September-October 2019 Colorado Medicine by Colorado Medical Society

VO LU M E 1 1 6 N O . 5 S E P T- O C T 2 0 1 9

COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE

EMERGING THEMES

IT AL S

R PA YE AS

W O RK

O VE RN G

LO N O CH TE

BS TA N

RE F EN T PA YM

RU G

CO N

ES S

IN HEALTH CARE

N U M CO

ER S M

IT AL S

RK FO

AS EN

G O VE

LO O N

U CE TA N

CH TE

BS SU

PA YM

RE F

PA YE

W O

D RU

G S

RC E

BU CR IP

PR ES

This issue’s cover story highlights the Colorado Health Institute’s environmental scan for the medical community, homing in on nine significant state and national drivers of change. It should come as no surprise that nearly all of these emerging themes are related to health care costs and the efforts to reduce them. PAGE 8 ⊲

Cover story: 9 emerging themes in health care

IT Y

C O NTE NT S

F E ATU R E S

10 PHYSICIANS TESTIFY BEFORE LEGISLATIVE COMMITTEE ON OPIOIDS CMS leaders and allies remain involved in meetings throughout the summer and fall of the legislative interim committee on opioids as lawmakers consider state interventions for the public health crisis of opioids. 14 PHYSICIANS PRODUCE SLATE OF RECOMMENDATIONS FOR REVERSING THE OPIOID CRISIS Two multi-specialty convenings of Colorado physicians produced a strategic action plan for combatting the opioid epidemic in Colorado. 19 UNINTENDED CONSEQUENCES OF THE OPIOID EPIDEMIC ON CANCER AND PALLIATIVE CARE PATIENTS Opioid prescriptions are going down and PDMP checks are going up but some physicians report their patients can’t fill needed opioid prescriptions or are fearful of taking the pain medications. 22 COLORADO REINSURANCE PROGRAM APPROVED Gov. Jared Polis announced that the federal government approved the Colorado reinsurance program, which is projected to help reduce certain insurance premiums by nearly 20 percent.

$8,979 $7,618 $4,240 $4,331 $3,335 $3,369 $3,205 $6,696 $6,354

23 SIM ENDS; STAKEHOLDERS CONTINUE WORK The Colorado State Innovation Model has ended but a grassroots effort, “Colorado is Ready,” connects stakeholders and builds on SIM’s work.

I N S I D E

C M S

25 CONGRESS TAKES ON SURPRISE BILLING Federal lawmakers are considering two bills to reduce the shock of “surprise” billing to patients. Not surprisingly, payers and providers are split on which should pass. 26 PHOTOS: MEDICAL STUDENTS AND PHYSICIANS COME TOGETHER FOR “WHITE COAT WISDOM” A well-attended and highly praised event in August brought medical students firsthand education on real-world medical practice from an all-star physician faculty. 28 FUNDRAISING CONTINUES FOR THE ALFRED D. GILCHRIST STUDENT LEADERSHIP SCHOLARSHIP As longtime CEO Alfred Gilchrist prepares to retire in early 2020, the Colorado Medical Society Foundation created a medical student scholarship to honor his legacy and support medical students. Donate to the fund today. 36 FINAL WORD: BUSINESS AND PHYSICIANS CAN COME TOGETHER TO DISRUPT HEALTH CARE COSTS Robert Smith, MBA, of the Colorado Business Group on Health makes the case for physicians and the business community leading the way to address rising health care costs.

D E PA R TM E NT S

President’s letter

30 Reflections

2019 CMS election results

31 Introspections

13 CMS Corporate Supporters and Advantage Partners

24 PHYSICIAN FEE SCHEDULE HOLDS GOOD NEWS FOR E/M CODING The 1,200-page proposed fee schedule rule for 2020 includes changes to evaluation and management levels, MIPS, access to treatment for opioid use disorder, and more.

32 COPIC Comment

34 Medical News • DOI shuts down a health care sharing ministry • CMS president wants better discipline for injection-based investigational care 35 Classifieds

CO LOR AD O M E D I CAL SOCI E T 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 2018-2019 OFFICERS Debra J. Parsons, MD, FACP President

David Markenson, MD, MBA President-elect

Patrick Pevoto, MD, RPh, MBA Treasurer

Alfred D. Gilchrist Chief Executive Officer

M. Robert Yakely, MD

BOARD OF DIRECTORS

AMA DELEGATES

Cory Carroll, MD Sofiya Diruba, MS Curtis Hagedorn, MD Mark B. Johnson, MD Jason L. Kelly, MD Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Brad A. Roberts, MD Kim Warner, MD C. Rocky White, MD Hap Young, MD

A. “Lee” Morgan, MD David Downs, MD, FACP Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD

Immediate Past President

AMA ALTERNATE DELEGATES Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Brigitta J. Robinson, MD Michael Volz, MD

AMA PAST PRESIDENT Jeremy Lazarus, MD

COLORADO MEDICAL SOCIETY STAFF EXECUTIVE OFFICE Alfred Gilchrist, Chief Executive Officer Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer Dean_Holzkamp@cms.org Chet Seward, Chief Strategy Officer Chet_Seward@cms.org

DIVISION OF HEALTH CARE POLICY AND FINANCING Amy Berenbaum Goodman, JD, MBE, Senior Director, Policy amy_goodman@cms.org Gene Richer, Director, Continuing Medical Education Gene_Richer@cms.org

Dianna Fetter, Director, Professional Services Dianna_Fetter@cms.org

DIVISION OF INFORMATION TECHNOLOGY/MEMBERSHIP

Tom Wilson, Manager, Accounting Tom_Wilson@cms.org

Krystle Medford, Director, Membership Krystle_Medford@cms.org

DIVISION OF COMMUNICATIONS AND MEMBER BENEFITS Mike Campo, Director, Business Development & Member Benefits Mike_Campo@cms.org Kate Alfano, Coordinator, Communications Kate_Alfano@cms.org

DIVISION OF GOVERNMENT RELATIONS Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Emily Bishop, Program Manager Emily_Bishop@cms.org COLORADO MEDICAL SOCIETY FOUNDATION COLORADO MEDICAL SOCIETY EDUCATION FOUNDATION Mike Campo, Staff Support Mike_Campo@cms.org

Tim Yanetta, Manager Tim_Yanetta@cms.org Susanna Barnett, Coordinator Susanna_Barnett@cms.org Stephanie Salazar, Coordinator Stephanie_salazar@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. Design by Scribner Creative.

Compliments of:

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

MEDICATION

A ATTENTION!A

NEW HIGHER DISCOUNTS!

QTY

RETAIL PRICE

MEMBER PRICE

MEMBER SAVINGS

AMLODIPINE TAB 10MG

$19.99

$10.32

48%

ATORVASTATIN TAB 20MG

$29.69

$12.18

59%

AZITHROMYCIN TAB 250MG

$25.08

$12.51

50%

PANTOPRAZOLE TAB 40MG

$36.26

$11.70

68%

PHENTERMINE TAB 37.5MG

$32.99

$12.53

62%

HYDROCO/APAP TAB 10-325MG

120

$84.48

$29.04

66%

FINASTERIDE TAB 1MG

$75.29

$15.93

79%

*Medication prices vary by pharmacy and prescription and are subject to change over time. Ask your pharmacist for the actual discounted price. THIS PROGRAM IS NOT INSURANCE.

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

Customize The

COLORADO DRUG CARD FOR YOUR PRACTICE!

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

For more information contact:

info@coloradodrugcard.com

Proud Supporter of:

Learn more at

COLORADODRUGCARD.COM and get your Free Prescription Savings Coupon Card

A donation will be made to your local CMN hospital each time a prescription is processed using this coupon.

P R E S I D E NT ’ S

LE T TE R

Embrace the “why”… ...you are a physician leader

Debra Parsons, MD, FACP President, Colorado Medical Society

In preparing to pass the baton to our incoming president, David Markenson, MD, MBA, and for this final Colorado Medicine president’s letter, I reflected on my year as your Colorado Medical Society president. Zooming out on my greater role as a physician, I think we can all benefit from pondering “why” we do our work; it is so easy to get lost in the “what” and the “how.” As your president, I checked off the day-to-day tasks outlined in our CMS operational plan, doing my part with physician colleagues and CMS staff to keep our society humming along. While we rose to these challenges, we strived to keep an eye on the bigger picture, why our medical society exists: to champion health care issues that improve patient care, promote physician professional satisfaction and create healthier communities in Colorado. Truly, the CMS mission demonstrates that the physicians of Colorado are members of an altruistic profession and not a self-interested guild. I participated in the Advanced Leadership Training Program (ALTP) with the Regional Institute for Health and Environmental Leadership (RIHEL) a few years ago and was greatly inspired by one of the recommended books, Leaders Eat Last, by Simon Sinek. In it, he made the point that “great leaders sacrifice their self-interests for the good of those in their care.” Doesn’t that 4 C O LO R A D O M E D I C I N E

sound familiar? As physicians we are called to give our all to help our patients and humanity as a whole to achieve a brighter future. Sinek’s point also resonates in our practices: Whether you’re in a one-physician practice, a 20-physician group or a 1,200-physician organization, we are leaders to the providers and staff who support us. We can help create an environment where people naturally thrive, as Sinek recommends. It’s about putting people first, helping them feel both valued and an integral part of the team. It is important for everyone to see the impact of our time and effort in order for our work to have meaning; this meaning then inspires us to work harder and do more, and creates greater organizational stability, better long-term performance, greater bonds and deeper loyalties, he says. Leadership character and the ability to cooperate and collaborate outweigh skills and knowledge. We can work to develop trust to serve the people we lead, follow the rules and know when to break them. Strong organizations work in their peoples’ best interest; weak organizations work in their own best interest.

