Jan-Feb 14 by Colorado Medical Society

January/February 2014

Volume 111, Number 1

Debt, data and deciders

Turning health care into a functional market system

Colorado Medicine for January/February 2014

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Colorado Medicine for January/February 2014

contents Jan/Feb 2014, Volume 111, Number 1

Features. . . 13

Cracking the code on health care costs–A commission led by former governor Bill Ritter Jr. challenges states to take action to reduce health care costs.

Fixing the SGR–Congress is closer than ever to digging out of the SGR hole before a scheduled 24.4 percent across-theboard cut in takes effect in March.

Legislative preview–Colorado legislators from both sides of the aisle share with Colorado Medicine what to expect in 2014.

Board work plan–The CMS Board of Directors set an aggressive agenda for 2014 to work on a variety of issues ranging from Medicaid reform to anti-competitive conduct.

Physician heroes–Frank Dumont, MD, tells the tale of the September floods and how the Estes Park medical community pulled together to help.

Acknowledging physician burnout–CMS introduces a partnership to develop a toolkit for physicians addressing the eight dimensions of wellness.

AMA interim meeting–Colorado leaders lobbied the congressional delegation and adopted new policies through the AMA House of Delegates.

Final Word–Christopher Fellenz, MD, of Kaiser discusses whole-person care, minimizing social determinants of health and practicing empathy.

Cover story

Debt, data and deciders: These are the three tsunamis of change that are affecting every aspect of American life. And they will shape how we approach the growing issue of reducing the cost of health care. CIVHC’s Jay Want, MD, takes a closer look at these market forces and advises physicians to find their place in teams, understand their performance and work in those teams to deliver value. Read more on page 8.

Inside CMS 5 7 31 34 36 38

President's Letter Executive Office Update ICD-10 Update Clean Claims Task Force Reflections COPIC Comment

Departments 39 41

Medical News Classified Advertising

Colorado Medicine for January/February 2014

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

PHOTO CREDIT: All photos of the Estes Park flooding appearing on pages 22-25 are the work of Katherine T. Dumont and are reprinted with permission.

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

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

Board of Directors Susan Bauer, MS Charles Breaux Jr., MD Leslie Capin, MD Joel Dickerman, DO Naomi Fieman, MD Carolyn Francavilla, MD T. Casey Gallagher, MD Jan Gillespie, MD Johnny Johnson, MD Richard Lamb, MD Lucy Loomis, MD Randy Marsh, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD Daniel Perlman, MD Scott Replogle, MD Floyd Russak, MD Ranee Shenoi, MD Stephen Sherick, MD Julia Tanguay, MS Theodore Timothy, MS

Michael Welch, DO Jennifer Wiler, MD Allison Wood, MS Harold “Hap” Young, MD AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Immediate Past President Jeremy Lazarus, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Mark Laitos, MD Tamaan Osbourne-Roberts, MD CMS Connection Mary Rice, President

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

Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Brad Pierson, Art Director, Assistant Editor; Chet Seward, Assistant Editor. Printed by Spectro Printing, Denver, Colorado

Colorado Medicine for January/February 2014

Inside CMS

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

Considering the amazing future of health care delivery “If I had asked people what they wanted, they would have said faster horses”– Henry Ford, inventor of the Model T automobile and the assembly line Salutations! Today, I ask you to take a moment to consider the amazing future of health care delivery. Our industry is on the verge of incredible change, as payment reform, the digitalization and exchange of health care information, robotics, genetics, cognitive computing and regulatory forces rapidly usher in new opportunities and new challenges for the marketplace. We can actually predict what behaviors and skills will be required of the disruptive innovators that will transform health care in the next decade. Here are some ideas you can take back to your organization to help create a vision for our state’s future. This “consumer mind share” vision for future products and services must be communicated across Colorado, and a strategic architecture built to develop the core competencies needed to distribute innovative products and services to future markets. This industry foresight will establish your company as the intellectual, competitive leader in terms of influence over the direction and shape of industry transformation. That foresight must include a point of view about the consumer benefits, organizational competencies and future consumer interface that can be produced via a “directed evolution” or created future. Acquisitions alone are not enough to establish industry foresight, as they generally rely on profits in existing markets. “Skunk works” projects deny the developing competency

of the full spectrum of the enterprise’s collective intelligence by fragmenting implementation of the new business unit apart from the rest of the organization’s resources and resourcefulness. The physician practice instead must first acknowledge not that the future is unknown but that it will be different. We must evaluate what “could be” and then work backward to what must happen in the new created future to come. Health care industry leaders have been laggards to expand their opportunity horizons and to see their core competencies as the portfolio, rather than their business units as their portfolios. This has been especially true for the 1970s paper-based independent private practitioner locked into a mindset of delivering cottage age industry health care. It is also true of the marketplace dominant incumbent, the hospital system, adding layers and layers of new expensive technology upon outmoded care delivery and payment systems. Health care has not generally seen the future with a “wideangle lens” that is envisioning a world with less clinics and fewer hospitals, or a world with more actual health care access and more personalized technology leverage and consumer empowerment. Traditional systems ignore vast segments of the population that do not even use clinics or hospitals… until they are dying and someone else calls for the ambulance! Physicians and hospital administrators are not genetically encoded in their training or hierarchy to embrace rebellious or subversive ideas. They eschew breaking the rules as unprofessional conduct or patient profiteering.

Colorado Medicine for January/February 2014

The patient safety flag is flung referee style without regard to whether actual outcomes with a new idea are producing inferior results. The benchmark for patient safety is mired in the past and reflective of case law, outdated scientific articles, and pre-digital systems of organized care delivery. Health care leaders traditionally respect seers over unorthodoxy, which limits their ability to master true industry foresight. Regulators are now forcing patient satisfaction surveys down the throats of hospital systems as part of measuring the value of care delivery and to determine prospective payments. Although customer feedback is important, this approach by regulators may have the unfortunate side effect of compelling hospital systems to design care delivery based on what consumers are currently valuing from other competing providers who have already made it to the future. This will limit the hospital systems as incumbent to merely “satisfying” their customers, not actually amazing them. The winners in the next round of this directed health care evolution will exploit unserved and unarticulated patient-consumer needs, and focus on solutions to the human condition. Large disparities in health care also mean large opportunities for entrepreneurs focused on true health care access. While payment reform will provide more insurance cards in 2014, it will not create more access or more physicians in the workforce. Innovators who can preempt significant increases in emergency room utilization as the substitute means of primary care for the newly insured have the best op-

President's letter (cont.) portunity for reducing costs and delivering value. I believe one of the greatest opportunities for our industry in expeditionary marketing and global preemption is the smart phone’s potential to be a valuable tool in health care access. The rampant deployment of Bluetoothenabled body sensors, along with apps that can deliver personalized health care information directly to the clinician, will allow us to deliver safe, effective asynchronous or real-time care remotely, creating a new convenience that has the potential to disrupt both traditional hospital and ambulatory clinic-based care. By marrying the new technologies of lower-cost, readily available smartphones, Bluetooth-

enabled body sensors, encrypted FaceTime remote clinical visits, and a cloud-based, accessible patient health care record, patients will feel more empowered going to their health care app than perhaps calling an ambulance, googling for answers, running to the ER, or leaving a message to schedule a doctor’s appointment next week. The opportunity even has a potential for global preemption, due to the ubiquitous nature of smartphones and the Internet. According to Diamandis (2012) smartphones are even now used by Masai Warriors on the plains of Africa, who commented “they can communicate better than Ronald Reagan could, and have more access to data than a Unit-

Inaction vs IN ACTION We understand the difference The Litigation Center of the American Medical Association and the State Medical Societies fights to protect doctors and uphold the highest standards of patient care. In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession. Whether we are challenging managed care organizations’ payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physicians’ rights. Learn more on how The Litigation Center can help you.

ama-assn.org/go/litigationcenter

Membership in the American Medical Association and the Colorado Medical Society makes the work of The Litigation Center possible. Join or renew your memberships today by calling the CMS at (800) 654-5653.

The Litigation Center is proud to have Alfred Gilchrist, CEO of the Colorado Medical Society, serve on its executive committee.

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ed States president 20 years ago.” The development of a smartphone “tricorder,” effective distribution of cognitive computing by IBM Watson’s naturallanguage style customer interfaces, and full digitalization and centralization of the health record will usher in a new era of health care access, cost reduction, safety and consumer amazement. The mind share (and market share) will go to the industry leaders with the foresight to capture the core competencies necessary to deliver the integrated product ahead of schedule. Please feel free to share with me your ideas about the future of health care delivery and making it real here in Colorado. I can be reached by email at jlbender@miramont.us n

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Colorado Medicine for January/February 2014

Inside CMS

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

Focus on the future – the next strategic initiative The CMS board of directors will convene in January for a weekend deep dive into the particulars of our ongoing strategic plan. Our current plan is a reality-based document that provides physician-led and exam room relevant direction to the CMS focus and the expenditure of the organization’s resources. The impetus to refresh our plan is directly related to the current “mediquake” and the tectonic plate shifts driven by powerful economic and political forces that are at the same time both a creative disruption opportunity and a potentially predatory realignment of medical practice. As more of those realignments become consolidated practice realities, we must assure that CMS advocacy proactively anticipates these changes so that professionalism and clinically-driven care delivery is preserved and promoted.

us. These surveys are vital to our decision-making and we are grateful to each of you who share your views! It’s not very practical to take a swing at a major policy challenge if there isn't a consensus to even raise medicine's voice, much less to make a fist. And we could hardly address your perceptions of CMS without the data. Along with your collective voice, we’ll use a top facilitator to tap into the wisdom and experience of our board of directors and consultants who will sort through the evidence to keep our goals and strategies focused and effective for you and your practice. The new survey demonstrates plenty of opportunity to unite the profession. A top priority continues to be the need to preserve Colorado’s stable medical liability environment. This is followed by a range of second-tier priorities, such as payment reform, payer issues, quality and cost effectiveness, access to

The weekend will be dedicated to deciding where to ratchet back on less urgent priorities, ramp up on the hot zones and reallocate resources accordingly. This blocking and tackling, the fundamentals in strategic preparation, will be guided by evidence drawn from our own experience as an organization, a member survey, an environmental scan prepared by the experts at Center for Improving Value in Health Care, and the views of the CMS board of directors.

