November-December 2017 Colorado Medicine by Colorado Medical Society

November/December 2017

Volume 114, Number 6

Finding encouragement in medicine: Doing more through CMS M. Robert Yakely, MD, CMS President

Award-winning publication of the Colorado Medical Society

contents Nov/Dec 2017, Volume 114, Number 6

Cover story M. Robert Yakely,

MD, was installed as CMS president at the 2017 annual meeting in Breckenridge and his advice to his colleagues and medical students for avoiding burnout in medicine is to celebrate the relationships you form with patients and colleagues, reflect on successes of good medical and surgical outcomes, and be an active member of the Colorado Medical Society where you can make even greater gains for patients and physicians. Read more starting on page 6.

Inside CMS 39 COPIC Comment 40 Reflections 42 Introspections

Departments 44 44

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Colorado Medicine for November/December 2017

Features. . . 10

Mapping the course– CMS will focus on payer issues, patient safety and substance use disorders in 2018.

A weekend to relax and connect–Read a report and view photos from the 2017 CMS Annual Meeting in Breckenridge.

Fighting compassion fatigue–A thought-provoking annual meeting session gave voice to patients’ stories.

Health care reform–Three speakers during the annual

Opioid crisis update–Revisit the thorough talk on the opioid crisis from the annual meeting.

COMPAC luncheon–Attorney General Cynthia Coffman was honored and a panel of legislators discussed state health policy during the annual COMPAC luncheon.

A pain physician’s plea–Jonathan Clapp, MD, presents his thoughts on pain management with or without opioids.

All-member opioid survey–An all-member survey examined physicians’ perception of the opioid crisis and potential action steps.

Legislative proposals–Legislators unveil a set of opioid bills they expect to see in the 2018 General Assembly.

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

Credentialing assistance–A new member benefit will help eliminate the time and cost burdens of credentialing with health systems, health plans and regulatory agencies.

Technology collaboration–A new AMA initiative brings stakeholders together around a common data model.

Medicaid payment–CMS pushes for immediate payment and interest on overdue clean claims.

Final Word– CMS Immediate Past President Katie Lozano, MD, FACR, talks about opportunities arising from the allmember opioid survey.

meeting explored health care reform at all levels.

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF

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

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

AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Katie Lozano, MD, FACR Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD

Katie Lozano, MD, FACR Immediate Past President COLORADO MEDICAL SOCIETY STAFF Executive Office Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Fetter, Director, Professional Services, Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org

Division of Health Care Financing Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

Division of Communications and Member Benefits Kate Alfano, Communications Coordinator, Kate_Alfano@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org

Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Program Manager Adrienne_Abatemarco@cms.org

Division of Health Care Policy Chet Seward, Senior Director, Chet_Seward@cms.org Gene Richer, Director, Continuing Medical Education, Gene_Richer@cms.org

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

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

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

Doctors and medical students as lobbyists: How hard could it be? CMS CPMG Section, Medical Student Component and COPIC invite physicians and medical students to attend Public Policy Leadership Forum on Saturday, Feb. 3, 2018 Advocacy in the public policy realm can be a powerful tool to effect positive change – if you understand the nuances of a powerful short game and strategic long game. The CMS CPMG Section, Medical Student Component and COPIC invite physicians and medical students to attend a Public Policy Leadership Forum on Saturday, Feb. 3, 2018. You advocate for your patients every day. Take that advocacy to the next level by learning from some of the best in the business, getting the information you need and practicing the key skills for success in public policy advocacy. The interactive and action-packed program will cover the basics on the legislative and rule-making process, how to approach hot-button issues, the importance of knowing your elected officials and candidates, the mechanics of lobbying and real-world opportunities to get involved now. Learning objectives • How to frame and pitch issues to elected officials, adjusting the pitch to the political environment and your audience • How to distinguish the meanings and obfuscations of an elected official’s response and intuit the motives and weaknesses of an adversary • How to identify the remarkably easy, user-friendly entry points into their world and how to capitalize on those opportunities • How to convert ideas into real-world public policy consequences, whether to advance policy or redirect it Speakers We are honored to feature an all-star faculty of health policy experts, legislators and physician leaders who will focus on the current public health crisis caused by opioid abuse and misuse to give participants the insider’s perspective. • The Honorable Brittany Pettersen (D-Lakewood), chair, interim legislative committee on opioid abuse • The Honorable Irene Aguilar, MD (D-Denver) and the Honorable Jack Tate (R-Aurora), members of the interim legislative committee on opioid abuse • Joe Gagen, JD, renowned legislative trainer • Jandel Allen-Davis, MD, vice president of government, external relations and research, Kaiser Permanente Colorado Region • Robert Valuck, PhD, RPh, chair, Colorado Consortium for Prescription Drug Abuse Prevention

Colorado Medicine for November/December 2017

• Joe Hanel, manager of public policy outreach, Colorado Health Institute • Benjamin Kupersmit, president, Kupersmit Research • Jan Kief, MD, CMS past president • Donald Stader, MD, CO-ACEP board member and CMS liaison to the interim legislative committee on opioid abuse Who should attend? • Emerging and current physician and medical student leaders • Practicing physicians who want to have a broader impact for the profession and their patients • Physicians and medical students who have questions about how the public policy process works and how to engage elected officials face to face • Physicians and medical students who are frustrated with the current system and want to help make a change in health policy • Physicians and medical students who want to overcome the cynical belief that politics is futile The event will be held at CMS/COPIC headquarters. Seating is limited to 85 participants divided between physicians and students. The first five Western Slope registrants receive a complimentary overnight stay in Denver. Watch your email in late November for registration instructions. Questions? Contact Dianna_ Fetter@cms.org.

Finding encouragement in medicine: Doing more through CMS M. Robert Yakely, MD, CMS President

Colorado Medicine for November/December 2017

Cover Story At an annual meeting one year a medical student told me that she was discouraged about her future after listening to all the administrative problems physicians face in order to take care of their patients. That really got me thinking. I am truly grateful for the gift I was given when I received that letter of acceptance to medical school at the Ohio State University College of Medicine in 1962. I started thinking about what has changed and what I could share with younger generations of physicians to encourage them as they enter this challenging career. Looking back, after 50 years, I still believe the practice of medicine is one of the most rewarding professions you can choose. The relationships we develop with our patients when we have the privilege of guiding their care during emotionally stressful parts of their lives gives our lives purpose. Finding clues to making diagnoses, working in camaraderie with caring professionals, and reflecting on successes of good medical and surgical outcomes gave me a great deal of satisfaction. The relationship we have with our patients allows us to be human and to connect with our patients even when the automation of the health care system threatens to reduce us to cogs in the machine. Physicians are making health care better, and we make larger gains for all our patients and our doctors when we band together through membership in the Colorado Medical Society. I urge all members to invite non-member colleagues to join us. Some of the nonmembers simply don’t know how much of our advocacy affects their practice. When we work at the state capitol to keep the trial lawyers from increasing the cap on non-economic damages, it helps all Colorado physicians. We helped block two mergers of the largest health insurers in the country to protect patient choice, physician bargaining and care quality. We were incredibly effective in 2017 General Assembly with managed care reform and look to continue our successes in the public policy realm. Help us reach physicians who get the benefit of our

work but don’t choose to belong. Let them know that it is easy to access the streamlined member application at www.cms.org/join. Our achievements as an organization, under the leadership of Alfred Gilchrist, and all the members of his excellent staff, are quite remarkable. We changed our governance structure by dissolving the House of Delegates and allowing all our members to propose policy platforms using Central Line – an online, award-winning, first-inthe-nation membership engagement platform. All members can now vote for our officers. During the next year we will face many challenges. The Board of Directors and I will continue to work to preserve health care insurance availability for all Coloradans, and advocate for you and our patients at the federal and state level so that we can provide the right health care at the right place at the right time when it is needed. I will also continue the work of Past President Katie Lozano, MD, FACR, of addressing prescription drug abuse. Physician-led organizations like CMS and COPIC are now five years into efforts to reverse what is being called the largest U.S. public health crisis in the last 125 years. We are fortunate to be joined by a broad stakeholder coalition of providers, consumers, and elected officials in the legislative and executive branches of state government. Read more in the Final Word column on page 46. When the time is right in your career, I encourage you to consider taking some of our CMS leadership courses and volunteering to serve on a committee. It is another way to keep your satisfaction with your chosen profession at a level that sustains you. As I read about the exciting discoveries in medicine, I can see that the things students will be able to do for patients in the years to come are the things my generation could only dream about. When current research in the use of stem cells

Colorado Medicine for November/December 2017

and the CRISPER Cas9 gene therapy and many others come to fruition, it will be incredibly gratifying to use these therapies to extend and change lives. Sometimes I almost wish I were a medical student again … almost! From my vantage point of having enjoyed being a physician for over 50 years, my recommendation to avoid burnout is to take the time to enjoy the good that you do for people every day. I challenge you to identify the barriers that prevent you from enjoying your practice, change what you have the

“Physicians are making health care better, and we make larger gains for all our patients and our doctors when we band together through membership in the Colorado Medical Society. I urge all members to invite non-member colleagues to join us. ” power to change, and work with your medical society colleagues to fix them. This is our privilege as doctors and CMS members. Meet your new president Robert Yakely, MD, is a retired urologist living in Denver. He married his wife, Rosemary, in 1965. He received his medical degree from the Ohio State University College of Medicine in 1966 and completed his internship at Ohio State University in 1967. His training was interrupted by the Vietnam War, when he was drafted in 1967 into the Navy’s medical corps. He was assigned to a squadron of destroyers’ home ported in Charleston, S.C. After finishing his service in the Navy,

Cover story (cont.) he was accepted into the urology program at the University of Colorado Hospital in 1969. He practiced adult urology for many years until he and Rosie felt the call back to the ocean. A colleague, Noel Sankey, MD, medical director of the Kidney Stone Center, approached Yakely with an opportunity to work part-time. In 1996, he retired from his general urology practice and accepted the job as co-medical director of the Kidney Stone Center until he retired in 2015. This job allowed him and his wife to spend 10 winters living on a 45-foot sailboat in the British Virgin Islands. During this time, he and his wife started a prostate cancer screening program. For this contribution, the legislature named them honorary citizens of the British Virgin Islands. Within CMS, Yakely served as vicespeaker and then speaker of the House of Delegates before running for president-elect of CMS in 2016. n

Incoming president M. Robert Yakely, MD, takes the presidential oath of office from outgoing president Katie Lozano, MD, FACR, at the 2017 inaugural gala during the CMS Annual Meeting.

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Together we can champion critical health care issues. From boardrooms to community rooms to the Capitol steps, CMS is the only group in the state fighting for you and your patients every day. Together with our legislative partners, we’ve: ü Stopped a trial lawyer push to strip damage caps from wrongful death actions. ü Blocked a dangerous clinical overreach by naturopaths to inject hormones. ü Prevented unfettered access to the PDMP by CDPHE. ü Persuaded the insurance commissioner to create a first-of-its-kind pilot to hear physician complaints in addition to consumer complaints. ü Provided the DOJ with crucial physician statistics and experts that made the monopsony case against the health plan mega-mergers and killed the deals. The Colorado Medical Society, the largest physician-based organization in Colorado with more than 7,500 members, supports your profession and patients with unrelenting advocacy.

