July-Aug-2012 by Colorado Medical Society

July/August 2012

Volume 109, Number 4

AMA President Jeremy A. Lazarus, MD

First Colorado physician in 91 years to hold AMAâ&#x20AC;&#x2122;s highest office Colorado Medicine for July/August 2012

Award-winning publication of the Colorado Medical Society

Colorado Medicine for July/August 2012

cont n ent nt ns nt July/August 2012, Volume 109, Number 4

Features. . . 14

Journey to AMA presidency a different kind of marathon –AMA President Jeremy Lazarus, MD, delivers his inaugural address and shares his vision for leading the nation’s largest physician organization.

AMA and CMS address trend of FTC engagement on scope of practice – Organized medicine is coordinating its efforts to stop FTC’s increasing antitrust examination of state actions relating to scope of practice limitations.

Providing better health care value through new benefit designs – Soaring health care costs and higher insurance premiums have patients and their employers partnering with physicians in engaged benefit design.

Red Rocks Cancer Center “dream come true” for patients and physicians – Learn how the physicians of Surgical Specialists of Colorado achieved their vision of providing patients with faster, more cost-effective care.

Electronic referral tool helping coordinate care in El Paso and Teller counties – CORHIO partners with local physicians, practice managers and other health partners to create a shared community standard for referrals.

Final Word–Dean Emeritus of the University of Denver Sturm College of Law Ed Dauer, LL.B, M.P.H., reviews the Supreme Court ACA decision and medicine’s continuing task of learning to practice under its provisions.

Cover story

In becoming the 167th president of the American Medical Association, CMS Past-president Jeremy Lazarus, MD, becomes only the second Colorado physician and the first in 91 years to ascend to the AMA’s highest office. Read complete coverage starting on page 8. Cover photo by Ted Grudzinski

Inside CMS 5 7 30 34

President’s Letter Executive Office Update COPIC Comment Annual Meeting Agenda

Departments 36 37 40

New Members Medical News Classified Advertising

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

Colorado Medicine for July/August 2012

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OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2011/2012 Officers F. Brent Keeler, MD

President

Jan M. Kief, MD President-elect Kay D. Lozano, MD

Treasurer

M. Robert Yakely, MD Speaker of the House Brigitta J. Robinson, MD Vice-speaker of the House Alfred D. Gilchrist Chief Executive Officer Michael J. Pramenko, MD Immediate Past President

Board of Directors John L. Bender, MD Charles W. Breaux Jr., MD Robert A. Brockmann, MD Ellen M. Burkett, MD David Elison, MS Naomi M. Fieman, MD T. Casey Gallagher, MD Ripley R. Hollister, MD Johnny E. Johnson, MD Donald Luebke, MD Randy C. Marsh, MD Gary Mohr, MD Nora E. Morgenstern, MD Jeffrey A. Moody, MD Edward A. Norman, MD Tamaan Osbourne-Roberts, MD Scott Replogle, MD Stephanie Sandhu, MS Ranee M. Shenoi, MD Alisa B. Lee Sherick, MD Stephen V, Sherick, MD Sean Slack, MS Thomas H. Soper, DO Kayla Steffensmeier, MS

Board of Directors Michael Volz, MD H. Dennis Waite, MD Michael Welch, DO Jennifer Wiler, MD Harold “Hap” Young, MD AMA Delegates A. “Lee” Morgan, MD M. Ray Painter, Jr., MD Lynn Parry, MD Brigitta Robinson, MD AMA President-elect Jeremy Lazarus, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Mark Laitos, MD Tamaan Osbourne-Roberts, MD CMS Connection Mary Rice, President

COLORADO MEDICAL SOCIETY STAFF Executive Office

Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Donna Jeakins, Manager, Accounting, Donna_Jeakins@cms.org Dianna Mellott-Yost, Executive Assistant to CEO and General Counsel, Dianna_Mellott-Yost@cms.org

Division of Communications and Member Benefits

Brad Pierson, Art Director/ Manager, Communications, Brad_Pierson@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 JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

Division of Government Relations

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org

Colorado Medical Society Education Foundation Colorado Medical Society Foundation Mike Campo, Staff Support, Mike_Campo@cms.org Donna Jeakins, Staff Support, Donna_Jeakins@cms.org

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

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

Colorado Medicine for July/August 2012

Inside CMS

president’s letter F. Brent Keeler, President Colorado Medical Society

Privileges, professionalism, personal During the past year, friends and colleagues have asked me how things are going during my term as CMS president. I have consistently replied to the effect that this has been the most rewarding experience of my professional life. Indeed, it has been a tremendous privilege to serve in this role. Particularly gratifying have been the numerous opportunities to meet physicians from all over Colorado. I want to personally thank all of those who make CMS so successful. Thanks to our CEO, Alfred Gilchrist, and his terrific staff. Thanks to the CMS board members who give of their own time to serve our membership. Thanks to the physician leaders, members and executive management of our various component societies. Thanks to those docs who participate on our various councils and committees. Thanks to all of our individual members. Thanks to our friends and allies in the greater Colorado community, from organizations to lobbyists to elected officials and beyond. The list goes on TNTC (too numerous to count). What a privilege to participate in the AMA House of Delegates meetings. It is very eye opening to realize all that the AMA does for our patients and us. For those who are not members, please reconsider joining. Yes, dues are involved – and, yes, it’s worth it! We have seen “professionalism” discussed and pondered and pontificated on. The AMA has spoken about it at length. State medical boards have policies and regulations on it. Each of us could write our own definition. We all stand behind the generally accepted concept of, first and foremost, renderColorado Medicine for July/August 2012

ing excellent patient care. I submit that there is more. Here are two ideas to broaden the concept. First, true “professionals” are self-aware and are aware of each other. This is the central tenet of physician wellness. It has been a privilege to be involved in the CMS initiative on physician wellness. It is my fervent hope that we will see a culture change: a move away from the old way of silent self-sacrifice, and toward a new paradigm in which seeking and offering help among colleagues is integrated into our basic professionalism. Second, “professionalism” entails “system-awareness.” We physicians have responsibilities above and beyond those directed toward any one individual patient. I submit that excellent patient care of any one patient is a basic expectation that our society has of physicians. This is no longer enough. Throughout the health care world, physician involvement is woven into the fabric. Without this, the system not only fails to improve, it crumbles. The depth of involvement isn’t really important. Rather, every physician should be doing

something to make health care better. From the Bylaws Committee at your local health care facility all the way to president of the AMA, there are abun-

“. . . this has been the most rewarding experience of my professional life . . . particularly gratifying have been the numerous opportunities to meet physicians from all over Colorado.” dant opportunities. I challenge Colorado’s physicians to seek out and engage! Finally, on a personal level, my family and I wish to express our heartfelt thank you for the outpouring of support from Colorado’s medical community. The loss of our daughter’s husband on July 17 is truly a tragedy. Love and support from family and friends has meant everything for us. Thank you. n

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Colorado Medical Political Action Committee Call 720-859-1001 or 800-654-5653, ext. 6321 5

Inaction vs IN ACTION We understand the difference The Litigation Center of the American Medical Association and the State Medical Societies fights to protect doctors and uphold the highest standards of patient care. In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession. Whether we are challenging managed care organizationsâ&#x20AC;&#x2122; payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physiciansâ&#x20AC;&#x2122; rights. Learn more on how The Litigation Center can help you.

ama-assn.org/go/litigationcenter

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

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

ama-assn.org

cms.org Colorado Medicine for July/August 2012

Inside CMS

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

Our silent partner Judging by the relatively low AMA membership penetration in Colorado, the association’s substantive, ongoing contributions to the welfare of the profession and our efforts here, in particular, are largely invisible to most practicing physicians. It is as though we have a silent partner in advocacy, albeit a talented, highlyeffective partnership that delivers results for us on a regular basis. I’d like to break that silence by detailing a short list of the types of regular support my colleagues at AMA bring to us and their relevance to physician and patient advocacy. Advocacy Resource Center Think of this as a team of health policy experts and attorneys. If you had to find this team on the street, this would be one of the top legal and consulting firms in the country. Its advisory body, on which I served for years, is comprised of state medical lobbyists, general counsels and CEOs. In other words, they are closely linked to local public policy realities and the needs of state medical societies. They see the tsunamis coming long before the practicing physician could possibly detect a problem. They have developed state-ofthe-art model legislative bills, white papers and extensive research support. You can bet that when we are preparing a regulatory or legislative initiative we start at the top, with our colleagues at the Advocacy Resource Center (ARC). The first-of-its-kind laws CMS pushed through the Colorado General Assembly had their origins with the ARC’s arsenal. Standardized contract law, physicians’ rights and standards for any health plan profiling scheme, truth in advertising, health plan merger and acquisition reform – to name more recent reform laws and efforts in Colorado – were all drawn from the resources, research and talent of the ARC. Colorado Medicine for July/August 2012

Private Sector Advocacy A complement to the ARC, Private Sector Advocacy (PSA) lawyers and practice management experts produce the kind of tools and national influencers that can literally change the landscape of commercial and market behavior. For example, they have built model physician contracts for health plans that every physician should read and consider. The health plan contract model is an interactive website that can take any clause or subparagraph and compare it to any state law in the country, rank it accordingly and discuss, with extensive annotation, the optimal language. And physicians can now join PSA’s “cutting edge contracting” on-line educational webinars and community for ongoing access to national managed care contracting experts. Another of PSAs influential intellectual properties is the National Health Insurer Report Card, now in its fifth year, which produces objective metrics measuring the performance of every major plan and ranks them according to payment accuracy and timeliness, prior authorization, use of claims edits and denial rates, and the wide array of plan operations and functions relevant to the business side of medical practice. I can tell you that this kind of national exposure and transparency has transformed many of the plans’ values and orientation. Indeed, error rates for these plans’ paid medical claims fell by 19.3 percent in 2012, resulting in $8 billion in health system savings due to a reduction in unnecessary paperwork! Litigation Center I am serving my second term on the Litigation Center (LC), which is also comprised of state medical society CEOs and general counsels. It is the voice of the medical profession in legal proceedings across the country. Established in 1995

as part of AMA’s physician resources program, the LC provides physicians with legal expertise assistance and has participated in more than 200 cases, many with precedent-setting results. The LC has provided financial and legal resources to us on several occasions during my tenure. Inside baseball with federal agencies There are many examples, and here’s one where we were involved. When the FTC started weighing in with letters opposing state legislation to regulate interventional pain management techniques and in support of legislation that would abolish or loosen standards for collaborative practice agreements between physicians and advanced practice nurses or physician assistants, AMA’s federal affairs team stepped in with the ARC and PSA to mount an impressive strategy in defense of the historical role of states to protect the public through regulatory action. Like all national trade and professional organizations, a big tent that encompasses the views and needs of an increasingly diverse medical profession is guaranteed internal disputes and tensions. Unfortunately, too many physicians walk away from the AMA rather than continue to engage and participate in an organization that has a wide-open process for resolving disputes and setting a consensus, and has steadfastly supported the Colorado Medical Society. The organization continues to make the tough choices in the public affairs arena that by definition cannot make every physician happy. Our work on behalf of Colorado physicians would be suboptimal without their resources, experience and expertise. Thank you to our partner, the AMA! n