P R E S I D E N T ’ S LE T T E R

Please allow me to share other highlights from Sinek’s examples of excellent leadership that are easily applicable to medicine.

INTEGRITY MATTERS – incorruptibility is the bedrock of trust when our words and deeds are consistent with our actions.

COOPERATION DOESN’T MEAN AGREEMENT… but rather a willingness to work together to advance the greater good.

LEAD FOR OUR PEOPLE AND OUR PATIENTS, and not the numbers; people are our No. 1 priority.

I thank you for the opportunity to have served as your CMS president this past year and, as your immediate past president, I look forward to continuing to work with all of you alongside David Markenson, our incoming president, and Sami Diab, MD, your president-elect.

As a last tidbit from Sinek: “Human beings have thrived for 50,000 years not because we were driven to serve ourselves but because we are inspired to serve others.” I encourage all Colorado physicians to keep up the good work you do and periodically reflect on “why” you do what you do. ■

REJECT INCENTIVE STRUCTURES THAT CREATE LACK OF CONCERN, self ishness and cloudy judgment; instead strive for those that reward cooperation, information-sharing and asking for help.

E X TR A

Colorado physicians elect Sami Diab, MD, as CMS president-elect

Thank you to all the members who voted during the 2019 Colorado Medical Society leadership election. Thanks, also, to the physician-candidates for stepping up as leaders in the society. Sami Diab, MD, a Denver oncologist, was elected CMS president-elect and will be inaugurated in fall 2020. Re-elected to the Colorado delegation to the American Medical Association were: David Downs, MD, FACP; Carolynn Francavilla Brown, MD; Jan Kief, MD; Rachelle Klammer, MD; Tamaan Osbourne-Roberts, MD; Lynn Parry, MSc, MD; Brigitta Robinson, MD, FACS; and Michael Volz, MD.

Congratulations to these CMS leaders. The nomination period for the 2020 CMS election is now open through Jan. 31, 2020. The Colorado Medical Society asks all members to consider nominating a colleague or self-nominating for one of the open leadership positions: President-elect (one position open) or AMA Delegation (two positions open). The election guide, available on www.cms.org, provides important information on the duties, eligibility, terms of office and honorarium for each open position, as well as candidate requirements, campaign guidelines, election process and more. Potential nominees can review the position descriptions and qualifications for office starting on page three of the election guide and the candidate requirements on page five of the election guide. Please email president@cms.org if you have any questions about becoming a CMS physician leader.

C O LO R A D O M E D I C I N E 5

9 C OV E R

S TO RY

EMERGING THEMES IN HEALTH CARE

SPOILER: THEY’RE NEARLY ALL ABOUT COST Kate Alfano, CMS Communications Coordinator

The Colorado Medical Society contracted with the Colorado Health Institute (CHI) to develop a comprehensive environmental scan of significant state and national drivers of change for the medical community to help inform the development of the 2019-2020 CMS operational plan.

Paul Presken, CHI senior consultant, presented the final scan during the July 12 meeting of the CMS Board of Directors, summarizing the top nine emerging themes in health care and answering questions from the board. Throughout them all, he explained, is a recurring theme of cost.

S IT AL RK

PA YE LO

AS T

G O VE

O N CH TE

M EN

SE U CE TA N BS SU

6 C O LO R A D O M E D I C I N E

W O

RE EN T PA YM

G S

Over the summer CHI staff conducted primary research into emerging trends that affect physicians. Leveraging their understanding of upcoming state legislative policy impacting health care in Colorado, CHI also conducted a

qualitative review of emerging trends in Colorado’s health care system, as well as national trends that will impact the state. The CMS Operational Plan Committee offered input and helped refine the scan.

C OV E R

ONE HEALTH CARE COSTS FOR CONSUMERS HAVE REACHED A TIPPING POINT. The most obvious example of increased attention on health care costs is Gov. Jared Polis’s Office of Saving People Money on Healthcare, headed by Lt. Gov. Dianna Primavera, Presken said. “This is an intense focus for him that we haven’t seen in any other administration.” Another example is the slate of bills passed by the 2019 Colorado General Assembly that aims to reduce health care costs for consumers. • Health care facilities and insurance carriers must now provide better disclosures about possible out-of-network billing situations. • A reinsurance program aims to reduce premiums on the individual market by covering the highest-cost claims for insurers. • Health care cooperatives are now permitted in Colorado, allowing people in a region to band together to negotiate rates with providers. “The idea is that it’s time to make sure there is tangible legislation at the state Capitol to control costs for Coloradans,” Presken said.

TWO PRESCRIPTION DRUG COSTS ARE INCREASING AND LEGISLATORS ARE CRAFTING BILLS TO CONTROL THEM. Prescription drug costs continue to outpace inflation at a rate of two to nine times for brand-name oral drugs and generic oral drugs, respectively. The highest-cost drug ever was announced in May, Zolgensma, a gene therapy from AveXis and Novartis designed to treat spinal muscular atrophy in one dose, but at a cost of $2.1 million. The 2019 legislature passed laws allowing for the importation of prescription drugs from Canada and capping insulin copy or coinsurance prices at $100 for a 30-day supply. A bill that failed but that will likely be revived in the 2020 legislature, Preskin said, would have required significant prescription drug transparency.

THREE HOSPITAL COSTS ARE IN THE CROSSHAIRS. The tone on hospital costs was set in January when the Colorado Department of Health Care Policy and Financing released a study contradicting the theory of the “cost shift” – that hospitals charge higher prices to people with private insurance to make up for the losses they take on Medicare, Medicaid and uninsured patients – and illustrating that policies intended to address hospital cost-shifting have had little impact on the high price of insurance. The Colorado Hospital Association disputed the findings. With hospital costs in the crosshairs, several laws were passed in 2019 to provide more transparency and control. • The very first bill introduced in the 2019 session requires hospitals to disclose data annually to HCPF on expenditures and uncompensated costs. • Another bill requires nonprofit hospitals to submit data on community benefit activities to the state instead of just the IRS. • And yet another bill creates new licensure requirements and new rules for freestanding emergency departments.

FOUR PAYMENT REFORM IS AFFECTING PHYSICIAN PAYMENT. Health plans are increasingly moving from up-side risk only to up-side and down-side risk arrangements, Presken said. And government programs like the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) are starting to have an impact: 2019 is the first year physicians are seeing payment affected by MIPS and 2021 is when more Colorado Medicaid quality measures will affect payment for primary care physicians. “We’ve been talking about this for a long time,” Presken said. “The private plans are not far behind. They look to the government to take the lead on these things. We’re seeing a lot of ACO [accountable care organization] expansion, most driven by Medicare advantage plans. Colorado is at the top of the list for the most ACO-covered lives. Private insurance, public insurance, this is going to have an increasing impact.” C O LO R A D O M E D I C I N E 7

C OV E R T H E M E S I N H E A LT H C A R E : C O N T

FIVE

CMS BOARD OF DIRECTORS DISCUSS 2020 OPERATIONAL PLAN

THE PHYSICIAN WORKFORCE IS SHIFTING. The American Medical Association recently announced that the year 2018 marks the first time there were fewer physician owners than employees in the United States: 45.9 percent vs. 47.4 percent, respectively. This has been slowly changing over time and it looks like the trend will continue, Presken said. At the same time, physician burnout is higher for employed physicians as illustrated in two studies: Physicians working in small, independent primary care practices report less burnout than the national average, and physicians employed by hospitals and corporations are more dissatisfied and burned out than those who work independently and in physician-owned practices.

SIX 2

COLORADO HAS EXPANDED SUBSTANCE USE AND REGULATION AND IS SEEING THE EFFECTS. Colorado continues to “experiment” with legalization, Presken said, citing actions by the 2019 legislature to expand who can sell cannabis and where it can be offered, and the Denver law de-criminalizing hallucinogenic mushrooms. Colorado now has some of the highest rates of substance use in the country, with the third-highest rate of illicit drug use in the country, the nation’s highest rate of youth vaping, and a three-fold increase in cannabis-related ER visits, according to a UCHealth study. Overdose deaths from opioids have declined significantly in the past year but deaths from cocaine and methamphetamine have risen.

SEVEN INVESTMENTS IN TECHNOLOGY AND DISRUPTION OF CURRENT MODELS ARE GROWING. Presken reported that venture capital firms invested record amounts in health care technology in 2018, and investment focused on “disruptive” technologies that hold significant promise: telehealth, robotics for surgical and non-surgical applications, artificial intelligence to analyze electronic medical records and medical imaging data, immunotherapy in cancer care, genetic sequencing to diagnose disease, and 3D printing for organ transplants and tissue repair.

6 1 CMS President Debra Parsons, MD, FACP, discusses emerging trends with CMS Treasurer Patrick Pevoto, MD, MBA, and Immediate Past President Robert Yakely, MD, at the July 12 CMS Board of Directors meeting. 2 Directors at work, clockwise from bottom: Mark Johnson, MD, MPH; Iris Burgard; Brad Roberts, MD; Parsons; and C. Rocky White, MD. 3 CHI’s Paul Presken, top left, presents the nine emerging health care themes to the board. 4 Kim Warner, MD, and Cory Carroll, MD, discuss the CMS initiatives. 5 Presken introduces the themes and their overarching focus on health care costs. 6 Directors consider CMS’ response to the themes first with individual brainstorming before moving into groups for discussion. From left, Johnson, Burgard, Roberts and White.

