July-August 2018 Colorado Medicine by Colorado Medical Society

July/August 2018

Volume 115, Number 4

PUTTING THE LID ON THE OVERPRESCRIBING OF OPIOIDS Physicians and legislators come together to pass laws to facilitate appropriate prescribing of opioids

Award-winning publication of the Colorado Medical Society

contents July/August 2018, Volume 115, Number 4

Features. . .

Cover story Five bills that will

change the way physicians treat acute pain passed the 2018 Colorado General Assembly and were signed into law by Gov. John Hickenlooper. Colorado, like virtually every state in the country, is struggling with ways to mitigate the medical and economic consequences of the opioid epidemic. Learn what you need to know to stay compliant with these new laws starting on page 6.

Inside CMS 5 President’s Letter 35 COPIC Comment 36 Annual Meeting preview 40 Reflections 42 Introspections 45 CMS election info and candidate statements 47 CMS Corporate Supporters and Member Benefit Partners

Departments 51 52 57

Member Benefits Spotlight Medical News Classified Advertising

Colorado Medicine for July/August 2018

Legislative success–CMS end-of-session reception brings together legislators and physicians.

Honors and thanks–CMS applauds members of Interim Study Committee, Consortium and CMS PDA committee.

Recent trends–AMA report shows 21 percent decrease in opioid prescriptions in Colo. and other advances.

Colorado solutions–Changing the practice of prescribing for pain – one physician at a time.

Colorado solutions–An evidenced-based answer to the opioid crisis.

Colorado solutions–Lessons learned fighting the opioid epidemic, from surgeon to surgeon.

Colorado solutions–Swedish Medical Center is reducing opioid use in the emergency department.

Colorado solutions–Colorado hospitals achieve 36 percent reduction in opioid administrations.

Colorado solutions–Harm reduction philosophy reduces negative consequences of drug use.

Help for your practice–Prescribing boards release revised guidelines for prescribing and dispensing opioids.

Help for your practice–“Guidelines and Tools for Improving Pain Management: Opioid Stewardship.”

Losing patience–Denver Metro Chamber brings business community together to tackle health care costs.

AMA annual meeting–Complete coverage of CMS AMA delegation and student delegation meetings.

Doctors Care–As it celebrates 30 years of care for the underserved, Doctors Care appeals for specialist help.

Final Word–SB22 Senate co-sponsors Sens. Aguilar and Tate celebrate working together to make a difference. 3

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF

2017-2018 Officers M. Robert Yakely, MD President Debra J. Parsons, MD, FACP President-elect David Markenson, MD Treasurer Alfred D. Gilchrist Chief Executive Officer

Board of Directors Cory Carroll, MD Curtis Hagedorn, MD Mark B. Johnson, MD Richard Lamb, MD David Markenson, MD Benjamin Nance, MS Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Brad Roberts, MD Charlie Tharp, MD Kim Warner, MD C. Rocky White, MD

Katie Lozano, MD, FACR Immediate Past President

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

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

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

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

Inside CMS

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

The back story: A tremendous amount of behind-thescenes work goes into the process of passing legislation When the Colorado General Assembly enacts a new law, the common misperception is that the passage of this legislation can always be traced as a linear lesson in civics. The back story of course is far more complex, intimately human, and evolves over time. This was certainly true for the recent bill aimed at helping to combat the opioid crisis by limiting opioid prescriptions. The 2018 legislative story to address the public health crisis caused by opioid abuse and misuse actually began in 2012, when Governor John Hickenlooper, as part of a multi-state National Governors Association initiative, appointed a multi-stakeholder collaboration to develop a Colorado response. CMS immediately signed on in support and convened a broad group of specialists to advise CMS policy and to collaborate with the governor, state agencies and legislative leaders. In terms of state legislative policy over the past six years, there has been, and will continue to be, a candid give-and-take conversation between our profession and the policy makers who ultimately pass laws and oversee their implementation. This is the crux of any good piece of public policy. As SB 22, Measures for Safer Opioid Prescribing, went through the legislative process this year, there were diversions and misdirections. When our colleagues suggested exceptions for obvious circumstances, such as chronic pain that typically lasts longer than 90 days, for patients with cancer and those who are experiencing cancer-related pain, or patients undergoing palliative or hospice care, The Denver Post called them Colorado Medicine for July/August 2018

“loopholes.” The bill sponsors however understood the meaning of medical necessity and the suggestions were adopted and sustained. When plaintiff attorneys arrived late to this half-decade effort with an attempt to open up the Prescription Drug Monitoring Program report card database for fishing expeditions, legislators held fast to the notion that the means by which doctors learn from varied patterns of treatment are often complex and must remain a learning tool, not a courtroom exercise. Unsung partners, the lobbyists suffer innumerable indignities on our behalf, performing heroics when making our case to antagonistic stakeholders. Their effectiveness ultimately comes from a combination of expertise in the legislative process and a methodical participation from our grassroots physician efforts. They engage physician activists

from local communities who know their legislators and help staff our policy and real-world frontline committees and work groups. Over time, a threshold level of expertise and pragmatism settles into these deliberations, as good ideas are sifted from the bad. One commendable manifestation of reaching that threshold: The body of law mandating prescription fill limits and PDMP checks will expire in three years. To the credit of the bill sponsors, they will see these three years through with us, monitoring and discussing the data as it evolves with our real-world experts, studying outcomes from other states, and eventually settling in once again on what will work best in the future. It is a tribute to our involved experts, our advocates and our legislators that evidence-based policy was chosen over ideology. n

New member benefit for CMS members only! Know Your Rights database Physician practices have rights under Colorado law that can be exercised to mitigate health plan barriers to care. These rights have been summarized and incorporated into a members-only online database – Know Your Legal Rights – at www.cms.org/kylr for easy access. The members-only tool is searchable, and will help physicians and practice managers understand what their rights are in disputes with health plans. 5

THE OPIOID CRISIS:

What physicians need to know to be in compliance with new laws Kate Alfano, CMS Communications Coordinator

Colorado Medicine for July/August 2018

Cover Story Five bills that will change the way physicians treat acute pain passed the 2018 Colorado General Assembly and were signed into law by Gov. John Hickenlooper. Colorado, like virtually every state in the country, is struggling with ways to mitigate the medical and economic consequences of the opioid epidemic.

Senate Bill 18-022: Clinical Measures for Safer Opioid Prescribing Effectivel immediately, SB18-022 limits physician prescribing of opioid narcotics for certain patients. Patients within the following categories are exceptions and the new law does not apply to them:

The suite of legislation – which included one additional bill that did not pass this session – was developed by the 2017 Opioid and Other Substance Use Disorders Interim Study Committee last summer with strong involvement and support by the Colorado Medical Society and many other stakeholders.

• Chronic pain patients with a history of pain lasting more than 90 days or following transfer from another physician who prescribed an opioid, • Cancer-related pain patients, • Hospice and palliative care patients, • Patients who undergo a surgical procedure with pain expected to last more than 14 days because of the nature of the procedure.

The bills include measures that increase funding for access to treatment, enhance misuse prevention, require health plans to cover certain FDA-approved drugs for medicationassisted opioid dependence treatment without prior authorization, and enact safer opioid prescribing. “We tried to take on the opioid crisis as comprehensively as we could,” said Sen. Jack Tate, R-Centennial, who served on the interim study committee and sponsored Senate Bills 22, 24 and House Bill 1136. “There are limits as to what the state government can do and fund, and limits with regard to intervening in the clinician-patient relationship. Keeping all those things in mind we got a package of bills through that I think touches a lot of parts of the crisis where we can help.” “Each of the bills doesn’t necessarily solve the problem of the opioid epidemic but for a crisis of this magnitude, a single piece of legislation can’t be expected to solve the problem,” said Rob Valuck, PhD, RPh, director of the Colorado Consortium for Prescription Drug Abuse Prevention and cochair of the interim study committee stakeholder task force. “These five bills represent a meaningful step forward in the right direction by addressing a wide range of issues within the crisis, from prevention to recovery.”

Colorado Medicine for July/August 2018

For all other patients, the prescribing physician must limit the initial prescription of an opioid narcotic to no more than a seven-day supply of the medication. For outpatient care, after issuing the first opioid narcotic prescription the prescribing physician must check the Prescription Drug Monitoring Program (PDMP) database before prescribing any further opioid narcotics for the patient. The prescribing physician may exercise discretion to prescribe a second additional sevenday supply of opioid narcotic medication to the patient. After the second opioid narcotic prescription, the law no longer applies to any patient and further prescribing of opioid narcotics to the patient is guided by the physician’s judgment and medical indications for treatment of the patient. “Prescribers at one point were a root problem [of the opioid crisis] – in part due to the active misrepresentations by a few drug manufacturers and the government’s establishment of pain as the fifth vital sign,” Tate said. “This situation has been reversed. Because of the concerted efforts of the health professions over the past five years to rethink and reeducate themselves, the pre-

scribing of opioids in Colorado is now in a state of decline. As the health professions are the first to say that much more work needs to be done, they see SB 22 as affirming, buttressing, and accelerating this progress.” “I think that physicians haven’t gotten enough credit for all the work they’ve done already at cutting back on the prescribing of opiates,” said Sen. Irene Aguilar, MD, D-Denver. “I’m sure the next steps won’t be very dramatic for most but for those physicians who may not realize how significant our opioid crisis is, I hope that the limit on initial prescriptions will help them rethink whether there might be a safer method of treating someone who has acute pain.” House Bill 18-1003: Opioid Misuse Prevention The most important actions of this broad-scoped bill are that it extends the work of the 2017 interim committee for two years by establishing the Opioid and Other Substance Use Disorders Study Committee and it directs the center for research into substance use disorder prevention, treatment and recovery to develop and implement continuing medical education activities to help prescribers of pain medication safely and effectively manage patients with chronic pain, and when appropriate, prescribe opioids. “We’re glad the committee will be around for two more years so they can keep doing this job for a meaningful length of time,” Valuck said. “We expect they’ll be able to figure out virtually everything the state could do and try to do it.” “We’re looking for even more engagement, especially from the physician community,” he continued. “CMS has been involved since the beginning. We’re hoping to see even more engagement from the component societies of CMS and the specialty societies. The more doctors step up in leadership positions and help lead the solution, the more successful we’ll be.”

Cover story (cont.) Of the need for medical society involvement, Rep. Brittany Pettersen, D-Jefferson, said “We need them at the table so legislation isn’t passed that has unintended consequences. We also need their help with outreach and education about the bills passed during this last session. There is a lot of misinformation out there and the medical societies can help inform physicians.” HB18-1003 also establishes the follow-

ing specific measures to combat opioid misuse in Colorado: • Requires the governor to direct the Colorado Consortium for Prescription Drug Abuse Prevention to report to the General Assembly on recovery services and approaches in other states; • Authorizes school-based health centers to apply for grants to expand behavioral health services to in-

clude substance use disorder treatment and requires the Department of Public Health and Environment to prioritize funding to the centers that serve communities with highrisk factors; • Directs the Department of Health Care Policy and Financing to award grants supporting substance abuse screening, brief intervention and referral programs; and • Establishes programs to prevent

State legislators pass opioid bills What physicians need to know

SENATE BILL 18-022:

Clinical Measures for Safer Opioid Prescribing  Passed  Effective immediately

HOUSE BILL 18-1003:

Opioid Misuse Prevention  Passed  Effective July 1

HOUSE BILL 18-1007:

Substance Use Disorder Payment and Coverage  Passed  Effective January 1

HOUSE BILL 18-1136: Support the CMSTreatment Foundation Substance Use Disorder Passed withyour tax-deductible donation

 Effective no later than October 1

Limits physician prescribing of initial opioid prescription to no more than a seven-day supply. Exceptions: • Chronic pain patients with a history of pain lasting more than 90 days or following transfer from another physician who prescribed an opioid, • Cancer-related pain patients, • Hospice and palliative care patients, • Patients who undergo a surgical procedure with pain expected to last more than 14 days because of the nature of the procedure. For outpatient care, after issuing the first opioid narcotic prescription the prescribing physician must check the Prescription Drug Monitoring Program (PDMP) database before prescribing any further opioids for the patient. The prescribing physician may exercise discretion to prescribe a second additional seven-day supply of opioid narcotic medication to the patient.

Establishes the Opioid and Other Substance Use Disorders Study Committee and directs the center for research into substance use disorder prevention, treatment and recovery to develop and implement continuing medical education activities to help prescribers of pain medication to safely and effectively manage patients with chronic pain, and when appropriate, prescribe opioids. Other measures listed in the cover story.

Requires all individual and group health benefit plans to provide coverage without prior authorization for a five-day supply of at least one FDA-approved drug for medication-assisted opioid dependence treatment for the first request within a 12-month period. Bans insurers from taking adverse action against a provider based solely on a patient satisfaction survey relating to pain treatment.

Seeks federal authorization to add residential and inpatient treatment and medical detoxification services to Colorado Medicaid to serve individuals with substance use disorders, including those with co-occuring mental health disorders.

The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of SENATE BILLBoard 18-024: Coloradans. The CMSF of Trustees is committed to the success ofAmends these programs and excited the Colorado service corps program by expanding the Expand Access (to) Behavioral Health Care Providers of We behavioral health care providers in shortage areas in about the possibilities they present for improving health care servicesavailability in Colorado. need your the state by establishing a system for school loan repayment and a  Passed help to meet our goals. scholarship for providers trained in addiction counseling.  Effective July 1

Consider giving a tax-deductible donation of $25, $50, or more to help CMSF continue its mission. Questions? Call 720-858-6310.

Colorado Medicine for July/August 2018

Cover Story youth addiction and support youth whose family members experience addiction. The law takes effect July 1. HB18-1007: Substance Use Disorder Payment and Coverage This legislation requires all individual and group health benefit plans to provide coverage without prior authorization for a five-day supply of at least one FDA-approved drug for medicationassisted opioid dependence treatment for the first request within a 12-month period. Under the bill, insurers cannot take adverse action against a provider based solely on a patient satisfaction survey relating to the patient’s satisfaction with pain treatment.

ic training in substance use disorders; advanced practice nurses; physicians certified or trained in addiction medicine, pain management or psychiatry; and candidates for licensure as an addiction counselor, professional counselor, clinical social worker, marriage and family therapist or psychologist. “We know that the opioid epidemic reaches into all areas of Colorado, both urban and rural, and across all socioeconomic classes,” Tate said. “Unfortunately, treatment for mental health and substance use disorders is not as widespread. With SB 24, the state will devote $2.5 million toward incentivizing behavioral health care providers to go into areas of the state where care is not readily available and also toward funding important addiction treatment training.” The law takes effect July 1.

The law takes effect Jan. 1, 2019. HB18-1136: Substance Use Disorder Treatment This bill adds residential and inpatient treatment coverage as well as medical detoxification services to Colorado Medicaid to serve individuals with substance use disorders, including those with cooccurring mental health disorders. The State Department has to seek federal approval no later than Oct. 1, 2018. SB18-024: Expand Access Behavioral Health Care Providers The final bill introduced from the 2017 interim study, it amends the Colorado service corps program by expanding the availability of behavioral health care providers in shortage areas in the state by establishing a system for school loan repayment and a scholarship for providers trained in addiction counseling. “Behavioral health care providers” comprises licensed and certified addiction counselors; licensed professional counselors; licensed clinical social workers; licensed marriage and family therapists; licensed psychologists; licensed physician assistants with specifColorado Medicine for July/August 2018

“I’m pleased with the progress we made passing five bills in our opioid package and securing funding increases

for treatment in the budget,” said Rep. Chris Kennedy, D-Lakewood, who sponsored or co-sponsored each of the opioid bills. “The steps we’ve taken will reduce overprescribing and increase access to treatment and recovery services across Colorado.” The interim study committee has been authorized to operate for two more years. “I think we have a huge opportunity to set the groundwork to be a leader nationally in the way we address the epidemic,” said Pettersen, who also said she is chairing the committee for a second year. “I am really proud of what we’ve been able to accomplish but it is just the first step and I am committed to having doctors at the table as we continue the conversation.” “The opioid crisis is very much one of those issues that thankfully isn’t partisan at all,” Aguilar said. “I hope going into the next session that more focus is put on treatment and looking at some of the social determinants that contribute to this issue.” n

Gov. Hickenlooper signs SB22 into law May 21

On May 21 Colorado joined the many states that limit an initial opioid prescription for some patients, and, for those patients, require physicians to conduct a screening on the state Prescription Drug Monitoring Program database (PDMP) on the first refill to reduce the risk of drug-seeking behavior for nonclinical use or abuse. CMS-member physicians and public policy leaders worked closely with legislators and the governor’s office to assure exemptions for patients with longer-term pain management needs as well as those in inpatient care, and to assure physicians can continue to use their medical-clinical judgement to determine the requirements’ applications in their patients' cases. CMS successfully persuaded legislators to reject an attempt by plaintiff attorneys to have open access to prescribing report cards – an important tool that will allow physicians to compare their prescribing to that of their peers.