Cover Story

First Colorado physician in 91 years to hold AMAâ&#x20AC;&#x2122;s highest office 8

Colorado Medicine for July/August 2012

photo by Ted Grudzinski, AMA

CMS Past-president Jeremy Lazarus, MD, elected AMA President

Cover Story Editor’s note: The following includes reporting from the American Medical Association reprinted with permission from American Medical News (“Strengthening Medicine for the Long Run”, by Carolyne Krupa). Copyright © (2012) American Medical Association. All rights reserved. It also includes photographs reprinted with permission from Marc Piscotty, http:// www.marcpiscotty.com, copyright (2012), all rights reserved. For only the second time in 167 years and the first time in 91 years, a Colorado physician has been elected as president of the American Medical Association. Colorado Medical Society Past-president Jeremy A. Lazarus, MD, was inaugurated June 19 as the 167th president of the American Medical Association, the nation’s largest and most influential physician organization. During an interview with Colorado Medicine, Dr. Lazarus credited his experience in Colorado with having played a crucial role in his ascent to the AMA’s top office. “My journey to the AMA presidency included my many activities within the Colorado psychiatric and medical communities, years of committee and advocacy work on behalf of organized medicine, and a consistent belief that physicians need to work together to achieve lasting results for our patients and our practices,” said Dr. Lazarus. “It was the spirit of working together as colleagues in Colorado, our willingness to listen to diverse viewpoints and the leadership of the Colorado Medical Society which has actively partnered with the AMA to the benefit of Colorado physicians and patients that provided me with the base on which to succeed at the AMA.” He also took the opportunity to speak to the need for physicians to join together with the AMA to have their voice heard. “Each year I learn new ways in which the AMA is the premier organization representing physicians both in practice

Colorado Medicine for July/August 2012

and advocacy,” he said. “It would be a great honor to me if those physicians who are not currently members of the AMA or have been in the past, would take another look at what the AMA is and has been doing on behalf of all of us and join. For those who are members, I sincerely thank you.” In his inaugural address as AMA president Dr. Lazarus emphasized the need for endurance and persistence in meeting the challenge of strengthening the heath care system for the long run. Dr. Lazarus told the nation’s physician leaders assembled for the AMA Annual Meeting that he looked forward to making great strides together on the road to a better health care system. “I am excited to be your president, now let’s run this race together and get the job done,” said Dr. Lazarus. “Now is the time to rise up. Rise to the occasion. Be persistent. And keep going no matter how tiring it may get.” Dr. Lazarus also pledged to assist the mental health needs of combat troops, veterans and their families, as well as victims of violence and abuse. “As AMA president, my focus will include the need to better integrate mental health care into other aspects of medical care – to provide more resources to treat more people,” said Dr. Lazarus. Colorado celebrates Physicians across Colorado have been celebrating the news that one of their own will bring his experience as a private practicing physician to the AMA’s highest office. Colorado Medical Society President Brent Keeler, MD, hailed Dr. Lazarus’ election as another indication of Colorado’s growing influence on the national health care scene, saying, “Jeremy’s election has the national health care spotlight shining once again on Colorado.” Jan Kief, MD, CMS President-elect, added, “I am absolutely thrilled with

Jeremy’s election to the AMA. Not only will his breadth and depth of leadership serve our nation’s physicians well, his consistent commitment to his Colorado roots will give our physicians a unique voice in the national health care debate.” Demanding journey ahead Dr. Lazarus has traveled the world participating in grueling athletic events.

“It was the spirit of working together as colleagues in Colorado, our willingness to listen to diverse viewpoints and the leadership of the Colorado Medical Society which has actively partnered with the AMA to the benefit of Colorado physicians and patients that provided me with the base on which to succeed at the AMA.” – Jeremy Lazarus, MD AMA President He has completed 13 marathons and 13 Ironman triathlons. Now he is preparing for a new kind of endurance test. During his year as AMA president, he will spend more than 200 days traveling throughout the country and abroad, speaking with physicians, students, health professionals and others to champion the AMA’s initiatives. Dr. Lazarus said it’s a crucial time in medicine, and he welcomes the challenge. “Things are changing in the way care is delivered,” he said. “I will be in a po-

Cover Story (cont.)

Richert Quinn Jr., MD, has known Dr. Lazarus for 20 years and said he will be an articulate spokesman. “He has been successful at every level, and people look up to him for his leadership,” said Dr. Quinn, a general surgeon from Greeley, Colo. and member of the AMA Senior Physicians Group. “He’s somebody you can really hold up as a role model for the profession.” In addition to being a physician and an athlete, Dr. Lazarus, 68, is a musician. He has performed on stage numerous times, directed synagogue choirs in Chicago and Denver, and sung with the Chicago Symphony Chorus, Central City Opera Chorus in Central City, Colo., and Colorado Chorale in Denver. His many talents and interests make him especially well-suited to represent physicians, said longtime friend and colleague Dick Allen, MD, a Portland, Ore., obstetrician-gynecologist and the 2007 recipient of the AMA Distinguished Service Award.

“The fact that Jerry has other interests outside of medicine adds to his resume as a physician leader. It makes him someone who is real, personable and friendly,” Dr. Allen said.

[Photo by Marc Piscotty / www.marcpiscotty.com]

sition to help make physicians aware of what those changes are, what they can do to prepare for them and how the AMA can help.”

A call to lead Dr. Lazarus has been active in organized medicine for more than two decades Dr. Lazarus and wife, Debbie Lazarus and has served in leadership roles in the “It came out of the blue,” said his wife, American Psychiatric Association, the Debbie. “It was a very shocking experiColorado Medical Society and what was ence. He was always very healthy and then the Arapahoe County Medical suddenly he could have been gone.” Society. He became an AMA alternate delegate in 1993 and was elected to the Dr. Lazarus took the health scare as anAMA Board of Trustees in 2003. other challenge. Instead of slowing him down, it pushed him to do more of the About 16 years ago, a personal health things he had always intended to do. He scare drove him to step up his involve- ran for AMA vice speaker and presiment. During a trip to Vail, Colo., he dent of the Colorado Medical Society developed a life-threatening acute intes- and won both races. He also edited his tinal blockage. He was in surgery within second book: Entering Private Practice: 12 hours, and spent more than a week in A Handbook for Psychiatrists. the hospital. He saw being involved in the AMA as The experience was startling, especially an opportunity to have a broader posifor someone who was so physically fit. tive impact on health care. Some of the issues he has advocated for are ensuring more physicians and other health professionals are trained to treat military veterans, providing access to care for the uninsured and repealing the Independent Payment Advisory Board.

[Photo by Marc Piscotty / www.marcpiscotty.com]

Dr. Lazarus said he hopes to help doctors find common ground despite different backgrounds, specialties and practice models.

Dr. Jeremy Lazarus 10

“I think the AMA has to have an open tent and represent the views of everyone,” he said. “We may take care of patients in different ways, but we need to work together.” A lifelong love of music His mother, who was a professional singer and music teacher, raised Dr. Lazarus with a love for music. He had voice training until he was in his 30s and plays the saxophone, violin and guitar. Colorado Medicine for July/August 2012

Cover Story

The trio mostly plays at medical association meetings, including gatherings of the AMA and the Colorado Medical Society. They perform songs by the Kingston Trio, Joan Baez, Bob Dylan and Pete Seeger, and have a bent toward music with a medical theme. Tunes such as “The Ballad of the Colorectal Surgeon” and the “Ballad of Sigmund Freud” always are favorites among physician audiences, Dr. Lazarus said. The first time they played for a large audience was a surprise performance at the Colorado Medical Society’s annual conference. They dressed alike in khaki pants and striped shirts.

www.marcpiscotty.com]

Today, Dr. Lazarus keeps his music skills alive by playing in a band with three physician friends. “Dr. Feelgood’s Folk Remedy” was formed about 15 years ago and includes Dr. Lazarus on guitar, Dr. Allen on banjo and Mark Levine, MD, on guitar.

She spent 10 years of her childhood in Israel and is fluent in Hebrew. In a “surreptitious arrangement,” Dr. Lazarus’ mother asked Debbie to come over to help her translate some Hebrew and introduced her to her son. “He was really, really different – very honest and sincere,” Debbie Lazarus said. “We told [his mother] that was probably the best thing she ever did for us was introduce us. She picked well.” At their wedding in a Chicago hotel, Dr. Lazarus surprised his bride with a song. “When I came in with my parents, I just stopped and he sang ‘And This Is My Beloved’ from ‘Kismet,’ ” she said. “It was fabulous.” The couple has been married 45 years and loves spending time with their three sons and eight grandchildren. Their oldest son, Steven, 45, is a psychologist in Littleton, Colo. Their middle son, Ethan, 42, is a family physician

[Photo by Marc Piscotty /

In medical school, he and a friend sang at synagogues, bar mitzvahs and other events to help pay the bills.

Dr. Lazarus can play the saxophone, violin and guitar. in Denver who specializes in bariatric medicine. Their youngest, David, 38, runs a day trading company in Miami Beach, Fla., and is married to dermatologist Melissa Lazarus, MD.

“The looks on the faces in the audience were priceless,” said Dr. Allen, a former CMS president. “Here you had major leadership of CMS, and no one knew that we could sing anything.” Dr. Lazarus is a good musician, friend and physician, said Dr. Levine, chief medical officer for the Centers for Medicare & Medicaid Services office in Denver and clinical professor at the University of Colorado Denver School of Medicine. “There is a difficult balance between being personable and professional; Jeremy has always managed to be both,” he said. A close-knit family Dr. Lazarus grew up in Chicago and earned a bachelor’s degree in chemistry from Northwestern University. He graduated with honors from the University of Illinois College of Medicine. During his second year of medical school, he met his future wife, Debbie.

Colorado Medicine for July/August 2012

Cover Story (cont.) Opportunity in Denver After medical school, Dr. Lazarus completed a mixed medical internship at Michael Reese Hospital in Chicago. In 1969, he received a residency position at the University of Colorado Health Sciences Center, and he and his wife made the move to Denver with their first son, who was two at the time. It was a good career opportunity, and Denver offered a good quality of life, he said.