8 C O LO R A D O M E D I C I N E

TH E M E S I N H E A LTH C A R E : C O N T C OV E R

EIGHT

NINE

THE BUSINESS COMMUNITY IS AND WILL CONTINUE TO BE ENGAGED.

THE GOVERNMENT HAS AN INCREASING ROLE AS A PAYER.

Pressure from the business community is increasing and specific to Colorado, Presken said. From 2008 to 2017, Colorado families with employer-sponsored insurance saw their premiums rise by more than 60 percent to nearly $20,000 per year. In 2020, national private employer medical costs are projected to increase by an average of 6 percent, up from the average of 5.5 percent annually over the past three years.

Since 2016 the Kaiser Family Foundation has found that the majority of the U.S. population has favored moving to universal health insurance. While it’s unclear whether consumers know what they’re being asked, it’s clearly a trend, Presken said. Another recent statistic from Reuters News shows that 70 percent of Americans now favor a “Medicare for All” program, though support fades when respondents are told this might mean that most private insurance plans will be eliminated.

Locally, employers in Summit County “finally had enough,” Presken said, and they formed Peak Health Alliance to negotiate lower insurance premiums directly with providers. They will offer a new plan in 2020. This is the first time in Colorado that employers can negotiate directly with providers, thanks to the law allowing health care cooperatives to operate in the state. According to Presken, employers throughout the state and community are exploring reducing premium costs by negotiating with employers. “We think this will be pretty significant. It can bend the cost curve and it won’t be as expensive. It is changing the whole dynamic of who is negotiating with whom.”

The 2019 Colorado legislature passed laws exploring options for increasing the state’s role in providing coverage. State agencies are currently researching and developing a proposal for an option for a state-sponsored health care plan. And another new law creates a health care cost analysis task force to look at costs and other impacts of various health care financing systems. “We’re inching closer to this but it is unclear as to when this is going to come to fruition,” Presken said. In the national debates for the democratic primary, government-sponsored coverage has been a big topic of discussion but positions run the gamut of elimination of private health insurance to expanding Medicare. Watch for more from the Colorado Medical Society on these trends in 2020, and read more about current work in this issue of Colorado Medicine. ■

Your Practice Assistance Program Partner • Confidential counseling • • • •

To see how MINES can help your practice create a happier and more productive workforce while reducing healthcare costs, call us at 1-800-873-7138 or visit minesandassociates.com Preferred Pricing for CMS members. MINES is proud to be an Advantage Partner of Colorado Medical Society

Resilience and stress management Legal consultation Unlimited work/Life referrals Professional wellness coaching

MINES and Associates’ Practice Assistance Program is your solution for workplace behavioral health and HR and management support. With MINES and Associates as your partner you have: An Employee Benefit: Counseling for Employees and Household Members, Customizable Online Platform, Legal Consultation, Resilience, Wellness, Work/life, and more. A Management Support Tool: Unlimited Management Consultations, Unlimited Work Performance Referrals, Conflict Resolution, and an Annual Organizational Assessment. A Wellness Partner: Workplace Trainings and Seminars, Expert Wellness Coaches, Work/Life Referral Services, and Wellness Resources. C O LO R A D O M E D I C I N E 9

F E ATU R E

Legislative committee on opioids continues crucial policymaking work PHYSICIANS PROVIDE TESTIMONY ON EDUCATION REQUIREMENT AND GAINS Kate Alfano, CMS Communications Coordinator

The 2019 Opioid and Other Substance Use Disorders Study Committee, chaired by Sen. Brittany Pettersen, has met throughout the summer to consider legislative solutions to the opioid crisis for the purpose of informing work in the 2020 General Assembly.

Now in their third year, the bipartisan committee is charged with reviewing data and statistics on the scope of

the substance use disorder problem in Colorado; compiling an over view of the current resources available to

Coloradans; reviewing the availability of medication-assisted treatment options and whether pharmacists can prescribe those medications; examining what other states and countries are doing to address substance use disorders; identifying the gaps in prevention, intervention, harm reduction, treatment and recovery resources; and identifying possible legislative options to address these gaps. CMS President Debra Parsons, MD, FACP, testified before the committee at their first meeting on July 9, joining other top provider experts: Jonathan Clapp, MD, a pain specialist in Denver; Robert Valuck, PhD, RPh, executive director of the Colorado Consortium on Prescription Drug Abuse Prevention; and Ronne Hines, director of DORA’s Division of Professions and Occupations. Parsons focused on three areas of CMS’ effort to address the pubic health crisis of opioids: positive trends in physician education and opioid prescribing; CMS’ strong partnership with the Colorado Consortium; and the recently released “Spotlight on Colorado” report that showed Colorado leading the way in combatting the opioid epidemic.

1 0 C O LO R A D O M E D I C I N E

TE S TI M O N Y: C O N T F E AT U R E S

Testifying at the July 9 meeting of the 2019 Legislative Study Committee on Opioids and Other Substance Use Disorders were, from left, Jonathan Clapp, MD, a pain specialist in Denver; CMS President Debra Parsons, MD, FACP; Robert Valuck, PhD, RPh, executive director of the Colorado Consortium on Prescription Drug Abuse Prevention; and Ronne Hines, director of DORA's Division of Professions and Occupations.

“CMS is thrilled” about trends in opioid prescribing and Prescription Drug Monitoring Program utilization, Parsons said in her testimony, citing that opioid prescribing rates in Colorado fell over 29 percent in the last five years and PDMP checks increased 650 percent since 2014, reaching nearly 4.5 million queries in 2018.

“This new state data is consistent with surveys of CMS members demonstrating broad uptake in voluntary continuing medical education credits across multiple specialties. An overwhelming majority of CMS physician members, collectively 70 percent, have had CME on opioids in the past two to three years. The CMS survey results along with the state data demonstrate that our educational efforts are working in substance use disorder prevention. These positive PAGE 12 ⊲

Members of the 2019 Opioid and Other Substance Use Disorders Study Committee

Sen. Brittany Pettersen, Chair (D-Lakewood) brittany.pettersen.senate@state.co.us Rep. Chris Kennedy, Vice Chair (D-Lakewood) chris.kennedy.house@state.co.us Rep. Perry Buck (R-Greeley) perrybuck49@gmail.com Rep. Bri Buentello (D-Pueblo) bri.buentello.house@state.co.us Rep. Leslie Herod (D-Denver) leslie.herod.house@state.co.us Sen. Dominick Moreno (D-Commerce City) dominick.moreno.senate@state.co.us Sen. Kevin Priola (R-Commerce City) kpriola@gmail.com Sen. Jack Tate (R-Centennial) jack.tate.senate@state.co.us Rep. James Wilson (R-Salida) representativewilson@gmail.com Sen. Faith Winter (D-Westminster) faith.winter.senate@state.co.us C O LO R A D O M E D I C I N E 1 1

T E S T I M O N Y: C O N T

trends are an important combination of many efforts and we applaud this committee for your good work on these issues.” She addressed the new mandatory CME requirement passed by the General Assembly in the 2019 session, SB19-228, pledging CMS’ commitment to working with the Consortium on Prescription Drug Abuse Prevention and the Department of Regulatory Agencies and requesting that physicians who have completed applicable CME in the last two to three years be credited toward the new requirement. Parsons referenced the CMS multi-specialty convening on opioids, which brought together physicians representing many specialties and geographic regions for two day-long brainstorming sessions, and work with the Colorado Hospital Association in the CO’s CURE project (Clinicians United to Resolve the Epidemic), which has set an ambitious goal of creating the nation’s first multi-specialty guidelines to address and resolve the opioid epidemic in Colorado. Finally, Parsons gave an update on the “Spotlight on Colorado” repor t, an in- depth analysis of Colorado’s responses to the opioid epidemic that was produced in collaboration with the American Medical Association and Manatt Health, highlighting the next step of creating a “crosswalk” between the recommendations from the Spotlight report and Colorado law to identify gaps still needing to be addressed. “We are eager to continue working with your Interim committee and are proud to support your efforts to curb opioid and other substance misuse,” she said.

Additional committee meetings have been held July 30, Aug. 13 and Aug. 27, with remaining meetings scheduled for Sept. 24 and Oct. 29.

Among the “house of medicine,” he recognizes “growing consensus that is being further advanced by CMS’ work with multiple stakeholders.”

Don Stader, MD, has been the CMS representative this year and since its inception in 2017. He praised CMS for being a “wonderful voice and advocate for physicians and patients in this space.” He also spoke to the committee’s efficiency this year. “There are some issues that still need to be addressed but many are not with physicians and providers. Obviously there are opinions regarding mandatory education and we are advocating for better PDMP and elimination of several issues such as prior authorization and the requirement to trial opioids prior to other medications.”

“The CO’s CURE Initiative and the CMS multi-specialty convenings are concrete examples of the growing willingness of physicians to work across specialties to combat the crisis,” Stader said. Get involved in the effort to reduce the public health crisis of opioids by volunteering on the CMS Committee on Prescription Drug Abuse, or joining a workgroup of the Colorado Consortium for Prescription Drug Abuse Prevention. ■

Contact CMS for more information: email amy_goodman@cms.org

SCOPE of Pain Symposium 2nd Annual Colorado Consortium Education Symposium Learn about the best practices for safely and effectively managing patients with acute and/or chronic pain and appropriate opioid use. SCOPE of Pain (Safer/Competent Opioid Prescriber Education) is an in-depth training that focuses on effective communication skills and the risks and benefits of opioids for managing acute and chronic pain. The training includes the assessment of opioid misuse risk and recognition and treatment of opioid use disorder. This course will be presented by nationally renowned expert Dr. Daniel Alford, MD, MPH, a professor at the Boston University School of Medicine. CME, CNE, ABIM MOC Part II credits are available. The event is free and will include time for networking. Register soon — space is limited! https://www.scopeofpain.org/core-curriculum/live-conferences/select-a-conference.php

Tuesday Oct. 22 5 to 9 p.m.