care, scope of practice and practice viability. And physician members clearly want to see CMS proactively involved in the continuing effort to “bend the cost curve.” They believe that the most influential drivers of cost in the health care system are medical device and pharmaceutical overpricing, end of life care, patient lifestyles and hospital overpricing, with misaligned payment incentives and lack of care coordination also playing an influential role. The outcomes of the January meeting will be shared with our members and we’ll ask for your perspective on any new strategic direction. We’ll conclude the process with final decisions at the Annual Meeting in September. Your continuing input will be invaluable as we refresh and move forward. You can contact me at alfred_gilchrist@cms.org or call me on my cell at 303-475-0144 to share your views. I will hear your call. n

Save the date for 2014 Date CMS Spring Conference changed! May 16 through May 18, 2014 Sonnenalp Resort, Vail

While it doesn't take a professional survey to intuitively know what keeps physicians up at night, we have polled our members since 2008 to measure the mounting pressures and uncertainties that pull at the profession and to get perspective on how you perceive Colorado Medicine for January/February 2014

Cover Story

Debt, data and deciders

Jay Want, MD Principal, Want Healthcare LLC Chief Medical Officer Center for Improving Value in Health Care

Turning health care into a functional market system 8

Colorado Medicine for January/February 2014

Cover Story Editor’s note: In each issue of Colorado Medicine in 2014, the Colorado Medical Society is exploring the complex issue of health care costs. The January/February issue features a column by Jay Want, MD, CMO of the Center for Improving Value in Health Care. Watch for this series to continue throughout the year. It's a privilege as a representative of the Center for Improving Value in Health Care (CIVHC) to write this article about the changing landscape in American health care, and how it affects us here in Colorado. For anyone who still doubts that health and health care in Colorado will be different in the future, here are a few facts from a recent article in JAMA1: • In 2000, 53 percent of physicians practiced independently and 18 percent were hospital-affiliated. In 2010, the proportions had almost completely reversed: 23 percent independents, 48 percent hospital-affiliated. The macro trends favor further vertical and horizontal integration, for reasons I'll go into later in this piece. • The trend toward consolidation affected many health care sectors in the last decade, including insurers, pharmacies and office-based physicians. The proportion of office-based physicians practicing in groups of six or larger rose from a third to nearly half. • Nearly three-quarters (72 percent) of physicians today practice on an EHR, as do nearly seven hospitals out of eight (87 percent), as of 2012. Contrast that with earlier in the last decade when less than half of both groups were on an EHR. The big question is: Why is this happening? And how should physicians in general adapt? At CIVHC we talk about three major trends in American health care: debt, data and deciders. These tsunamis of change are affecting every aspect of American life, not just health care. Let's look at each of them.

Debt Debt is at every level of our society today. The Baby Boomer generation was raised in an environment that could count on future growth to bail them out of unreasonable debt obligations. Big mortgage? Don't worry, you'll get raises later on that will make it affordable. Student loans? No problem, good jobs available upon graduation. But then the Great Recession hit, and now the Big Reset is taking place. People in my daughters' generation are working at Starbucks while looking for work in the field of their choice, often to no avail. We've gone through a series of asset bubbles, from technology to banking to housing. Credit, which fueled the illusion of Infinite Growth That Hides All Sins, is only now starting to become available again, this time on more disciplined terms. Debt, and particularly debt that prevents further borrowing, drives a search for value. As long as you think you have infinite resources, you care little about value, or more specifically, you are insensitive to the cost of things in order to get the benefits you want. But once we perceive resources to be limited, it's a whole different ballgame. We are suddenly looking at price tags and ratings by other consumers like ourselves. I notice this difference when I travel. If someone else is paying my expenses, I tend not to shop for my hotel, but to stay at the conference hotel for convenience. If I am paying with my own money (which I perceive correctly to be limited), I go to TripAdvisor and try to find a lower price for a similar hotel, close to the meeting. I carefully read about the pros and cons of that particular hotel, to predict whether I'll like it. What does this have to do with health care? Before, nothing; now, everything. Because of insurance, we acted like the traveler with the expense account. We didn't have to pay more to stay in the conference hotel, someone else did. We didn't comparison shop for medical services, because it didn't make a difference to us financially. We didn't experi-

Colorado Medicine for January/February 2014

ence costs (much), only benefits. So why wouldn't we metaphorically try to stay at the Ritz vs. La Quinta? If we stayed at La Quinta, we'd be saving money for someone we don't like (the insurance company) and in doing so, worry that we shorted ourselves. Who does that? I like to joke that being out of money has an amazing clarifying effect on thinking, but there is truth in that. And being out of money on so many levels is clarifying our thinking about health care costs. It's making us ask for the first time: What are we actually getting for $2.7 trillion, and 17 percent of our economy? And it is our debt – personally, corporately and nationally – that is compelling us to do so. Data Remember what I did when shopping with my own money for a hotel? I went to TripAdvisor. Why? Sociologic studies show that the aggregated opinions of others in the same situation more strongly predict my satisfaction with a product or experience than I can alone. But that's only possible because I can read their ratings and opinions online. In essence, massive computing power has allowed people to compile data about many experiences they have daily, and to make choices about those that involve giving other people money. This brings me to a guy named Gordon Moore. Moore was an engineer at a company called Fairchild Semiconductor, a strange name in the 1950s when people were just discovering uses for transistors. He figured out something cool working there, and it was this: Moore's job involved making microchips, and cramming more and more transistors onto chips as fast as he could. He noted that he could double the number of transistors on a chip about every 18 months, effectively halving the cost of computing power. This became Moore's Law, and the exponential trend he noted then continues today, half a century later. Moore also went on to found another little company with a funny name: Intel.

Cover story (cont.) Why should you care? Think about how you picked a hotel in a strange city before TripAdvisor. You asked around at work, or got a recommendation from your spouse's cousin who lived there 10 years ago. Pretty hit or miss. But now, with TripAdvisor, finding a hotel in your price range that people love is a snap. Technology, and in particular, Moore's Law, makes this information cheap, nearly free in fact, and cheaper every year from now until forever. Data makes shopping effectively really, really cheap. This brings me to deciders. Deciders Okay, now the average American family of four is deeply in debt, with no additional help from their employers or governments coming any time soon, and massive and growing amounts of data available to them on their smartphones. Their employers are providing health plans to them that have $10,000 deductibles, so they're spending their own money for anything beyond preventive care. Some health plans have reference pricing as a feature, in which when the plan does pay, it only pays the lowest price offered by a good quality provider, and the patients (you) get to pay the difference between that amount and what the provider charges. Remember TripAdvisor? Some companies are starting to do the same thing in health care. Sometimes employers are giving their employees subscriptions to these companies so the best value in knee replacement shows up on their smartphone when they click the search button. So what will the average consumer think? “I'm spending a lot of my own dollars and I have access to information to choose the best bang for the buck. While I still worry about making good choices, I can read online what people just like me think of the doctor and hospital I'm about to choose. Hey, remember when I used to have to ask my spouse's cousin who he chose when he had the same operation 10 years ago? That was so 20th century.” There's more to this story, but these three trends – debt, data and deciders – are bringing to health care what already 10

existed in most other sectors of our economy: functional markets. Markets are places where consumers can compare prices and benefits, and choose for themselves where to spend their money. And for arcane reasons, they’re just now catching on in health care because of these three forces. Consumers these days don't buy products so much as experiences – complete experiences where they can. That means they don't like buying the parts of the car and assembling the pieces themselves; they like buying the fully assembled car off the lot, and expect to be able to drive it without a lot of training. So the thought they'd have to pay for and assemble a surgeon, a hospital, a rehab center, physical therapist, etc. and manage them because they don't really talk to one another seems arcane. Separate bills for what seems like the same thing? That’s not how people will shop for this stuff in the future. Implications Now let’s discuss how this plays out for you. Despite a massive trend over the last half century toward equating specialization and segmentation with expertise, consumers are increasingly going to recognize that this segmentation makes them buy pistons and catalytic converters separately, and hope the parts fit together in a way that makes the car run in a predictable way. Because teams that communicate and coordinate action well can create coherence for patients and consumers, they have a definite advantage over the random chance that all the players in a care plan will do the right thing at the right time in the right way. At the beginning of this article, I pointed out a growing trend toward doctors working for hospitals. This is because hospitals believe they need to control every phase of a patient's experience to be successful in the future. They believe this because people who buy their stuff are starting to tell them that. While for many physicians this is anathema, and there is no rule that says hospitals have to be in control of the combined enterprise, there is no question in my mind that any entity that can actually create whole, coherent

and successful experiences for patients at a competitive price will be winners in the next decade. I hope those entities are provider-led, but the hard truth is that value-driven consumers with good information will buy the better car at the better price, no matter who built it. At CIVHC we are helping people put their teams together, measure their performance and then improve it in order to sell a higher-value experience. Currently my colleagues there are helping people construct bundles of care; increasing discharge reliability and thereby reducing readmissions; creating reports out of the All Payer Claims Database to inform providers of the cost and the quality of the experiences they create for patients; and implementing many other things that we hope will enable providers to create greater value. As a result, this process will be good for everyone, except those who insist that delivering care in a disorganized way is the best we can do. This model is the choice before you. You can either continue to contend that disorganized care is best, or you can acknowledge that you and others will do a much better job for people as teams that communicate well. You can continue to see only your piece of someone's care, or you can try to understand how you fit into that patient's total experience, from their perspective. You can also continue to imagine that our state spends money from someone else’s infinite health care expense account, or you can acknowledge that the money is limited, and we need to find ever-increasing value to make health care sustainable again. At CIVHC we hope that Colorado's physicians will choose to find their place in teams dedicated to better clinical and financial outcomes for patients; to understand their own performance though others' eyes; and to work in those teams to deliver value for people who have not a dime more to spend on care, and who increasingly know what they're getting when they check into the health care system. 1 The Anatomy of Health Care in the United States, JAMA, 2013; 310(18):1947-1963. n

Colorado Medicine for January/February 2014

Features

Cracking the code on health care costs Kate Alfano, CMS contributing writer

Report: States must act to reduce cost of health care The Miller Center at the University of Virginia has unveiled a new report, “Cracking the Code on Health Care Costs,” which challenges states to take action to reduce health care costs. The report represents two years of work by the bipartisan State Health Care Cost Containment Commission, co-chaired by Bill Ritter Jr., former Colorado governor, and Mike Leavitt, former Utah governor and secretary of the U.S. Department of Health and Human Services. Its membership also included other leaders from government, insurance plans, hospitals, physician groups and consumer advocates. It is well known that health care access, quality and cost have been the focus of the nation’s public policy discussion for the past two decades. The authors contend that the next few years will prove especially crucial with the implementation of the Affordable Care Act. They wrote that health care reform is still in its infancy and that “we must go through a period of accelerated state experimentation” to determine what works. “States need to lead this effort, because they have most of the policy levers and because reform must be tailored to the unique culture and health care market in each state,” wrote Raymond Scheppach, project director. “The federal government can support the states, but the leadership needs to start with governors, legislators, and other health care stakeholders and be adopted at the grass-roots level, where health care is delivered by individual clinics, hospitals, and physicians across the state.”