“We just knew this was the right place to raise sons,” Debbie added. Dr. Lazarus said he chose psychiatry because he is intensely interested in understanding how people think and behave. “It fascinated me the way people tick,” he said. He completed a three-year residency in general psychiatry and became chief

resident his third year. He then worked at the Veterans Affairs Eastern Colorado Health Care System, where he saw patients with conditions including schizophrenia, depression, anxiety disorders and various addictions. He has spent much of his career in private practice and still sees patients, many of whom he has treated for 10 to 20 years. Beyond his practice, Dr. Lazarus is a clinical professor at the University of Colorado Denver School of Medicine and a voluntary professor of psychiatry at the University of Miami Leonard M. Miller School of Medicine. It was during his residency that Dr. Lazarus became a runner. About five years after completing his residency, he ran his first marathon. At age 41, he finished his first triathlon. Competitions have taken him to Hawaii, New Zealand, Canada, Japan and Australia. “It just feels good to be able to finish something like that,” he said. “I was pretty lucky. I never got injured or hurt. It was hard, but it was always great finishing.” When he can, Dr. Lazarus runs about 6½ miles a day on a trail behind his house. He and Debbie, who has run seven marathons herself, also like to ride their tandem bicycle on long treks. They have biked together on trips up to 500 miles along the countrysides of France, Italy, Switzerland, Austria and Ireland. A unique opportunity As a physician, Dr. Lazarus said he believes he has helped thousands of patients. As AMA president, he hopes to help thousands of physicians help their patients. “It’s very obvious when you’re helping one person,” he said. “Feedback is very immediate. But with the AMA, things can take many years. The reach is broader, but the immediate gratification is slower in coming.” Rochester, N.Y., psychiatrist John “Jack”

Colorado Medicine for July/August 2012

McIntyre, MD, has known Dr. Lazarus for 30 years through the American Psychiatric Association He describes him as warm, engaging and tenacious. “He’s really a remarkable person, and he has an incredibly broad interest in many aspects of health care,” said Dr. McIntyre, clinical professor of psychiatry at the University of Rochester, former APA president and a member of the AMA Council on Medical Service. “He has great endurance in pursuing issues to workable solutions. He leads by example. You see him and you want to emulate him.” Serving as AMA president is always a challenging and critical role for the profession, Dr. Levine said. Regardless of whether the Patient Protection and Affordable Care Act survives the U.S. Supreme Court, the public recognizes health care system reform is necessary. “This is a particularly challenging time because of all of the opportunities that are ahead of us,” Dr. Levine said. “Jeremy, I think, is going to have a unique opportunity.” n

About Jeremy A. Lazarus, MD Specialty: Psychiatry Home: Denver Medical education: University of Illinois College of Medicine Family: Wife, Debbie; three sons, Steven, Ethan and David AMA positions: Speaker, House of Delegates; vice speaker, House of Delegates; chair, Board of Trustees Compensation Committee; member, Board of Trustees Executive Committee; member, Board of Trustees Finance Committee. Other posts and awards: Past president, Colorado Medical Society; past president, Colorado Psychiatric Society; past president, Arapahoe County Medical Society; past speaker and distinguished fellow, American Psychiatric Association; AMA representative, Health Coverage Coalition for the Uninsured; AMA representative, Ride for World Health; recipient, 2008 Colorado Psychiatric Society Outstanding Achievement Award; recipient, APA Special Presidential Commendation, APA Assembly Warren Williams Award and APA Distinguished Service Award.

The Jane Nugent Cochems Trust Financial help for physicians in need Application deadline: October 1, 2012

The Colorado Medical Society administers all grants with the average amount

ranging from $5,000 to $10,000. The application process is simple and the review processes are completely confidential. For more information or to obtain an application form, please call Donna Jeakins at the Colorado Medical Society, 720-858-6316. Visit http://www.cms.org/about-cms/cochems-trust/ to download an application form. Colorado Medicine for July/August 2012

[Photo by Brad Pierson, CMS

Features

Editor’s Note: AMA President Jeremy Lazarus, MD, delivered an inspiring inaugural address June 19 at the AMA Annual Meeting in Chicago. With the exception of a few references to events current to the time (i.e. the summer Olympics), the content of the speech is highly relevant to today’s practicing physician. The entire inaugural address is reprinted with permission below.

Journey to AMA presidency a different kind of marathon Jeremy Lazarus, MD, AMA President Tonight, there are many people to thank – those who supported me and encouraged me to keep on going. You are the ones who didn’t think I was completely crazy to keep on going race after race… well, most of you.

Could’ve been a disaster. For me, medicine and then psychiatry became a calling. When I was in college my brother died in an accident. That tragedy fueled my desire to do something that made a difference to help people. To become a physician.

Thank you for this profound honor. As you know, the summer Olympics start soon in London.

I’m reminded of what Olympic marathoner Don Kardong said: “No doubt a brain and some shoes are essential for success, although if it comes down to a choice, pick the shoes. More people finish marathons with no brains than with no shoes.”

I mention this because my journey to this stage has been – for me – something of an Olympic race itself.

Rest assured I’ve laced up my sneakers for the start of my run as AMA president.

I wanted to help someone who was troubled lead a fulfilling, normal and healthy life.

I love watching athletes compete. And at the Olympic level, they inspire a pride of accomplishment in each of us, and each of us feels part of their success.

And I look forward to making great strides together with you, who represent the best of our profession.

I wanted to pull a profoundly depressed person back from the ledge of a potential suicide, and watch him grow from a troubled adolescent to a productive adult.

Now some of you may know that I’ve run a race or two in my time, but I can tell you, running 13 marathons or completing 13 triathlons is something completely different than becoming the 167th president of the AMA. This was much harder. The truth is, I’ve learned we all need each other’s support to make great things happen. 14

Just like the Olympic athletes, when one of us wins, we all win. It’s all of us on that podium, wearing the medal.

[Photo by Marc Piscotty / www.marcpiscotty.com]

When an American athlete wins, we cheer. When they stand on the podium with a medal on their chest, as the national anthem plays, we share their tears of joy.

I wanted to help repair shattered minds – to guide people through the minefields of depression, or personality disorders – or crushing changes in circumstance.

Now, my path into this profession may have been different than that chosen by many of you. It turns out that my high school, here in Chicago, was named for Nicholas Senn, who happened to be the AMA’s 49th president. Say what you will about foreshadowing or fate, but given my skill set at the time, it was probably for the best that I didn’t go someplace named for another prominent Chicagoan – say, Michael Jordan Prep or Mike Ditka Magnet School.

Dr. Lazarus is an avid runner and has competed in marathons and triathlons. Colorado Medicine for July/August 2012

Features In 40 years as a psychiatrist, I’ve been fortunate to help many people. For me, that’s what it’s all about. For our specialty, taking a person whose mental health is in jeopardy – and helping them toward recovery – is like watching someone walk again, or curing cancer. When something is wrong in the brain or the mind, it affects the whole person. The challenge is in how we determine what’s really going on – whether it’s psychological or neurochemical or both.

alize only if we are unified on the issues that matter most to us, and our patients. Ask a random physician about what the AMA does and how it represents physicians. Chances are you would get a variety of responses. So we’re working to harness the legacy of the AMA – what was – in a way that helps us all define what the future of the AMA can be. You’ve heard a lot about the “AMA equation” this week.

It’s no coincidence the words psychiatrist and psychic are in some way connected. We are trained to listen both to what is said out loud and what isn’t said at all.

But it bears repeating: The AMA is the sum of many parts.

Listen to all sides, and then help people find their own path.

Membership – in which physicians engage each other and learn from each other.

By listening, and working to find common ground, I want to bring greater unity to our AMA.

The tools and expertise we provide to help physicians manage practices.

And while we can be thoughtful and deliberative and not act in haste, we recognize also that we stand at a healthcare crossroad.

Our House of Delegates, with more than 185 physician groups represented.

Our pacesetting work in ethics, our efforts to end disparities, and our crown jewel publication JAMA and others that make us a leader in research and education.

And advocacy – giving voice to physicians in courthouses, statehouses, the media and in Washington, D.C. We are proof that those with opposing views can see the bigger picture and do what’s best for physicians and patients. That’s how we all win. One recent example is the $200 million returned to physicians because of AMA leadership in the United Health settlement. Or the needed delays the AMA won in implementing costly and confusing ICD-10 measures. In these ways, the AMA touches the vast majority of physicians in this country – members and non-members – in tangible ways. And the AMA is well-positioned to influence an uncertain future. Nonetheless, to improve health outcomes, reform medical education and shape health care delivery and payment systems so they work better for physicians are not modest ambitions. To meet these challenges we some-

Our patients cannot afford the luxury of indefinite time for us to simply talk about the issues.

There’s a real opportunity, regardless of the political paralysis in Washington, for us to unify to promote the practice of medicine – to AMA members and nonmember physicians alike – around the country.

photo by Ted Grudzinski, AMA

In the 21st century, we can advance and grow only by incorporating the insights of physicians from all specialties, cultures, practice settings, states and regions, and ideologies.

With his wife Debbie at his side, Dr. Lazarus takes the oath of office and is sworn in as the 167th But any success will materi- president of the AMA by Dr. Robert Wah, chair of the AMA Board of Trustees. Colorado Medicine for July/August 2012

Inauguration (cont.) times go over them. Or go under them, or around them. Sometimes we ask for help – ask for a hand up to clear the obstacle. That’s what achievers do. I’ve been with the AMA and in the medical profession long enough to understand and respect the differences we have. But I’ve been witness to our mutual interests. And how powerful we are when we work together to fulfill them. I ask you to help me explore that aspect – and expand it. This year, the AMA celebrates its 165th birthday. Since our founding, we’ve been a player on the national stage. But great organizations with a long history do not need to live in the past. Respecting tradition does not mean we can’t create – and pursue – our future. The years ahead are a new race to be run, and to finish we’ll need more than just talented physicians. The AMA has shown both courage and a willingness to face what’s ahead – to shape it, confront it, and, when sensible, to conform to it. To succeed is to evolve. It reminds me of when Woody Allen compared a relationship to a shark – that it has to move forward or it dies. It’s not enough for the AMA merely to act, but to keep at it. To refuse to quit. To face challenges and rise above them. One of the most important lessons I have learned in medicine, in my pursuits – in my life – is the value of persistence. As I mentioned, competing in marathons and triathlons has been a passion for me. I enjoy the challenge and pushing myself beyond what some may find reasonable. And running 26.2 miles or finishing a 140.6-mile triathlon is no cakewalk. Mary Wittenberg of the New York Road 16

Runners Club described it this way. She said: “Virtually everyone who tries the marathon has trained for months. That commitment, physical and mental, gives it its meaning, be the day’s effort fast or slow. It’s all in conquering the challenge.” This persistence – this effort – helps give meaning to what the AMA accomplishes on behalf of physicians and patients every day. This is what we have in common. Each of us has already run a marathon. You completed medical school. Or you run a medical practice – a small business. Or make split-second treatment decisions where life and death are in the balance. Sometimes all of these. You, like me, want a positive outcome even when the unexpected happens. An example. In one triathlon, I was on the bicycle leg of the race going over Vail Pass in Colorado. I rounded a curve and came upon a woman who had wrecked her bike. She was sprawled on the ground, injured, exhausted, dazed from a concussion. With her was a fellow competitor – also a physician and fortunately an ER doc – administering first aid. I stopped as well, and when I could not be of further help, went on my way. But the doctor who stopped first ultimately suspended his race. He stayed with his new patient for two hours and sacrificed his chance to complete an event for which he’d trained for months. Why? Because he’d trained for years to be a physician. The well-being of the patient always comes first – even when it isn’t our own patient. This selfless service has been a hallmark of who we are, as physicians, since the dawn of time.