Physicians urgently need a voice and an ally to fight for their interests We don’t just check boxes: Statewide network of physicians | Leadership development | Everyday practice support and discounts | Improved practice environment and patient care | Individual input into advocacy issues

Join us now: www.cms.org/join or 720-858-6306 8

Colorado Medicine for November/December 2017

Features

Mapping the course Kate Alfano, CMS Communications Coordinator

Fiscal year 2017-2018 operational plan approved Each year the Colorado Medical Society Board of Directors approves an operational plan to focus the board’s work. The board approved the Oct. 1, 2017 Sept. 30, 2018 operational plan on Sept. 15. It includes 25 separate projects with the following major emphasis areas: • Payer issues and patient safety (Sunset of the Medical Practices Act and Professional Review), • Substance use disorders and the public health crisis caused by opioid misuse and abuse, and • Continuing to transition CMS to a 21st century state medical society by growing member awareness and promoting features, participation and achievements. The overriding theme is physician wellness, to maintain a focus on wellness to ensure members know they are supported. Regarding sunset review, the review of the Colorado Medical Board and Medical Practices Act (MPA) provides an excellent opportunity to review and modernize the programs and functions of the agency and law, and an opportunity for CMS to provide a leadership role. However, the requirement that legislation must be passed to extend the life of an agency or body gives medicine’s adversaries the opportunity to hold sunset legislation hostage in exchange for extraneous demands. The Medical Practices Act covers the powers and duties of the medical board, the practice of medicine, qualifications of licensure, unprofessional conduct, partnerships, obligations to protect medical records, and much more. CMS’s goal is to reenact an MPA that 10

maintains and advances the goal of contributing to patient safety, provider accountability and quality care. Regarding review of the Colorado Professional Review Act, this review will examine definitions, use and establishment of professional review committees, hospital professional review committees, definition and rules relating to governing board registering and reporting to the division, immunity from liability, and limitations on liability relating to professional review actions. The 2012 General Assembly modernized the professional review statute and the Colorado Supreme Court subsequently handed down a ruling that reaffirmed the confidentiality privilege. CMS’s goal is to reenact professional review statutes that maintain and advance the goal of contributing to patient safety, provider accountability and quality care. Regarding prescription drug abuse, the Colorado General Assembly has a special House-Senate interim study committee to address the epidemic. The governor’s office is asking CMS to consider limits on prescribing and ensuring PDMP (prescription drug monitoring program) checks under certain circumstances. The national, state and local media cover the crisis on a daily basis. CMS’s goal with prescription drug abuse is to ensure access to compassionate, evidence-based care for patients who suffer from acute and chronic pain while reducing the potential for medically inappropriate use and diversion of prescribed medications, eliminate abuse of opioids and opioid addiction,

and help patients who are addicted to opioid drugs. CMS will aggressively advocate for CMS opioid-related policies consistent with priorities of the Colorado Consortium for Prescription Drug Abuse Prevention. “During this time of rapid change and increasing levels of physician burnout, it is often hard to keep moving forward because sometimes you, like many of our colleagues, may wonder who has your back,” said Katie Lozano, MD, FACR, then-CMS president. “This operational plan is our answer to your concerns. It is the most concrete, clear and compelling statement about what we intend to do over the coming year to address many of the major issues facing physicians and the profession in Colorado.” n

Plug into your reinvented medical society! Log on today to choose Interest areas, submit policy proposals, and more. www.cms.org/central-line

Colorado Medicine for November/December 2017

A weekend to relax and connect

hysicians and guests who attended the 2017 Colorado Medical Society Annual Meeting in Breckenridge had a wonderful time socializing at great events, learning in general session and small-group workshops, and enjoying the beautiful fall colors of the Rocky Mountains. Nearly half of physicians and medical students were attending their first annual meeting and three-quarters say they’ll be back next year. Report from the 2017 Colorado Medical Society Annual Meeting Photos by Kate Alfano, CMS Communications Coordinator

Concurrent with CME for physicians on health care policy, physician wellness, the opioid crisis and more, was the first-ever medical student track. This tailored education connected students with advocacy experts – including special invited guests Rep. Bob Rankin (R), Rep. Jonathan Singer (D), messaging expert Kim Ross and moderator Joe Gagen, JD – to learn how to make a difference in the public policy realm.

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Best menu of speakers I can remember. All the

Attendees enjoyed beautiful mountain scenery and camaraderie at the CMS annual meeting.

sessions were very engaging and educational. Great job putting the meeting together!

CMS board members Charles Tharp, MD, and Cory Carroll, MD, take a few minutes to discuss Medicaid reform during Friday’s board meeting.

CMS board member Brandi Ring, MD, addresses the board of directors.

2017 Colorado Medical Society Annual Meeting

More than 100 Colorado medical students attended the annual meeting to participate in the first-ever student track for public policy training.

Medical students enjoy a wine and cheese reception hosted by Lynn Parry, MD, left, Friday evening.

It was wonderful to have the medical students sitting with physicians at the presidential gala – it

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totally changed the feel of the event and was much more integrated. We should do it every year!

CMS outgoing president Katie Lozano, MD, FACR, left, honors the physicians who are celebrating 50 years since medical school graduation: Thomas P. Larkin, MD, center, and Alfred N. Carr, MD, right.

Medical students practiced lobbying legislators on key topics of interest to physicians during the first-ever student track.

Attendees enjoyed the sumptuous COPIC dessert buffet during the Inaugural Gala.

2017 Colorado Medical Society Annual Meeting

The Children’s Activity Center was a hit with attendees’ children, who enjoyed beautiful mountain sunshine.

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Absolutely excellent; good topics and presentations. It was so nice having provided child care, I had no worries about my kids being

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taken care of while attending the conference. Thank you!

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Really enjoyed sharing my gala table with a group of students – great

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idea, would love to see it

continue!

he social highlight of the annual meeting was the black-tie President’s Inaugural Gala, with dinner, dancing and the sumptuous COPIC dessert bar.

Outgoing president Katie Lozano, MD, FACR, gave her final address and incoming president M. Robert Yakely, MD, was sworn in.

Children of annual meeting attendees had a great time with our childcare professionals, who ventured to a park and children’s museum on Saturday, watched a movie and had a dance party Friday, and played games Sunday.

M. Robert Yakely, MD, was installed as CMS president during the Inaugural Gala. Outgoing President Katie Lozano, MD, FACR, presents Yakely with the presidential medallion after his swearing in.

2017 Colorado Medical Society Annual Meeting

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As a medical student, I really appreciated the time and effort that

Friends pose together at the Exhibitor Reception. From left to right: AMA Past President Jeremy Lazarus, MD; Debbie Lazarus; Nick Newens, MD; Rosemary Yakely; Lee Morgan, MD; Incoming CMS President M. Robert Yakely, MD; and Mary Jane Newens.

went into planning the student track, and I came away with a lot of new knowledge and ideas on how to become

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a better advocate for my future patients and my profession.

Medical students pose with advisor Brandi Ring, MD, left of center, and legislators Rep. Bob Rankin and Rep. Jonathan Singer, seated center.

Congratulations to the state science fair winners in the medicine and health category. Colleen Farrell, center left, and Hari Sowrirajan, center right, are shown with science fair judges Donna Sullivan, MD, left, and Cory Carroll, right. Members enjoyed the many social events of the meeting. Above, David Markenson, MD, and Jason Kelly, MD, stop by Friday night’s nautical-themed Exhibitor Reception.

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Medical students were engaged in the special sessions on public policy, asking how to be better advocates for patients and physicians.

Fantastic panel with the Colorado legislators!

Save the date

FOR THE 2018 COLORADO MEDICAL SOCIETY ANNUAL MEETING, SEPT. 14-16, AT THE VAIL MARRIOTT.

Features

2017 CMS Annual Meeting Kate Alfano, CMS Communications Coordinator

Physicians can deploy skills of hospitality and listening to better connect with patients The Care Equity Project – a partnership between physicians, public health professionals and stage performers – presented a general session and workshop during the CMS Annual Meeting that informed attendees about the adverse health effects and challenges of navigating the health care system while living in poverty. The interactive session began with an actor portrayal of these challenges. One character in the portrayal demonstrated the emotional drain on physicians and practice staff when caring for this population. Betty Hart, special projects coordinator, arts integrated resources, Kaiser Permanente, explained that physicians can deploy the skill of hospitality – making a person feel welcome – to patients and co-workers, shifting from person to person how hospitality

is presented. “This requires more from us than ‘service’ because we can give service on autopilot,” she said. “One of the keys to demonstrating positive, strong hospitality is listening. Studies show that patients want 60-90 seconds of uninterrupted listening from their care providers. And we don’t give it to them. Why? Time constraints, fear of losing control, vulnerability to their emotions, efficiency, the feeling that physicians need to solve all problems. Listening takes time but saves time, and patients are asking for us to listen,” Hart said. A tool to listen differently is the “ABCD” method: Always be collecting dots. Dots are pieces of information that you hear that require the listener to synthesize. There are surface

Colorado Medicine for November/December 2017

dots, the things you hear out loud, and deeper dots, the things not necessarily said in words but demonstrated by actions. “Collecting dots is about listening to the person, not what society tells us about this person,” she said. Attendees then paired up for an exercise where they listened to their partner speak for one minute, then repeated back the “dots” they had gathered. “Whether easy or not, I hope you can see how powerful that minute is,” Hart concluded. “That minute will make patients feel much more connected to you.” n

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

Features

2017 CMS Annual Meeting Kate Alfano, CMS Communications Coordinator

Speakers examine health reform efforts underway Three intriguing presentations during the 2017 CMS Annual Meeting dove into the multifaceted issue of health reform, outlining action happening on the state level, federal level and in the health system overall. The first, the opening talk of the meeting, was “What the Heck Just Happened? Health Policy Beyond 2017 (We WILL Get Through This!)” with speaker Len Nichols, PhD, director of the Center for Health Policy Research and Ethics and a professor of Health Policy at George Mason University. “Everybody in Washington agrees that the ACA was trying to solve a problem,” Nichols said. “Health care and health insurance cost too much. Also, they agree the ACA was a ‘disaster,’ except for the parts everybody liked. Who knew the ACA was this complicated to fix?” He explained that most of the more than 20 million people who gained health insurance coverage gained it through Medicaid, which is a “problem politically” as Medicaid is the largest item in most state budgets. The marketplaces are working well in some places but not in others, and insurers are pulling out of the marketplaces. And roughly 4 million Americans were satisfied with their health insurance coverage before the mandates and risk pooling. “Even when everyone agrees upon the goals, health policy is hard,” he continued. “The ACA is far from perfect, and given enough time I can give you all of its flaws. But it is a step toward making access to health care affordable for all Americans…. I would say 85 percent of the opposition to the ACA has nothing 16

to do with health policy. It has everything to do with your philosophy for the role of government.” The bipartisan repeal-and-replace plans have a few factors in common. For the most part, they fund the cost-sharing reduction payments, strengthen reinsurance to lower premiums, restore outreach and enrollment funds, fix special enrollment period incentives, encourage flexibility, and preserve coverage gains. Nichols’ predictions for health reform are that SCHIP will be reauthorized, small-group practices will be exempt from MACRA for one more year, and the tax reform/cut debate will intensify pressure to cut federal health care spending. There are also bargaining chips on the table with the debt ceiling and hurricane relief. The second health reform-focused talk was the keynote, “Should Health Care Institutions be the Epicenter for Health?” with speaker Patricia Gabow, MD, former CEO of Denver Health. She answered four questions: What is health, what is our health care system’s performance, what are the determinants of health and their impact, and what is the way forward to health. She quoted from the World Health Organization: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” She demonstrated that the United States’ health care system ranks low among other developed countries in cost efficiency, coverage and access, quality, and equity and disparity. “We have significant issues in our health care system’s performance,” Gabow said.