The “policy levers” the authors said states can use to influence costs include government-sponsored health care programs and health insurance exchanges; state laws governing insurance, scope of practice, provider rates and medical malpractice; state laws promoting transparency of price and quality; policies guiding schools and public health; and the power of the governor to engage stakeholders in public policy issues. The commission’s ultimate goal is to replace the current fee-for-service system with comprehensive, coordinated care using payment models that encourage cost control and quality gains. The federal government can take a supportive role by encouraging the use of accountable care organizations in Medicare and reviewing and modifying regulations to strengthen states as they strive for higher-quality, cost-effective care. In turn, states can achieve meaningful reforms and create incentives with the support of payers, providers, insurers and consumers, the authors wrote. They present the following seven recommendations for states. 1. Create an alliance of stakeholders – government, purchasers, the medical community and others – to transform the health care system. 2. Define and collect data to fully understand the state’s health care spending, quality-tracking process and health care infrastructure. 3. Establish statewide baselines and goals for health care spending, quality and other measures.

Colorado Medicine for January/February 2014

4. Use existing health care spending programs – such as Medicaid, the state employee health program and health insurance exchanges – to accelerate the trend toward coordinated, risk-based care. 5. Encourage consumer selection of high-value care based on cost and quality data by increasing transparency, and promote market competition. 6. Reform health care regulations to promote system efficiency. This includes streamlining state requirements and mandates, modifying the medical malpractice policies that have substantial direct and indirect costs to the system, and supporting policies to expand the scope of practice of nonphysicians and allow them to bill independently. 7. Help promote better population health and personal responsibility in health care. “The strategies proposed in this report largely rely on transparency, purchasing power, payer and provider cooperation, persuasion, and ‘soft’ regulatory pressure to spur the transition to more efficient, quality care.” And while reform will take time, the commission urges states to act now to ensure they enjoy future benefits to individuals, families, businesses and governments, and avoid economic catastrophe. n

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

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Features

Fixing the Sustainable Growth Rate formula Kim Ross, CMS consultant

Politicians may finally be digging out of the SGR hole Politicians understand the first rule of holes that states, “If one wants to get out, stop digging.” Since 1998, when the Balanced Budget Act introduced the Sustainable Growth Rate trigger to reduce physician payments across the board when Medicare Part B spending exceeded a target calculation, Congress declined to pull that trigger roughly 10 times by negating the cut outright or delaying it for a year, digging that budget hole progressively deeper each cycle. The cumulative effect of more than a decade of brinkmanship and kicking that can down the road is a scheduled 24.4 percent across-the-board cut in March, temporarily patched in January so three committees of jurisdiction can continue to work toward a bipartisan, long-term solution. By all accounts, Congress may be on the verge of “fixing” what almost every analyst, physician and member of Congress agrees is a failed approach to limiting total Medicare Part B (physician) expenditures. The going price for dumping the (un)Sustainable Growth Rate has dropped from the $298 billion Congressional Budget Office estimate in 2011 to $116.5 billion as a consequence of the global decline in health care expenditures. It’s not exactly a fire sale, but approaches a price that might be considered financeable.

and plot a 10-year transition to realign physician payments from fee-for-service to alternate methods based more closely on performance metrics yet to be defined. This complex legislation may be the only health care proposal in Washington that has transcended the otherwise intractable partisan divides. This is not a Hobson's choice of no horse or a bad horse. It is more likely a calculated risk against the null hypothesis. What happens to medical practice if things are left as-is? There is a spirited debate in the houses of delegates and other medical forums on that test, but physician polling and the growing body of research shows support for the value of care coordination, hot spot case management, and payments that align with those services for properly structured, financed and supported collaborative models. This set of blueprints will evolve over the course of the legislation’s proposed 10-year trajectory. The design is a bit of a timing challenge – weaning physi-

That's still a pretty deep hole. However, despite physicians’ substantive concerns about the details, a bipartisan consensus has solidified around a set of interdependent proposals that may give physicians a shot at repealing the SGR Colorado Medicine for January/February 2014

cians off fee-for-service while providing the resources to make those daunting transitions to clinically defensible quality metrics. Unaligned practices will be at a disadvantage in the short run while more fully integrated and coordinated systems will probably do well much earlier in the process. Physicians are understandably skeptical about this change, given the lack of detail, a reliance on largely unconfirmed alternate payment experiments, potentially imbalanced quality incentives versus penalties that may have the inverse effect from the intended, and the structurally flawed notion of cannibalizing the funding streams from specialists. (Other than that, Mrs. Lincoln, how did you like the play?) Despite this, a wide range of medical societies are betting they can provide the exam room level perspectives and realities to revise and refine this incomplete work over the course of the legislation's development and life span because, ultimately, they're the ones at the bottom of that $100 billion hole. n

Promoting health care decisions that are non-duplicative, evidence-based, free from harm and truly necessary

Visit www.cms.org/choosing-wisely 15

Colorado Medicine for January/February 2014

Features

Legislative preview Susan Koontz, JD, CMS General Counsel

Colorado legislators share what to expect in 2014 The second regular session of the 69th Colorado General Assembly convened Jan. 8, 2014, and with its convening comes opportunities to advance the priorities of Colorado physicians and their patients. “Very big picture, we’re looking at things we can do to strengthen Colorado’s economy,” said Senate President Morgan Carroll (D-Aurora). “We’re interested in looking at education and affordability, things like that. In health care there are some big-ticket items worth emphasizing.” Lawmakers will continue to fine-tune the Medicaid expansion and rollout of the Affordable Care Act in Colorado but without making largescale changes because “the dust hasn’t settled yet,” she said. Sen. Irene Aguilar (D-Denver), chair of the Senate Health and Human Services Committee, said not to expect hot-button issues to be raised this session including any changes to tort laws. “[Medical liability] tends to be a very polarizing issue between Democrats and Republicans. And I think we’d like to show the kind of unity that people aren’t seeing in Washington so we’ll be avoiding things that are too controversial,” she said. Budget The Colorado Department of Health Care Policy and Financing will make several budget requests important to physicians including a rate increase to all eligible Medicaid providers and an additional targeted rate increase to allow the department to rebalance certain

rates to create incentives for outcomes. The targeted rate allocation would be set through stakeholder input. Within a few days of the start of the session, the Joint Budget Committee passed a 3 percent increase out of committee. “Members of the JBC know that physicians lose money on every Medicaid patient,” said Rep. Cheri Gerou (R-Evergreen). “Our recent unanimous vote to increase rates to 3 percent across the board was an attempt to close the gap between Medicaid and Medicare reimbursement rates.” Additionally, HCPF will request funding to assist Medicaid providers with adopting electronic health record systems and connecting to Colorado’s health information technology network. The department will work to build interfaces and an electronic infrastructure to allow data from Medicaid beneficiaries to be aggregated and exchanged between EHR systems, the department’s claims system and other Medicaid-related systems in the state. Another HCPF budget request would allow the department to explore telemedicine technology to facilitate the exchange of patient information between primary care physicians and specialist physicians without the need for an inperson patient visit, much like Project ECHO in New Mexico, said Katherine Blair, senior health policy advisor to Gov. John Hickenlooper. This technology will allow for increased access to care for patients in rural areas and reduce unnecessary utilization of specialty

Colorado Medicine for January/February 2014

care by allowing specialists to virtually screen clients. The JBC will continue to look at cost drivers in health care and solicit recommendations for controlling costs. “Especially at the legislature, we’re always looking for ways to make sure we’re using our dollars wisely and that’s going to be an ongoing conversation for years to come,” said JBC chair Rep. Crisanta Duran (D- Denver). She said they’re also looking for feedback on what more legislators can do to provide incentives to specialists to encourage more to see low-income patients. “I think that’s something many of us are very interested in. It will be a good conversation for years to come as well, and we appreciate all of the feedback that CMS has given us throughout the years.” Prescription drug abuse A top initiative of the governor’s office over the past year has been to reduce the abuse of prescription drugs. Blair said the administration will work with legislators to make changes to the Prescription Drug Monitoring Program to bring it up to speed with national best practices. The draft legislation will likely involve expanding delegated authority to other medical professionals and a requirement for all prescribers to register with the PDMP. “It’s not mandatory usage but we’re trying to encourage more doctors to get involved in checking that database before they write pre-