And it’s one of the valuable lessons I’ve learned from my own encounters with the hard ground. Not to give up. In this most contentious time in our country, the AMA will do more than step up to a podium. We will run. We will win the race to provide medical and mental health care services to all, and we will hear the cheers of those too often silent. The AMA rejects the idea of media ”spin doctors” – who hold no medical degree – attempting to dictate our future. We’ll stand with physicians and take back our message. The AMA rejects the idea that bowing to the policies of government and insurance industry bureaucracies are simply inevitable costs of doing business. The AMA rejects the notion that legislators can impose themselves into the patient-physician relationship and legislate how we practice, whether it concerns what we can ask or say to our patients or what tests and procedures are appropriate. We fight for the interests of physicians. Sometimes we have prevailed, sometimes we haven’t, but we’ve been on the course, pushing our limits, testing our endurance. Not always winning – but always being heard and always finishing. The documentary filmmaker Bud Greenspan, who chronicled the Olympic Games for almost 60 years, once described a moment he believed best captured the Olympic ideal of perseverance and commitment. In Mexico City in 1968, the Tanzanian runner John Ahkwari finished last in the marathon. Midway through the race, he had fallen and torn a deep gash in his leg. In agony, he limped into the stadium 90 minutes after the winner, his leg bruised, bandaged and bleeding. For everyone else, Colorado Medicine for July/August 2012

Features the race was over. The stadium was nearly empty, the lights dimmed.

able Care Organization” and “medical home” and “integration.”

Bud Greenspan was still there, his cameras still rolling. He asked John Ahkwari why on earth he kept going with such a serious injury, with no hope of winning.

We’ve come far since the days of a family doctor with a black bag holding the tools of his trade.

He replied, “My country did not send me 5,000 miles to start a race – they sent me to finish it.”

Today, a physician may text a patient on an iPad while viewing their medical history and coordinate care among a team of physicians and other health care professionals.

That thought will guide me as AMA president.

Such physician-led teams are crucial components of medicine’s future.

Training for medicine was much like training for a marathon or triathlon. You learn your strengths, focus on what you do best, do it – and don’t quit.

As more patients live longer and accumulate more complex medical conditions, their care will require more coordination, more use of clinical data and professionals working together.

To be part of a team – and following guidelines and best practices – doesn’t mean you’ve lost your ability to think, to create, to act on behalf of your patients. In the mental health field, a good example is the DIAMOND Initiative in Minnesota. Psychiatrists are paid to consult with primary care practices on the best way to manage patients with depression. It’s resulted in dramatic improvements in patient outcomes. The current system discourages this, since specialists are paid for face-to-face visits with patients, but not when they

If you get off course on the swim, adjust your stroke. (Unless you’re fortunate enough to see Dr. Cecil Wilson’s sailboat in the distance) If you get tired on the bike, shift to a lower gear. If you can’t run, walk. If you can’t walk, take a break and try again. That is an approach we can take to address the newest challenge we face: health system reform. It means changes for those previously without coverage, changes in payment methods, changes in how care is delivered. The Affordable Care Act will soon cover 32 million people without health insurance, provided neither the Supreme Court nor a new president overturns the law. It requires insurance market reforms. It invests in quality, prevention and wellness. And it does something else – it starts us down the road to a very different system of payment and delivery. We’re hearing jargon like “AccountColorado Medicine for July/August 2012

Inauguration (cont.) advise the primary care physician. In 2008, this House of Delegates adopted principles that support this approach.

We have a duty to care not only for our patient’s health, but also for our own, both physical and psychological.

The AMA has also backed the medical home model for mental illness and the principle of parity for mental health coverage, and is part of the Coalition for Fairness in Mental Illness. We’ve made tremendous progress, but we can do more.

That’s hard for many physicians to admit – that they, too, may sometimes need help or guidance.

As AMA president, I will note the need to better integrate mental health care into other aspects of medical care to provide more resources to treat more people. Because you can no more separate the heart from the mind of a person any more than you can separate the heart from the lungs and expect them still to function. I’ll also want to highlight the health impact of violence on both the mental and physical health of those abused. Just like we’ll need you to make a concerted effort through our Joining Forces Initiative to help our returning troops, veterans and their families who suffer with traumatic brain injury, post-traumatic stress disorder or post-combat depression. The wounds of those who have borne the battle are not always visible. We’re not just playing defense. Just like in football, you need a good offense, too. We’re being proactive, not just reactive. Education on exercise, preventive health and nutrition starting in early childhood that continues through a lifetime will help create a healthier society.

When we treat our patients – especially our youngest ones – remember that you might be treating or inspiring a future physician. Our family internist, Dr. Lerner, who suffered from poor circulation in his legs, nonetheless would climb four flights of stairs to make a house call. The doctor I saw was the doctor I knew and, to me, he represented the profession and as Dr. Carmel would say, he was my hero. To me, his actions said: Treat people the way you want to be cared for, because too often, this is an uncaring world. As physicians, as AMA members, we are the face of this profession, this organization. We are also its voice. Let’s be willing to sing from the same page. Those of you who have sung in choirs know how a collection of varied but trained voices can lift a crowd to their feet. When the AMA combines our many voices in harmony we can do just that. For me, it’s not just a metaphor. I paid my way through college and medical school by directing synagogue choirs. There, you have to combine many disparate voices and help them sing in harmony.

One with less obesity, cancer and the other illnesses that debilitate the very people we care about, and which exact a staggering societal and financial cost.

As director, you work with sopranos and tenors, altos and baritones, contraltos and basses. And in some choirs you have to designate a section called the “lip synchers.”

For them, physicians must be the role models for our patient’s health and for each other’s.

But even if a voice is out of tune or the pipes rusty, I learned that even a monotone can learn a second note. Colorado Medicine for July/August 2012

Features So we need to rise up – raise our voices – and sing out for medical liability reform, to end frivolous lawsuits, to end the fear of being dragged into court for no good reason, and to slow spending on defensive medicine. Sing out, and demand the Sustainable Growth Rate be scrapped and be replaced with a system that recognizes reality and reflects the actual costs of medical care in all its effective forms.

Sing out for an equitable health care system, where all its elements exist in harmony. We trained all of our adult lives to be the best physicians we can be. Now is the time to combine our voices and make a joyful noise. Rise to this occasion. Be persistent. And keep going no matter how rough the terrain, or how tiring the course.

Sing out for private contracting legislation and physician-led delivery and payment reforms.

I’ll be alongside AMA staff, every physician and this House of Delegates. Together, we can finish this – and we can win.

Sing out our commitment that Americans need health insurance coverage and that we finally end health care disparities.

Among the most inspirational words I’ve ever seen were at the 130-mile marker of a triathlon course in the

100-degree lava field in Kona, Hawaii. They were from Isaiah, and it read: “They that hope in the Lord will renew their strength. They will soar like wings on eagles. They will run and not grow weary – walk and not grow faint.” And to that I will add: we will rise up and be heard. We will run this race, together. We will persist. And together, we will cross the finish line. Thank you. n

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Features

FTC increasing antitrust examination of state scope of practice limitations AMA and CMS address trend of FTC engagement on scope of practice The Federal Trade Commission (FTC) is increasing its antitrust examination of state professional board actions, legislation and regulation relating to scope-ofpractice limitations. The FTC’s activity has taken the form of an enforcement action against the North Carolina State Board of Dental Examiners antitrust enforcement action against a state licensing board for attempting to fulfill its statutory mandate to regulate public health and safety. The case is currently on appeal in the U.S. Court of Appeals for the Fourth Circuit. This action has also taken the form of letters to a state medical board and state legislators, commenting on bills to regulate providers of interventional pain management procedures and bills and proposed regulations to expand nursing scope of practice. In these letters the FTC relies on “available evidence” to make clinical judgments on complex medical issues that have an impact on patient health and safety. For example, in letters to Missouri and Tennessee legislators, the FTC stated that nurse anesthetists could safely provide chronic interventional pain management services without physician supervision. The FTC has similarly weighed in on APRN supervisory arrangements stating that, “available empirical evidence indicates that APRN-delivered care ‘across settings, is at least equivalent to that of physician-delivered care as regards safety and quality.’” The AMA is greatly concerned that the 20

FTC appears comfortable making clinical judgments on such complex issues as the relative qualifications of health care professionals in the provision of chronic interventional pain management. The FTC concerns itself with competition matters; the AMA believes that the FTC does not have the clinical expertise to make judgments regarding the competency of providers to perform medical procedures, as is suggested by the FTC’s advocacy letters. These judgments must continue to be made by state medical boards and legislatures with the strong input of the physician community. The FTC’s actions must not prevent state legislatures, regulators and boards of medicine from initiating legislation, regulation or other actions to protect the public for fear of potential antitrust liability. What the AMA is doing for you The AMA is working to address this concerning trend of FTC engagement. Due to the significance of this challenge to the medical profession’s oversight of licensure, the practice of medicine and patient safety, as well as the consequences for states and other professional licensing bodies, the AMA has engaged a multi-pronged strategy to defend the work of the medical boards and the states. The AMA has held a series of meetings with FTC commissioners and senior staff, urging them to reexamine the FTC’s ability to advocate on the complex medical issues involved in state scope of practice activities and medical licensure. This is the first time AMA leadership has met with the full range

of commissioners. In these meetings, incoming AMA Board Chair Stephen Stack, MD, has emphasized the AMA’s position that the FTC does not have the clinical expertise to make judgments regarding the competency of providers to perform medical procedures, as is suggested by the FTC’s letters. The AMA will also engage in the courts through an amicus brief in the North Carolina dental board case. The AMA has enjoyed the strong support of the Colorado Medical Society for this advocacy work. In a recent letter to FTC Chairman Jon Leibowitz, CMS President F. Brent Keeler, MD, acknowledged CMS’ agreement with the AMA regarding the fundamental role of state medical boards and legislatures in issues relating to scope of practice and medical licensure. Since the meetings began, three FTC letters have been released. Misleading clinical judgment has been removed, and disclaimers have been added stating, “FTC staff are not experts in patient care or safety,” and do not offer advice on such matters. Moreover, the FTC acknowledged that “certain professional licensure requirements are necessary to protect patients” and “in particular, special practice requirements may be recommended or required for certain chronic or acute pain indications or treatments that may present heightened consumer risks.” The FTC has also agreed to reach out to medical associations before drafting its letters in the future. The FTC has recognized this Colorado Medicine for July/August 2012

Features transition, acknowledging in a letter to CMS that meetings with the AMA led to changes in the language and tone of subsequent FTC advocacy letters.

