compare all relocation options in the market before your current lease options expire. Tenants who miss their lease options incur more risk. Landlords view this as an opportunity to push rents higher as the window of opportunity to relocate closes. If tenants holdover (stay in the space after the lease expires), they often see penalties of 150-200 percent of their last month’s rent and can also incur damages if they holdover without permission. The bottom line is that if there is not ample time to relocate if necessary, the landlord has a strong upper hand.

What type of cost savings can be achieved through a successful renewal?

If properly negotiated, you can achieve significant rent savings, a buildout allowance, free rent and other concessions. It is very common to start a lease renewal term at a lower lease rate than

what you are currently paying. The amount of overall savings will depend on the availability of competitive vacancies, the efficiencies of the buildings, and your market knowledge and ability to negotiate business points.

What are some common mistakes practices make during the process?

One of the most common mistakes practices make is negotiating without the help of a commercial real estate professional, specifically one who specializes in representing health care providers. Some believe they can save money by not using an agent; but to benefit in real estate, leverage is the key to posture. Landlords are in the real estate business and negotiate with professional guidance. Selecting an expert to represent you provides the leverage needed to receive the best possible lease terms. Further, landlords are typically responsible for paying commissions so professional representation is available to you at no out-of-pocket cost.

Another mistake practices make when entering into a lease renewal negotiation is not being familiar with their current lease terms and risk exposure.

Prior to contacting the landlord about a lease renewal, you should be well aware of your current lease terms including every option and deadline.

Summary Successfully negotiating a lease renewal is more than bartering, bluffing or asking for a good deal. Landlords

Colorado Medicine for January/February 2018

Departments and their professional representatives are in the business of maximizing their profits, even if it means taking advantage of uninformed tenants. You can level the playing field by engaging your own professional representation, gaining competitive market knowledge and by having multiple options for your office space. When done properly, a well-negotiated lease renewal can have a dramatic impact on your practice’s profitability.

Carr Healthcare Realty is the nation’s leading provider of commercial real estate services for health care tenants and buyers. Every year, thousands of medical, dental, veterinary and other health care practices trust Carr to achieve the most favorable terms on their lease and purchase negotiations.

Carr’s team of experts assist with startups, lease renewals, expansions, relocations, additional offices, purchases and practice transitions. Health care practices choose Carr to save them a substantial amount of time and money while ensuring their interests are always first. Email Perry.Bacalis@ CarrHR.com n

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

Accredited CME is education that matters to patient care.

For more information contact the Colorado Medical Society CME office at 720-858-6309

Colorado Medicine for January/February 2018

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

AUTOMOBILE PURCHASE/ LEASE US Fleet Associates 303-753-0440 or visit usfacorp.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit copicfsg.com * CMS Member Benefit Partner Gold Medal Waters 720-867-1299 or visit www.goldmedalwaters.com INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit callcopic.com *CMS Member Benefit Partner MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or visit coloradodrugcard.com *CMS Member Benefit Partner MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, or visit medjet.com/cms *CMS Member Benefit Partner University of Colorado Hospital/CeDAR 877-999-0538 or visit CeDARColorado.org

PRACTICE VIABILITY, CONT. Dynamic Physician Billing Solutions 303-913-0508 or visit dynamicphysicianbilling.com Eide Bailly 303-770-5700 or eidebailly.com/healthcare Favorite Healthcare Staffing 720-210-9409 or medicalstaffing@ favoritestaffing.com *CMS Member Benefit Partner First Healthcare ComplianceTM 888-54-FIRST or visit 1sthcc.com *CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com * CMS Member Benefit Partner The Legacy Group 720-440-9095 or visit www.legacygroupestates.com TSYS 877-841-0606 or visit transfirstassociation.com/cms *CMS Member Benefit Partner

PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit alnmm.com

Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net

CARR HEALTHCARE REALTY 303-817-6654 or visit carrhr.com

TSI 800-873-8005 or visit web.transworldsystems.com/npeters * CMS Member Benefit Partner

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Departments

medical news Colorado Retina Associates recognized by governor as first and only Colorado practice to successfully complete TCPi provider compensation changes brought about by the Medicare Quality Payment Program and value-based payment programs through commercial insurance companies, which requires more strategic use of data and an ability to prove unique value. TCPi was initially geared toward primary care practices but opened to specialty practices this year.

“We were doing the work, we had the data but we didn’t know what to do with it,” Alan Kimura, MD, MPH, Colorado Retina Associates managing partner/ president, told Hickenlooper.

Staff from Colorado Retina Associates attended a ceremony at the state capitol to be honored by the governor for their TCPi involvement and completion. From left, Viktoriya Goncharov, Michele Cameron, Gov. John Hickenlooper, Jodi Mabb and Alan Kimura MD, MPH. Physicians and staff from Colorado Retina Associates were invited to the state capitol to be honored by Gov. John Hickenlooper as the first and only practice in the state of Colorado to have suc-

The governor recognized CRA’s work to lead practice transformation efforts in the state and acknowledged the work entailed in this federally funded initiative, noting the importance of having providers guide the way to a better health care delivery system. n

cessfully completed the Transforming Clinical Practice Initiative (TCPi).