1 2 C O LO R A D O M E D I C I N E

University of Colorado Anschutz Medical Campus Education 2 North 13120 E. 19th Ave. Aurora, CO 80045

INSIDE CMS

CMS CORPORATE SUPPORTERS AND ADVANTAGE PARTNERS While CMS analyzes the quality and viability of our Advantage Partners and their offerings, we do not guarantee any product or service will be right for you. Before you make a purchase, we recommend you perform your own due diligence.

AUTOMOBILE PURCHASE/LEASE

PRACTICE VIABILITY

US Fleet Associates 303-753-0440 or visit usfacorp.com *CMS Advantage Partner

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

FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit copicfsg.com *CMS Advantage Partner Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com PNC Bank 330-606-8315 or visit pnc.com/hcprofessionals TSI 800-873-8005 or visit web.transworldsystems.com/npeters *CMS Advantage Partner

INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit callcopic.com *CMS Advantage Partner Colorado Drug Card 720-539-1424 or coloradodrugcard.com *CMS Advantage Partner Medjet 1-800-527-7478, refer to Colorado Medical Society, or visit medjet.com/cms *CMS Advantage Partner University of Colorado Hospital/CeDAR 877-999-0538 or visit CeDARColorado.org

Carr Healthcare Realty 303-817-6654 or visit carrhr.com *CMS Advantage Partner Eide Bailly 303-770-5700 or eidebailly.com/healthcare Favorite Healthcare Staffing 720-210-9409 or medicalstaffing@favoritestaffing.com *CMS Advantage Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com *CMS Advantage Partner MINES & ASSOCIATES 800-873-7138 or visit minesandassociates.com *CMS Advantage Partner RainTech 844-TEL-RAIN or visit https://rain.tech Rx Security 800.667.9723 email: info@rxsecurity.com or visit rxsecurity.com The Legacy Group 720-440-9095 or visit healthcare.legacygroupestates.com TSYS 877-841-0606 or visit transfirstassociation.com/cms *CMS Advantage Partner Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net

C O LO R A D O M E D I C I N E 1 3

F E ATU R E

Physician participants in multi-specialty convening on opioids produce slate of recommendations Amy Berenbaum Goodman, JD, MBE, CMS Senior Director of Policy The Colorado Consortium for Prescription Drug Abuse Prevention – a statewide interuniversity/interagency network whose mission is to reduce prescription drug misuse and abuse by developing policies, programs, and partnerships with collaboration and buy-in from all interested public and private stakeholders – asked the Colorado Medical Society to convene physicians across multiple specialties to develop recommendations for how to combat the opioid crisis in Colorado and to help set a coordinated strategic course for activities and programs throughout the state. CMS has worked closely with the Consortium since its inception to help reverse the crisis. In this work, CMS has prioritized access to care; physician education; guaranteeing that insurance functions for patients; and continuing to limit the dispensing and use of opioids while assuring access to compassionate, evidencebased care for patients who suffer from acute and chronic pain.

After two day-long facilitations over six months, the physician participants put forth recommendations that fall into three broad categories: prevention and early intervention, treatment, and harm reduction. The participants identified key questions for each category and developed a list of initiatives and targets with accompanying actions and strategies to address each key question. See the matrix below for the resulting recommendations. CMS remains committed to the work of the Consortium and the goal of eradicating prescription drug misuse and abuse in Colorado. CMS and its Committee on Prescription Drug Abuse are engaged in next steps stemming from the key questions, initiatives and actions identified through the Multi-Specialty Convening on Opioids. Physicians will continue to partner with the Consortium to help reverse the opioid epidemic while providing compassionate, evidence-based care to patients who suffer from acute and chronic pain.

The Consortium’s request of CMS: GOAL Recommend to the Colorado Consortium for Prescription Drug Abuse Prevention a future strategic pathway for medical professions that contributes to a reversal of the opioid cirisis in Colorado.

OBJECTIVE Develop the perspective, ideas, and an ultimate consesus from practicing physicians on guideline development and other physician activities and programs to reverse the opioid crisis in Colorado.

STRATEGY Professionally facilitate a grassroots-derived multi-specialty convening with broad geographic representation.

1 4 C O LO R A D O M E D I C I N E

M U LTI - S P E C I A LT Y C O N V E N I N G : C O N T F E AT U R E S

Prevention and early intervention KEY QUESTIONS

INITIATIVES

ACTIONS

How do we address the upstream drivers of the chronic pain epidemic and opioid use disorders?

Change the mental model of pain

• Physician education: Develop curriculum, educational materials, and up-to-date modules on the science of pain • Patient education: Develop patient materials, public service announcements, and “nudges”

Improve early recognition of psychosocial contributors to pain and substance misuse

• Encourage use of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool across all settings to identify high-risk patients

Increase affordable access to behavioral health How do we ensure the appropriate use of opioids in the treatment of pain?

Minimize the initial exposure to opioids and increase the use of first-line therapies/ alternatives to opioids (ALTOs) for pain treatment

• Encourage a multimodal approach (pharmacological and non-pharmacological) to pain management • Develop specialty-oriented protocols and guidelines for appropriate opioid prescribing; pilot team-based training and implementation; disseminate best practices

Make the PDMP universally easy-to-use and more useful

• Integrate into EMRs (decrease costs, IT support); increase feedback to providers and patients (dosing, duration, frequency, refills, MMEs, co-prescribing); include hospital prescriptions and methadone clinics

Encourage health insurance coverage for ALTOs and easy use of benefits

• Engage plans to catalogue current efforts • Incentivize and possibly mandate affordable, timely access to evidence-based first-line therapies and ALTOs without prior authorizations – pain psych., acupuncture, physical therapy; better access to atypical opioids (e.g. buprenorphine and tapentadol); present cost-effectiveness, benefits of unity

Provider education

• Educate on ALTOs and atypicals/best practices; addictionology and pain “mentoring” • Make education accessible (virtually, state specialty society) and possibly incentivize education (financial, CME, COPIC ERS) • Marketing, testimonials

Patient education

• Set appropriate expectations for pain/symptom control and functional goals, depending on disease process • Education regarding opioid use risks and benefits • Handouts (specialty-specific/state society) • Public service announcements

Create (or leverage) a virtual multi-disciplinary case review/ consultation system

• Similar to tumor board or ECHO

Dentists/veterinarians – Increase partnership and outreach

• Collaborate with dentists’ and veterinarians’ specialty societies PAGE 16 ⊲ C O LO R A D O M E D I C I N E 1 5

F E AT U R E S M U LTI - S P E C I A LT Y C O N V E N I N G : C O N T

Treatment KEY QUESTION

INITIATIVES

ACTIONS

How do we develop effective addiction treatment (MAT and others) in the community, taking into account the varied cons of care?

Stigma reduction and education so the public understands that opioid addiction is a disease and not simply a poor lifestyle choice

• Public service announcements, flyers for physician offices, and web-based resources for patients • Promote and leverage public awareness campaigns, including Lift the Label • CMS and partners work to publish op-ed in media about stigma and enhancing empathy around opioid use disorder – target public, law enforcement, medical profession

Clinician outreach through all stages of training and career

• Incorporate training on pain, addiction and treatment, and treatment of both in medical schools • Outreach to practices/doctors/residencies

Increase practical/technical assistance for substance use disorders treatment, including MAT implementation/expansion

• Links and access to trainings/resources/ shadowing (ECHO, SIM, ALTOs, CBT DBT for pain, biofeedback, guidelines, forms, mentoring, community) to give clinicians on-site experience

Utilize and optimize hub-andspoke integrated care models

• Integrate into EMRs (decrease costs, IT support) • Increase feedback to providers and patients (dosing, duration, frequency, refills, MMEs, co-prescribing • Include hospital prescriptions and methadone clinics

Inventory available resources for substance abuse and mental health

• Monitor and address if there are gaps in treatment options

Public policy advocacy

• Treatment coverage, parity (42 CFR § 457.496)

Thank you to all of the physicians who participated in CMS’ two-part Multi-Specialty Convening on Opioids J. Scott Bainbridge, MD

George Gibson, MD

Jeff Nakano, MD

Mark E. Wallace, MD, MPH

Lisha C. Barre, MD

Jason Kelly, MD

Lynn Parry, MD

Tonya Wren, MD

Joshua D. Blum, MD

Kyle Knierim, MD

Deb Parsons, MD

Noel Sankey, MD

Jonathan Clapp, MD

Elizabeth Lowdermilk, MD

Rachael Rzasa-Lynn, MD

Dave Downs, MD

Mauricio Mejia, MD

Donald Stader, MD

Bradley D. Fanestil, MD

Matthew Moles, MD

Darlene B. Tad-y, MD

Thank you to all of the physicians who serve on CMS’ Committee on Prescription Drug Abuse John S. Hughes, MD (Chair)

Andrew Hall, MD

Richard May, MD

Donald Stader, MD

J. Scott Bainbridge, MD

Jason Hoppe, DO

Cyrus Mirshab, MD

Chris Unrein, DO

Jonathan Clapp, MD

Shannon Jantz, MD

Kathryn Mueller, MD

Ben Vernon, MD

Sami Diab, MD

Ellie Jensen, DO

Carla Murphy, MD

Steven Wright, MD

Tom Denberg, MD

Robin Johnson, MD

Erik Natkin, DO

Ken Finn, MD

Stuart Kassan, MD

Lee Newman, MD

Brian Flynn, MD

Rebecca Knight, MD

Lynn Parry, MD

Gary Ghiselli, MD

Tom Kurt, MD, MPH

Jens Peter-Witt, MD

Jan Gillespie, MD

Alan Lembitz, MD

John Sacha, MD

Elizabeth Grace, MD

Elizabeth Lowdermilk, MD

Bob Sammons, MD

1 6 C O LO R A D O M E D I C I N E

And a special thank you to Robert Valuck, PhD, RPh, FNAP, executive director of the Consortium for Prescription Drug Abuse Prevention, for his invaluable collaboration.