Features

Celebrating success Emily Bishop, Program Manager, Division of Government Relations

CMS end-of-session reception brings together legislators, physicians to celebrate progress against opioid epidemic On a cloudy evening in June, legislators, physicians, friends of medicine, and their families gathered to celebrate the end of another session with an evening of music, food, and conversation. Too often, the work of public servants goes unnoticed, the sacrifices they make – time away from family, setting aside careers – is overlooked. Physicians know this all too well, especially those who volunteer their limited free time to work

From left to right: CMS President Robert Yakely, MD, Sen. Tim Neville (R), COMPAC Chair Christopher Unrein, DO.

alongside CMS, advocating for health care at the Capitol. Taking a break from the already-building pressures of the 2019 session, CMS’ government affairs team used the evening as an opportunity to recognize the legislators that represent physicians and their patients. The reception, held at the historic Grant-Humphreys Mansion, was a collaboration with the Denver, ArapahoeDouglas-Elbert, Aurora-Adams, and

From left to right: Zainab Zullali and Oluwatosin Adebiyi represented the medical student component society at the reception.

From left to right: Rep. Jeff Bridges, (D), Andi Stader, Don Stader, MD, and Rep. Brittany Pettersen, (D), take time to celebrate the slate of opioid legislation that became law this year. 10

Foothills Medical Societies as well as Rocky Vista University and the Colorado Chapter of the American College of Emergency Physicians. While the majority of the evening was dedicated to conversation between colleagues and friends, the Chair of COMPAC, Christopher Unrein, DO, FACP, CMB, took a few minutes to express gratitude on behalf of CMS for the work of both lawmakers and physicians. He invited the attending legislators to introduce themselves to the gathered party; “It was remarkable how legislator after legislator all had the same remarks regarding the CMS lobbying staff,” Dr. Unrein remembered. “They all reiterated that our staff was professional, knowledgeable, and on their game . . . This should give all members of CMS something to be very proud of, knowing that the medical profession is so well represented at the capitol.” The reception brought together a wideranging group of physicians. The Council on Legislation, COMPAC, and student component were all represented, along with attendees from advocacy groups of specialty societies and graduates of CMS’ Public Policy Course. A jazz trio of students from the University of Colorado Denver kept the atmosphere lively as attendees dodged occasional rain showers to enjoy the beautiful grounds overlooking the Governor’s Mansion. The is the event’s second year in a row, CMS hopes to make the celebration an annual tradition to thank those that make advocating for the medical profession possible. n Colorado Medicine for July/August 2018

Features

CMS applauds the members of the 2017 Opioid and Other Substance Use Disorders Interim Study Committee The Colorado Medical Society honors the members of the 2017 Opioid and Other Substance Use Disorders Interim Study Committee. Over the course of the 2017 interim they met six times to discuss and hear testimony on the scope of the opioid epidemic from medical and mental health providers and learned about state agency programs and initiatives aimed at addressing opioid misuse, treatment and recovery. In addition, members of law enforcement spoke about issues that the criminal justice system faces when incarcerating individuals who use opioids, and health insurers discussed proactive steps they have taken to reduce the overprescribing of opioids and the misuse of opioids. Five of the six bills that came from the committeeâ&#x20AC;&#x2122;s work and were considered by the 2018 Colorado General Assembly were signed into law this year. One of the bills establishes the committee to continue its work until sunset in 2020.

Members of the 2017 Opioid and Other Substance Use Disorders Interim Study Committee

Rep. Brittany Pettersen, Chair (D)

Sen. Kent D. Lambert, Vice Chair (R)

Rep. Perry Buck (R)

Sen. Cheri Jahn (Unaffiliated)

Rep. Chris Kennedy (D)

Sen. Dominick Moreno (D)

Rep. Clarice Navarro (R)

Sen. Kevin Priola (R)

Rep. Jonathan Singer (D)

Sen. Jack Tate (R)

CMS would also like to recognize Robert Valuck, PhD, RPh, director of Gov. John Hickenlooperâ&#x20AC;&#x2122;s Colorado Consortium for Prescription Drug Abuse Prevention, who served as cochair of the task force established to assist the interim study committee in its work, and Donald Stader, MD, who served as CMS liaison on this task force. Robert Valuck, PhD, RPh

Donald Stader, MD

CMS Special Committee on Prescription Drug Abuse

Finally, CMS honors the members of the CMS Special Committee on Prescription Drug Abuse, whose diligent work to examine this issue and work toward solutions over the past five years has greatly benefitted patients and physicians. Colorado Medicine for July/August 2018

John S Hughes, MD (Chair) J. Scott Bainbridge, MD John Clapp, MD Tom Denberg, MD Ken Finn, MD Brian Flynn, MD Gary Ghiselli, MD Jan Gillespie, MD Elizabeth Grace, MD Andrew Hall, MD Jason Hoppe, DO Shannon Jantz, MD

Ellie Jensen, DO Robin Johnson, MD Stuart Kassan, MD Rebecca Knight, MD Tom Kurt, MD Alan Lembitz, MD Elizabeth Lowdermilk, MD Richard May, MD Cyrus Mirshab, MD Kathryn Mueller, MD Carla Murphy, MD Erik Natkin, DO

Lee Newman, MD Lynn Parry, MD Jens Peter-Witt, MD John Sacha, MD Bob Sammons, MD Donald Stader, MD Matthew Szvetecz, MD Chris Unrein, DO Ben Vernon, MD Steven Wright, MD Terry Boucher, CMS consultant 11

Features

Recent trends CMS staff report

New AMA report shows 21 percent decrease in opioid prescriptions in Colorado, other physician-led advances The American Medical Association issued a report May 31 documenting how physicians are advancing the fight against the opioid epidemic. It is based on a study by the IQVIA Institute for Human Data Science titled, “Medicine Use and Spending in the U.S.: A Review of 2017 and Outlook to 2022.” The Colorado Medical Society applauds all physicians making strides against this public health crisis through education and practice changes, and urges all physicians to work together on long-term solutions. The report found a decrease in opioid prescribing, and increases in the use of state prescription drug monitoring programs (PDMPs), the number of physicians trained and certified to treat patients with an opioid use disorder, and in access to naloxone. “While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose,” said Patrice A. Harris, MD, MA, chair, AMA Opioid Task Force. “What is needed now is a concerted effort to greatly expand access to high quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end.” “Over the last five years, Colorado physicians have consistently supported a range of voluntary and public policy initiatives aimed at reversing the public health crisis caused by opioid abuse and misuse,” said M. Robert Yakley, 12

MD, CMS president. “The AMA report demonstrates these efforts are paying off. Combined with a legislative package developed by the Opioid and Other Substance Use Disorders Interim Study Committee and passed by the 2018 Colorado General Assembly, Colorado will continue to make gains in reversing the crisis and expanding access to care for an opioid-addicted patient cohort that knows no regional, gender, age, income or other boundaries.” Fewer opioid prescriptions Opioid prescribing has decreased for the fifth year in a row. Physicians have decreased opioid prescriptions nationwide for the fifth year in a row. Between 2013 and 2017, the number of opioid prescriptions decreased by more than 55 million – a 22.2 percent decrease nationally. Decreases occurred in every state, including a 21.1 percent decrease here in Colorado. Increased PDMP use PDMP registration and use continues to increase. In 2017, health care professionals nationwide accessed state databases more than 300.4 million times – a 121-percent increase from 2016. States with and without mandates to use the PDMP saw large increases. Nearly 40,000 physicians and other health care providers were registered with the PDMP in Colorado in 2016 and queries increased from 683,000 in 2014 to 1.5 million in 2016 (2017 numbers were not reported). More physician education Physicians are enhancing their education. In 2017, nearly 550,000 physicians

and other health care professionals took continuing medical education classes and other education and training in pain management, substance use disorders and related areas. Many of these resources are offered by the AMA, state and specialty societies, and more than 350 of these resources can be found on the AMA opioid microsite, www.endopioid-epidemic.org. A separate CMS all-member opioid survey released in November 2017 showed that nearly three-quarters (70 percent) of CMS physicians report taking CME regarding opioids in at least the past two to three years. Access to naloxone is rising Naloxone prescriptions more than doubled in 2017, from approximately 3,500 to 8,000 naloxone prescriptions dispensed weekly. So far in 2018, that upward trend has continued; as of April, 11,600 naloxone prescriptions are dispensed weekly – the highest rate on record. Treatment capacity increasing As of May this year, there were more than 50,000 physicians certified to provide buprenorphine in office for the treatment of opioid use disorders across all 50 states – a 42.4 percent increase in the past 12 months. “We encourage policymakers to take a hard look at why patients continue to encounter barriers to accessing high quality care for pain and for substance use disorders,” Harris said. “This report underscores that while progress is being made in some areas, our patients Colorado Medicine for July/August 2018

Features need help to overcome barriers to multimodal, multidisciplinary pain care, including non-opioid pain care, as well as relief from harmful policies such as prior authorization and step therapy that delay and deny evidence-based care for opioid use disorder.” More needs to be done To further address the opioid epidemic, the AMA and CMS urge policymakers and insurers to remove barriers to care for pain and substance use disorders. These steps include the following. • All public and private payers should ensure that their formularies include all FDA-approved forms of medication-assisted treatment (MAT) and remove administrative barriers to treatment, including prior authorization. • Policymakers and regulators should increase oversight and enforcement of parity laws for mental health and substance use disorders to ensure patients receive the care that they need. • All public and private payers – as well as pharmacy benefit management companies – must ensure that patients have access to affordable, non-opioid pain care. • We can all help put an end to stigma. Patients with pain or substance use disorders deserve the same care and compassion as any other patient with a chronic medical condition. n

All friends of medicine are eligible to participate Email susan_koontz@cms.org or call 720-858-6327 or 800-654-5653, ext. 6327 9258_CMJClinicalGuidelinesAd_Resizes_060718_x1A.pdf

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Colorado Medicine for July/August 2018

Features

Colorado solutions Q & A with Shannon Jantz, MD, Colorado Permanente Medical Group

Changing the practice of prescribing for pain: One physician at a time Throughout 2018, Colorado Medicine has featured several stories about organizations and health systems in our state making important changes to address the opioid crisis in our country. This month, we want to focus on efforts at the individual physician level. What can you do today or tomorrow to impact change? Here we talk with one physician about what she is doing in her practice to change the way she addresses her patients’ pain. Shannon Jantz, MD, is a family medicine physician with Colorado Permanente Medical Group (CPMG). CPMG is one of the state’s largest multispecialty medical groups and serves the 660,000 members of Kaiser Permanente Colorado. Jantz also serves as a committee member on the CPMG Governance Council here at the Colorado Medical Society and sits on the board of the Colorado Academy of Family Physicians.

What’s the first step in talking to patients about pain? As a primary care physician, I deal with both acute and chronic pain every day. One of the most common acute pain conditions that I see is for back pain, whether from an injury, overuse, strain or long-term pain for which they are finally coming in to be seen. One of the first steps after empathy, of course, is to actively educate my patients about pain and the role of medications versus adjuvant therapy in treating pain. Medications have a relatively small role in the overall management of pain and I believe helping patients understand that is very important. How do you address opioids? When prescribing for more acute pain conditions I set the patient’s expectations up front that opioids are really only intended for the first three to five days. And at the same time, during

Share your success story Throughout 2018, Colorado Medicine has featured several stories about organizations and health systems in our state making important changes to address the opioid crisis in our country. Whether it's from a solo practice, small group, large group or as a large system employee, we’re interested in how other physicians in the community are changing their practice of prescribing for pain. Contact us at enews_editor@cms.org to share your story.

those first three to five days, we need to use scheduled acetaminophen and ibuprofen (when patients are able to take those). Recently, while splinting a patient’s fractured wrist, I explained to the patient about new data showing combination of acetaminophen and ibuprofen is just as efficacious for acute pain control as a dose of opioids. The patient was surprised – and very receptive to trying this instead of automatically going for opioids alone. What about chronic pain patients? For my chronic pain patients, I have worked very hard to make sure they are on multiple non-opioid pain medications and at appropriate doses. As physicians, we know this takes time and education as many patients are hesitant to take multiple medications. However, pain is complex and we need to treat it from a variety of angles to create a safe and successful plan. Are other physicians you work with on board with this approach? Working at Kaiser Permanente I am fortunate to have excellent specialty colleagues who provide the same messaging about the importance of both non-medication treatments and nonopioid pain medications in the treatment of pain. The more we all can work together to provide similar messaging to our patients the better our long-term outcomes will be. We’re interested in how other physicians in the community are changing their practice of prescribing for pain. Contact us at enews_editor@cms.org to share your story. n Colorado Medicine for July/August 2018

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Colorado solutions

Jonathan Clapp, MD, Board Certified Physical Medicine & Rehabilitation & American Board of Pain Medicine, Physician Pain Consultants, LLC J. Scott Bainbridge, MD, Denver Back Pain Specialists, LLC, BPS Research, LLC, MindYourPain, LLC, Secretary, Colorado Pain Society Board of Directors

An evidence-based answer to the opioid crisis Despite substantial efforts to reduce the impact of the opioid epidemic, death rates continue to climb both locally and nationally. According to the Centers for Disease Control and Prevention, in 2016 there were 32,445 deaths nationally involving prescription and illegal opioids, equivalent to about 89 deaths per day. This was an increase from approximately 22,598 in 2015. The Colorado Health Institute’s analysis reveals that in Colorado, 919 overdose deaths were recorded in 2016, and preliminary Colorado Department of Public Health and Environment data from 2017 shows yet another record increase to 959 deaths. Physicians need to lead Physicians need to lead the way to eradicate this crisis. The Colorado Medical Society and the Colorado Pain Society have offered insights and helped to guide legislation and other policymaking regarding the best ways to balance the appropriate treatment of pain, while decreasing opioid-related overdoses and addiction. The solution to this challenge can be found in the evidence; however, physicians have failed to universally adopt it. With two steps Colorado could become not just a national leader but also a national standard if: 1) Physicians are educated on proper diagnosis and better treatment of pain using alternatives to opioids, and 2) Health insurance companies ensure easy patient access to these evidence-based alternatives to pain treatment. Our institutions have failed to teach us about pain. The American Pain SociColorado Medicine for July/August 2018

ety published a study that showed U.S. medical schools offered only an average of 11.3 hours of “pain training” in some form compared to roughly 2.5 times that (27.6 hours) in Canada, where the overdose rate per population is roughly 2.5 times less than that of the United States. According to research, pain is the primary reason for all patient visits, but less than 1 percent of our training is dedicated to this complaint. Formal courses (or even single lectures) on pain treatment are uncommon for patients struggling with anxiety, addiction, high opioid tolerance, respiratory compromise and many other confounders. We learn about opioids and their pharmacology, but not how to best diagnose and treat pain and understand the variables inherent to treating patients in pain. Too often, older and cheaper opioids are used as a “fix-all.” More education available More than 80 percent of CMS members have already engaged in pain continuing medical education (CME) activities, but we need to take it a step further to eradicate the opioid crisis. Thanks to the Colorado Consortium, CMS and the Colorado Pain Society working together, we have an incredible opportunity to establish multiple web-based, live lectures and resources to educate physicians and pain providers on basic pain concepts like opioid-induced hyperalgesia, opioid-rotations, using safer atypical pain medications like tapentadol and buprenorphine, identifying the type of pain and pain generator, and treating with recommended nonopioids as first line. This would equip providers with alternatives to the more

dangerous (but cheaper) generic opioids like oxycodone, morphine, fentanyl, methadone, hydrocodone, hydromorphone and oxymorphone. Health plans need to step up Unfortunately, all too often it seems that the use of these dangerous opioids is the only pain treatment that health insurers either consistently cover or do not impose cumbersome prior authorization requirements. Safer and evidence-based, non-pharmacological pain treatments (pain psychology, physical therapy and acupuncture), appropriate interventional procedures, safer atypical opioids (tapentadol IR and ER, buprenorphine buccal films and transdermal patches) and at least one of existing, and future, FDA designated abuse-deterrent opioids for each specific molecule (oxycodone, hydrocodone, morphine, etc.) have to be easily accessible if we are to safely treat pain. Next steps The next step is for the profession to push for insurers to increase their role in solving the opioid crisis. It is not ethical to limit access to pain treatment and doing so only protects their bottom line. The hypocrisy is evident hundreds of times per day in Colorado, when the opioids that are most often abused and responsible for killing our loved ones are the only ones that are affordable for most patients. Or, they have to “try and fail” these dangerous opioids before getting something safer and more specific for the individual’s pain. This leads to greater exposure to the very drugs driving the addiction that is fueling the opioid epidemic. n 15