Legislative preview (cont.) scriptions for certain drugs,” said Rep. Beth McCann (D-Denver), chair of the House Health, Insurance and Environment Committee. Additionally, the administration is working on another bill, spearheaded by the Colorado Department of Public Health and Environment, related to the disposal of prescription drugs. Health care costs One of Aguilar’s goals for the session is to look at the drivers of health care costs that aren’t providing value and to have a serious conversation, as a state, about how to control costs. “Whenever you try to talk about controlling costs in health care it needs to include focusing on supporting providers, especially primary care providers, with the help they need to manage patients and keep them healthy.” Along those lines, Aguilar is studying urban free-standing emergency rooms without hospital affiliation, which have no obligation to see Medicaid, Medicare or the uninsured; this is another example, she said, of a facility that may add cost but not value to the health care system. Colorado has had an ongoing interest in transparency, and in collecting as much data as possible to help us make informed choices, Carroll said. “We’re trying to get more data about health care delivery systems overall, whether it’s on the insurance side or the provider side, what we can learn from pharmaceutical cost drivers or the hospital system.” Medical training Aguilar is also looking into whether it would be possible for Colorado to use Medicaid GME funding to start a rural residency program focused on primary care in the San Luis Valley – where roughly one-quarter of residents were Medicaid-eligible even before the expansion. “Ideally I’d like it to be an outpatient-based residency program to reflect the wave of the future,” she said. She’s working with the Commission on Family Medicine to analyze need and feasibility. Sen. Larry Crowder (R-Alamosa) supports this action. “Due to the vast geo 18

graphic area in southern Colorado, I would support a bill to increase medical residencies in this area.” And Rep. Clarice Navarro (R-Pueblo) said, “In order to keep these rural communities alive and thriving it is important that there is a variety of medical resources and/or residency programs available to meet their needs.” Wellness Rep. Dianna Primavera (D-Boulder), chair of the House Public Health Care and Human Services Committee, is focused on working with the governor on his goal to make Colorado the healthiest state in the nation. This includes a bipartisan bill that she and two other representatives hope to sponsor on childhood obesity. “Even though Colorado has always been considered one of the leanest states, we’re losing our battle with childhood obesity,” and that drives many costs to society, she said.

released from treatment so officials can decide how to proceed with the case. Immunization Building on work from the previous session, Aguilar is studying personal belief exemptions that allow individuals to opt out of immunizations, and the effect of the exemptions on public health. Colorado ranks high in the number of families who opt out of immunizations and a coalition suspects some opt out of immunizations for ease rather than by informed decision. Potential legislation would ensure people are adequately informed of the risks. “We want to be sure that people aren’t just doing it for convenience and have the ability to be given information about what the potential health consequences are of their decision,” Aguilar said. “We wouldn’t in any way get rid of people’s right to deny it.”

Mental health Primavera said the legislature is also beginning to see the importance of integrating behavioral health and physical health. “We’re hoping to get a crisis line put together, [with] more mental health navigators and regional crisis centers,” she said. “I just think we’re putting a bigger emphasis on mental health, which is very important in light of a lot of the violence we’ve seen in society.”

Importance of involvement Carroll encouraged all Coloradans to make their voices heard, even when they are part of a group like the Colorado Medical Society that has a lobbying presence at the Capitol. “There’s really nothing ever quite as effective as individuals getting engaged, getting to know their legislators, showing up at town hall meetings, showing up to testify when you can, submitting written testimony when you can.”

“Every time we’re looking at health care access issues, we’re explicitly looking at mental health services as well,” Carroll said. “Both last year and this year we’ll continue to see public financial support within the budget to try and improve our mental health services.”

“Physicians matter when they come to the Capitol,” said Rep. Amy Stephens (REl Paso). “I have watched physicians single-handedly change the course of a bill because of their testimony in opposition or support of the bill. Physicians need to be involved.”

Many are also looking at mental health in the corrections system. McCann is working on legislation to combine procedures for involuntary commitment for drug abuse and alcohol abuse, and is working on another bill to assist law enforcement when they take a person in for a mental health hold. This bill would allow an officer to direct an offender to treatment rather than jail, but it would also alert law enforcement when the person has been

Carroll said the legislature needs physicians to share their unique expertise and educate lawmakers. “There’s a very valuable role of education to help us make better policy. The more people who are involved with real-world experiences that weigh in and participate in shaping public policy, the better the public policy is in the end.” n

Colorado Medicine for January/February 2014

Features

Board of Directors Kate Alfano, CMS contributing writer

Board sets aggressive agenda for 2014 The CMS Board of Directors finalized the 2013-2014 work plan at its Nov. 8 meeting. The comprehensive document encompasses directives enacted or referred from the 2011 through 2013 annual meetings, as well as other strategic and organizational issues. Board members representing regions across the state split into breakout groups to review each topic, action plan and timeline, and made changes to ensure the initiatives would meet the needs of the society over the next year. The recommendations outlined in the plan will guide the efforts of CMS staff and committees this year, with many items requiring reports back to the HOD at the 2014 annual meeting. At the top of the agenda is a directive to implement the Medicaid Reform report as a high priority, giving special emphasis to the urgent need to increase access to specialty care while lobbying the congressional delegation to maintain Medicare parity for primary care payments. CEO Alfred Gilchrist will make routine progress reports to the board. A

goal of CMS President John L. Bender, MD, FAAFP is to increase Medicaid payments to specialists, and thereby access to specialty care. The next phase of health care is the medical neighborhood, which is an extension of the patient-centered medical home (PCMH) and a necessary architecture to a functional accountable care organization (ACO). “Specialty care is ready to contract with the Regional Care Collaborative Organizations (RCCOs) and deliver care that is integrated and higher quality,” Bender says. “By ensuring strong payment reform to specialists, Colorado can help ensure that Medicaid beneficiaries will have access to specialty care, and although payments to specialists will go up, just as we saw in the PCMH pilot, overall global costs will go down. The beneficiaries want access, taxpayers want lower costs, specialists want to see Medicaid patients with fair payment rules, and we all want to see less wasteful care being delivered solely through high-cost centers like hospitals.”

The board’s work will include a multimedia education and communications campaign for physicians about the continued progression of the Accountable Care Collaborative (ACC) and physician needs regarding new payment and delivery models in Medicaid. Additionally, CMS will collaborate with specialty societies and RCCO medical directors to enhance specialty care participation in the ACC through payment reforms. Bender sent a letter requesting feedback to these parties in early December. The Committee on Physician Practice Evolution (CPPE) will continue to execute a multimedia information and education campaign regarding new payment models, delivery system changes and transparency initiatives to help physicians prepare for and adapt to new systems of care. CPPE will also assess the feasibility of mandating through state law the standardized use of performance measures across entities that rate or report physician performance in Colorado. In advocacy, the Council on Legislation (COL) and government relations staff will continue to aggressively lobby the Colorado congressional delegation to repeal and replace the SGR and assist the AMA in these efforts. The COL will also work to protect the liability climate and the confidentiality of professional review in the Legislature and in the courts, placing immediate emphasis on Colorado Medical Board vs. Office of Administrative Courts pursuant to the Sept. 20, 2013 BOD action. The Workers’ Compensation and Personal Injury Committee (WCPIC) will prepare members for the release of re-

Colorado Medicine for January/February 2014

Features vised care guidelines and reimbursement reforms to be proposed by the Colorado Department of Workers’ Compensation. CMS hopes to recruit new members among physicians who care for injured workers. Kathryn Mueller, MD, a CMS member, medical director for the Division of Workers’ Compensation and a professor in the Department of Psychiatry and the School of Public Health, said one of the purposes of the guidelines is to expedite quality care and prompt payment for providers. “This year we will continue to focus on ways to assure that providers are promptly reimbursed for their services within guidelines and that administrative burdens for physicians who are operating within guidelines are minimal,” she said. “We are extremely appreciative of all of the time and effort CMS members and WCPIC continue to devote to assisting us in these areas.” The Committee on Employed Physicians (CEP) will implement CMS policy on anti-competitive conduct and report

to the board on progress. The committee will complete model staff bylaws that will be forwarded to all hospital CEOs and they will perform the first of two surveys of hospital CEOs. CEP will also implement policy on non-compete/ liquidated damages clauses in physician employment contracts, communicating a request to hospitals to remove these provisions and assessing the need for legislation based on their response. “Our CMS stances on anti-competitive conduct and employed physician termination issues are of great interest to many of us as the ranks of employed physicians grow,” said CEP Chairman Edward Norman, MD, FACP, FHM. “Regarding the former, physicians are becoming more worried that as health systems expand, there may be economic and strategic decisions made in communities that greatly impact the previously more free-flowing relationship between the patients and their physician. CMS is planning to work with the Colorado Hospital Association on a mutually acceptable grievance process, should a

Colorado Medicine for January/February 2014

physician feel that he is being clinically restricted for economic reasons in his relationship with the local health system.” “The second concern, while it is not a widespread problem as of yet, is that as physician employment increases, physicians may be treated as simple pieces in a puzzle as opposed to valuable community assets,” he continued. “The possibility that physicians could be forced to relocate away from their own patients without an explicit cause for termination of their employment has raised numerous issues. The committee has met previously and has heard a number of valid, and opposing, arguments, but they all have focused on the value of maintaining a successful practice for providers and the patients in the communities they serve.” Bender said that overall, the CMS work plan represents great advancements guided by strategies derived from the 2013 House of Delegates. “We will continue to lead the nation in health and wellness, Colorado style.” n

Features

Finding community amidst a disaster Kate Alfano, CMS contributing writer

Colorado Medicine introduces new series profiling physician heroes Editor's note: There are several warning signs of professional burnout, including having feelings of being rundown or drained of physical or emotional energy, being easily irritated by small problems, feeling misunderstood or unappreciated by your coworkers, feeling that you’re under too much pressure to succeed, feeling frustrated by organizational politics or bureaucracy, or feeling that there is more work than you practically have the ability to do. The Colorado Medical Society recognizes the prevalence of burnout among physicians, particularly in this time of great change in health care. To help our members reflect on the meaningful difference you’re making in the lives of your patients and community and to recognize extraordinary actions, Colorado Medicine has launched the new series, Physician Heroes. We will profile as many different members as we can who have gone above and beyond in the profession to help his or her colleagues or community. We hope you’ll see your own values reflected in these stories and be reminded of the joy of medicine. Members are invited to nominate themselves or a colleague by contacting Dean Holzkamp at dean_holzkamp@cms.org or 303-748-6113.

Frank Dumont, MD Historic Estes Park flooding Disasters can bring out the best – and the worst – in humanity. Colorado Medical Society member Frank Dumont, MD, an internal medicine physician in Estes Park, witnessed the best of humanity and performed at the top of his game during the historic Colorado floods of September 2013. Dumont practices what he calls “an older version of internal medicine.” While his responsibilities as chief of staff at Estes Park Medical Center have interjected more meetings into his schedule, he still takes care of patients in outpatient and inpatient settings and in the nursing home associated with his clinic. If his patients need hospital care, he sees them there and then follows up with them in his clinic after discharge. Early in the week when the rain first started, many in Estes Park were relieved as they had struggled with local forest fires for the past two years. Dumont can still recall the beautiful scene of the clouds swirling against the mountain backdrop.