Len Nichols, PhD “The system also suffers from duplication, fragmentation, misalignment between physicians and patients, etc. The National Academy of Medicine asked why, despite higher expenditures, we have achieved less health. The foci of our investments and incentives are too narrow. They are directed at a biomedical focus.” “Can the health care system be the entity that broadens our national focus from its current narrow biomedical focus to the broader determinates of health? I think the answer to this is a definite no. There are things we can do about it as physicians: We can be knowledgeable about the current shortfalls of the health care system and educate our leaders about the importance of addressing them. And we can all work with our professional societies to reduce waste and misuse of care, and demand that these savings go not to CEO salaries but to the social determinants of health.” The third talk on health reform was

Colorado Medicine for November/December 2017

Features

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member. Patricia Gabow, MD “State-view Update of Federal Health Care Reform” with Michele Lueck, CEO of the Colorado Health Institute. Her talk held three big takeaways: Half a million Coloradans have health insurance because of the Affordable Care Act, mostly through Medicaid; the Republican repeal-and-replace reform plan benefits younger, richer people at the expense of older, poorer people; and while uncertainty remains, Colorado finds its pragmatic way forward.

Michele Lueck “In Colorado we are still struggling with a number of issues, namely high deductibles, high premiums, low competition and regional price differences,” Lueck said. “But we are pragmatic, we are a frontier state, we are just marching right on. You should be proud of the work that’s coming out of the Colorado legislature and ideas that are surfacing out of the governor’s office and lieutenant governor’s office to mitigate these issues.” n

Colorado Medicine for November/December 2017

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

Features

2017 CMS Annual Meeting Kate Alfano, CMS Communications Coordinator

Latest developments in the opioid crisis The final general session topic of the meeting focused on the opioid epidemic. Speaker Robert Valuck, PhD, RPh, FNAP, opened with sobering statistics on drug overdose mortality: In 2016, over 63,000 people died from drug overdoses in the United States, one every 10 minutes. Nearly two-thirds of those deaths involved prescription drugs, and opioids were involved in 75 percent of those deaths. In Colorado, there were 912 drug overdose deaths in 2016 and of these, 504 were opioid-involved. “The good news is that prescription opioid deaths are down slightly but the bad news is heroin deaths, fentanyl deaths and methadone deaths are all up sharply,” Valuck said. “We know that the problem knows no bounds, whether that’s gender, age, income or other. It is truly an epidemic. Now it needs to be elevated to a public health concern.” However, deaths are the tip of the iceberg, he explained. For every one death, there are 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who abuse or are dependent, and 825 nonmedical users. According to two studies published in the Clinical Journal of Pain and Medical Care, the total cost of prescription drug abuse on the U.S. economy in 2013 was $78.5 billion. Medical complications comprised $1.2 billion, substance abuse treatment comprised $3.2 billion, and criminal justice comprised $12.1 billion. But the largest impact of prescription drug abuse is on productivity: $62 billion. The current epidemic was fueled by a rapid increase in the amount of opioids 18

Robert Valuck, PhD, RPh, FNAP, gives a presentation on the opioid crisis in Colorado and the United States at the 2017 CMS Annual Meeting. being prescribed and dispensed due to percent obtain opioids from friends or increased recognition of pain and un- relatives. It’s the leftover stuff in the der-treatment of pain; recognition of medicine cabinet that gets people startpain as the “fifth vital sign;” drug com- ed. Storage and disposal is an indirect pany advertising and promotion; practi- contribution to that part of the probtioners not specifically trained in opioid lem. If a patient ends up in the worst pharmacology, addiction or medication- possible place – injection drugs – the assisted treatment; the highly addictive vast majority started with prescribed nature of the drug; and illegal activity, opioids. That’s the most common spiral: Valuck said. prescription, medicine cabinet, doctor shopping, street.” “In Colorado we have been in the middle or lower percentile for prescrip- Much is being done on the federal level tions,” Valuck explained. “It’s not that to address this issue. On the state level, we prescribe more. We prescribe fewer the Colorado Consortium for Prescripprescriptions than most. What we are tion Drug Abuse Prevention has nine in Colorado is among the highest in different groups working on different nonmedical users, and that includes aspects of the issue. “It’s a very complex prescribed opioids, alcohol and canna- problem so all the things we need to do bis. In 2010-2011 we were No. 2 in non- about it are very complex,” Valuck said. medical use of prescription drugs.” The General Assembly appointed the “Where do people get these opioids Opioid and Other Substance Use Disthat they non-medically use? Seventy orders Interim Study Committee. “I’ve Colorado Medicine for November/December 2017

Features never seen a group of legislators come in so engaged,” he said. “They spent about 25 hours listening to people talking about what’s going on. There is a robust stakeholder process.” Valuck closed with his advice for CMSmember physicians: 1. In practice, follow the CMS 7 Strategies to Achieve Safe Opioid Prescribing (found on page 64 of the September/October Colorado Medicine). 2. Voice your opinions on proposed legislation to CMS and the Prescription Drug Abuse Committee. 3. Get involved with one of the Consortium’s work groups: www.corxconsortium.org.

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

“If you’re not engaged, we’re leaving out the best brainpower in the state. We need you and encourage you to participate.”

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

Valuck is chair of the Colorado Consortium for Prescription Drug Abuse Prevention and a professor in the departments of Clinical Pharmacy, Epidemiology and Family Medicine at the University of Colorado Schools of Pharmacy, Public Health and Medicine at the Anschutz Medical Campus in Aurora. n

MTC proudly received the prestigious 2009 Award of Excellence for the fourth year from ATSI (Association of TeleServices, Intl.), a service-quality award based on test calls placed over a six-month period. MTC is a member of the Denver/Boulder Bettter Business Bureau, ATSI and Telescan Users Network (TUNe). MTC particpates in the Colorado Medical Society's Disaster Preparedness Program by contacting volunteer providers in the event of a large scale disaster. In addition we collaborate with CMS every six month in testing the response time of the volunteer providers.

Join Now! Colorado Medical Political Action Committee www.cms.org/ contribute Colorado Medicine for November/December 2017

Features

COMPAC luncheon Kate Alfano, CMS Communications Coordinator

Physicians honor attorney general, hear from legislators COMPAC, the political action committee of the Colorado Medical Society, held its annual luncheon during the 2017 CMS Annual Meeting. Mark B. Johnson, MD, COMPAC chair, moderated the event. The lunch began with a special award presented to Attorney General Cynthia Coffman for her role in the legal challenge to block the merger of two of Colorado’s dominant health plans. “It takes a special kind of moral – not merely political resolve and courage – to pick a legal fight of this magnitude,” Johnson said. “Our attorney general stepped up when the odds were against us and the stakes unimaginably high.” This award honors a public official who understands by words and deeds the true meaning of advocacy, Johnson said. It was accepted on behalf of Coffman by Alissa Gardenswartz, deputy attorney general for consumer protection. Gardenswartz extended the attorney general’s gratitude for the honor and spoke about her section’s work. “This case exemplifies the importance of our antitrust enforcement when it comes to consumer protection because, really, what more important of an industry to ensure that there is continued fair pricing, continued incentive to innovate than in health care? Those things are necessary to ensure the continued high quality of care for the citizens of Colorado.” The highlight of the event was a legislative panel with Sen. Don Coram, Sen. Larry Crowder, Sen. Dominick Moreno, Rep. Bob Rankin and Rep. Jonathan Singer. Rep. Brittany Petters 20

Top: Alissa Gardenswartz, deputy attorney general for consumer protection, left, accepts an award on behalf of Attorney General Cynthia Coffman from COMPAC Chair Mark Johnson, MD. Bottom: A distinguished panel of legislators gave insights on health care policy. From left, Sen. Larry Crowder, Sen. Don Coram, Sen. Dominick Moreno, Rep. Jonathan Singer and Rep. Bob Rankin.

Colorado Medicine for November/December 2017

Features en was unable to speak due to a health issue. The panel spanned rural and urban districts and represented both political parties. Johnson asked the panel several questions and allowed each legislator to respond. When asked to identify the most pressing health care issue facing the state, all overwhelmingly mentioned health care costs, including the affordability of health care coverage and lack of competition among health insurers. “Across the political spectrum of state lawmakers – Democrats, Republicans, moderates, urban, rural – we can all agree the most pressing issue is cost. Now that we have agreed on the problem, I look forward to all of us agreeing on a solution,” Singer said. Another question was about advice legislators would give Colorado physicians to be more effective advocates. The panel encouraged physicians to continue to share knowledge and ideas for health care reform, develop relationships with legislators, and get involved at whatever level of government is desired. “One thing the medical community can do with the legislature is educate the general public,” Coram said. “The public doesn’t understand medical bills or the cost of malpractice insurance. These are huge items that we can address together to bring these costs down.” During the business portion of the meeting, Johnson announced that this meeting marked the end of his term as COMPAC chair. Christopher J. Unrein, DO, was approved to serve as chair and Patrick Pevoto, MD, MBA, was nominated to serve as vice-chair. COMPAC will need support going into 2018 to continue to effect positive change for physicians. To join COMPAC, go to www.cms.org/contribute. n

Colorado Medicine for November/December 2017

Features

Opinion/ editorial Jonathan Clapp, MD, board certified AAPM&R and ABPM

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

mary responsibility is to diagnose the problem, treat it and maximize function and quality of life for our patients. Opioid pain medications are a part of many of these treatment plans, mostly due to the substantial pain relief that they can provide. Unfortunately, they are extremely dangerous and addicting. Knowing how and when to use them is critical in keeping our patients safe.

I participated in a webinar in October during which pollster Benjamin Kupersmit outlined survey data from a recent all-member survey on the opioid epidemic (see pages 24-26).

The size and consistency of this epidemic indicates a fundamental and pandemic problem across the country. In my humble opinion, based on academic literature and experience, education for physicians is that root cause. The American Pain Society published a study that showed U.S. medical schools offered only an average of 11.3 hours of “pain training” in some form compared to roughly 2.5 times that (27.6 hours) in Canada, where the overdose rate per population is roughly 2.5 times less than that of the United States. Pain is the No. 1 reason for all patient visits, but less than 1 percent of our training is dedicated to this complaint. The recounts of many non-pain physicians about pain training is eerily similar and mostly anecdotal. This story is typical: A medical student or resident asks their attending physician (who also only got 11.3 hours of pain training) how they manage pain and the answer is often as unique and surprising as the stories we hear regarding opinions on pain and opioids that often counter the available evidence and “best practice.” A formal course, or even single lecture, on treating pain in patients struggling with anxiety, addiction, high opioid tolerance, respiratory compromise and many other confounders are not common, if occurring at all.