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Bruce Waring, MD, FACS, Surgical Specialists of Colorado, Partner Denver Academy of Surgery, President, Colorado Chapter of the American College of Surgeons

The opioid epidemic: Surgeon to surgeon Surgeons can play an important role in addressing the national opioid crisis. First, we must accept some of the responsibility, as 37 percent of all opioid prescriptions are written by surgeons. Recent studies indicate that 6 percent of general surgery patients will be taking an opioid for a reason other than their surgery one year after their procedure. The number increases to 14 percent for patients at the one-year mark after musculoskeletal procedures. Pain is a necessary but undesirable consequence of surgery, and surgeons are responsible for understanding effective treatment options and how to deal with acute exacerbation of chronic pain. We use our best judgement to provide appropriate therapy, and a specific strategy with protocols is helpful. Managing patient expectations may be the most

important aspect of their care. Surgeons are part of the solution in this significant problem; we must be proactive. Here are ten strategies our surgical group has implemented to reduce the use of opioids in our practice: 1. Initiating a preoperative discussion about expectations and postoperative pain options. 2. Identifying patients who already are on chronic pain meds and communicating with their pain management physician. 3. Ensuring preoperative administrative use of Gabapentin and NSAIDs with a defined protocol. 4. Collaborating with our anesthesia colleagues regarding increased use of epidurals, local /regional blocks, and On-Q pain pumps. 5. Working with hospital P&T com-

mittee for the approval of IV Tylenol and long-acting bupivacaine. 6. Encouraging ERAS protocol for limited opioid use post op which also reduces post op ileus. Expanding ERAS for other procedures as well. 7. Providing post op counseling for expected duration of opioid use. 8. Setting procedure-specific limits on opioid pain meds; for example, hernias and laparoscopic cholecystectomies. 9. Establishing call and weekend policies that limit prescription-seeking behavior and doctor shopping. PDMP monitoring is now required. 10. Conducting practice risk management reviews and shared review of quarterly PDMP reports. n

Colorado Medicine for July/August 2018

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Colorado solutions Erik Verzemnieks, MD

Case study: Swedish Medical Center is reducing opioid use in the emergency department Reducing our reliance on opioids is more than simply saying â&#x20AC;&#x153;stop.â&#x20AC;? Providing alternatives to providers is essential. At Swedish Medical Center, our emergency department has implemented a set of opioid-alternative pathways to give providers the tools to treat pain effectively but also expose fewer patients to the potentially harmful effects of opioids. Many conditions have more effective analgesic options than opioids, making implementation common sense. Intravenous lidocaine combined ketorolac is an effective way to control the pain of renal colic. Musculoskeletal pain, including back pain, can be treated with ketamine, lidocaine patches, and trigger point injections. In headaches, opioids can be detrimental, and there are many effective options ranging from simple high-flow oxygen to haloperidol and valproic acid.

indications where opioids are first-line or even required. Now we are not alone in this endeavor. Several other emergency departments and hospitals throughout the state have joined in a pilot study to assess the effectiveness of these alternative pathways. These include Boulder Community Health and BCH Community Medical Center Emergency Room, Gunnison Valley Health, Medical Center of the Rockies, UCHealth-Greeley Emergency and Surgery Center, Poudre Valley Hos-

pital, UCHealth Emergency Room-Harmony, Sedgwick County Health Center, Sky Ridge Medical Center and Yampa Valley Medical Center. It will be exciting to see the results of these interventions as we all work to fight the opioid epidemic and provide better care to our patients throughout Colorado. For those interested in learning more about these pathways, read the most recent Colorado ACEP 2017 Opioid Prescribing and Treatment Guidelines. Find the guidelines online: www.coacep.org. n

Though there is an emphasis on opioid alternatives, opioids do have a continued role in pain control in the emergency department. But with multiple alternatives now available to our providers, we are beginning to see many fewer

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Colorado solutions CMS staff report

Colorado hospitals achieve 36 percent reduction in opioid administration through CHA pilot Colorado currently has the nation’s 12th highest rate for misuse and abuse of prescription opioids. Beginning in June 2017, the Colorado Hospital Association (CHA) and its member hospitals conducted a six-month pilot in eight Colorado hospital emergency departments (EDs) and two freestanding emergency departments (FSEDs) with the goal of reducing the administration of opioids by ED clinicians. This initiative, one of the largest opioid research efforts in the United States, used treatment guidelines developed by the Colorado Chapter of the American College of Emergency Physicians (Colorado ACEP) that recommend the use of alternatives to opioids (ALTOs) as a first-line treatment for pain rather than opioids.

Pleased with the results of the pilot, CHA President and CEO Steven Summer said, “These results suggest that the opioid crisis in Colorado could be significantly reduced by a widespread implementation of the ALTO treatment guidelines and that is something we know our member hospitals and health systems are very interested in pursuing.”

clear,” said Donald Stader, MD, Colorado ACEP secretary, ED assistant medical director Swedish Medical Center. “My colleagues and I are very excited by the pilot results. It appears that we are one step closer to solving the opioid crisis in Colorado.” For more information and additional details about the results, visit www. cha.com/opioid. n

“The potential that opioid prescriptions carry for addiction and abuse made the need for these guidelines

All participating members successfully implemented the pilot, which returned remarkable results. The EDs achieved a 36 percent reduction in opioid administrations when compared to the same time period in 2016, far surpassing the original pilot goal of a 15 percent reduction. This amounted to a projection of 35,000 fewer individual opioid administrations between the 2017 pilot and the 2016 baseline period. The changes in ED pain management behaviors were dramatic, and the usage of ALTOs increased to the point that they became more commonly administered than opioids for some diagnoses in the treatment of pain. The pilot facilities treated a combined total of 130,631 unique patients during the six-month pilot period. Colorado Medicine for July/August 2018

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Colorado solutions Don Stader, MD, CMS Liason, Colorado Consortium for Prescription Drug Abuse Prevention

Harm reduction philosophy reduces negative consequences of drug use Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. The approach is predicated on respecting patients and their choices, removing stigma, and discussing with patients ways that they can keep safe and reduce risk if they choose to continue using drugs. Harm reduction aims to prevent the spread of infection, including HIV/ AIDS, hepatitis B and C, sepsis, soft

tissue infections and endocarditis; reduce the risk of overdose and other drug-related fatalities; and decrease the negative effects drug use may have on individuals and communities. Initially developed in response to the US AIDS epidemic, the harm reduction philosophy has been used in recent years for the treatment of people who inject drugs; however, its principles are broadly applicable to most patients who abuse drugs. Injection drug use is intertwined

2017 Colorado Syringe Access Locations 1. Harm Reduction Action Center 231 E. Colfax Ave. Denver, CO 80203 303-572-7800

6. The Works 3450 Broadway Boulder, CO 80304 303-413-7533

2. Denver Colorado AIDS Project 2480 W 26th Ave., Ste. B-26 Denver, CO 80211 303-837-0166

7. Northern Colorado AIDS Project 400 Remington, Ste. 100 Fort Collins, CO 80524 970-484-4469

3. Jefferson County Public Health Clinic 645 Parfet St. Lakewood, CO 80215 303-271-5700 4. Access Point Pueblo (available Fridays only) 505 West 8th St. Pueblo, CO 81003 719-621-1105 5. Aurora Syringe Access Services (Only available Wed. 1-3:30 pm.) 1475 Lima St. Aurora, CO 80010

8. Rocky Mountain Morpheus Project 414 Taos St., #B Georgetown, CO 80444 720-401-6569 (Syringe services not currently offered at this site.) 9. West Colorado AIDS Project 805 Main St. Grand Junction, CO 81501 970-243-2437

with the growing opioid epidemic; roughly 75 percent of injection heroin addictions originate with prescription opioids. Significant risks are associated with this behavior, as injection drug use accounts for between 12 percent and 26 percent of new HIV diagnoses and the majority of new hepatitis C infections. Rates of Hepatitis C in Colorado have increased by 80 percent from 2011 to 2015, demonstrating the need for medical providers to take a more proactive approach. For many clinicians, that may involve introducing harm reduction techniques into their practice. Four ways to implement harm reduction in your practice: 1. Judge not: Patients who abuse opioids should be managed without judgment; addiction is a medical condition and not a moral failing. Caregivers should endeavor to meet patients â&#x20AC;&#x153;where they are,â&#x20AC;? infusing empathy and understanding into the patient/medical provider relationship. A patient who believes that their doctor is judging them is unlikely to be open to counseling. 2. Know how to inject drugs safely: Clinicians should be well-versed in the safe injection of heroin and other intravenous drugs, and understand the practical steps for minimizing the dangers of overdose, infection and other complications. When treating patients with complications of IV drug use, injection habits should be discussed in detail, unsafe practices should be identified and instruction Colorado Medicine for July/August 2018

Features should be given about safe practices. A good video introduction to safe injection can be found at: www.youtube.com/watch?v=Miv8i-slK2w and more in-depth counseling advice can be found in the Colorado ACEP Opioid Guidelines available online at www.coacep.org. 3. Refer patients who inject drugs to syringe access programs: Local syringe access programs can be life changing. These facilities provide sterile injection materials and support services such as counseling, HIV/hepatitis testing and referrals to recovery centers. They are great public health partners, and medical practices should encourage their use for appropriate patients. 4. Embrace naloxone: High-risk patients such as those who are being treated for an overdose, are on high doses of daily prescription opioids, abuse prescription opioids or inject drugs should be provided naloxone. A best practice is to provide naloxone prior to discharge for high-risk patients. In Colorado, naloxone is available via a standing order at most Colorado pharmacies. However, providing a prescription to a patient or their family member can be a powerful motivator for a patient to follow through and fill their prescription. n

Owned and operated by the Colorado Medical Society and backed by a 50-year history of physician ownership, MTC is uniquely focused on the needs of its clients. Serving medical professionals is all we do. MTC's management team has over 50 years of experience in medical answering services. Our operators are professional, friendly and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule. MTC proudly received the prestigious 2009 Award of Excellence for the fourth year from ATSI (Association of TeleServices, Intl.), a service-quality award based on test calls placed over a six-month period. MTC is a member of the Denver/Boulder Bettter Business Bureau, ATSI and Telescan Users Network (TUNe). MTC particpates in the Colorado Medical Society's Disaster Preparedness Program by contacting volunteer providers in the event of a large scale disaster. In addition we collaborate with CMS every six month in testing the response time of the volunteer providers.

Plug in to your reinvented medical society! Choose interest areas today to be the first to know about new proposed policies. www.cms.org/central-line

Colorado Medicine for July/August 2018

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Help for your practice CMS staff report

Prescribing boards release revised guidelines for prescribing and dispensing opioids The seven prescribing and dispensing boards housed at the Colorado Division of Professions and Occupations has adopted revised Guidelines for Prescribing and Dispensing Opioids.

revised policy reflects their collaboration and the robust stakeholder feedback the boards received.

These boards – the Colorado Dental Board, Colorado Medical Board, State Board of Nursing, State Board of Optometry, Colorado Podiatry Board, State Board of Pharmacy, and State Board of Veterinary Medicine – embarked on an 18-month stakeholder engagement process in May 2016. The

www.colorado.gov/dora/opioid_guidelines

Visit DORA's new website for help

Learn about the revised Guidelines for Prescribing and Dispensing Opioids, the process for its revisions, stakeholder meeting recordings and more. Moving forward, the boards will continue to evaluate the policy, in-

corporating new legislation and collaborating with other state agencies, researchers, practitioners, patients, the Colorado Consortium for Prescription Drug Abuse Prevention, and other stakeholders to identify and evaluate outcomes. In a news release, the boards note that the policy is a “living document, reflective of the evolving science, technology, policy and law in their ongoing efforts to address Colorado's opioid crisis.” Written comments may be provided at any time to Holli Weaver at holli.weaver@state.co.us. n

Colorado Medicine for July/August 2018

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Help for your practice CMS staff report

Updated CME course, “Guidelines and Tools for Improving Pain Management: Opioid Stewardship” Working together, the Center for Health, Work & Environment and Colorado Consortium for Prescription Drug Abuse Prevention have launched this redesigned course to help health care professionals in Colorado stay in step with the latest opioid prescription guidelines and best practices. Over the past six years, more than 2,800 health professionals have completed the course. And more than 90% say that they have applied what they learned in their practice. Building on the past success of this course, it has been redesigned to cover current federal and state prescription guidelines, offer guidance on how to help patients with pain return to work, and much more.

CMS Education Foundation Founded in 1982, the Colorado Medical Society Education Foundation (CMS EF) is a nonprofit, taxexempt charitable foundation established primarily to support educational and charitable programs in Colorado. The Foundation has dedicated itself almost exclusively to the funding of scholarships to incoming students at the University of Colorado School of Medicine and Rocky Vista University. 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.