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Antitrust relief is a priority for physicians. Together with our state medical associations and national medical specialty societies, the AMA has reasserted the need for state medical boards to be the authorities on licensure, patient safety and the practice of medicine; physicians, not economists, must regulate the profession. The AMA will continue advocating to ensure that regulation of physicians remains squarely within the purview of the states and state medical boards.

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Providing better health care value through new benefit designs Sara Burnett, CMS contributing writer

In recent years, Grand Junction has earned accolades for its high quality, cost efficient care from everyone from the president of the United States to the country’s top policy wonks. But even this national model of efficiency hasn’t been immune to the soaring health care costs and higher premiums seen across the country – and patients and their employers have been taking notice. “Our patients are saying ‘What gives? Our premiums are still going up way too fast,’” said Mike Pramenko, MD, the immediate past president of the

Colorado Medical Society and executive director of Primary Care Partners in Grand Junction. That reality has prompted physicians in Grand Junction as well as other parts of Colorado and the nation to try an approach known as value-based benefit design, or engaged benefit design. The approach is based on a few key premises: • The fee-for-service payment model has pushed health care into its cur-

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rent system of “do more, get paid more” – and has been a driver of costlier types of care, such as hospitalizations and procedures. • Comparative effectiveness research – determining how effective one approach is compared with another – should be used to determine the value of a particular drug, medical treatment or procedure. If two approaches are the same, but one costs more, the patient should be able to choose that option – if he or she is willing to pay extra for it. Otherwise, the health plan should pay for the less costly of the two options. “Let’s stop paying for things that don’t show value,” Pramenko said. “Until we get there we’re not going to contain costs.” • Shared decision-making – in which patients have conversations with their physician about their options, and are provided materials to help them make an informed decision – should be encouraged. • Studies by both policy experts and private insurance companies have shown that focusing on population health, such as chronic disease management, wellness and prevention – especially for “high utilizers” who frequently use emergency rooms or who have complex medical conditions – can significantly bend the cost curve. Critics of this system have called it rationing. Pramenko says that’s not the case, since patients are still able to get the more expensive option if they choose to pay more for it. It’s not unlike the system that has long existed in which some health plans will cover generic drugs but Colorado Medicine for July/August 2012

Features not the brand-name version if the two drugs have been shown to be equally effective, he said. In January, Engaged Benefit Design was implemented for about 725 employees and dependents of the San Luis Valley Regional Medical Center in Alamosa, through a plan administered by San Luis Valley HMO. EBD was created by Engaged Public, which is supported through both public and philanthropic funding to test and study whether the approach leads to better outcomes and/ or lower costs. A team of physicians and other health care professionals helped develop EBD. It provides patients with options of treatments that are supported by strong scientific evidence (which are on the “No Co-Pay, High Value,” list), and those that fall under the “Costs More, Learn More” category. Treatments on the “No Co-Pay, High Value” list are available at no additional cost to the patient. If a patient is considering a “Costs More, Learn More” option, he or she is given educational materials to help decide if paying the additional out-of-pocket cost is right for them. By charging no co-pay for items on the first list – such as prenatal care and immunizations – the group hopes to encourage wellness. David Downs, MD, a former CMS president who is medical director of Engaged Public, said the EBD has been generally well received so far. As of July, 54 decision aids had been provided. “I think most employees think it’s a good idea,” Downs said, “and I think there’s good reason to think it will save money.” Other employers in Colorado that have implemented similar systems include the city of Colorado Springs, Colorado Springs Utilities and Marriott International, according to the Center for Value-Based Insurance Design at the University of Michigan. In Grand Junction, Primary Care Partners is working with Hilltop, a local nonprofit community resources/health care organization, to design a benefits Colorado Medicine for July/August 2012

system that would reduce costs and improve the health of its approximately 500 employees. The agreement came to be after Hilltop’s CEO approached Primary Care Partners about his organization’s rising health care expenditures. “Most business executives have just thrown up their arms and said, ‘Costs are up and I can’t control it, so I’ll just ask for higher deductibles, and that’s how we’re going to deal with it,’” Pramenko said. “Now we’re seeing employers figuring out where health care dollars are going, and they’re asking the system to change.” Under the agreement, Hilltop will pay Primary Care Partners a per-patient, per-month fee to coordinate a wellness program and serve as the employees’ patient-centered medical home. Primary Care Partners will provide expanded hours, to try to reduce visits to emergency rooms, and a secure patient portal that patients may use to email questions to their health care provider – thereby helping to cut down on the number of

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unnecessary visits. to see their physician. Because Hilltop is self-funded they also may provide incentives. If a patient does a wellness visit, for example, or meets a weight loss goal or quits smoking, he or she earns points. If they earn enough they can reduce their premium per month by $30. In the second year of the agreement, they will move more toward a value-based benefit system, in which they will look at utilization rates and analyze what patients are getting, Pramenko said. When there are different treatment modalities, patients will be asked to pay more for equivalent items that cost more. Pramenko said several area employers are keeping an eye on the program to see how it works. And that employer engagement, he added, is critical. “Once employers understand where value is in health care, and once you get employers invested in change, then you really truly can change the system.” n

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Red Rocks Cancer Center: A “dream come true” for patients and physicians Sara Burnett, CMS contributing writer

From the moment patients and their families enter Red Rocks Cancer Center, they get the sense this place is different. Behind a central desk is the cancer care coordinator – the nurse who will help arrange everything from transportation to hats and wigs to the annual Cancer Survivors Day celebration. A water feature on one wall emits a soft, soothing sound. A hallway leads outside to the Serenity Garden. And any medical services the patient needs – surgery, medical oncology, PET/CT, radiation oncology or physiotherapy – are located within a few feet. That means no need to drive from one office to another for appointments and no having to wait days for physicians in different locations to coordinate care. “We all hear it,” says Elizabeth Brew, MD, a surgeon with Surgical Specialists of Colorado. “Patients’ faces light up. They’ll say ‘You mean I can get everything done right here?’” The cancer center is part of Red Rocks Medical Center in Golden, a physicianled and owned facility that opened in 2010 and, one physician said, is “a dream come true.” “It’s like leaving your home and going to your home to go to work,” said Kevin Schewe, MD. “I’m in my 26th year of private practice of radiation and it is the best place I’ve ever worked … You have to pinch yourself sometimes.” The idea for the facility came about six years ago, just after Surgical Specialists 24

of Colorado opened Clear Creek Surgery Center in Wheat Ridge. The group began discussing its next goals. Surgeon Rebecca Wiebe, MD, envisioned a cancer center, where all of the services a cancer patient needed could be found under one roof and care could be provided in a faster, more cost-effective manner. They began building on that vision and inviting other like-minded physicians in other specialties to join them, until they had a group of about 30 physicians. Most of them had been working together for anywhere from five to 15 years. “We wanted doctors who we would trust to take care of us or our family if any of us became ill,” Schewe said. They wanted something else, too: To be the ones in charge. “We wanted to do it ourselves, to have ownership in it,” Schewe said. “And not strictly financial ownership. We wanted to own the product of our labor.” They began looking for sites, and settled on one on Indiana Street near 6th Avenue – in the heart of the area the physicians had been practicing in for years. Once they had a plan in place, they invited the three main health care systems in the area to bid to become their partner in the venture – thereby securing the substantial capital needed to establish the outpatient surgery center and the radiology and radiation oncology de-

partments. The three systems were asked in a request for proposals to make their best offer, and also to explain why they would be the best partner. HealthONE won the bid. The first group of doctors moved in to the building in November 2010, and the move-in process was staggered, with radiation opening in January 2011 and the surgery center in September 2011. Imaging, the breast center and the surgery center are on the first floor. On the third floor are other medical offices, including dermatology, urology, retina and ophthalmology. Each practice was able to design its own space. Radiation oncology, for example, was designed to feel like a home, complete with small kitchen areas, coffee and tea service, puzzle tables, fireplaces and hardwood floors. The consult rooms have carpeting and couches with throw pillows, so conversations don’t have to occur in the more sterile examination rooms. The facility also has a gourmet kitchen, where a holistic chef teaches classes three times a month titled “Kicking Cancer in the Kitchen.” Brew said the arrangement makes life easier both for patients and the medical staff. “There’s a real efficiency of care that you get here that you don’t get at a hospital,” she said. “I can see a woman in my office, have a question about something, send Colorado Medicine for July/August 2012

Features her down to the breast center, do an ultrasound, have the radiologist look at it and get it right back.” The arrangement has brought cost efficiencies because staff don’t have to chase down results or repeat tests or exams. Because the physicians make up the organization’s board, they are accountable to one another about everything from communication to which supplies to buy. And twice a month, all physicians, as well as staff such as the mammography and radiology technicians, participate in the group’s Tumor Board. Each patient’s primary care physician also is invited.

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Brew said she believes she and her colleagues are “lucky, but not unique.” She said they were fortunate to have people like Rossi who helped guide the physicians’ vision and to ensure the project stayed on track.

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“It’s so consuming you need someone like Terri who keeps that vision going,” she said. She and Schewe also noted that the area hospitals were not thrilled with the idea of what they were doing at first. Though the physicians remain affiliated with and practicing in hospital settings, there have been some tough times. That’s when it was especially important to know that they all were in it together. “Physicians as a group tend to be all the individual CEOs of their own empires, and the hospitals and the insurance industry take advantage of us because we don’t come together,” Schewe said. “If you want to do something similar, you need to band together with physicians who are like minded and who you trust in terms of getting the kind of care you would want to receive. You cannot do it alone.” n Photo caption page 24: From left to right, Surgical Specialists’ Terri Rossi, COO, Krisha Perry, and Kevin Schewe, MD. Colorado Medicine for July/August 2012

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 Better Business Bureau, ATSI and Telescan Users Network (TUNe). MTC participates 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 months in testing the response time of the volunteer providers.