The opioid epidemic is out of control. Despite efforts to curb opioid overdoses and deaths, they continue to rise. The latest U.S. national data indicates that drug overdose deaths increased 19 percent from 2015 to 2016 despite increased regulatory control and awareness surrounding the opioid epidemic. The need for improved education is paramount in limiting potentially dangerous opioids while providing adequate pain relief for the millions of people who struggle to meet vocational and family responsibilities because of their struggle with pain. We prescribe far more opioids than any other country in the world and efforts to curb this consumption have not yielded the desired results. As pain physicians, we have additional training and certifications that show our proficiency in diagnosing and treating pain. Opioids are only one of the tools that we use. “Rational polypharmacy” is a mantra that we try to live by regarding the medications and supplements we prescribe. However, our pri 22

Physicians are not the only ones with poor pain training. Nursing literature is riddled with calls for better education. One study showed, “Mean scores from the nursing knowledge and attitudes survey on pain revealed knowledge deficits and inconsistent responses in many areas related to pain management (mean, 62%; range, 41%-90%)”. Sixty-two percent, or a D minus, is not a grade anyone would consider acceptable to treat pain. In my personal experience, teaching over 100 nurses about pain has been eye-opening, as only two of them have raised their hand saying they received sufficient pain training to prepare them for what they see on their units and those two failed a pain knowledge test prior to my lecture, as did the rest of those in attendance. Insurance providers and some in the pharmaceutical industry have also made profits off of our lack of education. Not knowing the evidence has made claims by aggressive pharmaceutical reps (for one company, in particular) harder to dispute, and case studies concluding it is safe to prescribe chronic high doses of opioids became widely accepted as fact. We all fell victim to these claims, but when the evidence came out refuting these claims, too many were unaware and did not change their prescribing habits. All insurance companies (commercial, federal and state) have inexplicably avoided helping our patients, but are quick to point out limiting opioids and setting up more barriers to getting them (and non-opioid treatment) when they are needed, hence protecting their bottom line. Pain is the only field of medicine where 20- to 30-year-old practices are still the standard with generic,

Colorado Medicine for November/December 2017

Features cheaper and more easily abused medications being preferred over safer molecules or abuse-deterrent formulations. Claims that “we cover that medication” are often used, but are still prohibitively expensive and hence, useless. Addiction treatment, psychology and many other non-opioid pain treatments remain poorly covered and are critical to treating those who struggle with chronic pain and/or addiction. Pain physicians have been stigmatized due to the snapshot of total morphine equivalents we prescribe, that are higher than other specialties. The reason for this, most of the time, is we inherit patients on high doses and often dangerous combinations of opioids, benzodiazepines and other sedatives including alcohol. It is our job, that we accept, to find a better and safer way to treat their pain and minimize risks. A better way to judge a pain physician is by how many morphine equivalents per patient they decrease from their initial visit and/or resulting improved function. “Do no harm” is an oath we take very seriously and we do our best to minimize risks while treating pain in patients who would be much less functional in their daily lives without pain treatment. With the anecdotal and limited pain training we receive as physicians in general, please indulge me and imagine the following scenario: Insulin causes euphoria and addiction. Bear with me please! Insulin can kill people if prescribed recklessly and not using it is unacceptable due to the adverse effects diabetes causes to our patients. Replacing the words “diabetes” with “pain,” “insulin” with “opioids” and “endocrinologist” with “trained pain specialist” offers a new perspective on what is occurring and how problematic the reaction to the opioid epidemic has been. Please note, this is not meant to disparage endocrinologists, just to make a point to illuminate the problem in a new light. Here goes… Due to the widespread “insulin epidemic,” people are dying in record numbers across our country, some non-endocrinology

Features trained physicians looking for a full and busy practice market themselves as “endocrinologists” only because they are willing to prescribe higher doses of insulin than most other physicians. Endocrinologists as a whole become stigmatized and subject to state medical board (mostly made up of non-endocrinologists with only 11.3 hours of diabetes training each) discipline due to the high quantities of insulin they prescribe. Over the next six to seven years, endocrinologists are thought of as “docs who just prescribe insulin,” “part of the problem” and excluded from conversations to try and fix the epidemic, despite their expertise. Admittedly, there are a few “bad endocrinologists” in cases where insulin may be easier to give than to look more into the problem and use “non-insulin treatments” like diet and exercise which are known to help decrease insulin use, but these cases pale in comparison to the number of “good” endocrinologists. The CDC publishes guidelines aimed at limiting insulin consumption and not treating diabetes. JACHO covers their website with a video and messages saying blood glucose checks being the “fifth vital sign” was never their intent and they are not responsible for the outcomes. Some states put in strict insulin unit dose limitations. The president declares a “national emergency” and physicians talk about removing blood sugar checks that (for the sake of this argument) can cause poor hospital scores and put physician careers in jeopardy for not treating diabetes. Physicians may feel pressured to prescribe insulin, because only 11.3 hours of diabetes training has resulted in less experience with other tools available to them to effectively treat diabetes. Metformin, diet, exercise and other treatments were never taught. And so, the pendulum swings towards not treating diabetes due to the fear of causing addiction or deaths by overprescribing insulin and the cycle repeats as it has over the past 125 years with everyone missing that there is a “sweet spot” in the middle of these extremes. This results repeatedly in two alternating epidemics: untreated diabetes and overprescribing. We are physicians. That means we are public servants like firefighters or police officers. We are not to be concerned about customer service or surveys when

Colorado Medicine for November/December 2017

the safety and best interests of our patients are involved. Being pain free is sometimes as unreasonable as someone who expects a cure-in-a-pill for their diabetes. When we are not taught sufficiently in a field we are forced to treat, we do what we know. That is all we can ever do. Unfortunately, our medical schools, residency programs, nursing schools and medical culture have failed us. Prescribing opioids is taught more often than basic pain concepts like opioid-induced hyperalgesia, opioid rotations, mu opioid receptor polymorphisms, avoiding opioids in neuropathic or central pain conditions, comorbid anxiety and depression resulting in two to five times more likelihood of being on chronic opioids at six months, utility of safer atypical opioids like tapentadol or buprenorphine, importance of new abuse-deterrent opioids, and concomitant use of benzodiazepines (which are first-line only for anesthesia purposes or alcohol and benzodiazepine withdrawals) with opioids resulting in a 10-fold increased risk of death than with opioids alone. 11.3 hours of training is not sufficient to prescribe insulin and it should be the same for opioids, at least for longer periods. This is a fundamental problem in our medical training, hence its widespread nature. We can do so much better! Learning pain management is not difficult, but it takes hours and hours of training, just as other specialties do. As pain physicians, we are thrilled to be allowed to come out of the shadows in this epidemic and offer our expertise (and each of our hundreds of hours of opioid and pain training) to a problem that WE CAN help mitigate. I applaud the Colorado Medical Society for being one of the only state medical societies in the union to look to us for our opinion. We welcome the challenge and are confident we can offer better answers than those that are in play currently. n

CMS .ORG CMS ORG CMS.ORG CMS ORG Colorado Medical Society 23

Features

All-member opioid survey Benjamin Kupersmit, President, Kupersmit Research

Your voice: Physician collaboration, CMS advocacy needed to address the crisis Editor’s note: The Colorado Medical Society has been deeply involved in reversing the public health crisis caused by opioid abuse and misuse for the past five years. Colorado physicians and other health care providers have been nationally recognized by the American Medical Association for using the Colorado state prescription drug monitoring program (PDMP) more than 1.5 million times in 2016 (a 122-percent increase from 2014), and for decreasing overall opioid prescriptions by nearly half a million since 2013. Working with Gov. Hickenlooper’s Colorado Consortium for Prescription Drug Abuse Prevention and many other stakeholders to end harm from opioid-related abuse and misuse, CMS and other physician-led organizations such as COPIC, the CU School of Medicine, the Colorado Permanente Medical Group, and CPEP, among others, have led the charge to educate physicians to change their prescribing practices and their approach to pain treatment to combat the crisis. As part of that effort, CMS recently surveyed its members on: • Current perceptions of the prescription drug abuse crisis,

• Participation in efforts (including PDMP and continuing medical education) to mitigate the crisis, and • Reactions to proposals from the governor’s office to further address the crisis. The results show a deep awareness of the opioid crisis, and that physicians are actively working to combat the problem. CMS Committee on Prescription Abuse Chair, John Hughes, MD, reviewed the results and said, “I would have been extremely disappointed had this survey outcome not shown progress after all the work that CMS and other physician-led organizations have put into reversing the opioid crisis in our state. These numbers demonstrate that the combined efforts of CMS, COPIC, the CU School of Medicine, and the Colorado Consortium are working for Colorado.” CMS contracts with Kupersmit Research to conduct CMS surveys. The firm certified the opioid crisis survey for accuracy with a margin of error of +3.8% at the 95% confidence level. What follows is their official survey memo.

Kupersmit Research is pleased to present the results of the 2017 CMS member survey focusing on the prescription drug abuse crisis in Colorado. Nearly 700 CMS physicians completed the survey questionnaire. Landscape • A majority of CMS physicians agree that prescription drug abuse is “a very serious problem, among the top public health issues we face” (with 58%), while another 6% feel it is “a full-blown crisis, the No. 1 public health crisis we face.” • Another 32% say it is “a serious problem, but not the top problem we face in public health.” • Prescription drug abuse is seen as a patient management issue, with 62% saying it is a problem of “patient education and management,” versus 3% a “law enforcement problem” (33% say “both equally”). • CMS physicians are most concerned with the “misuse, abuse and diversion” aspect of the prescription drug abuse crisis.

TABLE 1: Thinking about the prescription drug abuse problem, how concerned are you about the following? (Extremely + Very Concerned Shown) Misuse, abuse and diversion of medications 75%

Physicians over-prescribing opioids for patients with legitimate pain problems (instead of other potential treatments, including other medications, physical therapy, massage/acupuncture, etc.)

Physicians over-prescribing opioids for patients who do not have legitimate pain problems

Patients turning to illegal narcotics, such as heroin, or other dangerous substances if they do not have supervised treatment with prescription medications by a practicing physician

Patients who have legitimate pain problems being treated poorly or with suspicion by medical professionals (which could include nurses, pharmacists and/or physicians)

Physicians being unwilling to treat patients who have chronic pain out of fear of being labeled a high prescriber

Colorado Medicine for November/December 2017

Features TABLE 2: Where do you believe the source of the problem lies? Please check all that apply: Patients who believe they should not have pain, perhaps unrealistically 75% Patients who want opioids instead of other remedies that would work just as well

Physicians who overprescribe

Lack of availability of treatment centers and substance abuse intervention programs

Pharmaceutical companies who overstated the benefits and understated the risks of opioids to physicians

Criminals who are illegally obtaining and diverting prescription drugs

Patients who have no alternatives to opioids for pain treatment at this time

TABLE 3: The following are options put forward by the governor’s office to help address prescription drug abuse in Colorado. For each one, please indicate whether you support or oppose that proposal. (Strongly + Somewhat Support Shown) Require prescribers who regularly prescribe opioids to complete a module on prescribing every few years

69%

Require prescribers to refer patients they identify as “doctor shoppers” to treatment, as follows: if the PDMP shows that a patient has requested multiple prescriptions from multiple providers in a given time frame, that prescriber would be prohibited from issuing a prescription for that patient and shall be required to refer that patient to substance abuse treatment.

Expand student loan repayment programs for providers who specialize in addiction treatment.

Roots of the problem • CMS physicians are most likely to believe the root of the prescription drug crisis lies in patient expectations around pain and opioids, followed by “physicians who overprescribe” and a lack of treatment centers and intervention programs. • Comments suggest a complex set of factors contributing to the perception among physicians that their colleagues overprescribe: “Ongoing overprescribing of opioids for chronic musculoskeletal pain, wisdom teeth extraction, headaches, abdominal pain, post-surgical pain for more than a few days, etc. Ongoing underfunding of treatments that actually help such as lifestyle modification (exercise, diet and relaxation skills training), cognitive and behavioral therapy, and minimally invasive treatments such as acupuncture, nonsteroidal trigger point injections, manual therapy, etc.” • Physicians repeatedly point to patient satisfaction surveys and the designation of pain as the “fifth vital sign” (and the

leverage patients feel they have over physicians as a result) as key factors contributing to the crisis as well: “Patient satisfaction scores that overemphasize patients being happy with their treatment of pain.” “Joint Commission recommendations years ago that needed to treat pain as the fifth vital sign and that no patient should ever have pain.” “I have been reported to medical board for not treating patients’ pain. Hard to win when we get in trouble for overprescribing from one entity and from patients reporting us to medical board.” Taking Action: Checking the PDMP, taking CME • Overall, 46% of CMS physicians report that they use the PDMP “all the time” or “pretty often” (up from 27% in 2013 CMS survey research). • Use of the PDMP is considerably higher in key specialties: family medicine (91%), emergency department (87%) and internal medicine (83%).