The historic floods of September 2013 brought widespread destruction to Estes Park and the surrounding communities.

Early Thursday morning around 3 a.m., Dumont called the hospital to check on one of his patients. A nurse told him highways 34 and 36 were

Colorado Medicine for January/February 2014

Features shut down. While rockslides, mudslides or snow slides frequently cause a highway to close, it’s uncommon for both major arteries to be shut down at once. At 5 a.m. he received a phone call that school was cancelled. “For rain? That’s a first,” he thought, but went into work as usual. As the morning progressed, Dumont began to realize the severity of the situation. EPMC is a small, 25-bed community critical access hospital without an ICU and without a full spectrum of specialists, thus patients needing higher levels of care are usually transported by ambulance or sent down to Denver by helicopter. “Highways 34 and 36 were not only down but were going to be inaccessible for a considerable amount of time. Sections of the road were being washed away with more crumbling by the minute,” Dumont recalled. Highway 7, another of the major roads connecting Estes Park to the outside world, was also compromised. And the remaining road, Trail Ridge, which winds through Rocky Mountain National Park up to a top elevation of 12,000 feet, was intermittently impassible because of freezing precipitation.

medications and antibiotics and crafted a plan to ensure they were using their medications wisely. They made the decision to stop scheduling and providing routine care to preserve limited resources. Dumont and the medical officer The floodwaters ravaged the lower areas of Estes Park including for the clinic de- Elkhorn Ave, the popular downtown street. vised a 12-hour shift rotation to make sure they had many, the mood was one of devastaadequate hospital coverage. As all tion. There were a number of nurses phone service and most Internet ser- and other staff members who had lost vice was out, staff wouldn’t be able to everything; cars were washed downcall physicians in to handle medical is- stream, and their homes were gone. sues; a physician would be needed on- Others hadn’t lost their homes but were stranded; they felt a tremendous site at all times. sense of displacement and loss because Dumont spent each day for the next they couldn’t be with their families two and a half weeks in the hospital, during this time of crisis. A few felt no staying late, going to various meet- effect because they were high enough ings and rounding on different depart- in town and still had passable roads to ments. An old-fashioned whiteboard the medical center. model was employed in the emergency department – physicians signed in and “Then there was the medical team, out of the hospital, noting their location in case they were needed. For

“There were times when we were completely isolated, and when we did have a road, it was a six- to seven-hour drive to Denver, where we get most of our supplies. Not only that, but because of all the rain and the cloud cover being so low, we didn’t have any helicopter service either.” None of the retail pharmacies could open as their staff pharmacists were stranded on the other side of the closed highways; the other two clinics in town also remained closed in the initial days of the disaster. EPMC was suddenly the only source of medical care available for Estes Park and the surrounding communities. Dumont and the medical staff began to organize. Without functional supply lines for food or medical supplies, they inventoried their pharmaceuticals,

The raging waters washed away large chucks of many roads, challenging transportation and making some roads impassable for months.

Colorado Medicine for January/February 2014

Physician heroes (cont.) and from my standpoint this is one of the most positive things about the whole experience,” Dumont said. “What kept coming to my mind over and over again was this amazing sense of pride for the medical team and what they were doing because everyone stepped in. As a leader in the facility, to see it happen that way and to see the best of people in that moment of crisis, that’s one of those things that you remember.” Physicians and nurses asked what was needed, and committed to being there to make it happen. They handled nearly everything that came through the door and if a case went beyond their capabilities, they did the best job possible to hold things together until they could get patients to a higher level of service, Dumont explained. A converted operating room became a makeshift ICU, staffed with nurses and internal medicine physicians who had previous ICU experience. A system was implemented to safely and appropriately distribute medications to patients whose normal pharmacy or clinic was closed. Nurses transferred departments and

Floodwaters spilled over many roads in town and damaged bridges. Many were not back in service until November. the surgical team jumped departments when they weren’t busy, even working with food distribution and supplies. Staff in town opened their homes to those who couldn’t reach their own. Even the EPMC CEO drove a large van six hours over Trail Ridge Road to Denver to pick up food and medical sup-

plies. Staff continued to pull together to coordinate a shuttle service to help with supplies and staffing until highway 36 reopened in early November. “People stopped asking questions about whose responsibility it was and said, ‘it is our responsibility because we are here to take care of the community,’” Dumont said. Months later, many things have returned to normal. The roads are open again ensuring adequate supplies and transportation for patients or specialists to and from Estes Park. The temporary communications lines aren’t as fast as they used to be but they’re working. Some things are gone forever. Some businesses were washed away and many people are still displaced from their homes. Economically, the busy tourist season for fall colors and wildlife viewing was completely disrupted, hurting local revenue.

Many local businesses were devastated by the flood. Estes Park is bracing for further economic loss if national coverage of the disaster keeps 2014 tourists from visiting.

Estes Park will be forever changed – as is Dumont. But he chooses to recognize the positive side of the flood: A community united to help everyone do their best. “I got to see that [unity] in the commu-

Colorado Medicine for January/February 2014

nity at large, and I witnessed this wonderful sense of medical community where people came together and made things happen that seemed unimaginable. We didn’t turn away a single person from the emergency department, the clinic or the hospital. And we accomplished this because people were willing to come together, saying ‘whatever needs to be done, we will find a way to make it happen.’ “And to watch that happen with everybody so positive and so focused, is one of the highlights of my career.” n The flood damaged many popular tourist attractions. According to a report from the Regional Economics Institute at CSU, resulting 2014 revenue losses could total tens of millions of dollars.

The powerful floodwaters swept over riverbanks and into the streets, destroying homes and displacing cars. National estimates report statewide flood damage to be nearly $2 billion.

Colorado Medicine for January/February 2014

Features

Acknowledging physician burnout Kate Alfano, CMS contributing writer

CMS aims to give physicians wellness tools for 2014 Health care professionals are more susceptible to burnout than workers in any other industry. A 2011 study published in the Journal of the American Medical Association revealed 30 to 40 percent of physicians experience burnout. A 2004 study published in the Journal of Academic Psychiatry showed 50 percent of residents met burnout criteria with various specialties reporting greater instances; the top three were obstetrics/gynecology at 75 percent, internal medicine at 63 percent and neurology at 63 percent. Family medicine had the most favorable burnout rate at 27 percent. Perhaps most disturbing, a 2007 study published in the Archives of Internal Medicine showed that 47 percent of medical students already exhibit symptoms of burnout and 49 percent exhibit depressive symptoms. And a separate study from 2010 showed that 10 percent of medical students have suicidal ideation.

their daily routine to not only prevent burnout but also create fulfilling professional and personal lives,” said Chad Morris, PhD, director of the Behavioral Health and Wellness Program. BHWP comprises a multifaceted group of experts from a range of professions. This team travels around the country presenting behavioral change strategies tailored to various groups. “While physicians often possess education about healthy living, knowledge isn’t enough,” said Cindy Morris, PsyD, BHWP clinical director. “Whether they have five minutes or an hour to dedicate to their self-care, physicians need practical wellness strategies that fit into their busy schedules.” In addition to the toolkit, the BHWP

It is for these reasons and more that the Colorado Medical Society and its Expert Panel on Physician Wellness have taken on the goal of improving physician wellness and reducing burnout in 2014. A crucial partner in the effort are the experts at the Behavioral Health and Wellness Program at the University of Colorado Anschutz Medical Campus, who will develop a toolkit over the next year specifically tailored to physicians to address the eight dimensions of wellness with a focus on stress and burnout.

team will provide monthly segments to be posted in the physician wellness section of CMS.org. The resources will allow for CMS member comments to shape its focus throughout the year. Also in the works is an “ambassador program,” where practices can designate a physician wellness champion who would receive training on good wellness traits to take back to colleagues, and a larger CME activity to be presented at an upcoming conference. As 2014 gets rolling, CMS encourages members to utilize these wellness resources and consider the implications of burnout in their professional and personal lives. Visit www.cms.org/ resources/category/physician-wellness to access these resources and to learn more. n

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

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

“There are a variety of protective practices that physicians can integrate into Colorado Medicine for January/February 2014

Features

Trip to the Hill Kate Alfano, CMS contributing writer

Report from 2013 AMA interim meeting Physician delegates and leadership representing the Colorado Medical Society traveled to Washington, D.C. in November to lobby the congressional delegation on Medicare physician payment and participate in the 2013 American Medical Association Interim Meeting. CMS leaders met with U.S. Sens. Mark Udall and Michael Bennet, and U.S. Reps. Mike Coffman, Ed Perlmutter and Doug Lamborn, and the staffs of U.S. Reps. Cory Gardner, Diana DeGette and Jared Polis on Nov. 19. CMS leaders urged the delegation to repeal the SGR to make the Medicare program sustainable for patients and physicians. Congressional lawmakers considered bipartisan and bicameral Medicare

payment transitions in the closing weeks of this session and the AMA announced its support for the proposals before the U.S. House Ways and Means Committee and the U.S. Senate Finance Committee, calling them “a significant improvement over current law” that will “result in a stronger Medicare program.” The AMA correctly reported that it was unlikely Congress would reach an agreement before the end of the year and that lawmakers will need to adopt a short-term patch for early 2014 as they work out the details, with the biggest obstacle being the need to find budgetary offsets for both a patch and a permanent fix. The Congressional Budget Office has re-scored the cost of repealing the SGR over the next 10 years from $150 billion to $116.5

billion, which AMA President Ardis Hoven, MD, said presents an opportunity for repeal that will not likely occur again. As CMS members heard in their meetings with lawmakers, all Colorado congressional delegation members support the SGR repeal and several are actively working to make the transition a reality. (Note: Both committees passed the proposal in mid-December and Congress passed the temporary patch.) The AMA House of Delegates adopted numerous policies on important topics that impact the stability of physician practices, quality of care and the advancement of patient health. The Colorado delegation brought forth a resolution, approved by the