TCPi is a free, federally funded support network that helps care teams navigate

Mesa County brings physicians together Support the Colorado Medical Society Foundation The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans.

CMS CEO Alfred Gilchrist addresses attendees of a Sept. 5 Mesa County Medical Society event. Other speakers explored the topics of hospice and death and dying/end-of-life care.

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Consider giving a tax-deductible donation of $25, $50 or more to help CMSF continue its mission. Questions?

Call 720-858-6310.

Colorado Medicine for January/February 2018

Colorado Medicine for January/February 2018

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Departments

medical news CDPHE: Medical marijuana information for physicians Ken Gershman, MD, MPH Manager, Marijuana Research Grants Program Note: This is primarily intended to inform physicians treating patients > age 18 years for whom a recommendation for medical use of marijuana is being considered.

There is no or insufficient evidence that cannabis or cannabinoids are effective for all other diseases and conditions, due to lack of published clinical trials.1

gether” rather than represent relationship). Thus, these should be extrapolated with especially in the context of marijuana use.

“Cannabis” is used interchangeably with “marijuana.” Cannabinoids refer to chemical components of cannabis (i.e., THC or cannabidiol [CBD], including synthetic versions).

Side effects From clinical trials, the following side effects were reported significantly more often among participants receiving cannabinoids than among controls: dizziness, disorientation /confusion, euphoria, dry mouth, drowsiness/somnolence, nausea, fatigue/asthenia.2

There is substantial evidence: • That cannabis use is associated with increased risk of motor vehicle crashes.1,4 • That cannabis users, including adolescent and young adult users, can develop cannabis use disorder.4 • That adolescent and young adult cannabis users are more likely than non-users to use and be addicted to illicit drugs in adulthood.4 • That frequent cannabis users are more likely than non-users to have memory impairment (lasting a week or more after last use).4 • That THC intoxication can cause dose-related acute psychotic symptoms.4 • That cannabis use is associated with development of schizophrenia, with highest risk among most frequent users.1,4 • That frequent cannabis smoking is associated with chronic bronchitis.1,4 • That cannabis smoke contains many of the same cancer-causing chemicals as tobacco smoke4; however, there is mixed evidence as to whether cannabis smoking is associated with lung cancer.4 • That THC crosses the placenta and into fetuses of women who use cannabis during pregnancy4; and THC is present in breast milk and passes into breastfeeding infants.4

Effectiveness There is substantial evidence that cannabis or cannabinoids are effective for: • Treatment of chronic pain in adults – primarily neuropathic pain.1,2 • Treatment of chemotherapy-induced nausea and vomiting.1 • Improving patient-reported multiple sclerosis (MS) spasticity symptoms.1,2 There is moderate evidence that cannabis or cannabinoids are effective for: • Treatment of short-term sleep outcomes (associated with obstructive sleep apnea, fibromyalgia, chronic pain, MS).1 • Treatment of drug resistant seizures with CBD in children and young adults with Dravet syndrome.3 There is limited evidence that cannabis or cannabinoids are effective for1: • Increasing appetite/decreasing weight loss associated with HIV/ AIDS. • Improving provider-measured MS spasticity symptoms.

• Improving Tourette syndrome symptoms.

• Improving anxiety symptoms (in context of assessment of social anxiety symptoms).

• Improving post-traumatic stress disorder (PTSD) symptoms.

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Drug interactions Note: The lack of a cited interaction does not preclude the possibility that a drug interaction exists (and no studies have yet reported an interaction with that particular drug).

There is evidence of clinically important drug-drug interactions between cannabis or cannabinoids and the following medications: chlorpromazine, clobazam, clozapine, CNS depressants (e.g., barbiturates, benzodiazepines), disulfiram, hexobarbital, hydrocortisone, ketoconazole, MAO inhibitors, phenytoin, protease inhibitors (indinavir, nelfinavir), theophylline, tricyclic antidepressants and warfarin.4 General risks of marijuana use Note: These mainly represent evidence from studies of recreational cannabis users focused on adverse health effects. Only content areas where there is “substantial” research evidence are presented. Furthermore, the studies informing the evidence statements below are “observational” in design, thus, for most of these statements, causality cannot be clearly established (e.g., cannabis use and schizophrenia may “travel to-

a causal findings caution, medical

References 1. National Academy of Sciences, Engineering, and Medicine. 2017. The Health Effects of Cannabis and

Colorado Medicine for January/February 2018

Departments Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press. https:// doi.org/10.17226/24625.

2. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-Analysis. JAMA 2015;313:24562473.

3. Devinsky O, Cross JH, Laux L, et al.

Trial of Cannabidiol for Drug-Resistant Seizures in the Dravet Syndrome. N Engl J Med 2017;376:20112020.