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Electronic referral tool helping to coordinate care in El Paso, Teller counties Sara Burnett, CMS contributing writer Physician practices in El Paso and Teller counties have begun implementing a new electronic tool that will help coordinate care, make the referral process more efficient and build a virtual medical neighborhood of providers. The electronic referral tool, known as e-Referral, is available free of charge to area physicians through a partnership between El Paso County Medical Society, the Colorado Medical Society and CORHIO, the Colorado Regional Health Information Organization. It is intended to support a shared community standard for referrals – one created by local physicians, practice managers and other health partners. So far, 229 providers in 22 practices have signed up for the tool. Of those, 58 providers in 10 practices already are live. “It’s kind of a no-brainer in terms of the right direction to go,” said Greg Sharp, MD, an EPCMS board member whose practice, Ideal Family Health Care of Woodland Park, tested e-Referral and was one of the first to implement it. “A lot of problems that providers experience when it comes to patients being referred from one office to another have to do with organization, and I just don’t think there are many tools out there for people to really track referrals and their status,” Sharp said. “This goes a long way toward helping people organize that whole process.” In a 2011 survey, only 16 percent El Paso County Medical Society members said 26

they were very or totally satisfied with the coordination of care between primary care physicians and specialists. Less than half – 39 percent – said they received the necessary information from referrals. That poor communication can be frustrating for patients, lead to costly duplication of services and increase the likelihood of medical or administrative errors.

Frederick-Gallegos added. “This is the tool that enables you to have those conversations.”

EPCMS began focusing on care coordination during a recent series of discussions on the “New Realities” of health care – one of which was about care compacts, or collaborative care agreements. Such agreements standardize communication between providers in the referral process, and make clear the expectations and responsibilities for all involved.

The tool allows practices to electronically send, receive and track referral requests in a secure system. They also may attach clinical notes and results, eliminating lost paper work and double faxing. Practices don’t need to have an electronic health record, but eReferrals will work with an EHR.

A workgroup made up of local physicians and practice administrators as well as representatives of EPCMS, CMS and CORHIO was formed to work on a community care compact. That template was then integrated into CORHIO’s eReferrals tool. “This is an important first step in shared care,” said Karen Frederick-Gallegos, director of quality improvement services and analytic services for the Colorado Foundation for Medical Care and the former director of quality initiatives for CMS. “Who’s in your medical neighborhood? Do you know what they want from you? Do you share the same expectations? And how effectively do you share data?”

The first implementations of eReferral took about four hours per practice, but the process is now averaging closer to two hours, said Mark Carlson, business development and outreach manager for CORHIO.

Sandra Robben-Webber, practice administrator at Colorado Springs Pulmonary Consultants, was a member of the workgroup and tested eReferrals with Sharp’s practice. She said she believes the tool provides clear responsibility and accountability. “There’s no longer the PCP saying ‘I faxed that referral to you three times, or I sent you that chart three times,’” she said. But all involved agree that to have the greatest impact, a critical mass of providers must participate. “It truly is a community-based tool,” Robben-Webber said. To learn more, contact Carlson at mcarlson@corhio.org or 303-886-1816. n Colorado Medicine for July/August 2012

Colorado Medicine for July/August 2012

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.

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Colorado Medicine for July/August 2012

CMS Education Foundation Help send a student through school About the CMS Education Foundation Founded in 1982, the Colorado Medical Society Education Foundation (CMS EF) is a non-profit, tax-exempt charitable foundation established primarily to support educational and charitable programs in Colorado. Since 1993 the Foundation has dedicated itself almost exclusively to the funding of scholarships to incoming first-year medical students at the University of Colorado School of Medicine. Scholarships are awarded to students who come from underserved areas, have high academic credentials, demonstrate a financial need, and anticipate practicing in a rural or underserved area. Call 720-858-6310 for more information and to donate

Colorado Medicine for July/August 2012

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

Investing in education today that prepares us for tomorrow We all know the value of education – from the years spent in medical school to ongoing training that keeps us connected to the ever-evolving world of health care. Because of the changes in technology, regulations and medical advancements, education is a key focus in COPIC’s partnership with the physicians, practices and facilities that we insure. COPIC invests more of its resources in patient safety and risk management education and initiatives than any other medical liability insurance provider in the country. Why do we do this? Not only is it a smart way to arm insureds with the knowledge they need but, more importantly, it’s the right thing to do. Expanded educational opportunities are essential in moving us toward the goals of reduced medical errors, a decrease in liability costs and enhanced patient safety. In addition, our insureds see benefits such as: • Participation in forums that foster shared insight among medical experts and their peers. • Reduced premiums through earning COPIC points that apply toward an associated annual discount. • Opportunities to earn required CME, AMA and other professional credits. COPIC’s forward-looking vision continues to drive new educational opportunities – both in their content and how people access them. Our Patient Safety and Risk Management department is constantly working with internal teams and external partners to develop courses, seminars and programs that are meaningful and relevant for the challenges health care professionals face. Access to online courses We understand the demands of your schedule and that’s why we continue to develop new online courses. From topics such as “Liability Aspects of EHRs” to “Risk Management in Infectious Diseases,” these courses can be accessed through our website and completed when the time is right for you. We are also expanding our offering of online courses based on reallife case studies. For example, “The Case Study of Jane Taylor,” provides an interactive learning experience that takes participants through a real case, illustrating its clinical and legal aspects. The format mirrors the expert analysis and review process of a closed claim. Comments from participants are solicited throughout and the final outcome is revealed in chronological order.

New seminars that focus on technology issues Do you understand the security issues associated with technologies used in health care communication? Today, there is an array of ways that technology facilitates communication and data is shared across millions of devices. These technologies expose medical providers to liability, including civil, criminal, regulatory, business, employment and reputational. To address this, COPIC developed a new, in-person seminar called “Electronic Communication in the Medical Practice: The Need and the Risk.” The seminar reviews a range of communication technologies (text messaging, EHR portals, Wi-Fi, social networking, smart phones and tablets), discusses the strengths and vulnerabilities of these technologies and outlines the basic requirements for setting up secure electronic messaging systems. An immersive, inside look at medical liability COPIC has developed a new program for physicians to learn from and interact with our leadership and risk management teams, attorneys, experts and other staff. “Inside COPIC: An Intensive Look at the World of Patient Safety and Medical Liability” is offered multiple times throughout the year and consists of two half-days – a Wednesday evening workshop, followed by a formal Claims Committee meeting the next morning. Both sessions are held at COPIC’s office and attendance qualifies for six COPIC points, allowing physicians to earn a preferred premium discount for two years. The Wednesday evening workshop focuses on topics such as: • COPIC’s advocacy for patient safety, a stable tort environment and active physician involvement. • The importance of timely reporting for accessing COPIC resources. • Key safety and risk principles such as communication, documentation, handoffs, systems failures, human factors and checklists. • The process of reporting an incident, a claim, or a lawsuit including notice, discovery, depositions, consent to settle and the trial process. • What makes a case defensible versus difficult to defend. You can access all of COPIC’s educational opportunities at www.callcopic.com/education. We will continue to develop new content based on cases, trends, professional society and literature-based materials, and national patient safety in-

Colorado Medicine for July/August 2012

formation. In addition, one of our most important sources for new educational content is the physicians we insure. What topics are of interest to you? How can we better serve your educational needs? Do you have useful comments on any courses or seminars that you have taken? If you have feedback, please contact our Patient Safety and Risk Management department.

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Inside CMS

2012 CMS Annual Meeting Keystone Resort and Conference Center September 6-9, 2012

CMS is pleased to recognize its sponsors and exhibitors for this yearâ&#x20AC;&#x2122;s annual meeting Presenting Level Sponsor: COPIC

Exhibitors:

Gold Level Sponsor: UnitedHealthcare Centura Health Silver Level Sponsors: Allscripts CIGNA Healthcare Colorado Business Bank KKB Millennium Laboratories

American Medical Association athenahealth CMS CodingToday Center for Personalized Education for Physicians Colorado Physician Health Program e-MDs Harmony Foundation Life Care Centers of America McKesson MedicalTeleCommunications Novitas Solutions Purdue Pharma Solve IT Solveras: A Division of TransFirst The Grillo Health Information Center

Leveraging Relationships: The Collaboration Imperative 32

Colorado Medicine for July/August 2012

Inside CMS

Leveraging Relationships: The Collaboration Imperative 2012 CMS Annual Meeting Agenda Purpose: This event is designed to provide information, practical tools and other resources to demonstrate how an engaged and connected medical community can become a collective force in addressing and adapting to health care reform. Topics include health system reform, value-based payment models, performance measurement and patient safety. This dynamic session will highlight best practices to help physicians guide the future direction of the Colorado Medical Society. Thursday, Sept. 6

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*Sessions with an asterisk are CME approved. Finance Committee Board of Directors Dinner on your own (save dessert for the Welcome Reception) Registration Open Welcome Reception (desserts, etc.)

Registration Exhibits open New Delegate Orientation Reference/Credentials Committee Breakfast House of Delegates Opening Session • Robert Yakely: Opening of House • Past President’s Speech • Nominees for Office (3 minutes each) Reference Committee: Board, Bylaws and Policy Break with Exhibitors Leveraging Through Strategy: Tune Polling-Plus (Interactive strategy session on critical issues to physicians and patients) AMA Luncheon: Leveraging Practice Viability (Showcase of AMA practice evolution and viability resources) Break with Exhibitors * Leveraging the Dollars: Aligning Payment and Quality (Interactive session with the state’s top health plan medical directors) Breakout Sessions (Pick One) * • Performance Measures: Leveraging Your Clinical Expertise * • Payment Reform Tool Kit: Leveraging AMA Resources * • Expanding Coverage: Leveraging the Colorado Health Benefit Exchange Reception with Exhibitors Colorado Academy of Family Physicians American College of Physicians, CO Chapter

Breakfast Buffet Leadership Alumni Registration Open Leveraging Access to Care Through Leadership (Advanced Physician Leadership Program Graduates Leverage Access to Care) Leveraging Public Opinion Post SCOTUS

Colorado Medicine for July/August 2012

Inside CMS 9:30 AM -

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(Interactive Session on voter perspectives with Pollster Benjamin Kupersmit Leveraging the (Optional) Medicaid Expansion (A professionally facilitated and interactive session on the state’s impending decision to opt-in or opt-out of the Medicaid expansion made optional by the U.S. Supreme Court ruling) Exhibitor Break Breakout session (Pick One) 1. Leveraging CMS: Future Relevance Regardless of Employment Setting * 2. Leveraging Into Intelligence: A CIVHC Focus Group COMPAC Luncheon: Leveraging Relationships 2012 peer review bill sponsors Rep. Bob Gardner (R-Colorado Springs) and Senator Irene Aguilar, MD (D-Denver) will be honored and hold an interactive open mike dialogue on health issues in the 2013 General Assembly Medical Students * Electronic Communication in Medical Practice: The Need and the Risk * Never Events: Defensibility, Prevention and Safety * Jeopardy with Dennis Boyle (Patient Safety/Risk Management) The Inaugural Warm Up: Meet The Candidates • President-elect • Speaker of the House of Delegates • Vice-speaker of the House of Delegates • AMA Delegate • AMA Alternate Inaugural Gala (Black tie optional) COPIC Dessert Reception