M U LTI - S P E C I A LT Y C O N V E N I N G : C O N T F E AT U R E S

Harm reduction KEY QUESTION

INITIATIVES

ACTIONS

How do we make sure people who are using/ abusing opioids (Rx and illicit) are doing so as safely as possible?

Publish harm reduction position statement based on best evidence

• Develop Colorado Medical Society policy

Create clinician education revolving around how to implement harmreduction practices

• Create a harm reduction toolkit for clinicians so they can implement harm reduction in their practices • Link to infectious disease treatment and precautions regarding safe use

Strive to have every hospital dispense naloxone to high-risk patients at discharge by 2020

• Collaborate with the Colorado Hospital Association on efforts to increase naloxone dispensing

Increase use of needle exchange programs

• Work with Colorado Hospital Association to create nation’s first hospital-based syringe exchange pilot program PAGE 18 ⊲

Romero

Group

Lisa Price Managing Broker

Realty

970.948.4467 lprice@romero-group.com

Establish Your Medical Practice in Basalt, Colorado These Two Opportunities Must be Seen! O W N YOUR SPACE

L E A S E YOUR SPACE

227 Midland Ave | Unit 15B | Basalt Colorado

350 Market Street | Unit 301| Basalt Colorado

2,037 sq. ft. beautifully designed with great architectural features! Located in the heart of downtown Basalt in the popular Riverwalk building. 6-treatment rooms, large reception area, two bathrooms a shower, kitchen and lots of cabinetry for storage. 3-covered parking spaces, ample client/guest parking, elevator access to unit.

2,452 sq. ft. open unfinished office space, ready for your unique design and fit out. This prime, top floor corner office is located in the heart of Willits, adjacent to Whole Foods and many other retailers/restaurants and service providers. Unit has elevator access, ample parking and amenities.

$1,250,000

$25 per sq. ft. base rent NNN Lease | 5-year term

INQUIRE NOW! C O LO R A D O M E D I C I N E 1 7

F E AT U R E S M U LTI - S P E C I A LT Y C O N V E N I N G : C O N T

Opioid statistics

% of all opioid overdose deaths involve a prescription opioid

Opioids killed more than 47,000 people in 2017 or 130 per day

Prescription opioid misuse

When used correctly prescription opioids are helpful for treating pain

The CDC issued guidelines for safe prescribing of opioids in primary care

An estimated 11.4 million people misused prescription opioids in 2017 -- putting them at risk for dependence and addiction

3 out of 4 people who used heroin misused prescription opioids first

Opioid use disorder

Over two million people have an opioid use disorder

Treatment options exist including medicationassisted treatment (MAT)

Source: Centers for Medicare & Medicaid Services

Only 20% of people with opioid use disorder receive treatment

1. Centers for Medicare & Medicaid Services

E X TR A

Specialties come together to develop guidelines for opioid prescribing in Colorado

A crucial initiative to address how to ensure appropriate use of opioids in the treatment of pain involves minimizing the initial exposure to opioids and increasing the use of first-line therapies and alternatives to opioids (ALTOs) for pain treatment. One of the actions identified during the Colorado Medical Society’s first Multi -Specialt y Convening on Opioids in October 2018 was t he need to develop

1 8 C O LO R A D O M E D I C I N E

specialty-oriented protocols and guidelines for appropriate opioid prescribing in Colorado. Following that convening, the Colorado Hospital Association, CMS and the Consortium developed a new initiative c a ll e d C o l o r a d o’s O p io i d Solution: Clinicians United to Resolve the Epidemic. CO’s CURE was announced in January 2019 and specialty societies’ work to develop

opioid prescribing guide lines is well underway. In the second phase of CO’s CURE, which will begin in 2020, these guidelines will be piloted in the clinical setting. “CMS continues to be committed to the work of the Consortium For Prescription Drug Abuse Prevention and looking forward to future work with the Colorado Hospital Association in the CO’s CURE

project … to create the nation’s first multi-specialty guidelines to address and resolve the opioid epidemic in Colorado,” said CMS President Debra Parsons, MD, FACP, in testimony before the Opioid and Other Substance Use Disorders Study Committee in July. Learn more about the initiative at www.cha.com/opioid-safety/ cos-cure. ■

F E ATU R E

Unintended consequences of the opioid epidemic for cancer and palliative care patients PHYSICIANS SPEAK UP ABOUT PATIENTS BEING DENIED NEEDED PRESCRIPTIONS Kate Alfano, CMS Communications Coordinator

Momentum is building in the effort to combat the opioid epidemic, and physicians and other stakeholders, especially in Colorado, should celebrate this progress. But as opioid restriction policies have increased, physicians – especially those specializing in oncology and palliative care – report that their patients face unnecessary barriers to filling the prescriptions they need for pain management. “It’s a huge problem for our patients,” said Sami Diab, MD, a physician who is board certified in medical oncology, supportive oncology and palliative care. “They get short on their pain medications, and the pharmacy says they cannot fill the prescription before a certain date or they cannot give them the prescribed number of pills.”

suf fered immensely,” said Eleanor Jensen, DO, a palliative care physician with Kaiser Permanente. “Then, the pendulum swung back and all pain was treated with opioids. I think there is real PTSD in the medical community, particularly in oncology, around returning to a time where our most fragile patients don’t have appropriate access to opioid pain management. That being said, I also think that if we – practitioners who support patients with cancer – insulate ourselves and have an open prescription pad policy

for all cancer patients that there will be a subset of patients who are not well managed and will suffer as others have from too much access to opioids and particularly benzodiazepines.” “When patients have been on high-dose opioids for chronic pain, it makes treating their pain at the end of life very difficult and they suffer more than many other patients – this is a real reason to help minimize opioids in the general population,” Jensen said. “I am grateful that PAGE 20 ⊲

Though uncertain whether the barriers originate with pharmacy chains with overarching corporate policies limiting opioids or certain payers’ policies, Diab says he receives at least an email a week from a frustrated patient or caregiver who has been turned away at the pharmacy counter. “If you look at the problems and statistics on the national level, you realize that it’s not an issue isolated to Colorado or one pharmacy,” Diab continued. “It’s a national issue where cancer patients are caught in the crossfire with [efforts to stem] narcotics and opioid overdose and all the new regulations to address them in the general population for good reasons.” “Previously the pendulum swung away from treating cancer pain and patients C O LO R A D O M E D I C I N E 1 9

F E AT U R E S U N I N T E N D E D C O N S E Q U E N C E S : C O N T

I’m able to help patients manage their symptoms in order to meet their goals. At the end of the day, I think this should be the framework for everything we do – goal-oriented care.” As the Centers for Disease Control and Prevention clarified in February, their Guideline for Prescribing Opioids for Chronic Pain is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management. “CDC encourages

physicians to continue to use their clinical judgment and base treatment on what they know about their patients, including the use of opioids if determined to be the best course of treatment.” The American Medical Association responded to the CDC in April with a statement by AMA President Patrice Harris, MD: “The AMA appreciates that the CDC recognizes that patients in pain require individualized care. … The

Together

Hope. Health.

Join our team …

Join a team of experienced medical and behaviorial healthcare providers committed to exceptional care with compassion and kindness. Health Solutions is a comprehensive community medical and behavioral healthcare provider with centers in Pueblo, Huerfano and Las Animas counties. Our mission is to make available a comprehensive range of affordable and quality community-based health services.

PRIMARY CARE PHYSICIAN

Integrated Primary Care Medical Center/Medication Assisted Recovery Center 41 Montebello Rd., Pueblo, Colo. We are looking for a licensed professional with experience managing substance use disorders and chronic medical conditions who can provide the full scope of primary care services including diagnosis, treatment, coordination of care, preventive care, addiction medicine and health maintenance. Compensation: $240,000-$255,000 annually, $30,000 signing and retention bonus, CME benefits, relocation allowance and comprehensive benefits package. Holidays and weekends off and a 40-hour work week with negotiable schedule. Please contact Erin Frew, Ph.D., Recruitment Manager at erinfr@Health.Solutions to learn more about this exceptional opportunity.