Help send a student through school. Call 720-858-6310 for information and to donate. Colorado Medicine for July/August 2018

As the opioid crisis grows, it’s more important than ever that health care professionals stay informed about the latest pain management policies and practices to deliver the best possible care to their patients. Any health care professional in Colorado who treats patients dealing with pain, from clinicians to dentists to practice managers, has something to learn from this course. Gain the skills and knowledge to: • Follow the latest state, federal, and

professional society guidelines to improve patient care; • Apply evidence-based, comprehensive pain management practices and address opioid misuse in your community; • Earn Continuing Medical Education (CME), Continuing Pharmacy Education (CPE), and Continuing Nursing Education (CNE) credit. Enroll today at http://maperc.mycrowdwisdom.com/diweb/catalog and click on the opioid stewardship link. n

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Losing patience Chet Seward, Senior Director, Division of Health Care Policy

Denver Metro Chamber brings business community together to tackle rising costs of health care The business community is fed up with the rising cost of health care and is taking action. While this issue has been a pain point for years, it has reached a critical stage fueled by recent activity by the Denver Metro Chamber of Commerce (DMCC) and more and more data show seemingly inexplicable variations in care and prices across the state. DMCC is leading an effort to immediately slow the rate of cost growth and sustain those changes over time using voluntary, regulatory and legislative proposals. It is essential that physicians continue to remain actively involved in efforts to decrease health care costs and improve quality. Growing concerns While health care cost growth has slowed over the past eight years, that growth still far outpaces inflation. More importantly, overall costs are at record levels ($28,000 a year for a family of four) and are squeezing out personal pay raises, business spending on growth and public-sector funding on priorities like transportation, education and jobs. Odds are you are hearing concerns from

both your patients and your practice’s HR department. Cost increases are now challenging the competitiveness of Colorado employers. The results of recent member focus groups by the DMCC underscore the extreme level of frustration and distrust of the health care industry by employers and employees, with some commenters worrying that their monthly health insurance premiums now cost more than their mortgage, others demanding full transparency on costs, and others calling the current system “a racket” and full of “cartels.” Pressure to act This spring the DMCC convened a coalition of health care stakeholders, including insurers, hospitals, pharma, the bio-science industry and physicians, to develop recommendations to decrease the cost of care and improve quality. The Colorado Medical Society (CMS) signed on from the start, viewing the chamber’s efforts as a unique opportunity to showcase and accelerate ongoing physician efforts. DMCC CEO Kelly Brough presented to the CMS board of directors in March on the initiative,

underscoring the intense pressure the DMCC is under to take meaningful action. She made clear that the DMCC intends to move forward with a suite of voluntary, regulatory and legislative actions in 2019, whether or not there is consensus within the coalition. Moreover, DMCC will share results of this work with other chambers of commerce around the state to grow support for this effort. Over a series of meetings, the coalition developed a slate of 95 proposals to contain costs while ensuring quality. At press time these ideas, which range from data and transparency, to reimbursement and workforce, were continuing to be refined and winnowed. Co-chair of the DMMC coalition Bill Lindsay emphasized the urgency and breadth of these recommendations: “Chamber members are saying that they want to see something happen now, not later. We are not talking about just legislation, we want to affect the market by using the market.” Denver-area radiologist and CMS representative to the coalition Peter Ricci, MD, said the focus has been on driving cost containment, improving quality, and ensuring that recommendations don’t make things worse and can be controlled by Coloradans. “There were a lot of ideas offered as potential solutions from the start. As discussions have progressed, they have sometimes become intense on topics like drug prices, hospital and health plan profits, the complexity of health care pricing, transparency and the need for uniform quality metrics and different payment models to drive better value,” he said. “But, there Colorado Medicine for July/August 2018

Features have also been areas of near universal agreement, including the need for better data to inform our decision making.” Physicians step up “As physicians, we recognize that on so many levels the current system is too costly, and that continued increases in the cost of care threaten our patients and our state, which is why bringing our profession’s collective voice to the table is essential,” Ricci said. Almost 40 presidents of component and state specialty societies, as well as chief medical officers from major hospital systems, met in early May to gain a sense of priorities regarding DMCC cost containment proposals. Outcomes from the meeting

were shared directly with the DMCC and helped to spur the development of a special CMS work group to help accelerate physician efforts to reduce costs and improve quality. While the profession is being proactive, much work remains and patience by the business community is wearing thin. If you have stories to share about your efforts or would like to participate, please contact CMS Director of Health Care Policy Chet Seward at chet_seward@ cms.org. A business-medicine coalition to drive meaningful cost containment and quality improvement efforts would be a powerful force for change at a time when it is clearly needed. n

Participate in the all-member electronic election of CMS officers The candidates for 2018-2019 office are: President-elect (select one for one position) David Markenson, MD AMA Delegates (select two for two positions) Katie Lozano, MD • Lee Morgan, MD Be sure to look for your ballot in your email on August 1. Ballots will be open until August 31.

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AMA annual meeting Lynn Parry, MD, CMS AMA Delegate

Colorado physicians and students gather in Chicago for participate in health care policy setting Physicians, medical students and medical society staff from around Colorado traveled to Chicago for the American Medical Association’s annual meeting. The Colorado delegation joined peers and colleagues in shaping the health care agenda of the nation’s largest physician organization. Ten physicians represent the physicians of Colorado, but Colorado’s impact on policy is felt throughout the organization by our representatives to the American College of Emergency Physicians, College of American Pathologists, Section on Medical Schools, Occupational Medicine, Association of Gynecologic Laparoscopists, Obesity Medicine Association, American College of Cardiology, and the Resident-Fellow Section as well as by two regional representatives from the Medical School Section who attend and vote in the House with the Colorado delegation. Setting and revising policy The AMA’s House of Delegates (HOD) is the policy-making forum at the center of American medicine, bringing together an inclusive group of physicians, residents and medical students representing every state and medical field. Delegates work in a democratic process to create a national physician consensus in response to emerging health care issues in the United States. The resulting policies will guide the AMA as it represents the physician voice in efforts to advance patient care and improve the nation's health care system. The House of Delegates tackled contentious issues at the meeting: The 26

CMS AMA Delegate David Downs, MD, CMS President Bob Yakely, MD, and CMS President-elect Deb Parsons, MD.

Colorado physicians and medical students come together for dinner Saturday night to socialize and review policy up for debate.

Colorado medical students join their peers from 15 states that form AMA-MSS Region 1 for a group photo at the AMA meeting.

CMS Delegate Lynn Parry, MD, MSS Region 1 Policy Chair Adam Panzer, Region Chair, Halea Meese, AMA-YPS chair Brandi Ring, MD.

Council on Ethical and Judicial Affairs (CEJA) Report 5 recommended that the AMA leave intact its policy opposing physician-assisted suicide. I testified on behalf of Colorado and PacWest, requesting the report not be adopted. The PacWest contains six states that have legal medical aid-in-dying. The HOD did not accept the report as written and the issue was returned to CEJA.

in discussions of health system reform. Colorado and PacWest supported the AMA being able to discuss all options with stakeholders. The resolution was referred.

A resolution from the medical students asked the AMA to alter its policy on single payer health care, which currently opposes consideration of this model

The HOD adopted amended language of Council on Medical Education Report 6 that recommends state licensure boards require disclosure only of an applicant’s current conditions that are not being treated appropriately and would adversely affect the applicant’s ability to practice medicine in a competent, ethical and professional manner. Colorado Medicine for July/August 2018

Features The HOD also passed a resolution directing the AMA to work with state and specialty societies to identify states in which physicians are restricted from providing the current standard of care with regards to obesity treatment and to remove out-of-date restrictions at the state and federal level prohibiting healthcare providers from providing the current standard of care to patients affected by obesity. The HOD also took an active position on firearm safety, adopting policy to support a ban of high-capacity weapons, require gun registration and education, and to support “red flag” requirements. The Colorado delegation is considering bringing the AMA policy to Central Line. Medical student updates For the first time, three Colorado student leaders are serving on the AMAMedical Student Section Region 1 executive board, demonstrating tremendous strength from the state on a national level. Halea Meese is the region chair, Adam Panzer is the policy chair and Krista Allen is the advocacy chair; these are some of the most vital positions on the executive board. Sohayla Rostami, MD, served in her final meeting as vice-chair of the medical student region and has been a mentor to all Colorado medical students. We thank her for her service, kindness and wisdom. In all, 12 Colorado medical students attended the annual meeting, including eight for the first time.

the sale of assault style rifles and bump stocks,” Meese said. “We also discussed issues that have particular relevance to physicians and our state, such as ensuring that medical licensure questions focus on current rather than any previous mental health impairment so as not to discourage physicians from seeking the resources they need.” “I'm very excited to be serving on the board for our region with my fellow Coloradans, Krista and Adam, who are also wonderful friends and mentors to the younger students,” Meese continued. “After my third meeting, our AMA feels like more of a family every year and I can't wait for our next meeting this November in Maryland!” Other leadership updates Colorado, part of the PacWest Conference of the AMA, helped host the PacWest wine reception to raise support for PacWest candidates running for office. Colorado delegates were pleased to bring the tastes of Colorado to Chicago, serving wine donated by Two Rivers Winery in Grand Junction. PacWest and Colorado continue to have great influence on the national level. To spread the influence of the Colorado delegation in the specialty arena, Kay Lozano, MD, FACR, ran for and was elected to the AMA Radiology Section Council Governing Council, and will serve as member-at-large. Jeremy

Lazarus, MD, former president of AMA and CMS, was appointed to the AMA Council on Ethical and Judicial Affairs. Carolynn Francavilla spoke as a panelist at the C Clayton Griffin Memorial Young Physician Section Assembly Luncheon. Several members of the Colorado delegation also reconnected with Jerome Adams, MD, MPH, who currently serves as the 20th surgeon general of the United States. He was a special guest at the meeting and gave a speech encouraging AMA members to lead the nation in a civil discussion on the pressing issues of our day, such as gun violence, substance-use disorder and health equity. Adams has worked with several of the Colorado physicians in the AMA Young Physicians Section in the past. Barbara L. McAneny, MD, an oncologist from Albuquerque, N.M. and member of the PacWest conference, was sworn in as the AMA’s 173rd president. In her address she shared her view of the health care landscape and told attendees that physicians are perfectly positioned to navigate the challenges and shape medicine to benefit patients. Patrice A. Harris, MD, a psychiatrist from Atlanta, was elected AMA president-elect. When she assumes the post of AMA president in June 2019, she will be the AMA’s first African-American female to hold that office. n

The AMA reinstated their medical student reception at the Annual Meeting on Friday night. Since this has traditionally been our evening to host the Colorado medical student reception, fellow delegates David Downs, MD, Debra Parsons, MD, and Tamaan Osborne-Roberts, MD, joined me in hosting a dinner for the Colorado medical students at Vermillion, where we celebrated their hard work with LatinIndian cuisine. “We had many fantastic discussions on important issues that affect the public, such as the gender pay gap and banning Colorado Medicine for July/August 2018

Colorado AMA Delegation members Tamaan Osbourne-Roberts, MD, Rachelle Klammer, MD, Jan Kief, MD, and Brigitta Robinson, MD, host the Colorado wine reception as part of the AMA PacWest Conference reception to raise support for PacWest candidates for AMA offices. 27

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Features

AMA student engagement CMS Medical Student Component Society

Medical students report on a successful meeting Editor's note: Colorado Medical Society has a long tradition of commitment to its medical student members, including funding the medical student component society to enable it to send interested students to state and national meetings. This feature is made up entirely of direct quotes from students writing about their experience at the AMA Annual Meeting held in Chicago in mid-June. What follows are unedited, direct quotes from some members of this year's student delegation.

through policy! I am truly grateful for the experience, and I am excited for an avenue for advocacy!” Ryan Friedman University of Colorado School of Medicine, MS2 “At the beginning of medical school, I believed that every physician had the duty to not only take care of patients inside the clinic but also to advocate for these individuals on a broader level when the medical system failed to meet their needs. As such, I entered the LEADS track, hoping to acquire a theoretical foundation of medical policy. Moreover, I applied to attend the AMA conference because I wanted to supplement this theoretical knowledge with practical application.

Joshua Abolarin University of Colorado School of Medicine, MS2 “I have to say, my experience at the conference was very enlightening. As a person who hopes to advocate for House of Delegates the underserved community, I felt the The AMA House of Delegates (HOD) is made up of conference provided me with an under170 groups. The 2018 conference had over 600 standingfellows, of theresidents procedure behindfrom policy physicians, and students around The conference far surpassed all of my the world. The HOD is similar to the MSS in regards to expectations: my biggest disappointmaking /approval. groups having a delegate and alternate delegate. They ment was learning how much the AMA play a critical role in the policy making process. But most of all, I was truly impressed and CMS accomplish and recognizThe HOD assembly is a space for major stakeholders to withtogether how topassionate people were ing that I missed out on engaging in come create policythe and discuss pressing issues affecting our communities and ourtruly nationfelt as a these organizations for the past year. about creating change they whole. would benefit their communities. Fur- Once I was able to understand how thermore, the level I received in sup- parliamentary procedure works, I was port from our team actually makes me very impressed by the resolutions that believe that I too can make a difference medical students put forward. While I still do not feel knowledgeable enough about gaps in the medical system to develop resolutions on my own, I intend to continue having conversations with the “veteran students” from CU, drawing on their expansive understanding of medical policies to provide me with the foundation of information that I need to feel confident to develop policy. From L to R: Marcus Marable, Ryan Friedman, Zainab Members of the medical student delegation Zullali, Gerald Yeung, Oluwatosin Adebiyi, Joshua Abolarin, toand theLakshmipriya AMA meeting from left to right: MarKaramsetty

cus Marable, Ryan Friedman, Zainab Zullali, Gerald Yeung, Oluwatosin Adebiyi, Joshua Abolarin, and Lakshmipriya Karamsetty. 28

My interactions with members of our MSS region and the Colorado delegation developed my pride in being an AMA member. At the Colorado del-

egation dinner I was impressed by the multi-layered depth of knowledge that members had on topics across the political spectrum, ranging from how discussions can be enhanced in a polarized political climate to what needs to be addressed to minimize gun violence, and I was amazed at the humility of the delegation heads. I sat next to the president-elect of CMS who, while clearly more knowledgeable than me on many topics, happily engaged me in conversation and took the time to hear my thoughts on issues. Moreover, I found the passion for policy, which was unanimously shared by members of the Colorado delegation, to be infectious. Now that the conference is over, I want to continue working with this incredible group of people, drawing from (and hopefully contributing to) their energy and passion for developing medical policy. I have spoken with Lakshmi and Tosin about finding a role for me within CMS or within the greater AMA that would allow me to draw on my strengths to help develop better health policy. I plan to meet with Halea to gain her input as well. Thank you for the opportunity to attend the conference. It was definitively one of the best experiences of medical school thus far for me, and I cannot wait to continue to be involved with CMS.” Marcus Marable University of Colorado School of Medicine, MS2 “Over the past year I’ve learned about anemia, memorized all the bones in the body, and have learned how to read an Colorado Medicine for July/August 2018

Features EKG, but I did not learn much concerning the medical field as a whole, or the business aspects of healthcare. Initially, I expected to spend the conference bouncing my ideas off of colleagues, and while this did happen, in attending the Small Changes, Big Results lecture, I underwent my most affecting experience. During this session, experienced physicians detailed their own payment structures, the ongoing innovations, and the unadopted evidenced- based practices. While I was ecstatic to be able to understand the words exiting several physicians’ mouths, the arguments and perspectives given flew right over my head, and over the heads of the other medical students in the room. Coming away from this session, I am now more aware of the gaps in my knowledge, and have a path to pursue my own development. Thank you for this opportunity.” Gerald Yeung University of Colorado School of Medicine, MS2 “The annual AMA conference was a truly amazing experience. It was incredible meeting so many other students and physicians coming together on their interests and passions within policy while having the opportunity to sit in on very relevant talks. For one, the scale with which AMA operates was energizing and it was inspiring to see this large body of individuals involved, spending their own time and money promoting changes they want to see in the medicine, both in terms of protecting/improving the profession and in terms of advocating for patients. This conference helped me find comfort knowing that I am not alone in my desire to change medicine for the better. In fact, here I have met colleagues that I will work with to champion issues such as single payer health care and the opioid crisis, and role models currently setting the foundations for this work, whose footsteps I will follow. While the more nuanced politics and parliamentary procedural elements of the AMA are aspects I realized do not fit my personality, it is still incredibly Colorado Medicine for July/August 2018

Physicians of the Colorado Medical Society AMA Delegation meet regularly with other Colorado and regional physicians in attendence and the medical student component society delegation to debate AMA policy under deliberation at the meeting. valuable for me to understand and appreciate. Vetting policies take incredible persistence and collaboration and these allow for everything downstream to follow. This has given me a newfound appreciation for this and now I have an idea of how policy formation works on the national level and on the more local level from my involvement in the CMS COL. Additionally, the workshops that were held throughout the conference provided me with useful tools and introductions to topics I was previously less familiar with. For example, during the mass casualty incident talk, there was mention on how to deal with media as they are always trying to bolster the story that sells with accounts of “babies crying, injured screaming,” but one can actually effectively utilize the media to broadcast a message such as a call for supplies while serving in a remote area. This is definitely a tool I can employ when I am in such situations in my career. Another interesting talk I had the chance to attend was the one discussing capitation and different models of taking on risk for value-based care. While much of the discussion went passed my current knowledge base, it was still very enlightening hearing how these different groups have been moving away from purely fee for service models.”