Component Caucuses ADEMS Aurora-Adams Boulder Creek Valley Denver El Paso County Larimer/Weld Medical Students Pueblo/Western Slope Credentials Committee Closing Session House of Delegates Wellness Break with Doris Gunderson, MD Closing Session House of Delegates

The Colorado Medical Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Colorado Medical Society designates this live activity for a maximum of six and one-half (6.5) AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Colorado Medicine for July/August 2012

Departments

New Members Arapahoe-DouglasElbert Medical Society Anna F Cosyleon, MD Benjamin Honigman, MD Judd M Jensen, MD Thomas T Mydler, MD William S C Payne, MD Byron R Spencer, MD Jeffrey C Wagner, MD Boulder County Medical Society Jeska Albuisson, MD Shoban A Dave, MD

Scott W Davis, MD Meighan W Elder, MD Jennifer M Johnson, MD Julie A Melchior, MD Jill M Olson, MD Pamela JB Stone, MD Tanya L Tivorsak, MD Juan E Weksler, MD CMS Direct Aja A Bjerke, MD Alexander D Blandford, MD Yevgeniya A Byekova, MD Marc F Comaratta, MD

Daniel J Corbett, MD Rebecca S Danhof, MD Kathryn F Echols, MD Ryan M Gasser, MD Matthew W Jackson, MD Agnieszka W Kubica, MD Jared L Matthews, MD Sasha Strul, MD Leigh M Sutton, MD Curecanti Medical Society Libuse Hardekopf, MD

Denver Medical Society Mark W Melberg, MD Stephen J Murphy, MD Douglas A Newton, MD Leslie K Proctor, MD Alan J Rastrelli, MD Medical Student Component Matthew C Iacovetto Northeast Colorado Medical Society Sidney J Adler, MD Pueblo County Medical Society Robert T Abbott, MD Sweekriti Adhikari, DO Kelly J Buerger, DO Trace C Caton, MD Johnny Cheng, DO Jennifer A Dalrymple, DO Jennifer L Fitzpatrick, MD Brita C Krabacher, DO Xuanha T Nguyen, DO Robert W Nolan, MD Tyler R Pearce, MD Rachel K Saul, DO Carolyn R Smallwood, DO Charis V Thatcher, MD Meghan M Timmerman, DO Jonathan W Von Koenig, DO Bonnie Wong, DO

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

Colorado Medicine for July/August 2012

Departments

medical news Former CMS President William Bailey, MD - 1927-2012 Colorado Medical Society Pastpresident Dr. Bailey (Bill) 85, of Silverthorne, passed away July 31 surrounded by family. He was born in William Bailey, MD Detroit, Michigan. Bill graduated from Wayne State Medical School, served in France with the Army Medical Corps, completed residences in surgery at the University of Michigan and pediatric surgery at Columbus Children’s Hospital. Bill moved to Denver in 1962 where he began his practice of pediatric surgery at The

Children’s Hospital, now Children’s Hospital Colorado. Bill founded the Burn Team at TCH, which grew into a major regional center for the treatment of complex burns. The Burn Team benefitted from the Summit Co. Pumpkin Bowl for many years. He served as president of the Denver and Colorado Medical Societies. When retired from clinical practice he was appointed an asst. Dean with the CU Medical School to promote collaboration between the school and the state’s engineering schools. Bill thought of Summit County as his second home long before he built a permanent residence there. He followed his passion

for skiing, sailing, fishing and all outdoor sports which he taught, and shared with, his family. Bill is survived by his wife, Joan, his children: Claire, Dave, Matt, Carl, their spouses and 10 grandchildren. A memorial service was held at Lord of the Mountains Lutheran Church, Dillon, on Friday, August 17 at 2 p.m. Memorials may be directed to Children’s Hospital Colorado Burn Camp,13123 East 16th Ave., Aurora, CO; Adam’s Camp, 6767 South Spruce St., Suite.102, Centennial CO; The Pacific Association. of Pediatric Surgeons; or The Frederick A. Coller Society. n

ANNOUNCING

Free website for Colorado physicians offering EHR tools and resources Your path to meaningful use The Colorado Medical Society and CO-REC are pleased to offer a free online EHR portal that provides the tools, resources and information to help Colorado physicians select, implement and meet “meaningful use” requirements.

• Step-by-step training with tools to track meaningful use progress

• Establish your own free account - quick registration • Self-guided and interactive content developed for Colorado physicians and staff

• Information and links to statewide resources • Online forms and downloadable documents to guide you through the meaningful use EHR process

Creating your free account is easy. Sign up today by logging on to

Funded by a grant from the Physicians Foundation

http://www.corhio.org/portal Colorado Medicine for July/August 2012

Departments

medical news John L. Bender, MD, FAAFP, running for CMS President-elect After much consideration, I am announcing my candidacy for CMS President-elect for the 2012 House of Delegates election cycle, to be held at the annual meeting in Keystone Colorado on September 9, John Bender, MD 2012. I am enthusiastic for the opportunities before the CMS and I have spent part of the last six months traveling the state to meet with your various component societies and local boards of directors to hear their suggestions for healthcare solutions in Colorado. It is amazing how much passion and innovation is occurring in Colorado, and I am encouraged to see the caliber of leadership among the delegates and component boards around the state. In February, I had the privilege to testify in Washington, D.C., before the United

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States Congress House and Ways Subcommittee on Health about the proven value of the patient-centered medical home. There, I told my story, of starting out with one employee and one computer and building to a network of four patient-centered medical homes that have achieved level III NCQA recognition, serving 27,000 patients. My story is one of choosing to focus on quality by actually measuring clinical outcomes and subjecting myself to a report card that compares me to my peers. But the story doesn’t end there. By reviewing data and managing population metrics, Miramont Family Medicine has been able to reduce readmission rates by 83% for commercial payers like United HealthCare, and for our Medicaid population we reduced emergency room utilization by 219%. In 2010 we won the national HiMSS Nicholas E. Davies Award of Excellence for outstanding achievement in the implementation and value from health information technology. In 2011, The Colorado Academy of Family Physicians Foundation named Miramont Family Medicine the Patient Centered Medical Home of the Year. I served as president and chair of the board of the Colorado Academy of Family Physicians (CAFP). I currently serve on the boards of directors for CMS and CAFP in addition to being past president of the Northern Colorado Individual Practice Association. From 20062007 I served as the Alternate Delegate for the American Medical Association’s Young Physician Section representing family physicians at the national level. Several of my resolutions are now national policy for both the AMA and AAFP. I regularly serve as doctor of the

day at the Colorado state capitol, testify on bills every session, and have worked on various pieces of legislation that are now law in Colorado dealing with immunization registries and the corporate practice of medicine. I also enjoy teaching and am an Associate Professor of Family Medicine with a preceptor appointment to the University of Colorado Health Sciences Center, and a preceptor to Rocky Vista University College of Osteopathic Medicine. I also serve as one of nine physicians on the national NCQA Review Oversight Committee (ROC) and chair the national HiMSS Davies Ambulatory Award committee. My past military experience includes eleven years as a commissioned officer in the United States Naval Reserve as a Flight Surgeon, and two years as a commissioned major in the United States Army Reserve. In July 2000, President Clinton ordered my unit to Kosovo where I served as the medical director for an acute care center in the surgical hospital at Camp Bondsteel after the Serbian offensive. I married my childhood sweetheart, Teresa, who is our practice administrator for our four clinic locations. We have two adult sons both who serve proudly in the United States Marine Corps, two adult daughters who help with the family business, and three grandchildren. I thank you for this moment of personal privilege and look forward to visiting with you soon at the annual House of Delegates meeting in Keystone! Sincerely, John L Bender, MD, FAAFP n

Colorado Medicine for July/August 2012

Departments

medical news Physician Defense Fund Trust gives CMS $25,000 Trustees of the Physician Defense Fund Trust have donated $25,000 to support the physician wellness strategic goal of the Colorado Medical Society. CMS President Dr. Brent Keeler accepted the generous donation at a recent leadership meeting of the medical society. The Physician Defense Fund Trust was established 25 years ago to assist physicians in defraying legal costs incurred by defending themselves against allegations leading to sanctions by Medicare. The scope of the trust was subsequently expanded to include assisting physicians with assistance in Board of Medical Examiners actions and medical malpractice actions and medical staff reviews and hearings. At the time the trust was established, the medical staffs of St. Anthony Hospital Systems, Lutheran Medical Center, Beth Israel Hospital and Mercy Medical Center were solicited and generously contributed to the fund. The trust has been used sparingly in the past and not at all for the last several years. The

CMS joins in appeal of anesthesia opt out to Supreme Court Colorado Medical Society will join in an appeal of the anesthesia optout to the Colorado Supreme Court.

Brent Keeler, MD, David Hutchison, MD, and Jan Kief, MD at check presentation. trustees met on June 21, 2012, and after obtaining legal counsel have decided to terminate the trust. The trust assets were divided equally between the Colorado Physician Health Program and Colorado Medical Society. Physician Defense Fund Trustees: Allan Carlin, MD David Hutchison, MD Raymond Mencini, MD Nicholas Napoli, MD Peter Weiss, MD n

The Colorado Medical Society Board of Directors has voted to join the Colorado Society of Anesthesiologists (CSA) in appealing the trial court’s decision to dismiss our joint lawsuit that sought to overturn former Governor Bill Ritter’s executive order to opt Colorado out of Medicare’s long-standing certified registered nurse anesthetists (CRNA) medical supervision requirement. The recent Court of Appeals ruling upheld former Gov. Ritter’s decision to allow hospitals to opt out of the Medicare requirement for physician supervision of CRNAs and concluded that the delivery of anesthesia by a CRNA without physician supervision is consistent with Colorado law. n

Colorado Deptartment of Health Care Policy and Finance announces promising results from Accountable Care Collaborative Program On July 31 the Colorado Department of Health Care Policy and Finance announced promising results from the Accountable Care Collaborative (ACC) with cost utilization and client experiences trending in the right direction. This confirms CMS’ strong belief in local innovation and care coordination and the medical society wrote to thank Gov. Hickenlooper for his commitment to the innovative program. “At this epic, crossroads moment in the trajectory of Medicaid, when Governors and Legislatures across the country are contemplating how to respond to the latitude granted by the U.S. Supreme Court, we commend you and the Colorado Medicine for July/August 2012