Colorado Medicine for November/December 2017

• Comments suggest that lower usage rates among some surgeons may be because they believe short-term prescriptions for acute pain are not as relevant to the opioid crisis. “Haven’t used the program (PDMP). I only treat post-operative short-term pain with opioids.” “My patient are post-surgical and only receive short-term narcotics if needed. I only check the registry if a patient is making unreasonable requests for additional prescriptions beyond one to two weeks, which is rare.” • Nearly three-quarters (70%) of CMS physicians report taking CME regarding opioids in at least the past two to three years. • Physicians in internal medicine (88%), family medicine (84%) and the emergency department (83%) are more likely to say they have had CME in the past two to three years.

Opioid survey (cont.) TABLE 4: How concerned would you be about the following happening in your practice if these regulations are implemented? IF PRESCRIBE OPIOIDS, N=462 Patients being automatically denied their pain medication at the moment they fit the “doctor shopper” algorithm until they can appeal, with no immediate recourse for the treating physician Patients not being able to get timely access to a new prescription after their initial seven- day prescription runs out

Patients who could accidentally be identified as “doctor shoppers” because of problems with uncoordinated care or other issues

Next Steps: Support proposals, but concerned resources are inadequate • As Table 3 shows, a solid majority of physicians support a range of potential proposals to help mitigate the prescription drug crisis. • Just under two-thirds support efforts to better identify “doctor shoppers” through the PDMP and then refer these patients to treatment, as well as expanding student loans for those who specialize in addiction treatment. • At the same time, there is significant concern about these proposals if adequate safeguards are not in place for patients who are identified erroneously as “doctor shoppers” or for patients who are unable to get needed medication because of other potential problems that might arise. • Furthermore, just half (46%) of those who prescribe opioids (n=462) currently know where to refer someone for substance abuse treatment, while 42% do not (and 12% are unsure how to respond). • Fully 83% of those who currently prescribe opioids are “not confident” that Medicaid patients will have access to a substance abuse specialist who accepts Medicaid. • Two-thirds (66%) are “not confident” that private insurance patients will have in-network access to a specialist for substance abuse treatment. Conclusions CMS physicians express a clear understanding that prescription drug abuse is a very serious public health issue, but we do not see a level of urgency reflective of “the most serious public health crisis in 125 years,” as the Colorado governor’s office has stated. At the same time, physicians 26

78%

understand that responsibility for addressing the problem is theirs; virtually no one believes this is a problem for only law enforcement to address. Prescription drug abuse is viewed as a complex problem with multiple root causes and myriad harmful impacts, and we hesitate to simplify the hundreds of individual statements of concern or anger or anxiety expressed in the survey’s open-ended replies. The overarching trends from the physician perspective, we believe, are perhaps twofold: • First, societal expectations regarding pain – bolstered with the inclusion of pain as the “fifth vital sign” in policy, along with the usage of pain as a metric in physician satisfaction surveys – are generating demand, and patients have leverage (e.g., reporting physicians who refuse to prescribe opioids to administration or the medical board), to push physicians to prescribe. • Second, a majority of CMS physicians feel that their colleagues are over-prescribing, with significant disagreement between specialties, and tremendous levels of stress and anxiety in specialties viewed as over-prescribers by others. CMS physicians are already working and taking steps to mitigate the crisis, such as checking the PDMP (for which usage has jumped substantially since 2013) and taking continuing medical education on opioids. The survey suggests that physicians are somewhat split on increasing these requirements, and would perhaps need to see clear evidence that such increased requirements will make a difference moving forward. We do see significant support for efforts to better identify doctor shoppers and limit their access to opioids and refer them to substance abuse treatment. However, there

is significant concern that patients with private insurance and Medicaid will not have affordable access to substance abuse treatment, and many physicians are currently unaware of where they would refer such patients. There is also significant concern in the survey about the lack of access to alternative treatments to opioids. In our view, the survey suggests a range of opportunities for CMS and its member physicians to pursue: 1. Educate patients through direct physician-to-patient education (pamphlets, conversations), ideally bolstered with messaging and advertising aimed at the wider public. 2. Convene physician leaders across specialties, perhaps starting with those most affected by the crisis. 3. Reach out to hospital administrators to let them know that physicians have significant concerns about including pain in satisfaction surveys and other key performance indicators. 4. Join national efforts to address issues with private and public payers around access to alternative treatments to opioids, as well as substance abuse treatment; efforts to remove the use of pain as the “fifth vital sign” should be joined by CMS as well. 5. Integrate PDMP checks into daily practice habits and EMR (particularly for surgeons who might feel that short-term prescriptions are not as relevant to the crisis). n Methodology This survey was administered online by the Colorado Medical Society. 673 members gave a full response to the survey, of a total of 5,815 CMS members emailed (with 743 beginning the survey), giving a 12% response rate. The survey was conducted Sept. 6-25, 2017; for the sample of 673 members, the margin of error is +3.8% at the 95% confidence level.

Colorado Medicine for November/December 2017

Features

Legislative proposals Kate Alfano, CMS Communications Coordinator

Opioid legislative committee presents bill drafts for 2018 General Assembly The Opioid and Other Substance Use Disorders Interim Study Committee has been working since July on their charge to study and propose legislative solutions to reduce the alarming trends of opioid abuse and misuse in Colorado. In late October the committee released the first take of what stakeholders can expect to see regarding new public policy to combat the opioid epidemic when the 2018 General Assembly convenes in January. “As a physician and a legislator, I am encouraged by the findings of the committee, that have only come about after hours of testimony by the top experts in this epidemic,” said Sen. Irene Aguilar, MD. “We look to continue this thoughtful process into the legislative session and beyond, keeping our top priority – patient safety – at the forefront.” “We are sensitive to doctors taking care of patients using their own discretion, but we are also aware of the trend of oversupply of these medications on first prescription. There must be a middle road and we are exploring options to strike this balance,” said Sen. Jack Tate. “We also must disconnect pain management from physician quality ratings and payment or else risk pressuring prescribers to end all pain management requests with an opioid prescription.” “The committee has been totally engaged in this very tough and emotional issue, spending hours listening to experts in the field to find ways to

address the opioid crisis in Colorado,” said Sen. Cheri Jahn. “I think there are several positive steps we will be able to move forward on. Included in our discussions are prevention, clinical practice measures for safer opioid prescribing, workforce shortages and bringing more providers in, treatment being made more readily available, and issues around payment for residential and inpatient services.” Bill 1: Prevention of Opioid Misuse Lead: Rep. Brittany Pettersen This bill establishes the committee in statute to continue their work for two more years. It comprises five senators and five representatives and may meet up to six times per year. The bill also directs the CU Center for Research into Substance Use Disorder Prevention, Treatment and Recovery Support Strategies to develop continuing medical education for prescribers, and provides for grants for behavioral health services and programs for screening, intervention and referral. Bill 2: Clinical Practice Measures for Safer Opioid Prescribing Lead: Sen. Jack Tate This bill restricts the duration of prescriptions that health care providers, including physicians, can prescribe for acute pain to an initial seven-day supply and one refill for a seven-day supply, with certain exceptions. These prescriptions can be made electronically. The bill also requires mandatory query

Colorado Medicine for November/December 2017

Members of the Opioid and Other Substance Use Disorders Interim Study Committee • Rep. Brittany Pettersen, Chair • Sen. Kent D. Lambert, Vice Chair • Sen. Irene Aguilar, MD • Sen. Cheri Jahn • Sen. Kevin Priola • Sen. Jack Tate • Rep. Chris Kennedy • Rep. Clarice Navarro • Rep. Kim Ransom • Rep. Jonathan Singer

of the prescription drug monitoring program after the initial prescription except under certain circumstances. Bill 3: Measures to Address Opioid Crisis in Colorado Lead: Sen. Kent Lambert This bill authorizes a supervised injection facility pilot, allows local public health agencies to establish clean syringe exchange programs and grants civil immunity to a person who provides clean syringes through a clean syringe exchange program, allows hospitals to be clean syringe exchange sites, and allows schools to obtain and administer opiate antagonists to those at risk of experiencing a drug overdose.

Features Bill 4: Expand Access to Behavioral Health Providers Lead: Sen. Cheri Jahn This bill makes it easier to identify shortages of behavioral health professionals, including addiction counselors and social workers, and opens loan repayment programs and scholarships to them. Bill 5: Medicaid Inpatient/ Residential Substance Use Disorder Treatment Lead: Rep. Brittany Pettersen

This bill adds residential and inpatient substance use disorder services to the Colorado medical assistance program, given the ability to secure federal funding. Bill 6: Payment Issues Relating to Substance Use Disorder Treatment Lead: Rep. Chris Kennedy This bill reduces and standardizes prior authorization requirements with commercial health plans and Medicaid for medication-assisted treatment for substance use disorders, prohibits car-

riers from requiring a covered person to undergo step therapy using a prescription drug that includes an opioid before covering a non-opioid prescription drug; and authorizes pharmacists to administer injectable naltrexone. The next step for these proposed bills is a review and approval by the Legislative Council on Nov. 15. Should they pass that review then they will be formally introduced during the 2018 legislative session that begins in January. n

Health Policy 101 – – – – –

Managed Care Reform Liability Reform Network Adequacy Scope of Practice Protecting Peer Review

No one can dispute that politics determines our health care policies. If we want our voices heard, we must be involved in who gets elected. Those incumbents and candidates who support our agenda – the ability to provide quality, affordable care to our patients AND keep our business doors open – have to go through the rigorous and expensive process of getting elected and re-elected. They need and deserve our support. Until a better process is invented, it costs money to win and stay in office. COMPAC is the nonpartisan political action committee for the Colorado Medical Society, responsible for approving candidates and campaign donations, coordinating election strategy, and other aspects important to the political strategy of CMS. The CMS Small Donor Committee works to elect candidates who support medicine’s efforts to preserve Colorado’s stable tort environment. Joining the CMS Small Donor Committee is an ideal way to contribute to ONLY those candidates who will protect Colorado’s liability caps and help us enact comprehensive liability reform.

JOIN TODAY! www.cms.org/contribute Your membership in COMPAC and contribution to the CMS Small Donor Committee will allow medicine to continue to support our champions so we can continue to move forward on medicine’s issues. You decide your contribution level based on your budget. Please join or renew your contribution to COMPAC and the SDC now so that we can continue to make positive gains for Colorado physicians and patients in the political arena. Voluntary political contributions by individuals to COMPAC/AMPAC should be written on personal checks. Funds from corporations will be used for political education activities and/or state election activities where allowed. Contributions are not limited to suggested amounts. $100 of the suggested contribution amount is transmitted to AMPAC for physicians and $10 for a student or resident. Neither the AMA nor its constituent state associations will favor or disadvantage anyone based on the amounts of or failure to make PAC contributions. Voluntary political contributions are subject to limitations of FEC regulations. COMPAC is a segregated fund established by the Colorado Medical Society. Contributions to COMPAC/AMPAC are not deductible for federal tax purposes. There is a $575.00 limit on COMPAC donations in any two-year election cycle. Call CMS at 720-858-6322 should you have any questions.

Colorado Medicine for November/December 2017

Features

State Innovation Model Heather Grimshaw, Communications Manager, SIM

Applications open for SIM cohort 3 Nov. 15-Jan. 10 The Colorado State Innovation Model (SIM), a governor’s office initiative funded by the Centers for Medicare and Medicaid Services, releases its final practice application Nov. 15: http://bit. ly/2yNCSxT. The application will be open through Jan. 10, 2018. SIM will help 400 practices (20 percent of primary care practices) integrate behavioral and physical health and test alternative payment models (APMs) by July 2019. A few successes to date: • Increased mental health screenings: SIM practices screened 130,336 eligible patients for depression; followed up on positive results.