Colorado Medicine for January/February 2014

Features CMS House of Delegates in September, to put in place a two-year “implementation period” for ICD-10 during which payers would not be allowed to deny payment based on specificity of ICD-10 diagnosis. Payers would be required to provide feedback for diagnosis determined to be incorrect. If unsuccessful in negotiating with payers, the resolution directs CMS to seek legislation to establish this implementation period. Colorado also brought forth a resolution on prepayment review by third parties. CMS directed the AMA to work with payers to stop the insurer practice of delaying payments by asking for documentation to review prior to payment, and to work with payers to establish rules to continue to allow the payer to conduct prepayment documentation review if the payer has performed a post-payment documentation review and proven that the provider has been submitting incorrect claims. Should efforts to work with payers to end the practice of delaying payments without reasonable justification fail, CMS directed the AMA to seek legislation to accomplish this.

tional opioid poisonings and deaths. And the third asks the Joint Commission to reevaluate its accreditation standard for pain management. CMS Immediate Past President Jan Kief, MD, participated on a panel at the Organization of State Medical Association Presidents covering states’ experiences with the insurance exchanges. “Dr. Kief demonstrated that Colorado excels in bringing together stakeholders of varying philosophies to produce an exchange product that is not perfect but has both patients and payers participating actively,” said Lynn Parry, MD, a past president of CMS. Kief awaits official nomination from the AMA Board in April for a position that she seeks on the Council on Constitution and Bylaws for June 2014. Young Colorado physicians continued to have a large presence on the national stage. Resident Carolynn Francavilla, MD, brought forth two policies from the Resident-Fellow Section. Steve Sherick, MD, chair of the AMA

Young Physician Section, directed the assembly and meeting for young physicians nationally and passed two resolutions that he lead-authored, one on cost transparency and one on AMA membership dues being discounted by national medical malpractice companies. And Nikesh Bajaj, a third-year student at Rocky Vista University College of Osteopathic Medicine, was elected to a position as a Medical Student Delegate to the AMA representing Region 1. Thanks to the members who attended the meeting: Nikesh Bajaj; John L. Bender, MD, FAAFP; Jeffrey Cain, MD; Dave Downs, MD; Dean Drizin; Andrew Flynn; Brendan Fowler; Carolynn Francavilla, MD; Jan Kief, MD; Mark Laitos, MD; Jeremy Lazarus, MD; Katie Lozano, MD; Lee Morgan, MD; Tamaan Osbourne-Roberts, MD; Ray Painter, MD; Lynn Parry, MD; Paul Pukurdpol; Brigitta Robinson, MD; Alisa Sherick, MD; Steve Sherick, MD; Ted Timothy; and Allison Wood. n

Delegates voted nearly unanimously to support a draft congressional framework that would repeal the SGR, while continuing to advocate for future positive payment updates and the inclusion of alternative payment models developed by organized medicine. Three policies addressed the appropriate availability and use of medications. The first gives a contemporary review of national drug control policy and calls for a variety of changes, including developing community-based prevention programs for at-risk youth and increasing the accessibility of treatment programs for substance use disorders. The second aims to address opioid-associated overdoses and deaths by directing the AMA to develop a set of best practices to inform clinical use of these drugs in managing pain and calling for the Centers for Disease Control and Prevention to collect more robust data on uninten-

Colorado Medicine for January/February 2014

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Colorado Medicine for January/February 2014

Inside CMS

ICD-10 update Marilyn Rissmiller, Senior Director, Health Care Financing

ICD-10 coalition: Year-end wrap up Since the Colorado ICD-10 Training Coalition launched last year, we’ve used a strategic approach to help build awareness among practices, assist them with developing implementation timelines, help them plan and prepare, and provide training and testing opportunities. Now many of the practices that have been on this journey with us have begun or are well on their way with the necessary transition planning and preparation. As many practices have realized, transition is not actually the final step in your ICD-10 journey. Staff will continue to adapt to an ongoing process, changing strategies to adapt to provider needs,

and we as a coalition will continue working with you to ensure success. During a Dec. 17 webinar, our panel of experts and practice staff reflected on the past year and gave advice for others, no matter where they are on their timeline. Todd Welter, CPC, founder and president of R.T. Welter and Associates, spoke about the “OMG Curve” that many are no doubt experiencing or about to experience as the Oct. 1, 2014 deadline approaches. This curve maps the work trajectory of a big project, understanding human nature to pro-

crastinate in the beginning then panic as time runs out. Ideally practices are evenly spacing your steps and moving along the pathway strategically to avoid the OMG Curve. He told the listeners that it’s not too late to plot a steady path, though those who haven’t started the process yet may soon realize that it’s getting “pretty darn close.” Welter encouraged working in teams, even outside of your practice. “No practice is able to do everything a patient might need so we’re working in partnership with other health care profession-

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Colorado Medicine for January/February 2014

ICD-10 update (cont.) als. This means we have to make sure that not only our practice is ready but that all of the partners are also ready,” he said. There are some payers [workers’ compensation and auto insurers] that may continue to stay on ICD-9 after Oct. 1, and practices may have to work on a dual system to accommodate this. Health plans may be working on legacy systems, which could affect claims and slow cash flow for a practice regardless

of whether the practice has transitioned successfully. Be prepared. Christine Hall of Mountain View Medical Group described her experience with ICD-10 so far. They started with chart audits and found that many of their providers were using unspecified codes. They decided to better define the ICD-9 codes to improve documentation. Their IT department is adding codes to their electronic medical record and they’ve hired an extra coder whose focus will be

guiding physicians and staff on ICD-10. “Physician reaction is mixed,” Hall said. “A lot are feeling that this is ‘just another thing to do’ as we’re also implementing the patient-centered medical home. We’re trying to be as positive as we can and ease them into it.” Sandra Robben-Webber of Colorado Springs Pulmonary Consultants completed an impact analysis earlier in 2013 and has been working with their software vendor and clearinghouse to make sure they’re on track. While she felt she wasn’t getting as much done as was needed, especially over the summer, she says she discovered when pulling information into a matrix for the webinar that they’d accomplished more than she realized just by “doing a couple of things every day.” “I think we’re on a good pathway going into 2014,” Robben-Webber said. “I’m glad we started earlier than later but I do still feel there’s time to utilize resources. Choose what resources will work for you and reach out to the coalition members. I really commend the coalition on what they’ve put together this year.” The coalition is in the process of putting together the 2014 work plan and, with just nine months remaining until implementation, polled webinar participants on their progress and needs. • 34.1 percent said planning is well underway • 43.2 percent said planning is in the early stages • 13.6 percent said they will begin planning after the holidays • 9.1 percent said they are not responsible for the plan For resources moving forward, participants overwhelmingly reported that they need “all of the above”: webinars on planning and preparation, coding training, access to peer support groups and one-on-one counseling. The Colorado ICD-10 Training Coalition will continue to develop resources. Visit our website at www.cms.org/icd-10 for on-demand webinars, checklists, worksheets and more. n

Colorado Medicine for January/February 2014

CMS Corporate Supporters and Member Benefit Partners

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Diagonal Medical Billing: 303-551-7944 or visit www.diagonalmedicalbilling.com PRACTICE VIABILITY (cont.) GL Advisor 877-552-9907 or visit www.gladvisor.com/cms * CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner IC System www.icmemberbenefits.com Line Pressure 303-742-0202 Massive Networks 303-800-1300 or visit www.massivenetworks.net Medical Telecommunications 866-345-0251 or 303-761-6594 or visit www.medteleco.com * CMS Member Benefit Partner Solve IT 303-800-9300 or visit www.solveit.us *CMS Member Benefit Partner TransFirst 800-613-0148 or visit www.transfirstassociation.com/cms *CMS Member Benefit Partner TMS Center of Colorado 303-884-3867 or www.tmscenterofcolorado.com Transcription Outsourcing 720-287-3710 or visit www.transcriptionoutsourcing.net Transworld Systems 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner

athenahealth 888-402-6942 or visit www.athenahealth.com/cms. *CMS Member Benefit Partner Colorado Medicine for January/February 2014

Inside CMS

Clean Claims Task Force Marilyn Rissmiller, Senior Director, Health Care Financing

Final set of rules to be submitted in early 2014 Colorado enacted the Medical Clean Claims Transparency and Uniformity Act in 2010. It was designed to save the state millions of dollars a year with the understanding that payers and providers will face less administrative redundancy

and waste, which can be redirected toward reducing the actual cost of care. CMS strongly supported the act and actively participates in the resulting 28-member task force, which also com-

prises representatives from major payers, claims software vendors, the Colorado Medical Group Management Association, the American Medical Association, local physician billing personnel and the State of Colorado. The group is working to identify and develop a standardized set of health care claim edits and payment rules to process medical claims. The work of the task force is guided by principles that focus on administrative simplification: consistency, standardization, transparency and improved system efficiency. The task force submitted a report to the General Assembly in January 2013, which resulted in a bill sponsored by Sen. Irene Aguilar, MD, and Rep. Sue Schafer concerning the development of standardized rules in processing medical claims and extending the deadlines and authorizing appropriation of state funds for the development of a set of rules. The task force presented its final set of rules at the beginning of December 2013 and accepted public comments through Jan. 6, 2014. There were five in this set. 1. Bundled: identifies when certain services and supplies are considered part of the overall care and should not be billed separately. 2. Multiple E/Ms on the same day: identifies when multiple evaluation and management services are billed on the same day by the same provider. With exceptions and the appropriate modifier, only one E/M may be eligible. 3. Procedure to modifier validation: identifies when a modifier is inappro-

Colorado Medicine for January/February 2014

Inside CMS priately reported with a procedure code. 4. Rebundled: identifies incorrect coding when two or more codes submitted together are better described by a single code or series of codes, which ensures accurate coding with the most comprehensive code that best describes the service performed. 5. Effect of CPT and HCPCS modifiers on edits: identifies those modifiers that have an effect on claims processing. All stakeholders – especially specialty societies in Colorado and nationally – were invited to be engaged throughout the entire process and we are grateful for all comments. Aggregated comments were posted online and considered by the task force for inclusion in the following set of rules. Sixteen rules have already completed the rule development in its entirety. The process requires consensus on the initial draft, distribution for public review, second review by the task force, official response to comments and final consensus. The final rules will be submitted to the General Assembly in early 2015 and used by all payers and providers in Colorado by Jan. 1, 2016. Colorado leads the nation in efforts to standardize claim edits and payment rules across private payers. For more information, go to www.hb101332taskforce.org. n

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Colorado Medicine for January/February 2014

Inside CMS

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

right in. I’d work hard, see her in the mornings and afternoons, write my notes, and she’d be gone on the third day. Routine.