Competitive salaries. Outstanding benefits. Amazing organization.

www.Health.Solutions 2 0 C O LO R A D O M E D I C I N E

guidelines have been treated as hard and fast rules, leaving physicians unable to offer the best care for their patients. … [They] have been misapplied so widely that it will be a challenge to undo the damage. The AMA is urging a detailed regulatory review of formulary and benefit design by payers and pharmacy benefit managers to ensure that patients have affordable, timely access to medically appropriate treatment, pharmacologic and non-pharmacologic.” In Colorado, the General Assembly passed a law in 2018 limiting initial prescriptions to seven days for patients who have not had an opioid prescription in 12 months by that physician, with exceptions for patients who have been diagnosed with cancer or are experiencing cancer-related pain, or who are undergoing palliative care or hospice care focused on providing the patient with relief from symptoms to improve quality of life. This restriction is scheduled to repeal in September 2021. Additional Colorado Medicaid policies limit morphine equivalents and pill quantities for beneficiaries. Patients currently on a pain management regimen are limited to daily morphine milligram equivalents of 200 MME per day. Medicaid’s pill quantity limits apply to short-acting opioids, allowing a maximum of four tablets per day or 120 tablets per 30 days. “There’s an opportunity for the legislature, whenever they are passing any new laws, to think about the impact of this on terminal patients; consider the impact on access for patients who legitimately need pain medications, whether it’s hospice or cancer patients getting active treatment for advanced cancer,” Diab said. Any physician whose patients are having difficulty filling opioid prescriptions should contact the Colorado Consortium for Prescription Drug Abuse Prevention. Staff is tracking the issue and will act as needed. Email info@corxconsortium.org. ■

F E ATU R E

Gov. Jared Polis announces federal approval of Colorado reinsurance program DOI PROJECTS 18.2 PERCENT AVERAGE DECREASE IN 2020 PREMIUMS FOR INDIVIDUAL MARKET

18.2% PROJECTED REDUCTION IN COST

Kate Alfano, CMS Communications Coordinator

On July 31, Gov. Jared Polis announced that the federal government approved Colorado’s application for a 1332 waiver to establish a reinsurance program. With the program in place, combined with other market factors, Colorado health insurance companies that sell individual plans expect to reduce premiums by an average of 18.2 percent from their 2019 premiums, and premiums could go down as much as 41 percent in some areas of the state, according to figures from the Colorado Division of Insurance. Individual plans are for 7 to 8 percent of Coloradans who do not get their health insurance from an employer or government program and instead buy insurance through Colorado’s Connect for Health Colorado insurance marketplace. Reinsurance works by the state paying a portion of high-cost claims. As insurance companies don’t have to pay that portion of the high-dollar claims, they can lower the premiums for individual health insurance plans. And as health insurance premiums go down, the amount of money the federal government spends on tax credits will also go down. But rather than the federal government pocketing the savings, they will pass that

AVERAGE SAVINGS PER YEAR

$8,979

money through to the state to fund the reinsurance program. The process for the 1332 wavier was established under the Affordable Care Act. “We are thrilled to announce that Colorado has received federal approval for our reinsurance program, which will directly reduce health care premiums for hundreds of thousands of Colorado families,” Polis said in a July 31 news release. “Bringing down the outrageous cost of health care in our state has been a top priority for my administration from the beginning, and this is a significant milestone on our way toward achieving that goal. We’re already seeing the direct impact this program will have on premiums on the individual market. That’s thousands of dollars in savings that Coloradans can put toward paying the mortgage, saving for college or retirement, taking a family vacation, or just living their lives.” “This approval highlights Colorado as a leader in making the individual health insurance market affordable and accessible for its citizens,” said Insurance Commissioner Michael Conway. “I am proud of all of the work over the last three years that the DOI has put into making this possible, as well as the

support of Gov. Polis and the legislature. Bold actions require bold leadership.” Over the past three years, the division conducted studies, talked frequently with the Centers for Medicare and Medicaid Services, and worked with actuaries to study the program from different angles, Conway said. Then in January 2019, as part of his top priorities to save Coloradans money on health care, the governor called on the legislature to work together to pass reinsurance during his state of the state address. The bill that established the program, HB19 -1168, directs the DOI to study the effects of the program after two years, in particular focusing on affordability and the impact to consumers eligible for ACA tax credits. The premium reductions are preliminary and only reflect what the companies have requested, not the final approved plans for 2020. The DOI will continue to review the plans and premiums for 2020 for the individual health insurance market and release the final approved plans by October. All of the preliminary 2020 facts and figures are available on the Division’s webpage for health insurance plan filings, located in the “for consumers” section. ■

GOVERNOR’S STRATEGY TO REDUCE HEALTH CARE COSTS

$7,618

 Establish a reinsurance pool to reduce premiums

$4,240

 Increase hospital price transparency

$4,331 $3,335 $3,369 $3,205 $6,696 $6,354 2 2 C O LO R A D O M E D I C I N E

 Negotiate to drive down the cost of health insurance  Lower the cost of prescription drugs  Reduce out-of-pocket costs  New investment in primary care, mental health and substance abuse

F E ATU R E

Colorado is ready: Maintaining SIM’s momentum with integrated care Over the past four years, the Colorado State Innovation Model (SIM) has worked to improve patient access to integrated behavioral and physical health in primary care settings. While SIM ended July 31, a group of industry partners started a new conversation Aug. 1 to maintain momentum and ensure patients receive whole-person care that improves health outcomes and reduces or avoids unnecessary health care costs. The grassroots ef for t, “Colorado is Ready,” connects stakeholders across sectors to inspire the motivation to continue; demonstrates the state’s readiness with a visible, collaborative social media effort; and facilitates listening to a wide variety of experiences to elevate voices across sectors. As stated on the stakeholder website, www.ColoradoIsReady.org, “the fouryear Colorado SIM Initiative was a powerful accelerator that advanced efforts to integrate care. It brought together major health care actors in the state, identified common priorities, created understanding, fostered partnerships, and gathered best practices. Colorado SIM’s efforts were always about creating an environment where the workforce and cross-sector partners could drive integration efforts forward. With advancements to integrating care underway across the state, it’s up to us to build on the momentum Colorado SIM helped to achieve — it’d be a waste not to.” THERE ARE SEVERAL WAYS TO PARTICIPATE IN THIS EFFORT. • Visit www.ColoradoIsReady.org to learn more. • Join the Colorado Is Ready LinkedIn Group to connect with colleagues across sectors, share experiences and suppor t the network. • Use #coloradoisready on social m e d i a p l a t fo r m s to s p re a d awareness. ■

All Medical Answering Service

Owned and operated by the Colorado Medical Society, and backed by history of physician ownership, MTC is uniquely focused on the needs of its clients. Serving medical professionals is all we do. MTC’s management team has over 50 years of combined experience in medical answering services. Our operators are professional, friendly, and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule. MTC is committed to providing the highest level of customer service. MTC is a member of the Association of TeleServices Int’l (ASTI) and a proud recipient of the prestigious ASTI Award of Excellence for service quality. MTC continually upgrades its technology and our servers and your data are kept in a secured state-of-the art data center with redundant internet and power supply.

Serving Medical Professionals for Over 40 Years

• • • •

Secure Messaging Application Voice Logger and Voicemail Appointment Confirmations/Reminders Custom Applications

CMS MEMBERS:

Contact us today for your FREE two-month trial and monthly discount call 303.761.6594 or 1.866.345.0251 www.medteleco.com email info@medteleco.com Member Benefit Partner MTC is the Only Answering Service Endorsed by CMS

C O LO R A D O M E D I C I N E 2 3

F E ATU R E

Federal CMS releases 2020 proposed Medicare physician fee schedule rule with good news for E/M coding Marilyn Rissmiller, CMS Senior Director of Health Care Financing In late July the Centers for Medicare and Medicaid Services (federal CMS) released the proposed fee schedule rule for 2020. In short, the good news is that the federal CMS accepted the recommendations from the American Medical Association (AMA) and RVS Update Committee (RUC) and will not collapse the evaluation and management (E/M) levels with a blended payment rate as previously proposed. The AMA and federal CMS worked together to modify the office visit policy while retaining the modifications that reduce the documentation burden. The CPT Editorial Panel and the RUC proposed revisions to simplify the guidelines and code descriptions and increase their value. The CPT coding changes will retain five levels of coding for established patients and reduce the number of levels for new patients to four. (CPT code 99201 will be deleted.) The proposed changes to the E/M coding and payment will go into effect in 2021.

Under the new documentation guidelines, history and examination alone will no longer select the level of the E/M code. Rather the code selection can either be based on the medical decision-making or the time spent on the date of the encounter. Under the new guidelines the outdated system of counting the number of body systems/areas reviewed and examined will no longer apply, and these components will only need to be performed (and documented) when and to the extent medically necessary and clinically appropriate for the patient. The effective date of these changes was extended until 2021 in recognition of the time needed for physicians to become familiar with the new documentation requirements. The AMA has established a website dedicated to providing physicians with resources and training tools to help. That website is www.ama-assn. org /pr ac t ice - management /cpt /cptevaluation-and-management.

“Your specialty is medicine and serving patients. Our specialty is real estate and serving

you.

”

In the meantime, the documentation requirements that were put in place for 2019 will remain in effect; that is the elimination of the requirement to document medical necessity of furnishing visits in the home rather than in the office; and elimination of requirements for the physician to re-record elements of the history and physical exam when there is evidence that the information has been reviewed and updated. The p rop ose d r ule al so inclu de d changes for 2020 to the Merit-based Incentive Payment System (MIPS) and expanded access to treatment for opioid use disorder. More information on the proposed fee schedule rule can be found on the federal CMS website at www.cms.gov/newsroom/fact-sheets/ proposed-policy-payment-andquality-provisions-changes-medicarep h y s i c i a n - fe e - s c h e d u l e - c a l e n d a ryear-2. ■

Know Your Legal Rights – www.cms.org/kylr Did you know you have access to a searchable catalog of provider protection statutes that you can use in disputes with health plans? Know Your Legal Rights contains decades of public policy victories that may assist you in your dealings with payers. Go to www.cms.org/kylr; member login required.