• SIM providers reported decreased burnout. • SIM providers improved their ability to report and gained confidence in clinical quality measure (CQMs) data that helps providers articulate a unique value and negotiate with health plans. In the second quarter of 2017, 100 percent of SIM practices reported on at least one CQM. • SIM created a new workforce – 21 regional health connectors identify community resources to help improve patient health, and avoid duplication of efforts. • Improved integration: 42 percent of SIM practices moved to a higher level of integration: http://bit.ly/2ijUWai.

• SIM aligned measures across state and national initiatives to reduce provider burden: https://goo.gl/wcJiYm. • SIM funded “Let’s Talk Colorado,” a bilingual media campaign to address mental health stigma. “It feels better to be able to take care of the whole patient,” says Glenn Madrid, MD, a cohort-1 practice representative, who talks about his practice’s journey to provide integrated care in a SIM video: http://bit.ly/2xRKv3X. Apply for the last SIM cohort before Jan. 10 for valuable coaching and support to integrate care and test APMs: http://bit.ly/2yNCSxT. n

Colorado Medicine for November/December 2017

Features

Colorado Medicine for November/December 2017

Features

Credentialing assistance Tom Bartlett, President and CEO, 3Won

Provider data management 101: What you need to know typical name representing three data elements – and usually occurs every two years. Health plan credentialing for enrollment requires about 180 data elements, can take more than 90 days to complete and occurs every three years. Many physicians are privileged at multiple hospitals and contract with 10 or more health plans, so it’s easy to see how complying with these requests can be burdensome.

Tom Bartlett According to data circulated by the Physicians Foundation/Merritt Hawkins and CAQH, the average physician completes 17.8 credentialingrelated applications each year complying with requirements from health systems, health plans and regulatory agencies. Studies suggest this amounts to an average of $3,000 in expense and 25 hours each year in non-clinical paperwork. That said, some independent physicians spend upwards of $10,000 a year and employ a full-time employee to manage this function. In short, it’s unnecessarily burdensome, if not arcane at times, costly and inefficient if you are an independent practitioner or a hospital administering these services for your full-time employees. Credentialing for privileging at a hospital or health system can be painstaking and typically occurs over a 90-day time frame requiring you to provide somewhere around 350 data elements – the 32

What most physicians may not fully understand is the degree to which your data, and the accuracy of that data, is critical to your practice and revenue cycle management. Here’s why. When you submit claims to health plans they identify you using data in their master provider files, a data repository of medical professionals participating in their various health plan networks. The data in those files includes information such as your name and any aliases associated with your name such as Jack, John, J., Sr., Jr., and so on. Very often physicians may be represented multiple times in the same database and health plans use “matching” logic algorithms to ensure you are properly identified. The files also contain other data about you and your practice, much of it demographic in nature, to promote greater payment integrity and provider directory accuracy. Unfortunately, because data about you ages, or degrades, at an industry-wide average of 2 percent each month, roughly 40 percent of the data in those files is incorrect. Bad data is a systemic problem for health plans and the industry spends literally billions of dollars each year contending with the downstream effects of inaccurate provider data.

Because credentialing processes repeat every two to three years, it’s conceivable that your data could degrade by as much as 72 percent over a threeyear time frame, which inevitably will cause challenges in the claim adjudication and payment process. As a result of this data degradation issue, health plans are challenged when they can’t accurately identify you, your practice location, group affiliation, correct Tax ID or product participation, and very often adjudicate claims using the wrong information such as the incorrect fee schedule; that is, the contract between you or your group and the health plan. That’s a big issue for health plans like United Healthcare, for example, which pays over $1 billion in claims daily. Claim reconciliation processes to fix claim payment errors are very costly and time-consuming. Many of these errors can be avoided if the information about you is accurate at the point of claim receipt. Inaccurate provider data also impacts patients negatively when seeking access to care, especially when they believe you are an in-network provider only to determine otherwise at the point of access. Very often patients are given conflicting network and product participation by both the group practice staff and their health care insurance provider or health plan. In fact, 20 percent of the provider data transmitted to health plans from hospitals is incorrect. Patients often contend with bad addresses, phone and fax numbers, and incorrect participating providers, all of which delay access to care. Indi-

Colorado Medicine for November/December 2017

Features gent patients typically rely on public transportation when seeking care and it is very frustrating for them to determine your practice is actually located in a different location than the one they were given. Similarly, referrals are often complicated when a referring physician accesses inaccurate provider data and gives that to their patients. Health plans who offer managed Medicare and Medicaid plans are now being held to a much more rigorous data accuracy standard by the Centers for Medicare and Medicaid Services, and a number of states like California are imposing material financial fines for medical directory inaccuracy. Currently, the average health plan directory has an accuracy rate of about 60 percent. The federal CMS has mandated remediation action from a number of plans to promote higher accuracy levels and patient access to care. So, make no mistake, this is a big and serious issue for health plans. The problem is how to effectively address the problem without adding more cost and burden to you and your practice. A number of organizations like AHIP and CAQH are currently piloting new programs designed to improve provider data management practices. Like many ineffective processes, lack of communication is very often to blame for failure. The health insurance industry has not done an effective job of educating physicians and allied health professionals about their provider data and the need for greater accuracy. Moreover, increasing data and document compliance requirements have frustrated most medical professionals and further exacerbated challenges in the provider-payer relationship. What is required is greater efficiency in the data collection, management and distribution process, reducing both the time and expense of physicians in legacy data management processes. Thankfully, many state medical and hospital associations, in alliance with 3WON, are addressing this issue directly by centralizing credentialing processes and eliminating redundancy.

In Colorado, for example, the Colorado Medical Society recently began promoting a credentialing and health plan enrollment product for their members powered by 3WON, a national CVO and health information technology company. Here, CMS assumes 100 percent data and document management for practitioners for a nominal annual fee. Acting on their members’ behalf, CMS collects physician data once, updates the data daily, weekly and monthly ensuring accuracy, and distributes the data to all requesting parties when authorized to do so by each physician. All documentation is managed and completed by CMS and forwarded to physicians for final attestation. In short, CMS acts as a kind of data agent on behalf of the practice, substantially alleviating the administrative burden associated with these processes and reducing costs. Similar to the single universal college admission application in use now in the United States, 3WON’s SmartForm application centralizes data collection and then populates all other documents and supplemental forms used by health systems, health plans and regulatory agencies for credentialing, re-credentialing, enrollment, certifications and other compliance requirements. SmartForm acts as a central data repository for medical professionals and can be updated anytime, anywhere. It also serves to manage a professional’s CV, which can be printed or distributed on demand. Medical students, for example, can populate SmartForm early in their careers and use it to store and update all pertinent data and documents pertaining to their credentials, ongoing training, certifications and specialties, publications and professional affiliations over the course of their careers. 3WON also provides helpful tools to promote efficiency in maintaining your data, which can be viewed, edited and attested to from your smartphone or tablet. Notifications are easily programmed to alert medical professionals or their proxies to upcoming requirements such as recredentialing events, continuing education requirements for maintenance

Colorado Medicine for November/December 2017

of certification, contract renewals and so on. And, if any data is changed in your profile by any entity, 3WON will alert you quickly to determine its accuracy. Centralizing data is only one step in the data management revolution underway. Data accuracy relies on continuous updates in near real-time to ensure integrity, which in turn requires engagement on the part of medical professionals. In the legacy world it is unlikely physicians would engage if they had to provide updates to numerous entities all requesting their data in disparate formats. It would be overwhelming. Entrusting one entity, however, to collect, manage and distribute data on your behalf provides numerous advantages beginning with sole source management. In dealing with one entity, along with practical data management tools, your data can be managed in near real-time, with minimal demands on you personally. What is necessary is that physicians and other medical professionals recognize the importance of their data and how “bad” data negatively impacts you and your practice, from accurate reimbursement to patient access and practice promotion, and a slew of other realities not typically in your purview. Simply put, inaccurate data is not good for business, and medical professionals – especially physicians – should protect their profile data and ensure its accuracy. That requires the subject to be top of mind and not something considered irregularly. Useful reminder alerts are helpful in monitoring your data and minimizing practice disruption. Legacy credentialing runs the gamut from automated to manual and relatively unsophisticated paper-based processes. A cardiovascular surgeon practicing in Chicago, where I live, may be privileged at multiple inpatient hospitals and health systems with many credentialing the surgeon independently using various disciplines, process and documents to do so. Our largest health system requires physi-

Credentialing service (cont.) cians to be credentialed independently at four of their 12 hospitals across Chicagoland. Approximately 20,000 physicians practice in Chicago. If we assume that the majority of re-credentialing events occur every two years at hospitals, then technically we should be re-credentialing about 10,000 physicians each year across Cook County and the six collar counties comprising Chicagoland. In fact, we credential in excess of 55,000 each year. Why? Redundancy. In supply chain management, why would you purchase 55,000 of something if you only need 10,000? In Texas, home to some 49,000 practicing physicians, the Texas Hospital Association (THA) has partnered with 3WON to centralize credentialing data management across the state, reduce redundancy and administrative burden and cost, and, most important, ensure data accuracy and quality. Here, the object is centralization promoting efficiency. Hospitals and health systems are being encouraged to consider the necessity of numerous independent CVOs across the state and the value of a single data repository serving the needs of all hospitals and health systems where data is often managed in two distinct cost centers: Medical staff services and managed care. THA offers credentialing and health plan enrollment services in one vertically integrated service centered on single-source data management. Moreover, a single repository represents significant value to health plans which continue to collect data from multiple sources across the state and which seek a cure to their data accuracy challenges. In turn, medical professionals rely on THA to distribute their data to all parties in Texas so that unlike the surgeon in Chicago, they deal with one entity as opposed to many. There are approximately 875,000 practicing physicians in the U.S. today and data analyses tell us upwards of 40 percent of that data is incorrect. How much of that inaccurate data is about you and your practice? The Colorado Medical Society now has a valuable service that ensures your data is accurate and substantially reduces the administrative burden and cost associated with credentialing compliance requirements. To learn more about the benefits to you and your practice, contact Tim Smith at tim. smith@3won.com or (630) 328-7930. For independent reports on data accuracy from the federal CMS, CAQH and AHIP, or for data concerning practice patterns from the Physicians Foundation/Merritt Hawkins, email info@cms.org/PDM. n

Colorado Medicine for November/December 2017

Features

Technology collaboration American Medical Association

New collaborative initiative brings health and technology stakeholders together around a common data model A new collaborative initiative founded by the American Medical Association is working to unleash a new era of better, more effective patient care by introducing a data evolution for improving, organizing and sharing health care information. The Integrated Health Model Initiative (IHMI) is a platform for bringing together the health and technology sectors around a common data model that is missing in health care. IHMI fills the national imperative to pioneer a shared framework for organizing health data, emphasizing patient centric information, and refining data elements to those most predictive of achieving better outcomes. Evolving available health data to depict a complete picture of a patient’s journey from wellness to illness to treatment and beyond allows health care delivery to fully focus on patient outcomes, goals and wellness. Participation in IHMI is open to all health care and technology stakeholders, and early collaborators include IBM, Cerner, Intermountain Healthcare, the American Heart Association, the American Medical Informatics Association and others. IHMI supports a continuous learning environment with an online platform that enables a common data model to evolve with real-world use and feedback from participants. “We spend more than three trillion dollars a year on health care in America and generate more health data than ever before. Yet some of the most meaningful data – data to unlock potential improvements in patient outcomes – is fragmented, inaccessible or incomplete,”

said AMA CEO James L. Madara, MD. “The collaborative effort of IHMI will help the health system learn how to collect, organize, and exchange patientcentered data in a common structure that captures what is most important for improving care and long-term wellness, and transform the data into a rich stream of accessible and actionable information.” By offering a common data model for the health system to collect, organize, exchange and analyze critical data elements, IHMI imagines a world where all clinicians are equipped with essential information to shift care plans towards achieving outcomes that are more relevant to a patient’s quality of life and consistent with the patient’s lifestyle, goals and health status. Given the high economic and societal burden of chronic diseases, IHMI will initially prioritize its resources and efforts in clinical areas such as hypertension, diabetes and asthma. A common data model with clinically validated data elements can accelerate the development of improved data organization, management and analytics. This collective effort will foster patient care models that achieve better outcomes, as well as technical innovations to address poor interoperability, cumbersome or inadequate data structures, and an overload of point-and-click tasks that dampen clinician morale. As IHMI launches, the AMA is currently focused on: • Hosting clinical and issue-based communities focused on costly and