Zainab Zullali University of Colorado School of Medicine, MS2 “Going to this year’s annual AMA conference in Chicago was an enriching and empowering experience. As a member of the Colorado Medical Society Council on Legislation, I choose to play an active role in understanding and engaging in policies that affect patients and physicians; this conference allowed me to take a glimpse at the national issues that are at the forefront of the field that I am becoming a part of, and to begin formulating solutions to them with other individuals that are passionate about health care policy. It was inspiring to see the collaborative effort that was already underway amongst the student delegates from across the country, their passionate testimonies, and their commitment to moving medicine in a positive direction. The most impactful lecture that I attended was “A day in the life of me: Tackling prejudice against providers.” Four medical students detailed their experiences as minorities in the field, which solidified my desire to become an advocate and mentor to future students who, like me, do not have easily accessible role models who look like them. This lecture was an affirmation of the struggles that students like me face, and the impact that we can have by making our voices heard.” n 29

Features

Liz Herr, MD, Volunteer Care Coordinator at Doctors Care

Specialists – Doctors Care appeals to you to care for the most vulnerable, and promises to make it work for your practice Since its establishment 30 years ago by Arapahoe Medical Society physicians, Doctors Care has served as the nonprofit safety net clinic for south metro Denver, providing high quality affordable primary medical care to the uninsured and underserved, regardless of ability to pay. Until a few years ago, Doctors Care operated a program that connected uninsured adult patients requiring specialty care with a large network of specialty care providers in the community who were willing to care for those patients on a sliding-fee-scale basis. Doctors Care is immensely grateful to those physicians who have worked with us, providing excellent specialty care to those uninsured patients. Since the implementation of the Affordable Care Act in 2014, the combination of Connect for Health Colorado and Medicaid expansion significantly reduced the number of uninsured in our state. While this was an important step in improving health access for the medically underserved, we are encountering a new and expanding crisis of patients who have “coverage but no care,” particularly related to specialty consults and visits. Would you be willing to see one or two patients a month? Many Doctors Care patients needing specialty care find themselves without specialty care. In response, Doctors Care is reaching out to specialists, asking you to walk alongside us once again in caring for these patients in our com 30

munity. Would you be willing to see one or two patients a month? Or even one patient every couple of months? Many specialty practices have closed to new Medicaid patients other than those that come through hospitalizations or established referral physicians. Reasons are practical and understandable, often with concerns about potentially overwhelming numbers of patients coming in to practices at Medicaid reimbursement rates, and the complex social and economic barriers to care that exist for some underserved patients. Here's what you can expect We respect these concerns and want to minimize any challenges to providing specialty care for Doctors Care patients. Medicaid patient referrals from Doctors Care are different from other sources because of their experience working directly with a patient population charged with complex issues. In addition to the satisfaction of participating in a group providing a needed community service, when a specialist agrees to accept referrals from Doctors Care, they can expect the following: • Absolute control over number and type of patients they will accept. • Doctors Care providers obtain any requested pre- or post- appointment studies. • Well established Patient Navigation and Care Coordination services address non-medical barriers to care and assist patients in being accountable and reliable. • Patients have coverage necessary to

complete additional evaluation and treatment recommended by specialist. • Patients are seen earlier in their disease process rather than presenting for specialty care only after progressing to the point of ED visit or hospitalization. In return, our doors are open. We are happy to accept Medicaid or uninsured patients in your practice who need primary care and want to designate Doctors Care as their PCP. Adults up to age 50 can be seen at the Doctors Care Clinic, and health navigators assist patients over age 50 in establishing primary care in associated practices. In addition to high quality medical, dental and behavioral health care, patients at the Doctors Care Clinic can receive the wide range of care coordination and social support services that make Doctors Care unique. Our plea is simple – please consider collaborating with Doctors Care in accepting a limited number of referrals for much-needed specialty care for our patients. We are in particular need of specialty referrals for Orthopedists, Neurologists, Urologists and Endocrinologists, but would love to hear from others as well. Doctors Care takes the main barriers to seeing Medicaid patients away, leaving you to focus on their specialty care alone. If you are interested in partnering with Doctors Care, or would like additional information please contact me, Liz Herr, MD at eherr@DoctorsCare.org or 720-4586122. n Colorado Medicine for July/August 2018

Features

Volunteer providers, like Joel Boulder, MD, allow Doctors Care to leverage in-kind support to help more vulnerable Coloradans.

Nancy Mitchell, MD, a longtime volunteer pediatric provider, has treated some clinic patients from infancy all the way into their teens.

All well visits include an audiometry screen, vision acuity screen, oral exam with fluoride treatment, and age-appropriate developmental and depression screens.

Health navigation and connection to coverage programs offer free one-on-one assistance.

Doctors Care staff work as a team to ensure seamless, comprehensive services are available for all patients.

Integrated behavioral health care is available to Doctors Care clinic patients in one convenient location.

Alethia (Lee) Morgan, MD, helps Doctors Care meet adult Medicaid patient needs, recently increased from age 35 to age 50.

In 2017, over 1,000 dental hygiene visits were provided within the Doctors Care Clinic.

Doctors Care Board of Directors: (left to right) Andrea Chase; Morre Dean; Ellen M. Burkett, MD; Larry Wood, MD; Katie Spong Lozano, MD; Gary VanderArk, MD; Kathy Ashenfelter; Mary Ann Littler; Bebe Kleinman; Dakeana Bishop-Jones; Mark Dennis; Cheryl Curry; Sam Huenergardt; Craig Sargent (not pictured: Jason Kelly, MD; Mary Newell; LaNee Reynolds; Mary White; Brad Winslow, MD).

Bebe Kleinman, MNM, has served as CEO of Doctors Care for over 18 years. Bebe has more than 30 years experience in the nonprofit sector focusing on the needs of low income children and families.

Colorado Medicine for July/August 2018

Features

Barb Hanson, Director, Development & Marketing, Doctors Care

Celebrating 30 years as safety net for medically underserved For 30 years, Doctors Care has been known as “a gem in the community” for providing healthcare and services to low-income, medically underserved individuals in south metro Denver. The Doctors Care model is built on a commitment to providing long-term solutions to access which begin with coverage, extend to care, and ultimately to patients’ overall health and well-being. In the 30 years since its founding, Doctors Care has served more than 30,000 low-income residents of south metro Denver and provided more than $70 million in medical services to individuals in need. Brief history of the organization Founded in 1988 by the physicians of the Arapahoe Medical Society, Doctors Care is a private, nonprofit organization dedicated to improving health access and improving lives of people in need. Through a network of volunteer physicians, Doctors Care began providing care on a sliding scale, targeting individuals whose earnings were above the criteria to qualify for Medicaid and other public assistance, but below the level to pay for health care or private health insurance. After the successful establishment of this network, Doctors Care opened a clinic to treat medically underserved children and young adults. Following the Affordable Care Act, Doctors Care responded to the needs of the underserved in new ways by adding programs designed to assist individuals in accessing health coverage, and with utilizing that new coverage. 32

Current programs Today, Doctors Care provides care to disadvantaged Coloradans through its Four Core Services: a primary care Clinic and three Health Access Programs. The Clinic serves Medicaid recipients and the uninsured. Doctors Care Advantage is a community-based health access program that aims to improve access to care and resources for uninsured and Medicaid participants. Connection to Coverage helps individuals apply for Medicaid or shop and apply for subsidized insurance plans through Connect for Health Colorado. Health Navigation addresses socioeconomic barriers to health and well-being. The Doctors Care clinic offers healthcare that includes integrated medical, behavioral health and dental hygiene services in one convenient location. Over 3,000 active patients receive services from staff or volunteer providers through nearly 8,000 visits each year. Demographically, over half of the patients are ethnic minorities, with statistically higher incidences of complications from treatable illnesses and increased risks of adverse health outcomes due to lack of affordable care. Clinic patients receive care from staff or volunteer medical providers familiar with challenges inherent in the patient population. Typical appointments allow sufficient time to address the comprehensive nature of their needs. Health Access Programs at Doctors Care improve access to care and wellbeing for over 1,000 underserved individuals in the community annually.

Each program strives to alleviate barriers to care, including lack of health coverage, limited access to specialty providers, and socioeconomic circumstances that prevent individuals from addressing their health care needs. Health Access services are available to Doctors Care patients, individuals referred by provider partners, and any community member in need. The Health Access Team includes five staff members and nearly a dozen volunteers. The social determinants of health for low-income individuals can result in challenges to access and care. Doctors Care addresses the issue by screening patients prior to clinic appointments for needs such as food insecurities, transportation issues, financial problems, housing needs and other life challenges. Doctors Care staff and volunteers begin “connecting the dots” for the patient through warm handoffs and referrals to Health Navigation. In many instances, patients are immediately connected to other services and community resources. This process increases the impact of patient visits to Doctors Care, saves time and the inconvenience of a return visit and improves patients’ overall health and well-being. Organizational governance The organization is governed by a Board of Directors comprised of leadership from south metro Denver hospitals, local physicians, ADEMS, COPIC and community representatives from financial and legal fields, among others. Board members are active participants in financial oversight of the Colorado Medicine for July/August 2018

Features organization, as well as in shaping its future programmatic and financial sustainability.

and services grow over my 18-year tenure, I realize what Doctors Care does best is equalize access to health care for our entire community. We ensure high quality, integrated care is available to all – despite whatever challenges brought on by poverty and socioeconomic insecurities like lack of food, transportation, housing and others,” states Kleinman.

Doctors Care’s 30 years of service includes a long history of innovation and adapting programs to fit the needs of underprivileged individuals. As the healthcare landscape changes, challenges are met quickly with responsibility, creativity and compassion. CEO Bebe Kleinman has been at the helm of Doctors Care for over 18 years, providing visionary leadership and inspiration to board, staff, volunteers and patients alike. “Seeing our programs

This year, Doctors Care celebrates 30 years of quality, compassionate care designed to help individuals facing health and life challenges. Donations to Doctors Care help provide services

Core Services

2017 Highlights

to thousands of vulnerable Coloradans that are timely, comprehensive and responsive to each individual’s needs. The approach addresses health issues before they become catastrophic, reduces costs to the organization and the patient, and allows a greater number of individuals to access basic services. For more information, visit DoctorsCare.org or contact Barb Hanson, Director of Development and Marketing at bhanson@DoctorsCare.org or 720458-6173 for information on how you can support Doctors Care. n

The connections between our Four Core Services provide quality, comprehensive care that impacts over 4,000 lives each year.

Doctors Care Clinic

Quality, integrated primary care for children and young adults up to age 35.

2,700

786

patients served

new clinic patients

1,070

4,117

dental hygiene visits

immunizations given

Connection to Coverage Enrollment assistance for Connect for Health Colorado subsidized plans and Medicaid.

1,300

518

1,199

appointments provided

350

enrolled in Medicaid enrolled in Qualified Health Plans

Colorado Medicine for July/August 2018

total clinic visits

458

389

onsite counseling visits

behavioral health visits for medication management

Health Navigation

Addressing socioeconomic barriers to health and well-being.

300

clients served

7,114

1,445

children received physicals

clients served

404

appointments provided

Doctors Care Advantage The Premium Sponsorship Program assists eligible individuals with securing a Silver Level Qualified Health Plan.

165

individuals enrolled

Colorado Medicine for July/August 2018

Inside CMS

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

COPIC partners with accelerator program to support health tech startups The increased influence of technology in health care is opening up new opportunities. In particular, we are seeing growth in startup companies that harness the power of advanced technology to address challenges in health care. And, during the last decade, the Denver-Boulder technology community has emerged as a hub of innovation that supports partnerships with the potential to improve health care. COPIC recently formed one of these partnerships with Boomtown Accelerator, a startup accelerator that nurtures selected startups through a 12-week mentoring program. The partnership will fund and train 20 early-stage patient safety and risk management startup companies over the next three years. Based in Boulder, Boomtown runs a competitive selection process for very early-stage (pre-commercialization) startups from all over the country to participate in the accelerator’s twice annual, three-month program. Startups that are candidates for this program are focused on reducing medical errors and improving patient safety, quality of care, disease management, and transitions in care using tools such as software, devices, analytics, artificial intelligence and other tech applications. Each selected startup receives a robust training program that guides founders through core subject areas such as product development, financial modeling, working with investors, and presentation skills. Health care-specific topics covered include the shift to value-based care, data security and interoperability, regulatory strategy, intellectual property and HIPAA compliance. Programming is supplemented with a network of subject matter expert mentors. The program also provides $20,000 in funding. Since its founding in 2014, Boomtown has invested in 98 companies. Of those, 86 percent are in operation, 71 percent are generating revenue and the companies have raised more than $70 million in capital. “We’re thrilled to be partnered with COPIC, a nationally recognized leader in patient safety and risk management,” said Tom Base, managing director of Boomtown’s HealthTech Accelerator. “COPIC’s expert advice and resources Colorado Medicine for July/August 2018

will prove invaluable to our efforts to develop startups through this accelerator.” Examples of companies that are currently involved with the program include: • BehaviorMe is developing immersive virtual reality simulations for behavioral specialists to treat and teach basic life skills to individuals with Autism Spectrum Disorder and developmental disabilities in a new, innovative and effective way. • PatientOne offers a unique software platform that dramatically improves the informed consent process for patients and their providers. The software creates a demonstrable understanding for patients of both the risks and benefits of a particular surgical procedure, increases in-office efficiency, and improves provider-patient communication. • Visible Network Labs leverages an individual’s own unique social support network to help them realize their best possible health and well-being outcomes. Know a startup that would be a good candidate for this program? Qualified startups should refer to https://boomtownaccelerator.com/apply/ to apply for the next program that begins August 27. Boomtown reviews applications on a rolling basis. The earlier you apply, the better. Are you a provider or facility that is interested in getting involved in this program? Providers that may be interested in serving as subject matter expert mentors or facilities that may be interested in serving as product testing sites are encouraged to contact Tom Base at: tom@boomtownaccelerator.com. As health care evolves, COPIC recognizes that we need to evolve as well. We are excited about our partnership with Boomtown and see it as an opportunity to creatively explore options with the potential to benefit the medical community and its patients. n

Inside CMS

CMS 2018 Annual Meeting Sept. 14-15 • Vail Marriott • Vail, CO CMS thanks the following sponsors and exhibitors for their support of this year’s annual meeting

Presenting Level Sponsor COPIC Gold Level Sponsors BioTE Medical CARR HEALTHCARE REALTY Colorado Drug Card Fortis Private Bank Officite UnitedHealthcare

Exhibitors 3WON Center for Personalized Education for Physicians CIGNA HealthCare CORHIO Colorado Physician Health Program Gilead Sciences Gold Medal Waters Medical Telecommunications R.T. Welter & Associates Telligen TSYS U.S. Army 36

Colorado Medicine for July/August 2018

Inside CMS

2018 CMS Annual Meeting Sept. 14-15 Vail Marriott • Vail, CO

Daniel Kelly, CMS contributing writer

Join your colleagues for the premiere event for Colorado physicians, the 2018 CMS Annual Meeting Alright folks, it’s that time of year again and we hope you are all ready for the annual event you’re not going to want to miss this fall: The 2018 CMS Annual Meeting! All year physicians and medical students wait for this weekend for the chance to meet with one another to discuss current events and find out new and exciting things that are happening in the medical world. Always striving to better the experience for all in attendance, a workgroup of physicians and medical students are tirelessly working to make this year’s meeting the most relevant for your practice and career. With entertaining social events to help you forget about work for a few hours and highquality professional development sessions to help refresh and recharge those mental batteries, this year’s conference is going to be one you are glad you attended. This year’s meeting will be held at the Vail Marriott in the stunningly beautiful mountain city of Vail, Colo., Sept. 14-15. Registration is free for members and their guests and CMS has secured discounted group pricing for lodging at the resort. Bring the whole family! Free childcare will be provided during conColorado Medicine for July/August 2018