720-440-9095

rmb@legacygroupestates.com www.legacygroupestates.com 8600 Park Meadows Drive, Duite 300 | Lone Tree, CO 80124

2 4 C O LO R A D O M E D I C I N E

Robert Marinaro, MHS, CLHMS Mary Beth Marinaro, CT (ASCP), CLHMS Broker Associates/Realtors

Email membership@cms.org for your login.

F E ATU R E

Congress is getting serious about surprise billing Kate Alfano, CMS Communications Coordinator

Congress has taken significant steps in moving legislation aimed at tackling the issue of surprise billing. One bipartisan approach, H.R. 3502 sponsored by Rep. Raul Ruiz, MD (D-CA) and Rep. Phil Roe, MD (R-TN), is supported by organized medicine. AMA analysts say it addresses surprise billing in a balanced manner and encourages reasonable out-of-network billing and payment practices by resolving disputes by an independent dispute resolution process that relies on independent data, stabilizes insurer premium growth, strengthens provider networks and preserves patient access to care. Two other bills – H.R. 3630 and S.B.1895 – championed by insurance companies, use a payment benchmark that would resolve payment disputes between physicians and insurers by setting out-of-network payments at the median amount each insurer pays for in-network care. The AMA warns the benchmark could devastate physician practices by giving insurers full rate-setting authority, undermining provider networks and causing even more consolidation. The AMA wrote in their August recess action kit that legislation that limits plan obligations to only the median rate paid to in-network physicians greatly advantage insurers by absolving them of the need to create strong networks for the provision of hospital-based and other services and protecting them from the consequences of their failure to create those networks.

Regardless of their lack of effort to create an adequate network, they would enjoy federal limits on the amount they would have to pay for care. Median in-network rates do not fairly reflect the cost of providing services by all providers nor do they capture other benefits that go hand in hand with being in-network, such as additional incentive payments as part of value-based contracts, prompt and direct payment by plans, and listing in provider directories. “It is not reasonable, therefore, to impute that adequate rates for in-network physicians are sufficient or equitable for those that do not enjoy the additional benefits of being in network and are therefore not able to discount their rates,” the AMA said. Terri Folk, AMA regional political director, urged physicians to speak out on this issue. “Physicians need to be communicating with their legislators now that surprise billing needs to be fixed in a way that holds insurance companies accountable while protecting patients.” Go to physiciansgrassrootsnetwork.org/surprise-billing to learn more about the federal effort, find talking points, and connect with your legislators. ■

Preparing for the implementation of Colorado’s out-of-network bill: Read the CIVHC FAQ The Colorado General Assembly passed HB 19-1174 during the 2019 legislative session to help protect Colorado patients from surprise out-of-network bills. Included in the bill are specifications regarding provider reimbursements for out-of-network emergency and non-emergency visits. The Colorado All Payer Claims Database is identified in the bill as a data source related specifically to the statewide commercial carrier median

geographic payments specified in the bill, and CIVHC – the administrator of the APCD – is working collaboratively with the Division of Insurance to finalize specifics regarding the methodology that will be used and the data elements that will be available to the DOI from the CO APCD. CIVHC has compiled a “frequently asked questions” document to provide some guidance to providers. Access the FAQ at www.civhc.org.

C O LO R A D O M E D I C I N E 2 5

F E ATU R E

Medical students convene for “White Coat Wisdom,” the CMS MSC’s annual meeting Medical students from Rocky Vista University College of Osteopathic Medicine and the University of Colorado School of Medicine convened Aug. 13 at CMS headquarters for an engaging evening of socialization, giveaways and small-group sessions focused on work-life balance, public health, the practice of medicine and the business of medicine. The faculty comprised real-world experts from a variety of settings who shared their experiences on each topic and answered the students’ questions to help them navigate their future. Student attendees praised the ability to have candid conversations with doctors about topics not always covered in their curriculum. Faculty complimented thoughtful and energetic students who show great promise in their careers. Medical students: Get involved in the Medical School Component of the Colorado Medical Society by emailing dianna_fetter@cms.org. ■

“ “

There is so much that can’t be taught in a standard medical school curriculum and WCW filled in those gaps about what kind of practice setting is right for me, how to stay excited about medicine and not get burned out, the logistics of practicing underserved or international relief medicine, and how to set myself up for success financially and legally as a future physician. Sofiya Diurba University of Colorado School of Medicine The business of medicine session was invaluable. This is what we don’t get in medical school. We’re learning invaluable pieces of clinical medicine. Until tonight, no one had taught me to negotiate. Danielle Coleman Rocky Vista University College of Osteopathic Medicine

2 6 C O LO R A D O M E D I C I N E

WHITE COAT WISDOM

Aug. 13

“ “ “

Other state societies aren’t as engaging of students as the Colorado Medical Society. With CMS we have had the support to get involved, especially with policy issues. Following the success of the MSC Medical Student Day at the Capitol in March, we knew we had to do something to bring the next group of students into the CMS family. Rachel Landin Rocky Vista University College of Osteopathic Medicine It was very enjoyable spending the evening with this group of bright and attentive medical students. Visiting with them bolstered my hopes that I will be well cared for in my old age! Mark B. Johnson, MD, MPH Executive Director, Jefferson County Public Health It was wonderful to see the enthusiasm of medical students embarking on their new careers in medicine with such thoughtfulness as to what their paths should look like while learning from those of us further along in our careers. When you spend so many years trying to get into medical school it can be daunting to think about what comes after it but these students are trying to learn as much as they can so they can make a plan for what their lives will be once they become doctors. Yadira Caraveo, MD Representative, Colorado State House, District 31

“ “ “

Health care continues to evolve and I believe we have a responsibility to draw upon our insight and experience to help prepare the next generation of physicians. It is invaluable to expose medical students to the realities they will face through opportunities like the White Coat Wisdom event. These sessions provide students a chance to connect with physician leaders and their peers while they dive into topics that complement what they are learning in medical school. In particular, understanding how to navigate the business side of medicine is essential and equips students to manage the ever-changing demands that occur in the world of medicine. Gerry Zarlengo, MD COPIC CEO I thoroughly enjoyed meeting with medical students to talk about what “life is really like” as a physician. It is always energizing to be around students who really are committed to making a difference. It renews my hope for the future of medicine. Kathleen Cowie, MD Family Physician, Chief Medical Officer, Summit Community Care Clinic It was a great evening of exchange with curious, energetic students thinking about the future of medicine. Chris Tonozzi, MD Physician, Director of Data Quality Mountain Family Health Centers

C O LO R A D O M E D I C I N E 2 7

F E ATU R E

Join the Colorado Medical Society in the inaugural fundraising effort for the Alfred D. Gilchrist Student Leader Scholarship CMS is currently fundraising for the Alfred D. G ilchr is t Student Leader ship Scholarship. After serving as CMS CEO since 2004, Gilchris t announced that he will retire in first-quarter 2020. CMS created this scholarship in recognition of Gilchrist’s dedication to supporting future physician leaders. During his years of leadership at the CMS, Gilchrist has used his ability to form strong relationships and partnerships to secure numerous legislative victories in Colorado, while advancing the whole organization. In addition to his critical work on Medicaid expansion and insurance mergers, Gilchrist also designed the nation’s first standardized managed care

2 8 C O LO R A D O M E D I C I N E

contract law, requiring oversight of payer profiling and rating of physicians, and the first body of law in the country requiring oversight of payer profiling and rating of physician performance. He also played a critical role in securing grants and funding to improve care and ensure public health, including $1.5 million for pandemic flu preparedness.

any amount are gladly accepted and appreciated. Donors are encouraged to check with their employers for matching donation programs. Pledges can be fulfilled at any time with final payments to be received prior to Dec. 31, 2019 for scholarship awards to start in 2020.

Prior to joining CMS, Alfred was the lead lobbyist for the 40,000-member Texas Medical Association where he coordinated all state and federal legislative advocacy. He staffed and advised TMA policy bodies on setting policy positions and strategy on approximately 900 pieces of legislation each legislative session for 20 years.

Colorado Medical Society; 7351 E. Lowry Blvd., Ste. 110; Denver, CO 80230.

One-time and monthly donations to the student leadership scholarship in

Donations can be sent by mail to:

Please make checks to Colorado Medical Society with “Gilchrist Scholarship Fund” recorded on the memo line. Donors may also make donations by credit card by calling Tom Wilson, CMS accountant, at (720) 858-6316. All donations are being held in a special reserve account at CMS exclusively for the scholarship. ■

D E PA R T M E N T S

R E F LE C TI O N S

A case for compassion Bryant Elrick

Bryant Elrick is a fourth-year medical student at the University of Colorado School of Medicine. He is currently on leave, participating in a year-long orthopedic research internship at the Steadman Philippon Research Institute in Vail, Colo. He grew up in a small farming and ranching community on the eastern plains of Colorado and completed his undergraduate education in chemical and biochemical engineering at the Colorado School of Mines. Bryant furthered his education at Creighton University where he obtained a master’s degree in clinical anatomy before beginning medical school. Bryant is committed to pursuing a career in orthopedic surgery and is passionate about helping people maintain active lifestyles and continue to participate in the activities they enjoy.