Colorado Medicine for November/December 2017

burdensome areas. This fosters collaborative efforts around common interests and areas of need, such as hypertension management, diabetes prevention, asthma function, and the identification of the best available science and practices that define patient-centric care. • Providing a clinical validation process to determine and apply appropriate clinical frameworks. Participants will provide contributions and feedback online to specify data elements and relationships. Clinical content submissions will go through a validation process to review clinical applicability. • Specifying a model to encode information in the IHMI data model. Clinical content will enable configurations of the model and reference value sets that can be distributed. Additional communities will be developed and added to the online platform based on market needs throughout 2018. “IHMI is the latest development in the AMA’s ongoing work to build bridges with health technology leaders and bring the physician voice into the innovation space. Patients deserve – and the marketplace should expect – physician input on the real-world value and feasibility of products and health technologies,” said AMA Senior Vice President of Health Solutions Laurie McGraw. The AMA invites all health care innovators and stakeholders to join the IHMI and contribute their unique expertise to transforming health care. To join IHMI, visit www.ama-assn.org/ihmi for more details. n 35

Features

Medicaid payment Kate Alfano, CMS Communications Coordinator

CMS pushes for immediate payment and interest on overdue clean claims Ongoing issues with Colorado’s new Medicaid vendor – DXC Technologies – since its rollout in March has left many practices in a dire financial state as some wait for hundreds of thousands of dollars in claims to be paid. The Colorado Medical Society is looking to the state and its leaders to diminish the harm and has been conveying physician concerns to state agency leaders and legislators. CMS has been in discussions with the Colorado Department of Health Care Policy and Financing since the summer and put concerns in writing on Sept. 1 with a strongly worded letter to HCPF Executive Director Sue Birch, MBA, BSN, RN. Cosignatories of the letter included 16 other state and regional provider organizations. CMS expressed doctors’ frustrations with lengthy payment delays for the care and treatment of Medicaid enrollees – and asked for payment on clean claims as soon as possible, plus interest and penalties. Since enactment of the American Recovery and Reinvestment Act of 2009, federal law requires state Medicaid programs to pay 90 percent of clean claims within 30 days of receipt of the claim, and 99 percent of clean claims within 90 days of receipt of the claim. Additionally, the Colorado statute concerning the Prompt Payment of Claims recognizes that the delay in payment of claims causes an unwarranted drain on the financial resources of health care providers and requires the payment of not only interest but a penalty as well. As a financial hardship has clearly been demonstrated to be the case for some 36

physicians, CMS is asking the state to pay not only interest but also penalties. Director Birch responded on Sept. 6, apologizing for the billing problems doctors have experienced and committing to resolving these issues, as it is the agency’s “responsibility to provide timely reimbursement for properly submitted claims.” Birch’s response left unanswered questions, however, and CMS submitted a follow-up letter on Sept. 18 asking for clarification and additional information. “The payment system conversion has caused practice disruption for many of our members and the patients they serve,” wrote CMS President M. Robert Yakely, MD, in the Sept. 18 letter. “We continue to hear from more member physicians regarding burdensome and costly steps that they are having to take in order to cope with payment problems associated with the conversion. Importantly, we are also hearing from more physicians that have exhausted their efforts and opted to just quit being Medicaid providers.” In an August interview with Colorado Public Radio, then-CMS President Katie Lozano, MD, FACR, said, “The system crash currently underway threatens the Medicaid program’s credibility and reliability to thousands of doctors and other health care providers who treat Medicaid patients.” These are not mere inconveniences; “economic disruptions of this magnitude threaten the economic stability of medical practices that by definition operate on thin margins. This situation, in turn, could rip wider holes in Colorado’s fragile safety net system of care for the working poor.”

Chris Underwood, HCPF health information office director, says they have not seen providers leave Medicaid “yet” and are optimistic the department can work through remaining claim denials so providers can continue to see Medicaid clients. He said the top reason for denial is because of provider enrollment errors: either the physician doesn’t have an enrollment record on file or the information used in billing does not match their enrollment record. He requested more feedback and details from stakeholders on claim denials that providers think should be paid. The coalition of provider organizations, which includes CMS, continues the discussion in the legislature, raising alarm bells on the severity of this problem. In addition to the interest and penalties, the coalition has pushed for legislative oversight and for the Medicaid Department to set up a “red team” comprised of DXC, HCPF and providers to identify problems with the claims IT system, clarify timelines for various fixes and better communicate ways to address common problems, and triage system fixes. “We’re hopeful this approach can accelerate the pace at which claims issues are resolved for practices,” said Ryan Biehle, MPH, MPA, deputy CEO for policy and external affairs of the Colorado Academy of Family Physicians. To contact HCPF with concerns and issues, go to www.colorado.gov/hcpf/ provider-help for a list of contacts. For comments on your experience with Medicaid payment, email president@ cms.org. n

Colorado Medicine for November/December 2017

Inside CMS

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

A look back on 2017: Our commitment to improve health care I want to reflect back on this past year of health care: new challenges emerged, aspects of care delivery evolved and technology continued to have an influential role. What did not change, however, was COPIC’s steadfast commitment to supporting medical professionals and improving patient safety. Here are some highlights from 2017 that we are proud to share. Market expansion COPIC continued its efforts to expand our regional footprint. This supports our long-term goals of reaching new groups of medical professionals; it aligns with the changing geographic needs of our current insureds; and it allows us to introduce our patient safety and risk management programs to other health care professionals. We grew our presence in Iowa, South Dakota and Oklahoma, while also making our services available in states such as Arizona, North Dakota and Minnesota. We were also proud to be named the “medical professional liability carrier of choice” by the Iowa Medical Society, a distinction we already have with the Colorado Medical Society and Nebraska Medical Association. Legislative advocacy Health care remained at the forefront of legislative issues. Working closely with our key partners, including CMS and the Colorado Hospital Association, COPIC monitored and engaged (when necessary) on legislative bills related to the state’s Prescription Drug Monitoring Program, the system for mental health holds and domestic reporting requirements. These efforts are key to maintaining Colorado’s health care environment and ensuring that we retain the best providers while reinforcing patient safety. • During the 2017 Colorado legislative session, we tracked approximately 50 proposed bills, reviewed 18 bills and engaged on 11 bills to provide input prior to enactment. Education on timely issues As new issues emerged or current issues changed, COPIC provided professional education through in-person seminars and on-demand courses to help address these. Topics included liability issues with EHRs and social media, managing opioids, requirements with allied health professionals, and treating patients dealing with mental health issues. Colorado Medicine for November/December 2017

These core efforts connect back to our ongoing commitment of being an education partner that insureds turn to for guidance. Trusted resource on regulatory/legal issues There’s a reason we encourage people to “call COPIC.” Our staff of physicians, lawyers, medical professionals, and HR and claims experts stand ready to talk directly with insureds and help them navigate the challenges they face. More than 24,278 calls have been fielded by our staff so far in 2017, on issues that ranged from HIPAA requirements to best practices in human resources. Key grant funding In 2017, the COPIC Medical Foundation provided grants that helped fund the following: • Emergency Department Training Program – Eating Recovery Center • Community-Based Trauma Informed Training – The Fields Foundation • Bereavement Training – The Wishbone Foundation • Physician Colleague Services for Rural Colorado – Lumunos • Human Trafficking Education – The Lab to Combat Human Trafficking • Managing and Mitigating Risk on the Western Slope – Montrose Memorial Hospital • Meals for Care Transitions – Project Angel Heart COPIC Humanitarian Award Monte Uyemura, MD, of Wray received our annual COPIC Humanitarian Award. He is a family practice physician who has spent the majority of his career in Wray, where he is affiliated with Wray Community District Hospital. The COPIC Humanitarian Award recognizes the irreplaceable work a physician does for his or her community. Dr. Uyemura chose the Wray Community Hospital Foundation as the beneficiary of the $10,000 grant associated with the award. As we move into 2018, COPIC looks forward to being there to support medical professionals – a certainty in health care that you can always count on. n

Inside CMS

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

Michael Klausner University of Colorado School of Medicine

Michael Klausner is a veteran of the U.S. Marine Corps. After his military service he attended Colorado State University to earn bachelor’s degrees in Political Science and Biology, and a master’s in Biomedical Science. During this time and afterwards he had the opportunity to work in various fields including in cancer research, as a nurse aide, as a medical laboratory scientist and in the Colorado Army National Guard, and these experiences, in various ways, moved him to pursue medicine. When he is not studying, he climbs 14ers, works with the homeless, fly-fishes, and trains for the Colorado Marathon. After medical school, Michael will serve as an Army physician, either in internal or emergency medicine, and continue to live his Catholic faith as a physician and serve patients and their families.

A covered face When I think of a person, I recall images of their face, intimately followed by myriad memories, sensations, opinions, shared experiences and various other associations that coalesce into a single idea of that person – unique entirely from other persons, a being which affects and moves my being merely by existing and my knowing them. A slight bend of the eyebrow, an angled corner of a lip, the flushing of cheek skin warm with embarrassment or love; these perturbations of the facial surface anatomy elicit an emotional response 40

within me that seems far out of proportion to the minor distortion observed. Why should a flared nostril indicate anything other than simply a flared nostril? Yet the surface of the face masks an interior reality, a stained-glass window that tells a story, and a narrow exchange of light between exterior and interior. My first reaction in cadaver dissection upon seeing the body was a visceral response to the face being covered. The entire body appeared entirely human – to be that of any other person whom I have ever encountered. But I could not encounter the covered face. Though in a physical sense I might have been more intimately invested in knowing a person than at any other time in my life – as I held the once-beating heart or cleaned the once-singing larynx or the once-full uterus – yet I did not encounter the person, despite my study. This at one and the same time relieved me, as I could study the body objectively, but also perplexed me, as I well knew that this body was an unimaginably generous gift by that very same person to aide me in my study, not to mention the simple yet weighty gravity of dissecting a human body. Should there be an emotional connection, a tremulous appreciation with each cut? Or what should I feel toward a deceased human body with a covered face? My Catholic faith holds the human person in the highest regard, and that all human life is of inestimable worth, along with the necessary moral and social implications of that worth. Further, we might say that human beings are more enfleshed souls rather than en-souled bodies, though the body is not of a lesser dignity than the soul, as both natures together form the person. Is it true then that the face is somehow a window to the soul? Can it be that such a small and flat region comprised of the most superficial structures of the anterior surface of the head be the pivotal point of encounter between a finite temporal reality and an infinite, timeless spiritual one? Colorado Medicine for November/December 2017

Inside CMS It seems to me then that the human body, living or deceased, warrants the utmost respect and even reverence, even if an emotional connection is not immediately engendered because of a veiled face. I constantly reminded myself of the dignity of the human body which we dismantled â&#x20AC;&#x201C; that is until we uncovered the face. Here at last I was struck by the reality of our subject of study, the body of a human person, the physical manifestation of an emotional, psychological and spiritual reality; the corporal apparatus of a life that was existing and moving and living; the means by which an interior life and exterior reality encountered each other, even if only veiled. I do not remember the details of our dissections, but I do remember the details of the unveiled face and the lesson it taught me â&#x20AC;&#x201C; that the study and work of physicians centers fundamentally on encountering persons, and the vocation is inextricably dedicated and married to their care. n

Colorado Medicine for November/December 2017

Departments Inside CMS

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

Charlotte Ballantine Rocky Vista University College of Osteopathic Medicine

Charlotte Ballantine, OMS II, grew up in rural New Hampshire and received a Bachelor of Arts in Biology from Smith College in 2009. She worked as a therapist for young children with autism for four years before moving to Colorado to pursue a degree in Physical Therapy at the University of Colorado. After completing the summer semester (and first half of clinical anatomy), she decided that three years of graduate school was not enough and withdrew to apply to medical school. She is excited about many medical specialties, including emergency, internal medicine and pediatrics. In her free time, Charlotte enjoys quintessential Colorado activities such as rock climbing, hiking and backcountry skiing.