4. Colorado Department of Public health and Environment. Monitoring Health Concerns Related to Marijuana in Colorado: 2016. www. colorado.gov/cdphe/ma rijua nahealth-report More information www.colorado.gov/cdphe/categories/ services-and-information/marijuana; email: marijuana.research@state.co.us n

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

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Malpractice is provided. Good compensation. Great team. Contact the Fort Logan Medical Clinic at 303866-7050 or send your contact info / CV to Debora.Din@state.co.us.

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, call Tim at 720-858-6306 or email tim_yanetta@cms.org

Colorado Medicine for January/February 2018

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Features

the final word The Colorado Medical Society strives to fulfill “its” job protecting “our” profession This issue of Colorado Medicine shows how CMS shed light externally and internally: the Colorado Health Institute (CHI) Drivers of Change 2018, and the CMS Member Survey, respectively. (See pages 6-10.)

CHI’s 10 Drivers of Change 2018 – distilled. Six of the drivers (1-4 and 8-9) described in this issue’s cover story speak to the costs that different stakeholders in society must somehow pay for – the winners and losers are yet to be determined.

Three of the drivers illuminate hidden relationships: Drivers 5-6 focus attention on the importance of behavioral health for the patient, as well as for the providers of care. Driver 7 reframes the conventional thinking of “one patient – one doctor care,” now linking population health care to public health. Finally, driver 10 aims to shift knowledge towards action (advocacy): physicians must engage or have their fate decided by others.

Physician engagement ideally occurs at three levels. Deep engagement in clinical work is axiomatic to provide empathic, patient-centric care, and to obtain meaningful, personal satisfaction. Engagement at the medical society level aggregates many physician voices to achieve greater advocacy impact, in pursuit of our professional goals.

The pillars of physician engagement consist of autonomy, mastery and purpose1.

Autonomy: Physicians often choose between different job settings depending upon their relative need for autonomy. A health care organization’s culture deals with issues of governance, leadership, compensation and data-driven decisions – all influencing the willingness of physicians to engage.

Our profession is fortunate to retain these practice choices, though the independent versus employed ratio is changing due to external pressures detailed in the drivers.

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Mastery: The “practice of medicine” aims to achieve mastery through thousands of hours of training and continuing education. Our experience summated over a long career is transferred to the next generation.

In turn, the next generation must adapt their practices to the Drivers of Change, or risk obsolescence.

Delivering health care at the highest level requires that the practice’s internal operations are optimized. Data-driven outcomes (quality, patient satisfaction) and understanding costs are fundamental to transitioning practices from fee-for-service to new, value-based payment schemes.

As managing partner for our practice, I have engaged broadly outside of clinic, seeking ideas that will reposition our enterprise in anticipation of new opportunities.

Our practice is the first practice in Colorado to have completed the Transforming Clinical Practice Initiative (TCPi) training . TCPi is a program within the Center for Medicare and Medicaid Innovation (CMMI). Data and outcomes to improve quality and lower costs are some of TCPi’s goals.

Key staff and I attended a workshop on data visualization, learning from business professionals how to model our data. After modeling, we will analyze and display the information visually to tell a compelling story, informing our business intelligence. Value-based care mathematically is an outcome per cost – good data, properly analyzed is fundamental – yet beyond our grasp. We all must learn to “skate to where the puck will be” (Wayne Gretzky, Hockey Hall of Fame).

Intrinsic practice improvements are being undertaken in clinic, embarking upon a long journey of cultural change incorporating Toyota Lean processes. Elimination of waste and inefficiencies in our own practices are vital as we transition to value-based

Alan Kimura, MD care. These necessary changes, known best by you in your own practice, tie into the principle of autonomy, in turn allowing you to achieve clinical mastery.

Purpose: How can you expect to perform at a higher level (better outcomes, less waste, more satisfied patients) if you have no data or performance metrics, and instead rely only upon intuition? These practice-level improvements allow you to achieve mastery, that in turn allows you to achieve the ultimate purpose – empathic service to our patients.

The existential question is simple and stark: “Can our profession adapt as quickly as the world is changing?”

While health care is delivered “one doctorone patient” at a time, increasingly it will be delivered by coordinated teams seeking continuous improvement – yet the future is still to be written. Indeed, the future of our profession undoubtedly rests upon physician engagement, collectively.

The ask: CMS needs you to join and renew your membership annually, and encourage your colleagues to join and renew. In election years, your support of candidates screened through COMPAC creates further advocacy impact. For CMS members (young and old) desiring greater engagement, a variety of roles within CMS are possible.

Closing the circle: It is time for “us” to do “our” job in support of CMS. n 1. Kathy Kennedy, DrPH, MA. Director of Regional Institute for Health & Environmental Leadership. Associate Clinical Professor, University of Colorado – Colorado School of Public health.

2. www.colorado.gov/pacific/healthinnovation/executive-support-sim-tcpi-practices

Colorado Medicine for January/February 2018