Hotel accommodations: Reserve your room online at https://book.passkey.com/go/ ColoradoMedicalSociety2018 Register: https://www.cms.org/ register Bring your kids for the Children’s Activity Center! • Free. • Available during conference events Friday evening and Saturday. • Children will be grouped by age. • Meals and snacks provided. • Fun age-appropriate activities planned. For more information and to

ference events Friday and Saturday with meals and snacks provided throughout, and plenty of fun, age-appropriate activities. Advance registration for children (separate from conference registration) is strongly encouraged to ensure proper caregiver-to-child ratios.

register your children: www.cms. org/events/annual-meetingchildrens-activity-center Key takeaways: • No registration fee. • Group rate for lodging. • COMPAC luncheon Saturday. • Black Tie Presidential Gala and COPIC Dessert Buffet Saturday evening. • Meeting concludes Saturday evening with a full day Sunday to enjoy local activities including Oktoberfest and the Vail farmers market and art show. More information: www.cms. org/events/annual-meeting

exhibitor reception. Taking place Friday evening, CMS’s opening social event allows you to enjoy a fun evening catching up with friends and colleagues from all fields of medicine and trading interesting and funny stories from each respective field. Midday Saturday the COMPAC luncheon will serve up good food

If you love food and live music, you’re not going to want to miss out on the 37

CMS Annual Meeting (cont.) and insightful political commentary. To end the conference, a black-tie presidential gala and COPIC dessert buffet will take place Saturday evening to kick off the presidency of Debra Parsons, MD, FACP. Devoted to celebrating the community of medicine, our annual CMS meeting brings Colorado physicians together for social, clinical and intellectual stimulation. Led by an impressive slate of state and national speakers, attendees will experience informative panel discussions and worthwhile workshops on the hottest topics in medicine, such as the opioid epidemic and health care reform. As part of the conference’s dedication to providing special training to the next generation of physicians, medical students will experience an engaging medical student track while also experiencing the main conference. This year the meeting will conclude Saturday night, Sept. 15, to allow you and your family a full day on Sunday, Sept. 16 to explore the scenic area surround-

ing Vail, the village itself, and to participate in the local activities such as hiking, biking and fishing. Talk about perfect timing because this year the CMS annual meeting coincides perfectly with the Vail Oktoberfest! Held Sept. 14-16, enjoy as much Bavarian beer, music and dancing, yodeling and alpenhorn blowing as you can in a traditional Bavarian fare fashion. If beer and music isn’t what you or your family are looking for there is no need to worry: Vail’s farmers market and art show will take place Sept. 16. Stroll down East Meadow Drive and enjoy local Colorado treats and art from over 135 different tents. This year’s conference is sure to be one that you are not going to want to miss. With the selected panel of speakers, events and discussions planned, location and time for activities, this is sure to be a weekend to look forward to. We are excited to welcome you and your family to the 2018 CMS Annual Meeting. For more information and to register online, visit www.cms.org. n

2019 CMS Annual Meeting suspended; be sure to attend 2018 The 2019 CMS Annual Meeting has been suspended but the 2018 Annual Meeting is still on so please make plans to join your colleagues this year! The CMS Board of Directors voted to suspend the 2019 Annual Meeting at their May 18 meeting to ensure adequate funding to meet the extraordinary challenges coming in the 2019 legislature and to investigate alternatives to the annual meeting for meaningful member engagement. This decision came after an in-depth discussion on the public policy challenges facing the profession in 2019, as well as a review of past and projected annual meeting member participation and related organizational expenses. This action does not affect the 2018 meeting, which will go on as scheduled and planned.

Join Now! Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or email susan_koontz@cms.org 38

Colorado Medicine for July/August 2018

Inside CMS

CMS 2018 ANNUAL MEETING AGENDA Sept. 14-15 • Vail Marriott • Vail, CO

Meeting registration free to CMS members: at www.cms.org/register Reserve your hotel room for the Vail Marriott online at: https://book.passkey.com/go/ColoradoMedicalSociety2018 FRIDAY, SEPTEMBER 14

12:00 p.m. - 12:45 p.m. 12:00 p.m. - 1:00 p.m. 1:00 p.m. - 5:00 p.m. 3:00 p.m. - 3:30 p.m. 3:00 p.m. 5:00 p.m. - 9:00 p.m. 5:00 p.m. - 7:00 p.m. 7:15 p.m. - 9:00 p.m.

Finance Committee Board of Directors lunch: Recharging the Star Command War Council Board of Directors meeting: Set phasers to stun – scanners calibrated (open to all CMS members) BOD exhibitor break and refreshments: Space tech lab and scientific inquiries Registration opens for all members and guests: Waiting to beam up Children’s Activity Center (child care): Offspring unloading and parental unit relief Exhibitor reception, including heavy appetizers and cash bar: Space tech lab and scientific inquiries Shedding Light on the Black Holes of Health Costs • Brian Shiozawa, MD, Regional Director, District 8, U.S. Dept. of Health and Human Services • Bill Lindsay, co-chair, Denver Metro Chamber of Commerce • Michele Lueck, President & CEO, Colorado Health Institute • Tamaan Osbourne-Roberts, MD, Chief Medical Officer, Center for Improving in Health Care

SATURDAY, SEPTEMBER 15

7:00 a.m. - 8:00 a.m. 8:00 a.m. - 4:10 p.m. 8:00 a.m. - 8:25 a.m.

8:00 a.m. - 9:30 a.m. 8:00 a.m. - 9:30 a.m. 9:30 a.m. - 10:30 a.m. 9:30 a.m. - 11:15 a.m.

10:30 a.m. - 11:15 a.m. 11:15 a.m. - 12:15 p.m. 11:15 p.m. - 12:15 p.m. 12:30 p.m. - 1:45 p.m. 2:00 p.m. - 4:00 p.m. 2:00 p.m. - 3:00 p.m. 2:00 p.m. - 3:00 p.m. 3:00 p.m. - 4:00 p.m. 3:00 p.m. - 4:00 p.m. 4:00 p.m. - 5:30 p.m. 5:30 p.m. - 9:30 p.m. 5:30 p.m. - 6:00 p.m. 6:00 p.m. - 11:00 p.m.

All-member breakfast with the Board of Directors: Fleet recharging cells; choice of fuel pods Children’s Activity Center (child care): Offspring unloading and parental unit relief CMS and COPIC: Universe scan and situational reports • Robert Yakely, MD, CMS President: Planetary status, orbital projections • Cory Carroll, MD, Science Fair winners • Ted Clarke, MD, COPIC Chairman and CEO: Nuclear threat assessments Student Track: Medical Student Component Business Meeting Alternative Approaches to the Opioid Alien Invasion of our Communities • Robert Valuck, PhD, RPh, Director, Colorado Consortium for Prescription Drug Abuse Prevention • Robert Hoppe, DO, Co-chair, Prescription Drug Monitoring Program Work Group Student Track: Medical Advocacy TED Talks • Invited physicians to give 5-10 minute talks within area of expertise Finding Intelligent Life on Planet Health Care • Brian Shiozawa, MD, Regional Director, District 8, U.S. Dept. of Health and Human Services • Bill Lindsay, co-chair, Denver Metro Chamber of Commerce • Michele Lueck, President & CEO, Colorado Health Institute • Tamaan Osbourne-Roberts, MD, Chief Medical Officer, Center for Improving in Health Care Student Track: Student-Physician Roundtable Discussions • All physicians invited to participate to sit at tables and have students rotate around for casual chats Exhibitor Break and Giveaways: Space tech lab and scientific inquiries Student Track: Financial Planning • Brandi Ring, MD, CMS board liason to the medical student component society; medical students COMPAC Luncheon: Take Us to Your Leader -Gubernatorial Debate (both candidates invited) Student Track: Legislative Session • Students pitch policy initiatives to invited legislators in front of an audience followed by a debrief. COPIC Programming to be determined (*CME and COPIC Points available) Physician Wellness Toolkit: Space survival check–How to thrive in an oxygen-starved environment • Deb Parsons, MD, CMS President-elect • Doris Gunderson, MD, Medical Director, Colorado Physician Health Program COPIC Programming to be determined (*CME and COPIC Points available) Physician Leadership Skills Series: My Communication Style: A Strength or a Crutch? • Kathy Kennedy, DrPH, MA, Director, Regional Institute for Health & Environmental Leadership Free time Children’s Activity Center (child care): Offspring unloading and parental unit relief Inaugural Gala Reception: Meet your future leaders Inaugural Gala: Interstellar mingling, feeding, and dancing the time warp with the Nacho Men • COPIC Dessert Reception

Colorado Medicine for July/August 2018

Inside CMS

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

Brandon Sklar University of Colorado School of Medicine

My name is Brandon Sklar, and I started my fourth year of medical school at CU. My career aspiration is to become a child psychiatrist. I am particularly drawn to patients who have been struggling with abuse. I hope to someday become an advocate for the field of psychiatry and market its vital importance in society to anyone who cares to listen.

When beliefs don't matter GP was a 62-year-old morbidly-obese, Spanish-speaking female who came to the hospital with worsening congestive heart failure. Over her course, we bumped up her Lasix to a dose that I didn’t even know was possible as we continued to watch her BUN steadily rise with each morning lab, her leg and lower abdomen edema unwavering from its 3+ classification. It didn’t take too long for the palliative care team to be consulted and hold a session with the attending nephrologist, about 15 of her family members and me. I listened to the kidney expert explain to the family that transporting GP to the dialysis center 2-3 times a week would be unrealistic, given her weight and how most dialysis centers may not even accept her. Even for the most health illiterate in the room, the prognosis was understood. 40

Every day I paid GP a visit, doing my diligent pre- and afternoon rounds. On the last day before we were to discharge her to home hospice care, I stopped by to say goodbye. When I walked into the room, I just saw her and her granddaughter who has been by her side for most of the past two weeks. I asked if she wouldn’t mind interpreting, and she lit up at the opportunity. I asked GP about how she was feeling, picking up on her sad affect. She confessed to me that she was afraid to die and wasn’t ready, as she began to shed tears. Furthermore, she told me that her husband died a year prior, and she has felt depressed ever since because she missed him so much. The granddaughter, too, began to choke up as she continued to interpret. I sat there for a little while, racking my brain for what I could possibly say to comfort my dying patient whom I had grown so fond of. My formal medical training, I quickly realized, had failed to prepare me for such an encounter. I then asked her a question that shocked me to the core, “Do you believe in heaven…?” She seemed taken aback by the question, “Si…” she whispered quietly. I paused, as I began to feel the power of the moment, “Do you believe that you will see your husband there?” “Si…” as we all proceeded to weep openly together. Before third year started, I thought I had conceptualized what it meant to practice patient-centered medicine. But it wasn’t until I used a patient’s religious beliefs to comfort her, beliefs which I shared nothing in common with, for it to truly hit me. I never truly understood the degree to which physicians must set aside their own beliefs, their biases, and their cultural expectations until I had to do it myself. Because in that moment, my atheism was literally the last thing that mattered. n

Colorado Medicine for July/August 2018

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Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member. For more information, call Tim at 720-858-6306 or email tim_yanetta@cms.org

Colorado Medicine for July/August 2018

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

Annelisa Pessetto Rocky Vista University College of Osteopathic Medicine Annelisa Pessetto is a third year medical student who hopes to eventually find her place in preventive medicine and public health, working to keep Colorado the healthiest state in the nation. She grew up in Fort Collins and received her undergraduate degree from the University of Colorado, Boulder. She later completed her master’s degree in Exercise Science and Health Promotion at Arizona State University, researching health behavior change. She enjoys thunderstorms and salmon fishing.

Examining the emotional side of medicine As I reflect on my experience of the first two years of medical school, I am filled with a tremendous sense of gratitude and wonder. When I started at Rocky Vista in July of 2016, my primary daily emotion was fear. I was overwhelmed and constantly concerned that I would not be able to perform at the level needed to succeed academically. Each day I worked as hard and as long as I was able with the hope that somehow my efforts would be adequate. Through this time, I learned to cope with the high levels of stress by reminding myself that my purpose in studying medicine was not to compete or achieve but rather to contribute. After tough tests or big disappointments, I would imagine how it would feel to use the knowledge I am acquiring to serve others. I tried to picture myself as a confident and trustworthy provider. This exercise reliably stoked my motivation and kept the process meaningful for me. Even now as I prepare for boards, I try to envision how the things I am learning will help me to work within a medical team and the joy I will feel when I am able to be useful, rather than worried about scores. 42

Although I think it is likely I will have similar feelings of inadequacy in my third year clinical rotations, my biggest concern now is how I will handle the more emotional side of medicine. During my clinical shadowing, I had the opportunity to observe a very experienced neurologist who worked almost exclusively with Alzheimer and Parkinson patients. None of his patients could expect to be cured of their disease; rather they would invariably progress to a loss of physical function and sense of self before succumbing to their disease. Several times in my day at the neurology clinic, I was overcome with grief and teared up. The case I remember most clearly was a loving couple that came in for a follow up of the husband’s Alzheimer disease before a scheduled hip surgery. The man was handsome and still looked strong at 70; his wife was younger and brightly optimistic about her husband’s condition. She told us how he had been improving lately and how delighted she was to “have him back” in her life. Her plans for his treatment included a trip to California for hyperbaric chamber treatments. The husband sat quietly with a pleasant social smile, contributing little. Her hope, and possible denial of her husband’s terminal disease were so clearly a manifestation of her love for him. I struggled as tears welled up in my eyes; witnessing her commitment and unabashed determination to preserve her husband’s well-being revealed her deep bond and need for him. I certainly sniffled as the doctor gently reminded her that such treatments had not been shown to be clinically useful, but also that hyperbaric chamber treatments were not likely to be harmful either. At the end of the day, I asked my preceptor how he was able to continue this work when there is so little available to offer his patients. He paused for a while and then told me it was sometimes difficult, but it was a matter of balance and focus. He balanced his clinical practice with his treatment research studies, never losing sight of what he was working toward. He also learned to focus on making a contribution, not on his shortterm clinical outcomes or the difficulties of his daily work. I think that he was able to demonstrate courage in that setting because he was confident in his clinical and emotional skills; he knew that he contributed to improving the situation even if he could not cure the disease. Colorado Medicine for July/August 2018

Inside CMS For many doctors, bad news is not just something to be delivered but a journey that must be taken with the patient and their loved ones. I tend to be an emotional person and don’t want this personal characteristic to become a distraction from the care I am learning to provide. I am concerned that in a clinical setting, my own emotional reaction could reduce a patient’s hope or confidence in their treatment plan. I believe that my desire to help care for those who are ill comes from my emotional ability to connect to their pain, so it is not something I would want to entirely stifle, but I do think it is worth training. In researching emotion in medical training, I found that it is rather common for young doctors to cry. Anthony Sung, MD, of Harvard Medical School and colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once in a medical setting.1 In What Doctors Feel, author Danielle Ofri, MD, advocates for expression of emotion to be commonplace in educational settings, suggesting that emotions should be dealt with in a “head on” approach but at an appropriate time.2 In my training, I plan to incorporate this strategy by speaking with my attending about difficult encounters as soon as the proper context becomes available. I believe that I am able to verbalize emotion well; I hope that this ability will lead to the type of conversations with my teachers that will enrich my perspective and give me the framework I need to keep my emotional nature, but groom it into a professional skill.

be happier in my daily work and have longevity in my career.

humanizing; I believe a synthesis between the two viewpoints in the future will result in a more empathetic standard of care that reflects the values of the real people who receive and give care. n

Overall, I am grateful to be receiving my medical education during a time in which emotion and reflection are becoming recognized as important components References of health care for both the provider and 1. Lerner, B. A doctor's dilemma: Stay stoic or display emotions? NY Times. https://www. patient. I hope that this progression will nytimes.com/2008/04/23/health/23iht-22escontinue over the course of my career sa.12270843.html. Published April 23, 2008. and that I will be an active participant. Accessed March 31, 2018. For many years a bias of science over emo- 2. Ofri, D. What doctors feel: How emotions aftion has made the experience of receiving fect the practice of3medicine. 9258_CMJClinicalGuidelinesAd_Resizes_060718_x1A.pdf 6/7/18 Boston. 4:49 PM MA: Beaand providing health care somewhat de- con Press; 2013.