Kinsey Roth

I am a native Coloradan from Colorado Springs where my immediate family still resides. I graduated from the University of Colorado at Boulder with a degree in Integrative Physiology and began work as a certified nurse’s aide before coming to the School of Medicine for the University of Colorado. As an MD candidate, I became an active member in the LEADS advocacy track and am a student advisor for the Advisory College Program at the School of Medicine. I will be matching in March to a pediatrics residency where I may continue investing in my passions for education and advocacy.

Nothing was routine. As post-op day #2 arrived, she started declining instead of improving. Her pressures were unstable, her belly felt tight, her pain wasn’t controlled, and her legs were edematous to her thighs. I found myself constantly in her room reassessing complaints while trying to reassure her and play liaison with my team. Her friend, Beth, kept asking me questions from a medium-sized composition book until I answered all I could and took the rest to my resident. To my dismay, I didn’t have all the answers and even more discouraging, my resident didn’t either. Finally, her kidneys decided to quit in an effort to scream, “Something is wrong!”

I knocked and entered just like so many times before, but this time was different. I had never seen her standing up straight by herself. She was even in real clothes, a simple black dress that we had hung on the back of her door as a reminder of hope and promise. She looked at me with a quiet smile and tears in her eyes. She softly glided over to me, so steady, so serine. She put her hands around my waist and whispered, “Thank you.” This was my time of rededication, my baptism.

The next morning, a low rumble of guilt underscored my every thought as I read her overnight emergency laparotomy report that described 1.7 L of puss in her abdomen and the placement of a colostomy. I slowly walked to the SICU thinking that if I had just understood her better, if I knew more, I would have realized sooner. In the somber room, I introduced myself to Angie who immediately grabbed for the notebook ready to take down any information and ensure no questions were left unanswered. I repeated this again with Angie in the afternoon, and Connie the next morning. Each time as I left, they ended by praying. By the newest post-op day #2, Ms. White was awake, but anxiety flickered across her face when I asked to check her wounds. She grimaced, partially from pain, partially from disgust. She knew that she would heal but it would be longer and harder than she had anticipated.

Her name was Ms. White. Our relationship began 36 days ago when I was reading through her chart for an OR case. I knew her medical history, the workup, the procedure; I was ready for any question the team had for me. When I finally met her and one of her many companions, Connie, I expected routine. I had learned so many routines so far in third year: pre-rounding, rounding, OR, post-op, medicine, surgery. I thought she would fit

In the ICU, I spent hours with Ms. White and her companions to understand her life and her routines. I learned about her law firm and how anxious she was to get back to work and to be in control of her life again. I learned about her visitors, women from her church, who drove up from Colorado Springs on a rotating schedule. They took shifts to ensure that she was never alone at night and participated in prayer and scripture readings

The saga of Ms. White: From porcupine to prophet

Colorado Medicine for January/February 2014

Inside CMS to encourage her through the day. The composition book I kept seeing was originally her prayer journal. I looked at the nondescript book knowing that inside; her most private scriptures and epiphanies were juxtaposed against medical jargon and innumerable questions. Her spiritual and medical identities had become entangled just like our lives were now. The next several weeks after the ICU may not have been very eventful for a surgeon, but for us, they were momentous. Ms. White was moved to the floor where our new challenges were wound dehiscence and ostomy leaks. It took forever to find good seals, but we succeeded and she was encouraged. She was finally ready to go home. On the morning of her anticipated discharge, a new fever and abdominal pain prompted a workup that ended in four abdominal drains. This was surgery #3. When I went to her in the afternoon, she lay despondently on the bed, shook her head, and said, “Why is God letting this happen?” I sat next to her while she described feeling like a gutted fish, who had morphed into a disgusting porcupine. Her question, “why?” rang brassily in my head and its weight was as heavy as a cathedral bell. She felt she had lost control and lost her protection. After already taking her health, her medical struggles now threatened her faith. My heart ached for the levels of suffering she now had to endure. She was my patient; I had to find something for this new pain that dilaudid couldn’t diminish and fluoxetine couldn’t help her forget. I had to help her regain control. We started with OT, PT, and nutrition. I scheduled education nearly every day either for drain management, ostomy care or wound vac checks. She became responsible for the medical paraphernalia, which she now carried but started seeing it all as hers as opposed to something we did to her. We were ready again, but then another setback. Bilateral pleural effusions, each with its own chest tube.

without her companions to banish them away. So I fell into the liturgy that I had seen played out so many times over the past month. I grabbed the notebook and one by one wrote in her questions with the accompanying answers. I had almost filled up the last few pages when she stopped crying, but I couldn’t leave the ritual incomplete; I asked if she wanted to pray. She nodded, grabbed my hands, bowed her head and began; only what she started saying wasn’t for her, it was for me. As her words poured over me, the past month flooded back. How I loved the OR and procedures and sutures. But the times that stood out, that I waited for each day, that left me fulfilled, those were all Ms. White. They were her family and her confidantes. It brought back my entrance essay in which I spoke about how medicine was about advocacy and how I wanted so desperately to fill the role of listener and comforter in people’s most vulnerable times. The flurry of third year settled and was silent, and I heard a warm, embracing, resonance that reminded me of what gave my work meaning. As she said “Amen,” I was refreshed. Tears were now in my eyes, maybe a little unprofessional but she just smiled. She was back, and she was ready to go home. So there she stood only a few hours later, in her loose fitting black dress. A little paler, certainly thinner, but there she stood, strong and beautiful. She had shared all of herself with me and renewed my purpose as a physician. So when she said, “Thank you,” I hope you understand why all I could do was whisper, “Thank you,” back. n

The drains now number six and she was spinier than ever. This was surgery #4 and her second failed discharge. For the next five days she persevered with her friends at her side and me cheering from the back, but she was obviously weary, waiting for some amount of peace. So on the third discharge attempt, there wasn’t that tinkling in the air of little chimes of excitement that there had been during the first. Instead the news landed hard with a dull thud. On this day that was supposed to be a triumph, Ms. White was alone for the first time, and she started to cry. My team let me stay and as she spoke the room filled with her fears and doubts and worries Colorado Medicine for January/February 2014

Inside CMS

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

Support for changes and challenges ahead in health care As we move into 2014, all eyes will be on health care as we see more data related to the implementation of the Affordable Care Act that will fuel discussions around the question: Is our health care system headed in the right direction? Amidst all the opinions and perspectives, there is one fact of which we cannot lose sight – the challenges that have been placed upon medical professionals and facilities to meet requirements, manage costs and show results of improved care.

owners, they participate in the oversight of operations and have a voice in how the RRG is managed. • Rate stability – Increased emphasis on risk management and careful selection of members allows for improved loss experience, and this often translates into lower costs.

COPIC recognizes these challenges and looks at ways in which we can further support our insureds as they navigate the complexities of today’s health care environment, while also planning for the years to come. The following are some of the ways in which we are providing support.

Expertise for your personal and business needs COPIC Financial Service Group offers products and services that complement your medical liability insurance and address situations specific to health care professionals. Whether it’s planning for your personal insurance needs or reviewing coverage options to protect your business practice, COPIC Financial can provide expert consultation on timely issues such as:

Separate limits of liability for employed allied health professionals (AHPs) The changes in health care have placed an increased focus on the role AHPs will serve in delivering care to patients. To support flexibility in this area for medical practices and health care systems, COPIC now offers separate limits of liability for employed AHPs. Some key provisions of this new option include: • Insureds can select specific AHPs for which they would like separate limits. • AHPs with separate limits are offered tail coverage upon cancellation. For more information about this coverage option, please contact your COPIC underwriter by calling (720) 858-6000. Alternative risk management arrangements COPIC facilitated the formation of a Risk Retention Group (RRG) – a liability insurance company that is owned by its members – as a flexible option for insureds who expand their operations into other states. Some of the benefits of working with this RRG include: • Nationwide reach and protection – An RRG can insure members throughout the country by registering in all states where coverage needs to be written. • Return on investment – Members may benefit when there are favorable loss conditions that allow for the distribution of dividends or reductions in premiums. • Ownership in business decisions – Because members are 38

For more information, contact COPIC Sales at (720) 8586186 or sales@copic.com.

• Additional cyber liability insurance to meet the level of protection that your organization requires. • A review of benefit plans for your employees to determine cost-effective solutions that meet ACA requirements. • Other areas of service include: workers’ compensation, business owners insurance, disability/life insurance and investment/retirement planning. For more information, contact COPIC Financial at (720) 858-6280 or visit www.copicfsg.com. Advocacy that informs and educates on a state and national level COPIC continues to invest in proactive advocacy efforts to educate legislators about the importance of a stable medical liability environment. As health care is experiencing significant change and there is substantial “noise” about what is wrong and what is right, it is vital that we continue these efforts to inform legislators about the factors and issues that matter. In particular, we focus on how access to care, quality of care and cost are interconnected. The relationships we build through these efforts not only benefit our insureds in Colorado, but they also extend our connection when policymakers are involved with national organizations or move onto positions at a federal level. n Colorado Medicine for January/February 2014

Departments

medical news Gov. Hickenlooper dedicates CMS Presidents’ Lounge Colorado Gov. John Hickenlooper dedicated the new Presidents’ Lounge at the Colorado Medical Society headquarters on Tuesday, Jan. 7, 2014, surrounded by past, current and future CMS presidents. Standing with the governor were CMS President John L. Bender, MD; President-elect Tamaan Osbourne-Roberts, MD; and past presidents Alethia (Lee) E Morgan, MD, Ben Vernon, MD, Rick May, MD, Dave Downs, MD, and Christoper Unrein, DO. Before cutting a large red ribbon to

open the lounge, Gov. Hickenlooper said the following. “It is my honor to dedicate this space for the important purpose of bringing together health policy experts, not just from this state but around the country, to make sure that we have an informal setting focused on solving problems rather than laying blame, a time-honored tradition of this medical society of which you are all members.