Department for the work already underway,” said CMS President Brent Keeler, MD. “We strongly believe that locallycollaborative health care delivery models, like Colorado’s ACC program, will bend the cost curve and demonstrably improve the value of state and federallyfinanced services by reducing redundant or unnecessary care and by improving the probability that our patients will get the right care at the right time and place.” The ACC program is reflective of Colorado’s well-earned national reputation for cultivating homegrown, community-centric care delivery models. All of these programs provide the time-

honored proof that locally guided care coordination works. From the widely reported Grand Junction model to the remarkable HealthTeamWorks medical home pilot, our health care communities continue to band together to provide greater value for the premium dollar. Colorado Medical Society pledged its unqualified support for this crucial, locally-led endeavor, and offered any assistance needed to assure this program’s continued growth and success as the department works to develop a broader vision for payment reform within the ACC program and integration across various delivery systems. n 39

Departments

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

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NEED A HAND WITH PHYSICIAN STAFFING? ExtraMD, a local locum provides local physicians, reasonably priced with instant availability! Not ready to hire but need some extra help? Looking for a reasonable alternative to expensive national companies? ExtraMD is Denver based, physician owned and managed. ExtraMD provides experienced, caring physicians that will cover your practice when you are gone or overloaded. ExtraMD’s physicians cover family practice, internal medicine, urgent care and hospital medicine. Our physicians can work just a single day or months at a time. ExtraMD offers same day/next day coverage for emergencies. Call 720.202.3358, or email: admin@extramd.com

➤ PROFESSIONAL OPPORTUNITIES ➤ MISCELLANEOUS FAMILY PRACTICE MD – ENGLEWOOD – Small established Family Medicine Practice seeking a full-time provider to buy-in to practice (half ownership). Must be prochoice, female preferred. Please send CV to healthyfutures05@gmail.com FAMILY MEDICINE PHYSICIAN - VIRGINIA – CasePro is a Federal Contracting Employer with full-time opportunities at the Naval Branch Clinics in Virginia Beach, Virginia. • B/C by the ABFM • Minimum 1 yr exp within the last 3 yrs • Any current state license accepted • Clinics are open 7am – 7pm, 7 days a week • Full-time is 34.5 hrs/week • You may pick up additional shifts • PTO and Federal Holidays paid Contact Rob Penner at 888.999.5415 or rob@caseproinc.com

LOOKING FOR LOCUMS WORK IN COLORADO? – We place physician and mid-level providers with family practice, urgent care, internal medicine, pediatric and occupational medicine clients. Competitive rates. Are you a provider that needs strong locums providers to work in your practice while you are away? Securely email to RMoore@ mednowstaffing.com or visit our website at www.MedNOWStaffing.com

DONATE SUPPLIES OR EQUIPMENT Project C.U.R.E. collects donated medical equipment and supplies and organizes them for delivery to people in need in developing countries. Volunteers needed locally to sort medical supplies and internationally to participate in C.U.R.E. Clinics. For more information, visit http://www.projectcureorg, call 303-792-0729, fax 303-792-0744, or e-mail projectcureinfo@projectcure.org. Colorado Medicine for July/August 2012

classified advertising ➤ PROFESSIONAL OPPORTUNITIES PHYSICIAN WANTED – Midtown Occupational Health Services, a Workers Compensation Clinic located in Down Town Denver, is seeking a level II certified physician. Fax CV to 303-468-9818 or send via e-mail to pclatterbuck@mdtwn. com. Contact Pam at 303-831-9393 for details. INTERNAL MEDICINE - HOSPITALIST AND OUTPATIENT OPPORTUNITIES IN SUMMIT COUNTY, CO – We have a need for a part time hospitalist in Summit County, CO with opportunity to be full time if desired. Our community also needs outpatient Internal Medicine and the option to do both outpatient care and hospitalist work exists if interested. Board certification or eligibility required. Please contact Mark Norden, MD, 303-885-4673 to discuss. URGENT CARE – Board Certified M.D. or D.O. Full time position available for Colorado and New Mexico. Busy, growing, walk-in Urgent Care Clinic looking for quality, caring, physician. 12 to 15 shifts per month, flexible schedule, 10 hour shifts. Benefits include Health Insurance, Malpractice Insurance and Continuing Ed allowance. Live in beautiful Southwest Colorado, Northern New Mexico where quality is a way of life. Email C.V.’s to: russ@durangourgentcare.com or call 970-247-8382 extn 103. CHIEF MEDICAL OFFICER WANTED – Chief Medical Officer responsible for the coordination and oversight of all primary care services provides 0.8 FTE patient care 0.2 FTE administrative services. Plains Medical Center www.pmcnc.org. CMS ORG CMS ORG CMS..ORG CMS ORG Colorado Medical Society

Colorado Medicine for July/August 2012

Final Word (cont.) shoreline with no lasting effects. Meteorologists will study it for years, just as lawyers and Constitutional scholars will study the several opinions of the Court in this case. But the beachfront developers – by the metaphor, those who are rebuilding American health care – just get to go back to work, to finish the job they were already on. There are still risks to the federal statute, though they are mostly of the political kind, about which it would be unwise to speculate much before November 6. And there are legal challenges floating about, yet to be decided – for example whether, due to some infelicitous drafting in the Act, the federal government can legally offer premium subsidies in an exchange which it creates in a nonparticipating state, since the statutory text provides for subsidies only in statecreated exchanges. Of greater interest, however, may be actions by and within the individual states. With the super-penalty gone, a state could decline to participate in the Medicaid expansion without losing its existing funds. It would forgo only its share of the expansion funds. A state might do that for any of several reasons: one unsavory possibility is that the state could experience an out-migration of its poorer and most costly citizens to neighboring states which do offer care more inclusively. Another might be a matter of political principle – “federalism,” it’s called. The governor of one state has already announced an intention to do just that. But it’s a nice question whether even a go-it-alone sort could get away with it. For one thing, the expansion moneys, if accepted, would in turn be paid as feesfor-services to in-state hospitals and physicians, creating political pressure from that quarter not to turn down the state’s take from the expanded federal funds. For another, there is at bottom no such thing as “federal funds,” apart from the fact of who assembles them. It all comes from the people who are si-

multaneously citizens of a state and of the federation. If, say, Texas declines to take its share of the expansion, Texas citizens’ federal tax money will leave the state for places where it would be more welcome, thereby benefitting the citizens of, say, Minnesota, at Texas’ expense. Like everything else, political principle has its limits. Back to the metaphor. The Affordable Care Act, despite its thousands of pages of technical legal text, is still very much a work in progress. Apart from the new insurance rules, much of what it achieves will come from implementation decisions made by the professionals and leaders of health care itself – ACOs and other forms of integrating care are one example, experiments in payment reform another, and so on through the applications of comparative effectiveness research and many of the statute’s other strokes. A significant enhancement of medicine’s opportunity to shape the health care of the future was created by the passage of the Act, not by the decision of the Supreme Court. The hurricane may have come close, it may have to suffer analysis by scholars of jurisprudence for a generation to come, but it did not wash away or make more difficult the developments already being built on the shoreline. Those who are capable, and responsible, for that construction may now simply continue their work. n

LOOKING? Whether you’re looking for new opportunities or selling your product or service, CMS’ classified ad section is the place to be seen. To place your ad call (720) 858-6310 41

Features

the final word Edward A. Dauer, LL.B., M.P.H. Dean Emeritus, University of Denver Sturm College of Law

The Supreme Court, the ACA and medicine’s continuing task At the CMS Spring Conference in Vail last May, I participated in a forum about the then-upcoming Supreme Court decision on the Constitutional vitality of the Affordable Care Act, the federal health care law enacted in 2010 and scheduled to be fully implemented by 2014. When pressed to predict the outcome in the Court, I hedged. I thought the Medicaid expansion (the chief vehicle by which the poorest uninsured would be covered) would survive, and that the “individual mandate” (the lynchpin of premium limitations and guaranteed issue) would either be struck down 5-4, or upheld 6-3. The theory was that the three more conservative justices (Alito, Scalia and Thomas) would vote to strike the mandate down. The four more liberal justices (Breyer, Ginsburg, Kagan and Sotomayor) would vote to uphold it. And if Justice Kennedy – often the swing vote on the Court – agreed with the conservatives, Chief Justice Roberts would join that group making it a 5-4 decision to invalidate the mandate, and thereby open the additional question of what other parts of the Act should go down with it (the so-called “severability” debate.) If, on the other hand, Justice Kennedy voted with the liberal wing, the Chief Justice might join that majority, making it 6-3 to uphold, so that he could control the writing of the opinion of the Court. Under the Supreme Court’s internal rules the Chief Justice assigns the opinion unless he is in the minority, in which case it is assigned by the senior justice in the majority group. 42

Fortunately, I did not place a large bet on that prediction. As we know, Justice Kennedy voted to strike the mandate and the Chief Justice voted to uphold it – an outcome some pundits thought amazing if not inexplicable. And the legal reasoning by which the mandate was upheld was, so far as I know, predicted by no one. More on that in a moment. I was nonetheless on target with one (admittedly very easy) prediction, and pretty close with another. I felt that the decision on the mandate, whichever way it went, would say nothing of any importance about health care or health care policy. It would, instead, deal entirely with an abstract Constitutional question: does Congress have the authority to require citizens to “engage in commerce” in ways some might not want to do? And while I thought the Medicaid expansion would survive, like many others I thought its weak spot was the Act’s penalty provision. As it was written, the federal government could strip a state that did not join in the expansion not only of its share of the expansion funds, but also of all of the Medicaid funds it is already receiving. Justice Roberts’ opinion – the operative decision of the Court despite the fact that there are four opinions with varying permutations of votes on the several key questions – reads pretty much that way. As expected, and not inappropriately, it contributes nothing of significance to the national discussion about health care. As to the mandate, five justices concluded that under the Constitution’s Commerce Clause the federal govern-

ment cannot force individuals to participate in unwanted commercial activity. More technically, the government cannot regulate commercial inactivity, such as not buying health insurance. The penalty for not buying insurance, however, was construed by a somewhat different configuration of justices to be a tax, thereby allowing the mandate to be upheld not under the Commerce Clause but under the government’s taxing power. The practical meaning of those two conclusions for Congress’ overall authority is not entirely clear. While citizens can’t be forced to buy something they don’t want, they can apparently be taxed if they don’t. On the Medicaid expansion, the Chief Justice wrote that while the super-penalty for a state’s not joining in was too coercive to be Constitutionally valid, it was severable from the rest of the Act, leaving the expansion intact but without the penalty. So what does it mean for health care? As I see it, the Affordable Care Act itself is supremely important. But in a very real way the Supreme Court’s decision is not. A metaphor that comes to mind is something like this: The most complex hurricane ever to form offshore, despite the varying forecasts about its path, does not hit the shoreline where an elaborate beachfront development is in process of being built. The developers incur some delay as they all hunker down before the storm, and a bit of flotsam litters the beach for a while, but the hurricane bypasses the (Continued on page 41)

Colorado Medicine for July/August 2012