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Although I was initially embarrassed that I was not able to keep my emotions hidden during that first exposure to neurology, I am hopeful that over time I will learn to deal with my feelings in ways that benefit my patients’ and my own well-being and further a feeling of purpose in medicine. I do believe that delivering bad news with skill affects subsequent patient psychological adjustment, satisfaction with care, and quality of life. I am also committed to addressing the emotion of medicine for my own well-being. I think that if I am able to adjust and grow in these domains, I will Colorado Medicine for July/August 2018

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Colorado Medicine for July/August 2018

Inside CMS

2018 CMS elections Kate Alfano, CMS Communications Coordinator

Cast your vote in August for CMS president-elect and CMS delegates to the American Medical Association On Wednesday, Aug. 1, you will receive an invitation to vote for a slate of Colorado Medical Society (CMS) officers from the CMS Constant Contact email account. To assure your election ballot email arrives safely in your inbox, please add Constant Contact as an approved sender (directions at end of this article), especially if you have opted out of receiving ASAP or any other CMS electronic publications in the past. If CMS does not have your email address, email membership@cms.org or call 720858-6306.

tails on the 2019 nomination period will be available in September. Thank you for your participation in your medical society. What does it mean to add an address to a safe senders list? Email newsletters can be blocked or filtered into your email bulk folder especially now that email filters are focusing more strongly on “grey mail” or commercial mail. As a result, you may miss important announcements or alerts from

CMS, like this one for the all-member election. If you already receive CMS electronic newsletters like ASAP, you need not worry because you are already signed up and will be able to vote. If you have not, please consider signing up for CMS email communications by visiting this link with easy to follow instructions at https://tinyurl.com/yapf9sfd. This form will let you choose which email communications you want to receive. n

The following CMS physicians have announced their candidacy for office. Read their candidate statements starting on page 47. President-elect (one position) • David Markenson, MD AMA Delegates/Alternate Delegates (two positions open, listed in alpha order) • Katie Lozano, MD, incumbent AMA Alternate Delegate • Lee (Alethia) Morgan, MD, incumbent AMA Delegate This is the third year of all-member elections and once again all ballots will be cast electronically. All CMS members are encouraged to use this opportunity to vote, affirming the significant commitment of our organization to engage all members in the governance process. We also ask you to consider seeking a leadership position next year. More deColorado Medicine for July/August 2018

Inside CMS

CMS elections

Be an informed voter, visit: www.cms.org/2018-cms-all-member-election

Candidate statement: David Markenson, MD, President-elect

David Markenson, MD Candidate for President-elect I have announced my candidacy for CMS President-elect and respectfully ask for your support. I am proud to put my name forward to serve as the leader of such an exceptional and well-respected state medical society. I am especially excited about the opportunity to serve as your president-elect during this time of great change in the way we operate as a society including how we connect with our members and as we face significant challenges as physicians in maintaining our role, protection of our patients and support for our practices. As your Treasurer and chair of the Finance Committee for this past year, a CMS board member for the past few years and the current President of ADEMS, I have come to appreciate your concerns regarding the ability to practice as you would wish, the challenges in advocating for our profession and our patents, the complexity of changes to healthcare that are occurring and being requested and the extreme pressures from external forces on our profession and practice. My decision to ask for your consideration to become your President-Elect is based on many factors but key amongst them are passion, dedication, experience and opportunity/timing. 46

I have always been passionate about the role of the physician and the important bond between physician and our patients. In a time when many factors are trying to disrupt our profession, alter the relationship we have with our patients, and non-physicians who are attempting to hold themselves out in this same sacred role that we have held as physicians for centuries, it is vital to have a leader to advocate and protect both the role of the physician and the relationship with our patients. Throughout my career and my role in organized medicine including serving on the CMS Board and CMS Council on Legislation, I feel I have expressed and demonstrated my passion for the unique role of a physician and our need to protect that role and relationship with patients. Not only must one be passionate about such an important cause as the physicianâ&#x20AC;&#x2122;s practice of medicine, but one must be dedicated to the advocacy for physicians and the leadership to assure protection of our profession and respect for the knowledge and commitment we bring. Throughout my career, I have had the opportunity, honor and privilege to serve as a leader to advocate on behalf of the practice of medicine and for patients for whom we provide care including one of our most vulnerable populations we serve, children. These leadership roles have included positons with state and local medical societies, specialty societies such as the American Academy of Pediatrics, American College of Emergency Physicians and the Society of Critical Care Medicine and for local and national philanthropic and service organizations such as the American Red Cross and the March of Dimes. I bring to this role many years of experience as a physician, advocate, physician executive and educator. I have been involved in organized medicine since the beginning of my career as a medical student serving on national committees

with the American Academy of Pediatrics through my role with CMS today. As such, I have come to understand the vital role of organized medicine, how as physicians we can leverage our combined voice, and the importance of an experienced, passionate and proactive leader for our society. As a clinician, I have practiced general pediatrics, pediatric emergency medicine and pediatric critical care. Based on this diverse clinical experience I have had the opportunity to understand and experience the needs of the primary care generalist, sub-specialist, inpatient based physicians and emergency medicine physicians. This has given me exposure to the challenges and opportunities across the spectrum of care we physicians provide and locations where we practice. As a physician executive having held different positons including serving as Chief Medical Officer, I have gained valuable knowledge into the practice of medicine, healthcare financing issues, healthcare system challenges and interactions with physicians, and the need for effective, safe and ever improving patient care. Lastly as an educator including serving as Vice President of GME across multiple facilities and states, I have come to understand the importance of recruiting and training the next generation of physicians. I have also come to appreciate the concerns of our medical students and residents regarding the future of medicine and their practice as well as many of the reasons why so many are not choosing medicine as a profession. While we must acknowledge the worries of our young physicians and the risks for a future adequate physician workforce, I feel we as a medical society are both knowledgeable and well positioned to put forth solutions and to advocate for their adoption. As you know, this is both an exciting time and opportunity for the Colorado Medical Society. Our society has embarked on a reorganization and structural Colorado Medicine for July/August 2018

Inside CMS change that is in my view groundbreaking amongst medical societies and exceptionally forward thinking. These changes have positioned our society to be better equipped to communicate with our members, hear grass roots ideas and feedback, and allow us to be nimble enough to address our members concerns and react to the ever and quickly changing healthcare landscape. Of all these benefits to me, the truly special aspect is that our members can be confident that their voice will be heard and their concerns will be addressed by the society. I am truly excited and humbled for the potential opportunity to serve as your leader at the time when our society has changed in such a positive way. I feel my skill set and experiences will allow me to help as we continue to improve this new and vastly improved model for a medical society. At this time of constant attacks on healthcare and on our sacred and unique role as a physician, I feel the need for us to use our collective voice and influence to advocate for a better future state. We must ensure that physicians are driving decisions regarding healthcare delivery, that patient choice is maintained, and that care is available in the correct setting, by a qualified and appropriate physician and in an efficient, safe and evidence- based manner. I would be honored as your President-Elect, with your help, support and input, to leverage our society to assure this goal of physician directed solutions is achieved. We as physicians are fortunate to have a state society that has a proven record of effectively advocating for physicians and our patients, leading change in healthcare, protecting the unique role and place of a physician and responding to the direction provided by our members. I would be honored to serve as president-elect of the Colorado Medical Society that has established itself as a strong advocate, consensus builder, leader and platform for great leaders in the house of medicine to speak for our profession and our patients. I thank you for your consideration and for all you do as physicians, and as advocates and educators for patients and the practice of medicine. n

Colorado Medicine for July/August 2018

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

AUTOMOBILE PURCHASE/ LEASE US Fleet Associates 303-753-0440 or visit usfacorp.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit copicfsg.com * CMS Member Benefit Partner Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit callcopic.com *CMS Member Benefit Partner MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or coloradodrugcard.com *CMS Member Benefit Partner MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, or visit medjet.com/cms *CMS Member Benefit Partner University of Colorado Hospital/CeDAR 877-999-0538 or visit CeDARColorado.org PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit alnmm.com CARR HEALTHCARE REALTY 303-817-6654 or visit carrhr.com *CMS Member Benefit Partner Dynamic Physician Billing Solutions 303-913-0508 or visit dynamicphysicianbilling.com

PRACTICE VIABILITY, CONT. Eide Bailly 303-770-5700 or eidebailly.com/healthcare Favorite Healthcare Staffing 720-210-9409 or medicalstaffing@ favoritestaffing.com *CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com * CMS Member Benefit Partner Officite 866-508-9176 or officite.com/webcheck/cms * CMS Member Benefit Partner RainTech 844-TEL-RAIN or visit https://rain.tec The Legacy Group 720-440-9095 or visit www.legacygroupestates.com TSYS 877-841-0606 or visit transfirstassociation.com/cms *CMS Member Benefit Partner Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net TSI 800-873-8005 or visit web.transworldsystems.com/npeters * CMS Member Benefit Partner

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CMS elections

Be an informed voter, visit: www.cms.org/2018-cms-all-member-election

Candidate statement: Katie Lozano, MD, FACR, AMA Delegate

Katie Lozano, MD, FACR Candidate for CMS AMA Delegate Thank you so much for electing me to serve on your board of directors since 2008, as your treasurer from 2010 to 2015, as your president-elect in September 2015,

and as your AMA alternate delegate since 2016. I have significant relevant experience in advocacy, leadership, and networking in CMS and in the AMA, and I respectfully ask for your vote for me to continue to represent you at the AMA.

delegation is broad networking contacts across the house of medicine in the AMA, given my partnership over years with physicians of all specialties when we worked together in the Young Physicians Section.

I ran successful campaigns on a national level to serve as delegate and chair of the AMA Young Physicians Section, serving for five years on their executive council from 2008 to 2013. After serving for two years as the sole delegate representing the AMA Young Physician Section (YPS) as a young physician and coordinating our testimony across the AMA, I have extensive experience representing a diverse group of physicians with different practice types and different practice goals. Effective work with and within the AMA is a long-term investment and I have invested many hours, days, and years in both the AMA and CMS. One of the strengths I will continue to bring to the Colorado

My service to the medical profession through my work with numerous boards, committees, commissions, task forces, and legislators is carefully considered as an investment in enhancing communication between and amongst those organizations and the people and patients involved.

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As a strong patient advocate with an interest in medical ethics, I served as co-director of a medical student-run free clinic in Galveston in the late 90’s and have served since 2007 on the board of Doctors Care, a nonprofit Denver area clinic for the uninsured and underinsured. Given my work with the CMS Council on Ethical and Judicial Affairs from 2006 till now, my specialty society’s Ethics Committee since I was a resident in 2002, Ethics and Patient Advocacy Committees when I was an intern, and currently with the Regional West Medical Center Ethics Committee, one of my goals in the AMA is to someday serve on the AMA Council on Ethical and Judicial Affairs. We have a number of challenges before us at CMS and at the AMA, but we also have many opportunities to improve care. We also have a strong history of turning challenges into opportunities to improve patient care and the practice of medicine. I would like to thank you all for everything you do for your patients and communities, through your daily (and nightly) work, and through your work with your county and specialty societies, patient advocacy and volunteer organizations, and CMS. I ask for your vote for me to continue to represent you and your patients in the AMA. n Colorado Medicine for July/August 2018

Inside CMS Be an informed voter, visit: www.cms.org/2018-cms-all-member-election

CMS elections

Candidate statement: Lee Morgan, MD, FACOG, AMA Delegate Chair of the Refcom B Evaluation Committee.

Lee (Alethia) Morgan, MD, FACOG Candidate for AMA Delegate I have had the honor and privilege to serve the physicians of Colorado in multiple capacities over the past 30 years. I have served as President of the Pueblo County Medical Society, the Colorado Gynecology and Obstetric Society and the Colorado Medical Society (CMS). I currently Chair the Colorado Section of the American College of Obstetrics and Gynecology. I have participated on every major council of the CMS. I currently serve as chair of the Council on Legislation. I am a past chair of the COMPAC Board of Directors as well. I have served on the Physicians Congress and the ad hoc Committee on Patient Safety and Physician Accountability, to mention a few. I have been a member of the AMA since 1978 and an active member of our AMA delegation for 15 years. I served as co-chair of the Colorado delegation to the AMA for 2 years and now have, for 4 years, served as chair of the delegation. At the AMA I have been active within the prior Western Mountain States Conference having served as Treasurer and Chair. I played an active role in the merger of the PacRim Conference with the WMSC into the PacWest Conference, currently serve on the Nomination Committee and Colorado Medicine for July/August 2018

My practice experience includes a large multispecialty group as well as a smaller single specialty group. I have practiced in both a large urban environment and a more rural environment. As an Obstetrician/Gynecologist I am times considered a primary care and times a specialist. This varied background gives me the ability to look at all sides of an issue. Though I no longer practice full time, I do volunteer work at Drs. Care regularly. My full-time position as a physician risk manager, doing patient safety and risk management at COPIC. I travel the state regularly and have the opportunity to visit with physicians in a variety of practice situations and locations, thus able to stay up to date with the concerns of physicians of Colorado. I have the leadership experience, the experience of listening to multiple points of

view and helping forge consensus, as well as strong interest and concern about the issues that affect the practice of medicine today. This last decade has been a time of many changes and challenges for physicians. It is more important now than ever that we work together as a cohesive force in organized medicine on a local, state and national level. I have a long interest in legislation affecting the physicians of Colorado and the nation. One of my aspirations at the AMA is to become a member of the AMA Council on Legislation. I believe that, with your support I can continue to contribute significantly to organized medicine on a local, state and national level. It is for this reason that I ask for your vote to return me to the AMA as one of your delegates so that I can continue to represent you as we move forward in these interesting and difficult times. n

Serving the Continuing Medical Education needs of Colorado physicians Your bridge to quality improvement in health care Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720-858-6309 49

Colorado Medicine for July/August 2018

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Member Benefits

Spotlight Perry Bacalis

Perry Bacalis, Carr Healthcare Realty

Maximize your profitability through real estate In today’s economy, maximizing profitability is not just a desire, it's essential for the majority of medical practices to stay in business. If you own a practice, you most likely have an office. That office carries with it many expenses: the most obvious is the monthly rent or mortgage, which is likely the second highest expense behind payroll. In an effort to cut costs, you may decide to cut staff, but when it comes to payroll, you either pay people what they are valued at, or they go somewhere else. Real estate however, is 100% negotiable. You can decide if you want to be in an office building, retail center or medical office building. You can decide if you lease or own. You can determine the size, location, and amenities your space will offer. You can choose to be in a stand-alone or multi-tenant building. You can determine the length of lease, concessions you ask for, economic terms, business terms, etc. So if real estate is your second highest expense behind payroll, and if there are so many options and choices to make when it comes to your office space, how can you maximize the opportunity? To start, you need to understand that as a healthcare professional, the playing field is not level. You might engage in two to five commercial transactions in your career; whereas most landlords and sellers negotiate professionally for a living. You specialize in your field; they specialize in theirs. If the outcome was based upon understanding medicine or providing a health-related service, you would certainly win. However, the process and outcome are instead based upon comprehensive real estate market knowledge, authoritative posturing, and negotiation expertise. Colorado Medicine for July/August 2018