The cadaver connection The study of anatomy and the experience of cadaver dissection are nearly universal in the education of medical students. The benefits are many: a clearer visual understanding of human anatomy, an appreciation for the variability of individualsâ&#x20AC;&#x2122; anatomy and an initial introduction to basic surgical techniques. The challenges for students are also many. How to understand and integrate the bizarre experience of reducing a human body to the sum of its parts. How to balance respect and empathy with the detachment that is essential to perform increasingly invasive dissections. I entered my first year of medical school aware of these challenges. I had briefly dissected human cadavers in my 42

education previously, and vividly remembered the feelings that accompanied the first few weeks of lab. Confusion as I touched the skin of my cadaver for the first time and discovered a tough, unyielding substance that felt nothing like human skin. Visceral shock at seeing the fingernails of my cadaver painted pink. Trepidation and fear before uncovering her face for the first time. I knew that I would try not to listen when my fellow students discussed her cause of death because it was easier the less I thought about her life. I knew that, at first, my fellow students and I would work quietly. We might talk politely about our individual journeys to medical school, but we would never acknowledge the enormity of what we were doing. Finally, after a week or two, someone would get a piece of half-liquid, half-solid fatty tissue flicked into their hair. The depth of this horror would force us to leap straight over the intricacy of our emotions and dive into humor. From then on, we would make crass jokes, pocketing our empathy and telling ourselves we had no other choice. For the most part, my memories were spot-on. By some morbid coincidence, my cadaver for my first year of medical school again had her fingernails painted pink. Within the first week, a piece of fatty tissue had caused horrified hilarity, this time when it landed in my hair. The shell I had developed several years ago still fit comfortably, and I experienced very little immediate shock or discomfort. However, as the months went on, I found myself thinking more and more often about the family of my cadaver. I understood the motivation of the woman who had donated her body; I could feel her desire to give back, maybe out of appreciation for medical care she or a family member had received, maybe from pure altruism. I understood it, was grateful for it and felt at peace with it. But when I pictured her children, grandchildren or partner still living, missing her terribly, as we cut her to pieces and laughed, I felt a new kind of guilt and sadness. If my mother were on a dissection table somewhere, how would I feel? Proud? Confused? Simply sad? How would I grieve for her and let that grief go without a ceremonial rest for her body? Colorado Medicine for November/December 2017

Inside CMS Recently, as I finished my first year of medical school and completed my last cadaver dissection, I was talking with my mother about the experience. I explained my guilt about our humor and detachment, and she, as mothers do, asked me what I had learned from the experience. As I thought back over the year, I realized there were as many moments of wonder as there were of guilt and confusion. I would be plodding through a tedious dissection, my mind wandering, when all of a sudden the many branches of the facial nerve would peek out through the dense parotid gland, and I would transpose in my imagination the course of that nerve onto my own face. Or I would discover an alternate arterial pattern in our cadaver’s liver and wonder about the blood supply to my own organs. The enduring toughness of the many layers of tissue in the foot was contrasted with the intricacy of the pterygopalatine fossa, each formed to maximize its function. Although I could not honor the human spirit of my cadaver at all times, through study of her body,

I had gained a deep appreciation for humanity. An analogy often given to first-year medical students is that the donors will be our “first patients.” After working in the lab for the past year, I disagree. The relationship between physicians and patients is necessarily one in which we, as physicians, will be serving our patients. We will give them our knowledge, experience and empathy and do our best to help them heal. The men and women who donated their bodies had no such expectations. They selflessly gave an incredible gift, without which my education as a physician would not be complete. I will always consider them my teachers. I want to express my sincere appreciation and admiration for each and every donor, and everyone who loved them. My fellow students and I will remember the lessons your loved ones taught us for the rest of our lives, and I have a feeling our appreciation will only grow the more we learn. n

Colorado Medicine for November/December 2017

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

Departments

medical news Rep. Donald Valdez honored for service to Colorado physicians

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

➤ PROFESSIONAL OPPORTUNITIES SEEKING OB/GYN IN GLENWOOD SPRINGS, CO: Fulltime, will consider part-time with shared call; call 1:3; salary with bonus; private practice; full benefits, including free lift tickets for Aspen resorts. Requirements: 4-5 years post-residency experience, active CO license, board certified. Email CV to kris@womens-carepc.com.

CMS President M. Robert Yakely, MD, left, presents an award to Rep. Donald Valdez, center, in appreciation for his support of Colorado physicians. Also pictured is Steven Nafziger, MD, right, a family physician in Pueblo.

Central Line recognized for innovative and effective member engagement The Colorado Medical Society received the American Association of Medical Society Executives’ 2017 President’s Award for Innovative Physician Engagement within Organized Medicine for our innovative program: “Central Line – Your Profession – Your Future.” Central Line is a revolutionary application that allows any CMS member to submit policy proposals, to give input on policy proposals submitted by colleagues, and to give the board of directors input before and after votes are taken on policy. Since its launch in November 2016, 10 policy proposals from Central Line have been considered during this year’s board meetings. More than 3,200 votes have been cast on policy proposals in advance of a board meeting and more than 2,400 votes have been cast after a board 44

DENVER, CO. PHYSICIAN MD / DO – PRIMARY CARE / FP / IM The Colorado Mental Health Institute at Fort Logan is seeking temporary FP / IM physician over the next several months. Will consider full-time / parttime / prn. Great opportunity to truly make a difference without worrying about insurance hassles or production quotas. Currently paper-based charting. Malpractice is provided. Good compensation. Great team. Contact the Fort Logan Medical Clinic at 303-8667050 or send your contact info / CV to Debora.Din@state.co.us

➤ PROPERTIES

AAMSE’s 2017 President’s Award meeting when asked if the board “got it right.” More than 1,700 individual members have voted through Central Line and 212 have designated “interest areas.” Have you experienced Central Line? Join the more than 1,700 Colorado physicians who have and engage with your society today. Go to www.cms.org/ central-line. n

COLORADO ALLERGY & ASTHMA CENTERS LOOKING FOR POTENTIAL SUBLEASE OPPORTUNITY in the Eastern Denver Metro Area: E470 & Smoky Hill-Southlands or Green Valley Ranch. Searching for: established clinic, 2-3 days per week, 5 exam rooms, en-suite bathroom, large receptions area (20+ chairs). Call Cammie Latta, Director of Business Development with information 720-858-7449.

Colorado Medicine for November/December 2017

Compliments of:

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

Attention! New Higher Discounts!

RETAIL PRICE

MEMBER PRICE

MEMBER SAVINGS

MEDICATION

QTY

Azithromycin 250mg Tab

$29.29

$15.86

46%

Lamotrigine 100mg Tab

$54.79

$14.65

73%

Topiramate 100mg Tab

$87.60

$8.98

90%

Levofloxacin 500mg Tab

$114.79

$11.15

90%

Losartan 100mg Tab

$57.06

$13.82

76%

Rosuvastatin 40mg Tab

$226.56

$17.46

92%

Pantoprazole DR 40mg Tab

$69.81

$12.42

82%

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

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

www.coloradodrugcard.com

Customize the Colorado Drug Card for your practice!

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

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

Milton Perkins - Program Director mperkins@coloradodrugcard.com Colorado Medicine for November/December 2017

45 Colorado Drug Card

Features

the final word Katie Lozano, MD, FACR CMS Immediate Past President

Prescription drug abuse survey illuminates opportunities to further reduce the opioid epidemic As you may know, I designated the opioid epidemic as one of the top priorities of my CMS presidency last year, continuing the momentum and commitment of CMS over the past five years to address this issue. I was encouraged by the results of the recently released survey – Prescription Drug Abuse: The Physician’s Perspective – featured on page 24, that shows that

“One point physicians should seriously discuss is the fact that the most common start to nonmedical use and addiction is the result of unused prescription opioids obtained free from friends or relatives.” many of us have responded proactively to this public health threat by recognizing the urgency of the situation, educating ourselves on safe opioid prescribing, checking the PDMP on a regular basis, incorporating patient safety counseling and limiting opioid prescriptions. We still have a long way to go, though, and I hope all CMS members will read the survey results and consider how we can work together to make further gains to benefit our patients. One point physicians should seriously 46

discuss is the fact that the most common start to nonmedical use and addiction is the result of unused prescription opioids obtained free from friends or relatives. Experts have labeled this phenomenon the “medicine cabinet” problem. Physicians overprescribe and do not properly counsel patients; opioids are not properly stored during or after a course of care and are then used by the patient after legitimate pain has subsided or are stolen by people in the home and given to friends and neighbors, thus creating the cycle of misuse, abuse and addiction. There were 912 Colorado drug overdose deaths in 2016 and 504 of these were opioid involved. Virtually every member of the General Assembly has a personal story directly related to the “medicine cabinet” problem. Our own survey supports their stories – 67 percent of respondents say they are “concerned about physicians who overprescribe opioids for patients with legitimate pain” and 62 percent are “concerned that physicians are overprescribing opioids for patients who do not have legitimate pain.” The executive and legislative branches of Colorado state government are fully engaged on the opioid epidemic. Lt. Gov. Donna Lynne, on behalf of Gov. John Hickenlooper, has brought CMS leaders in for private meetings on the opioid crisis three separate times in the last seven months. And the bipartisan Opioid and Other Substance Use Disorders Interim Study Committee established by the 2017 General Assembly has completed its work on recommendations for legislation re-

lating to opioid and other substance abuse disorders (see pages 27-28). The message to us from the governor and members of the interim committee has been crystal clear – they are grateful for the hard work of CMS on the opioid crisis over the last five years and ask physicians to continue to step up with other stakeholders to do even more to protect the public. The interim committee and the governor will work to enact legislation in 2018 to enact opioid prescription fill limits and mandatory PDMP checks. CMS has already agreed to suspend our long-standing policy in opposition to statutory limits on prescription fills and PDMP checks. Because these elected officials understand that the epidemic is multifaceted, that future progress will require a multi-pronged approach, and that physicians are partners working with them to address the epidemic, they are open to exceptions and time-limiting these statutes to two years. At the end of this twoyear period, we will need to demonstrate that our profession has been working together to address issues under our control or else expect the 2021 General Assembly to take action. I am confident we can continue to make a difference. The lives of our patients and their families depend on it. n

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Colorado Medicine for November/December 2017