“It is a privilege and honor to work with this venerable profession and this highly regarded medical society. “You and your colleagues see more suffering and take care of more of our fellow Coloradans than elected people like me could do in a lifetime, and for that we are deeply grateful. “Let this room from this day forward be a place where participants further your cause, your goals, your mission.” n

“This will be a room for great ideas and deep thought.

Past, present and future CMS presidents celebrate the opening of the Colorado Medical Society Physicians’ Lounge. From left to right: Tamaan Osbourne-Roberts, MD; Ben Vernon, MD; Alethia (Lee) E Morgan, MD; Rick May, MD; Gov. John Hickenlooper; Dave Downs, MD; John L. Bender, MD; and Christopher Unrein, DO. Colorado Medicine for January/February 2014

Departments

medical news Report: CMS, DMS and One Colorado address LGBT health The Colorado Medical Society, Denver Medical Society and One Colorado Education Fund have partnered over the past year to address the objective of eliminating health disparities in the lesbian, gay, bisexual and transgender (LGBT) populations. In 2013, CMS and DMS were awarded One Colorado’s Ally Award for this work. The latest collaboration has resulted in a new report through which the organizations sought to better understand how physicians see, include and treat LGBT patients. The report is titled “Becoming Visible: Working with Colorado Physicians to Improve

LGBT Health” in recognition that LGBT Coloradans often feel invisible in the health care system. The report is specific to the LGBT patient population in Colorado and the views of Colorado physicians. It includes data analysis by health policy researchers who worked with a physician advisory committee. The major findings include the following. • Physicians and their staff overwhelmingly report high levels of comfort in serving lesbian, gay and bisexual patients. These groups reported slightly lower comfort with

Medicaid preventive and wellness services effective Jan. 1, 2014 Beginning Jan. 1, 2014, Colorado Medicaid covers all recommended preventive and wellness services defined by the U.S. Preventive Services Task Force (USPSTF) with a rating of A or B and the Advisory Committee on Immunization Practices (ACIP) without patient cost sharing (co-payments). Most USPSTF and ACIP recommended preventive and wellness services were covered by Medicaid, but begin-

ning Jan. 1, 2014, new preventive and wellness procedure codes were made available. Proper coding is critical to receiving accurate payment for the USPSTF and ACIP recommended preventive and wellness services. For more information about the preventive and wellness services procedure codes and their utilization go to Colorado.gov/HCPF/ ProviderACAInfo. n

CMS receives highest CME accreditation level The Accreditation Council for Continuing Medical Education (ACCME) has awarded the Colorado Medical Society “Accreditation with Commendation,” the highest level of continuing medical education accreditation. Only organizations that demonstrate compliance in all 22 40

criteria and the accreditation policies achieve this highest honor. CMS has further demonstrated engagement with our environment in support of physician learning and change that is part of a system for quality improvement. n

serving transgender patients but a super-majority reported they are comfortable. • Colorado physicians are more comfortable with patients self-disclosing their sexual orientation or gender identity than they are asking their patients directly. • A minority of physicians is taking steps to create LGBT-friendly practices, for example, developing policies against discrimination and using LGBT-friendly forms. Other physicians have expressed interest in these steps. • Colorado physicians believe they already treat their LGBT patients equally to other patients. However, equal treatment doesn’t mean LGBT Coloradans are getting the care they need. • Primary care physicians were more likely than specialty care physicians to acknowledge the role sexual orientation and gender identity play in patient health and are more likely to be taking steps to be more LGBT-friendly. • There is a great interest in becoming more LGBT-friendly among physicians in the Denver metro area, younger physicians in the state and male physicians. In addition to the report, this partnership has produced an accredited online Continuing Medical Education program specific to improving the care experience of the LGBT patient population and resources for physician offices: “Health and Health Care for the LGBT Community: Identifying and Minimizing Disparities.” To access the program, go to tinyurl.com/ CMS-LGBT-study. n

Colorado Medicine for January/February 2014

Departments

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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Management position providing medical leadership for Assessment Services. This person is responsible to direct clinical aspects of CPEP's Assessment programmatic services through oversight, and to be involved with clinically-related program activities. Included in this role is clinical oversight of the individualized assessments of a physician-participant’s clinical abilities. The person in this position is expected to support an atmosphere at CPEP that conveys respect and concern toward participants and an overall ethic of accountability. The employee is also expected to maintain objectivity in all proceedings with participants and referring organizations. Hours: 75% to 100% FTE, on-site 4-5 days per week Responsibilities:

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Provide direct oversight of a minimum of 5 clinical competence Assessments per month: Conduct CPEP Assessments, the evaluation of a participating physician (“Participant”) to determine the level o current medical knowledge and clinical skill, and to identify deficiencies, if any, with sufficient detail to determine whether education and training can correct such deficiencies.

• Prepare Assessment Report for each Participant for whom direct oversight was provided. • Assist CPEP staff in compiling pre-assessment information to determine scope of all Assessments, including but not limited to:

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Communicating with the Participant (telephone intake) and any referring agency(ies); Reviewing intake materials; Providing input on consultant selection and test selection; Providing any post-assessment follow-up needed with the Participant and/or referring agency(ies). Work with Assessment staff to ensure clinical integrity and consistency of Assessments and Assessment Reports produced.

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Participate in the oversight of the Associate Medical Directors for Assessment Services (AMDs) and maintain the quality of clinical aspects of the program. Provide testimony and support in legal matters.

Qualifications: Must have active Colorado medical license or be eligible to obtain active license, and be board-certified in ABMS specialty. Prior experience in clinical practice is preferred. Optimally, this person will have experience working with state licensing boards, hospital peer review committees or medical staff leadership as well as experience in physician education activities (residency precepting or faculty activities). Must have very strong analytical and writing skills, computer skills, and superb communication skills. Email CV and cover letter to Gary Secino at gsecino@cpepdoc.org

Colorado Medicine for January/February 2014

WE ARE LOOKING FOR A NEW TENANT(S) - for an Imaging Clinic in the heart of Lone Tree, CO. There is 6,000 sq/ft available which is currently finished. We are open to making any additional changes to the space per tenant request. Lease will be $18 sq/ft plus NNN. There are also 3 separate entrances into this space so desired sq. footage is negotiable. This space also has its own parking and is located within a mile of Sky Ridge Hospital and Light Rail. The address is 8683 E. Lincoln Ave, Lone Tree, CO 80124. Cross roads are Lincoln Ave and Yosemite Rd. We can be reached for any additional questions at 303-888-0231 or 303-919-5515.

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DONATE SUPPLIES OR EQUIPMENT Project C.U.R.E. collects donated medical equipment and supplies and organizes them for delivery to people in need in developing countries. Volunteers needed locally to sort medical supplies and internationally to participate in C.U.R.E. Clinics. For more information, visit http://www.projectcureorg, call 303-792-0729, fax 303-792-0744, or e-mail projectcureinfo@projectcure.org. 41

Features

the final word Christopher Fellenz, MD Kaiser Permanente Community Benefit Program

Whole patient care maximizes health outcomes To be effective physicians, we must base our patients’ care on the evidence of medical science. However, there is also an art to healing patients – one that requires creativity and empathy. It is exceedingly fulfilling to see patients achieve better health because we’ve accurately diagnosed their condition and prescribed an effective treatment plan that they have successfully followed. Unfortunately, a few patients will remain in poor health despite our best interventions. Typically categorized as “noncompliant” or “difficult,” these patients require a second, deeper look to understand what interfering life circumstances may be affecting their ability to access health care or follow a treatment plan. Research shows that when providers approach these patients’ care with empathy and a more complete understanding of their lives better clinical outcomes are achieved. These interfering life circumstances, also known as social determinants of health, include factors such as a patient’s income, education, access to quality food and housing, race or eth-

nicity, and many others. Many Coloradans face significant barriers to getting their health care needs met. Patients may face issues accessing care without insurance, filling prescriptions they cannot afford, finding stable transportation to get them to and from appointments on time, or communicating in their non-native language. Noncompliant behaviors – such as not taking a prescribed medication or scheduling a follow-up visit – may be the result of limited resources or understanding. We can be more successful providers if we recognize each patient’s unique challenges and work to address their needs in a way that is appropriate for their situation. Additional research shows a troubling trend affecting our future colleagues – medical students experience a marked decline in empathy as they enter their third year of school. Empathy requires a focused time and presence that can be difficult to balance with the already extensive demands on a clinician’s time and attention. It can be especially challenging for students and new clinicians

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

E-mail: Letters to the editor dean_holzkamp@cms.org 42

to strike this balance, but it is critical for our patients’ health. In an attempt to address this issue, the Colorado Coalition for the Medically Underserved (CCMU) has produced an educational video that demonstrates how some social determinants interfere with health care treatment (www.ccmu.org/sdoh). I consulted on and participated in the video, and am excited to share it with my colleagues of today and tomorrow. In addition to the video, there is a discussion guide aimed at stimulating conversation around common-sense and creative solutions for approaching whole patient care. It is CCMU’s goal to incorporate the video into the curriculum of our state medical schools and other health professional training programs. Our society at large must work to minimize the effects of these social determinants of health, as it is far outside the scope of an individual provider’s abilities. We will need changes at the federal, state, local and community levels to make health care accessible to all Coloradans. However, physicians do have a responsibility in this work. We must challenge ourselves to look beyond our patients’ symptoms to see the whole of their complicated lives. We must practice empathy and think creatively. Better clinical outcomes mean happier, healthier patients, and that’s ultimately what patients, providers and all Coloradans strive to achieve. Dr. Fellenz serves as a family physician at Kaiser Permanente in Westminster, Colo., and is the physician consultant for Kaiser Permanente’s Community Benefit Program. n

Colorado Medicine for January/February 2014

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Wells WellsFargo Fargo Healthcare HealthcareServices Services Whether you’re preparing for ownership or planning Whether you’re preparing for ownership or planning for growth, Wells Fargo cancan helphelp youyou achieve youryour for growth, Wells Fargo achieve practice goals. practice goals.

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Chris Strabala Chris Strabala

Senior ViceVice President / Healthcare Market Manager Senior President / Healthcare Market Manager 303-863-6014 | christopher.j.strabala@wellsfargo.com 303-863-6014 | christopher.j.strabala@wellsfargo.com

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Colorado Medicine for January/February 2014