Winning requires having more options, understanding the correct timing, posture and negotiation tactics that landlords use, and in many cases, being able to withstand the stress and conflict that many landlords and sellers use to exploit unsophisticated tenants and buyers. Consider the following concepts: If you start the transaction at the wrong time, you lose leverage and posture. If you don’t know the market, you are simply begging or bluffing. If you can’t handle conflict, you will most likely receive even more pressure from the landlord or seller that makes you uncomfortable and forces you into making a decision that you will regret. Even if you could overcome all of these scenarios, without professional representation you are going to be viewed as a novice and are not going to receive the respect that is necessary to achieve the most favorable terms available to you. Nearly all landlords and sellers hire or consult with professional commercial real estate brokers to give them even more leverage so they can win. Why? Because they understand what is really on the table when it comes to each negotiation. For them, if they give up unnecessary concessions or go lower on rates than they need to, it costs them tens to hundreds of thousands of dollars of profit per lease. They understand the potential upside or downside involved in every transaction, and they are committed to getting the best possible terms in every transaction. Most doctors and administrators don’t understand that commissions in commercial real estate are typically paid the same as they are in residential real estate: by the seller or landlord. This means representation does not cost the practice

more money. Fees are set aside in advance and are either used to provide each party with representation, or the landlord/seller keeps that money or gives their broker a double commission. If you are looking to maximize profitability, start by understanding how much is on the line with your lease or mortgage. Then, make the choice to hire representation that is at no cost to you. Select a commercial real estate broker that understands healthcare, only works for you as the tenant or buyer, can help you find the most options, has the strongest game plan, and who can take and absorb the conflict and confrontation that is inherent in every negotiation that involves a lot of money. In doing so you are positioning yourself to win. The bottom line is there are tens to hundreds of thousands of dollars available to either be won or lost in every commercial real estate transaction; especially with healthcare real estate. Your profitability affects your patients, your staff, your family, and many others. Maximize every commercial real estate opportunity by taking advantage of the best resources available to you. Winning on your next commercial real estate transaction can transform your practice! n Carr Healthcare Realty is the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, thousands of healthcare practices trust Carr to achieve the most favorable terms on their lease and purchase negotiations. Carr’s team of experts assist with start-ups, lease renewals, expansions, relocations, additional offices, purchases, and practice transitions. Healthcare practices choose Carr to save them a substantial amount of time and money; while ensuring their interests are always first. Email Perry Bacalis at perry.bacalis@ carrhr.com to learn more. 51

Departments

medical news CMS President M. Robert Yakely, MD, receives University of Colorado School of Medicine Alumni Humanitarian Award CMS President M. Robert Yakely, MD, was honored with the 2018 University of Colorado School of Medicine Alumni Association Humanitarian Award for his leadership in Colorado and his humanitarian contribution in the British Virgin Islands. He received this award at the Silver and Gold Banquet at the Grand Hyatt on May 24.

volunteers to work, and together he and Rosemary provided services and education on prostate cancer screening. The prostate cancer clinic screened 50 men the first year. By 2007, the clinic was screening 1,500 men per year. Later the BVI legislature made the Yakelys honorary citizens in recognition of their achievement.

Yakely has had a 45-year history of service to organized medicine in Colorado through the Clear Creek Valley Medical Society and the Colorado Medical Society as well as the Rocky Mountain Urologic Society and American Medical Association.

“When I became aware of a need in the British Virgin Islands for a prostate cancer screening, I responded by saying ‘yes’ to the urge to start a screening,” he said in his acceptance speech. “Along the way, many other people said ‘yes.’ I accepted the award on behalf of all physicians who say ‘yes’ to doing things that improve health for others, for which our only compensation is the satisfaction derived from doing what we are uniquely trained to do to help our fellow man.”

His contributions in the British Virgin Islands started in 1996 when he and his wife, Rosemary, started their annual tradition of living on a sailboat in this area for five months each year. During this time Yakely recognized the need in Tortola in the BVI for prostate cancer screening. Through an involved process and many other physicians saying “yes” to his requests for training and equipment, he was able to set up a clinic, find

In a video interview for the award, Yakely was asked about his greatest source of satisfaction as president of the Colorado Medical Society. He replied that it is “seeing the successful results or working with many other physicians

Yakely photo

CMS President Bob Yakely, MD, (right) was awarded the 2018 CU School of Medicine Alumni Association Humanitarian Award for his work creating a prostate cancer screening clinic in the British Virgin Islands (BVI) shown above with his wife Rosie, (center) receiving honorory citizenship in BVI for their work. to work within CMS to solve problems that positively affect the health care of a large population of our patients. … Our team’s work with the Colorado Legislature affects every doctor’s practice.” He concluded: “What drives me is my lifelong goal to see that every American has access to quality health care.” n

ASAM and the AMA announce innovative payment model to improve treatment of opioid use disorder The American Society of Addiction Medicine (ASAM) and the American Medical Association (AMA) jointly announced the release of a concept paper detailing a groundbreaking alternative payment model (APM) that could revolutionize how patients with opioid use disorder are treated.

the number of patients with opioid use disorder who are able to lead satisfying, productive lives through successful management of their condition while also reducing health care spending on costs associated with addiction in general, such as emergency department visits and hospitalizations.

The new payment model, known as Patient-Centered Opioid Addiction Treatment (P-COAT), is expected to increase

The new payment model seeks to increase utilization of and access to medications for the treatment of opioid use

disorder by providing the appropriate financial support to successfully treat patients and broaden the coordinated delivery of medical, psychological, and social support services. P-COAT is also designed to support office-based opioid treatment to facilitate coordination between multiple treatment providers. Previously, payment for these services has been segregated, which contributes to patient difficulties in receiving comprehensive care. Colorado Medicine for July/August 2018

Departments The P-COAT APM is based on research showing that medications combined with psychosocial supports is effective in treating individuals with opioid use disorder. Unfortunately, the current physician payment system offers little support for the coordination of behavioral, social and other support services that patients being treated for opioid use disorder need in addition to their medication. Non-face-to-face services – such as phone calls and email consultations with patients – in addition to better coordination between specialists, outpatient treatment programs and other health providers such as emergency rooms, are essential to the delivery of effective, evidence-based treatment to the individuals who need it. For more information visit www.asam.org. n

CCVMS becomes Foothills Medical Society After soliciting input from its members and c o n d u c ting other market research, the Clear Creek Valley Medical Society has changed its name to the Foothills Medical Society. Foothills Medical Society has a long history of representing physicians in Jefferson, Clear Creek, Gilpin, Broomfield, and a western sliver of Adams County. Its physicians believe the name change will better reflect the medical society's representation of the western Denver metropolitan area. Foothills Medical Society's mission is to promote the ethical and compassionate provision of safe, effective, efficient, equitable, patient-centered and timely medical care and the advancement of public health in its community. Learn more about the medical society at its website: www.foothillsmedicalsociety.org. n

Colorado Medicine for July/August 2018

medical news AMA files amicus brief in response to court case that would turn back patient protections and insurance reforms The American Medical Association in conjunction with the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry, filed an amicus brief in response to the court case, Texas v. United States. With this action, the AMA opposes a lawsuit that would undermine the policies supported by the AMA House of Delegates, including expanded health insurance coverage and other patient protections. This lawsuit challenges the constitutionality of the Affordable Care Act (ACA), arguing that Congressional action that reduced the tax on individuals who fail to comply with the individual mandate to purchase insurance voids the law itself. The Trump administration announced that it wouldn’t defend the law. If the plaintiffs are successful, the following patient protections and insurance reforms that are current law would cease to exist: • Patients would no longer have protections for pre-existing conditions. • Children would no longer have coverage under their parents’ health insurance plan until age 26. • Insurers would no longer be held to the 85 percent medical loss ratio, meaning they could generate higher profits at the expense of coverage and payments for services. • One hundred percent coverage for certain preventive services would cease. • Annual and lifetime dollar limits could be reinstated, leading to more bankruptcies due to health care costs.

“Each of these provisions has broad, bipartisan and public support, and as physicians, we know how much these policies improve the lives of our patients,” said Barbara L. McAneny, MD, AMA president. “This new lawsuit seeks to change the federal government’s health care policy through the courts, instead of through the legislature. The AMA firmly believes that these are judgments for Congress and not the courts to make. For these reasons, we will be fighting efforts to undermine this law in our judicial system.” “Guaranteed health insurance coverage for people with pre-existing conditions is enshrined in Colorado law,” said Interim Insurance Commissioner Michael Conway, in a news release from the Colorado Department of Regulatory Agencies (DORA). “Regardless of how the Justice Department or the Trump administration attempt to change the Affordable Care Act, the Division of Insurance will continue to enforce Colorado law and maintain this important protection for our citizens.” “Providing access to health insurance to people with pre-existing conditions and not charging them more simply because they’ve been sick are two of the fundamental improvements of the ACA,” continued Commissioner Conway. “That’s why the Division will continue to make sure that plans offered in Colorado conform to Colorado law. We won’t be turning back the clock.” The Division of Insurance, part of the DORA, will be reviewing individual and small group plans for 2019 over the summer. n

Compliments of:

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

Attention! New Higher Discounts!

RETAIL PRICE

MEMBER PRICE

MEMBER SAVINGS

MEDICATION

QTY

Azithromycin 250mg Tab

$29.29

$15.86

46%

Lamotrigine 100mg Tab

$54.79

$14.65

73%

Topiramate 100mg Tab

$87.60

$8.98

90%

Levofloxacin 500mg Tab

$114.79

$11.15

90%

Losartan 100mg Tab

$57.06

$13.82

76%

Rosuvastatin 40mg Tab

$226.56

$17.46

92%

Pantoprazole DR 40mg Tab

$69.81

$12.42

82%

NOTE: Our price is the average price members paid on that prescription during the month of January, 2017. Retail price was obtained by calling CVS/pharmacy. Pricing varies by pharmacy and by region. Prices are subject to change.

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

www.coloradodrugcard.com

Customize the Colorado Drug Card for your practice!

Program Highlights: Free to all patients. Cards are pre-activated, no sign-up forms needed. Discounts on brand and generic medications. Helps patients that have high deductible plans or are uninsured. Reduces patient callbacks. Enhances physiciansâ&#x20AC;&#x2122; ability to treat patients with drugs that may not otherwise be affordable. HIPAA Compliant

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

Milton Perkins - Program Director 54

mperkins@coloradodrugcard.com Colorado Medicine for July/August 2018

Colorado Drug Card

Departments

medical news CMS holds medical ethics event in coordination with the “Deadly Medicine” Holocaust exhibit The Colorado Medical Society hosted a special evening event in May exploring medical ethics in concert with a provocative exhibition from the United States Holocaust Memorial Museum, “Deadly Medicine: Creating the Master Race.”

religions and national origin as well as gender/gender choices – on the internet and in national policy.” She encouraged attendees to listen to the presentation, reflecting on the tremendous disparities in access to health care and how physicians’ biases, preferences or philosophies

contribute to those disparities, either in terms of policy or practice. “Also consider the role of physicians in reporting, commenting or objecting when they see potentially harmful medical actions or policies. There is much to think about,” Parry said. n

The traveling exhibition – which was hosted on the University of Colorado Anschutz Medical Campus March 20 through May 22 – explores the Nazi regime’s “science of race” and its implications for medical ethics and social responsibility today. It was brought to UC Denver as an extension of the Center for Bioethics and Humanities’ annual Holocaust Genocide and Contemporary Bioethics Program. Attendees of the CMS-sponsored event attended a reception before the presentation, “How Healers Became Killers” by Matthew Wynia, MD, MPH/MSPH, followed by a discussion and exploration of the exhibit.

Matthew Wynia, MD, MPH/MSPH, presented “How Healers Became Killers” as part of a CMS-sponsored ethics event in concert with the U.S. Holocaust Memorial Museum, “Deadly Medicine: Creating the Master Race” traveling exhibition.

Lynn Parry, MD, past CMS president and current chair of the CMS Council on Ethical and Judicial Affairs, welcomed attendees to the event. “We cannot resign to history alone the lessons that come from the participation of physicians in Nazi Germany in abandoning their positions of trust and causing incalculable harm. Certainly, genocide remains a recurrent horror in the world community,” Parry said. “But the true horror of the Holocaust was the medicalization of a policy of extermination. Today, we are witnessing an insidious erosion of tolerance and an acceptance of bias against communities of color, certain

Attendees review the traveling exhibition from the U.S. Holocaust Memorial Museum that was brought to UC Denver as an extension of the Center for Bioethics and Humanities’ annual Holocaust Genocide and Contemporary Bioethics Program.

Colorado Medicine for July/August 2018

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.

➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES

Please help support the Colorado Medical Society Foundation In March 1997, Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization. The foundation’s mission is to administer and financially manage programs that seek to improve access to health care and health services, with the potential to improve the health of Coloradans. The Board of Trustees of CMSF is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. The spirit of Colorado is alive in the many ways that we help our neighbors. Call 720-858-6310 for more information and to learn how you can donate.

Colorado Medicine for July/August 2018

OUTREACH CLINIC OFFICES FOR RENT In La Junta, Colorado and Goodland, Kansas. Available one day per month or more. Lease required. Physicians only–no third parties. Must bring own supplies. Send inquiries to cmrc@pcisys. net. PHYSICIAN ASSISTANT/ NURSE PRACTITIONER WANTED FOR MEDICAL PRACTICE MANAGING INJURED PATIENTS Job requirements included experience in primary care, occupational medicine

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ANNOUNCING THE CANDIDATES FOR THE AUGUST 2018 ALL-MEMBER

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

The candidates for 2018-2019 office are: President-elect (select one for one position) David Markenson, MD AMA Delegates (select two for two positions) Katie Lozano, MD Lee Morgan, MD Be sure to look for your ballot in your email on August 1. Ballots will be open until August 31.

Features

the final word The Honorable Irene Aguilar, MD, (D), Senate District 32 and The Honorable Jack Tate, (R), Senate District 27 Senate co-sponsors, SB18-022, Clinical Practice for Opioid Prescribing

Working together to make a difference in the opioid epidemic Earlier this summer Gov. John Hickenlooper signed into law nextgeneration legislation aimed at reducing the risk of prescription drug abuse and diversion of opioids while balancing the clinical needs of your patients and your own professional judgement as to medical necessity. Like every state, the policy challenge is drafting an approach that requires medical insights and expertise in a lawmaking body made up of mostly non-physicians, and few if any experts in pain treatment and addictive medicine. That is why, in response to the epidemic rise in opioid addiction and the wreckage left in its wake to communities and families, Colorado lawmakers have relied on the expertise and wisdom of real-world organiza-

tions from the front lines, especially the Colorado Medical Society. It is a sustained collaboration that assures your ideas have real-world applications drawn from the sometimescontorted process of lawmaking. The urgent need to reverse the downward spiral of opioid abuse only succeeds with the cooperation of the medical profession. The Colorado Medical Society’s leadership in this endeavor has been exemplary, though not without conflict and controversy. In addition to bringing the credibility and influence of your organization to the statehouse to help reframe the thinking and biases of a diverse legislative body, you convened a formidable panel of experts on the CMS Special Committee on Prescription Drug Abuse, who con-

sistently brought their insights and experience into the halls and chambers of the Legislature and executive offices. While we have labored at grinding out the laws to buttress a statewide effort, with your support, Colorado physicians have also moved the needle by rethinking pain treatment and modifying those standards and protocols. Your own surveys show an impressive, determined effort. Between 2013 and 2017, the number of opioid prescriptions decreased by 21.1 percent in Colorado. Nearly 40,000 physicians and other health care providers were registered with the PDMP in Colorado in 2016 and queries increased from 683,000 in 2014 to 1.5 million in 2016. Nearly three-quarters (70 percent) of CMS physicians report taking CME regarding opioids in at least the past two to three years. With the enactment of this body of law, similar to – but improved upon – legislation passed by other states in the last 18 months, we are stepping up the pace but not while stranding your patients who would suffer needlessly by globally limiting patient access to pain treatment.

Sen. Irene Aguilar, MD, (D), Senate District 32, and Sen. Jack Tate, (R), Senate District 27, were the Senate co-sponsors for SB18-022, Clinical Practice for Opioid Prescribing and instrumental in the 2018 Colorado Legislature's success in passing legislation to address opioid misuse, treatment and recovery. 58

Step by step, we can only continue progress with the active support and compliance of your profession. In exchange for that cooperation, we have set a timer on this. SB 18-022, Clinical Practice For Opioid Prescribing, expires in September 2021. We can review, reboot and reenact the parts of the policies that work, and discard what has not. It will be up to us – together. n Colorado Medicine for July/August 2018