I was holding the door open when the veteran for his name. He comforted the pounced on top of him. I watched as a police arrived. The social worker was veteran, assuring him that their only intent fist flew through the air, only disengaginside, seated on the sofa, adjacent to was to keep him safe. ing after striking the veteran across the the veteran. He was lying face up on the forehead. couch, disguised behind a mask of inebri- As I watched this scene unfold, my eyes ation. Barely able to utter comprehensible were directed to a second officer in the “Settle down, buddy,” they called out, but phrases, he calmly engaged in conver- corner. His impatience visibly intensi- I saw no signs of a struggle. Confusion sation. The room was overwhelmed by fied with each moment. Finally, he had overwhelmed me. What did he do to the staggering smell of alcohol. His dirt- enough. deserve this type of restraint? He could stained New Balance sneakers lay untied barely keep his eyes open, let alone fight. on the floor, a deep state of intoxication “Let me handle this,” he gruffly asserted, My attending pulled at my arm, motioning preventing him from putting them on. He as he dismissed his colleague. He for me to follow him into the hallway. knew what he had done. approached the veteran, who was still lying face up on the couch. Without Without warning the veteran was shoved “Who wants to live?!” the veteran screamed warning, the officer picked up the veter- through the doorway, bleeding from a as he learned the police arrived, “Who an’s shoes and chucked them towards four-inch gash on his forehead. Handcares about being safe?!” His distress his face, yelling, “Get up! Let’s go!” He cuffed and barely able to walk, he was was visible – yet hurting himself, or any proceeded by violently kicking a pack of escorted by all four men. As he was of us, seemed far from his intent. He was cigarettes and an ashtray out of the way. pulled past me, our eyes met for a split troubled, but not a threat. The police officer grabbed the veteran by second. My eyes followed him as he his arm and forced him up. bobbed to and fro down the hallway. The Upon the arrival of the authorities, three deep-seated unease in my stomach was police officers and a fireman greeted us in “You’re out of here, bud!” the officer comforted by the fact he’d probably never the hallway. My attending informed them berated, “you’ve lost this privilege!” My remember how he got that four-inch scar, that the veteran had suggested thoughts gut quivered. my conscience comforted by the fact that of suicide, but never made threats to I’d never forget. ■ anyone else. As they entered the room, “I can’t,” uttered the veteran as he was I quietly followed. One police officer ordered to stand. Without a chance to took the lead and politely prompted the explain, all four of the first responders

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. 3 0 C O LO R A D O M E D I C I N E

D E PA R T M E N T S

I NTR O S P E C TI O N S

Processing the chaos of the first patient death: A conversation Peter Stacy and Meng Smith Peter Stacy is an OMS-IV at Rocky Vista University pursuing a residency in psychiatry with the Air Force under the Health Professions Scholarship Program.

Meng: Peter and I were on the same GI rotation, and this event occurred during one of our on-call weeks. Peter: It was a great rotation, but this was one of the busiest weeks I had during clinical rotations: Day after day of long hours seeing hundreds of patients over that week. Meng: It was a pretty busy day, and we were told by our attending to go and check on a patient. When we got there, they were transporting her up to the ICU. She had recently undergone surgery and she was suspected to have a duodenal-aortic fistula. She had already lost a lot of blood by the time we were called. The patient was pretty scared. People rushed in and out of the room, hooking her up to different monitors and fluids. We tried our best to explain what was being done and to make the patient feel calm and relaxed. Our attending arrived and performed a procedure to clip the different sites of the bleed. Surgery team took over and we left thinking we had done our part and that she was going to be all right.

Meng Smith is an OMS-IV at Rocky Vista University pursuing a residency in family medicine.

physician running the code called time of death. Meng: The surgical resident looked up and said, “Does anyone have a problem with me calling it?” The room was silent. A million thoughts were running through my mind: “What does she mean by calling it? Why are we stopping? We can’t call it yet. We cannot give up on her yet.” There were so many things I wanted to say, but nothing came out. The next thing I knew, we were having a moment of silence for the patient and then everyone was leaving. Peter: I’d gotten to know the patient and her family that day. It was the first patient death I’d experienced in the hospital and afterwards, questions kept rolling around my head: “Could we have done more? Did we miss anything that predicted this?” I didn’t feel comfortable with the outcome and it was troubling to process afterward.

Meng: We were downstairs when we heard the Code Blue just 15 minutes after we left the patient. We looked at each other and asked, “wait...wasn’t that our patient’s room number?” We dropped everything and ran upstairs.

Meng: It definitely hit me harder than expected. I had asked her if she wanted her family back in the room after she settled in on the ICU floor. She told me she would see them after the procedure, but she never got the chance. A million “what ifs” and thoughts of “what else could we have done differently?” were running through my mind. I knew there was nothing I could have done differently, but I still felt like I failed her.

Peter: There we found a team attempting to revive her and inserted ourselves into the compressions rotation. Exactly 15 compressions into my rotation, the

Peter: We found the attending and told her what happened. She sat, shoulders hunched, eyes to the floor, and hand over her mouth. She sat so still I couldn’t even

tell if she was breathing. Finally, she lifted her eyes and the team moved on, though we all felt distracted. I felt like I was being disrespectful by moving on so quickly. Meng: On the way home that night, I called one of my best friends and all of my suppressed emotions came flooding out. I was able to talk with several other friends and family members to express my grief and receive support. Although she was not my patient for very long, we had established a bond. I am grateful to have had such solid support from my friends and family as I dealt with my first patient death. I hope grief can be further destigmatized in the field of medicine and resources made available to medical professionals coping with the loss of their patients. Peter: I process events like this in the days and weeks that follow, rather than in the immediate aftermath. Reflecting on this event, I’ve had to process a lot of feelings and questions. “Could we have done more? Did we miss signs of the severity? What if we had started transfusions earlier?” I felt grief. Instead of taking months to process, I should have used the following days to write my thoughts. This event has been one that challenged me for many months and led me to think critically about my reaction to death. I hope that in the future I can be a positive influence on creating an environment that encourages discussion and vulnerability in one of the most difficult situations in medicine. ■

Critical reflective writing holds a prominent place in the Medical Humanities curriculum at Rocky Vista University, College of Osteopathic Medicine. Beginning in the first semester of Medical Ethics, students engage in critical reflection to explore their own assumptions and biases and how their values impact their practice. This submission is selected and edited by Nicole Michels, PhD, chair of the Department of Medical Humanities; and Alexis Horst, MA, writing center instructor. C O LO R A D O M E D I C I N E 3 1

D E PA R T M E N T S

C O M M E NT

A better claims management process Gerald Zarlengo, MD, Chairman & CEO, COPIC Insurance Company

I’ll admit, I didn’t fully appreciate the support COPIC provides

At COPIC, we know the challenges that come with lawsuits,

until I faced my first medical liability lawsuit. The initial feelings

and we believe that working with your medical liability carrier

of fear, frustration, self doubt and uncertainty pushed me into a

shouldn’t be one of them.

place that I didn’t know how to handle. Then, after speaking with someone at COPIC, it was clear that they understood what I was struggling with and would guide me through the process with expertise I could trust.

Over the years, we have developed a claims management process built on key principles that are designed to treat you

Despite improvements in patient safety and risk management,

like a person and not a policy number.

the likelihood of facing a medical liability claim or lawsuit is still a common concern. According to the American Medical Association’s 2016 Physician Practice Benchmark Survey, 34 percent of all physicians have been sued, and almost half of physicians over the age of 54 have been sued.

34%

3 2 C O LO R A D O M E D I C I N E

34 percent of all physicians have been sued

50%

Half of physicians over the age of 54 have been sued

B E T TE R C L A I M S M A N AG E M E NT: C O N T D E PA R T M E N T S

KEY PRINCIPLES COPIC GETS TO THE HEART OF THE MATTER, FASTER

WE’RE IN THIS TOGETHER

COPIC encourages early repor ting because the sooner we know about an incident, the better we can manage it and address the patient’s needs. This also allows us to determine if an incident may be eligible for our 3Rs Program or the Colorado Candor Act, two approaches that focus on preserving the patient-provider relationship.

COPIC’s defense team stands beside our insured providers every step of the way. We believe the more a provider knows, the more comfortable he or she will be throughout the process. Other carriers may look at cases primarily through a fiscal perspective, opting to settle when it makes financial sense. COPIC doesn’t take that approach. We focus on protecting our insureds’ reputations when medicine meets the standard of care and we put all of our resources behind this.

PROGRAMS THAT OFFER AN INSIDE LOOK Litigation is unfamiliar territory for most medical providers. That’s why COPIC offers programs to help our insureds understand key parts of this process: Mock Trials present enactments of a medical liability trial. Attendees learn about expert witnesses, legal tactics, the review of medical records and more. Mock Depositions provide a detailed look at the important considerations in depositions, what can be expected and how to effectively prepare.

SUPPORT WHEN IT’S NEEDED MOST COPIC knows a claim can be stressful for you, your family, friends and colleagues. That’s why we’ve developed programs to help cope with the emotional toll of a claim or lawsuit. Care for the Caregiver® pairs an insured with a peer provider who has also been through a lawsuit and can offer an empathetic and helpful ear. COPIC’s Lawsuit Stress Support Session is a forum for insureds, their spouses , and s t af f to share t heir experiences and learn what to expect during litigation.

CASE REVIEWS THAT DIG DEEPER COPIC’s claims process includes multiple, in-depth reviews of cases. These reviews are conducted by COPIC practitioners, legal staff and claims consultants, as well as specialty advisors and defense attorneys. Together, they dissect the facts, look at every angle and discuss the results with the insured to determine the best course of action.

GETTING YOU BACK TO YOUR PRACTICE COPIC’s ultimate goal is to get providers back to what they’re trained for – taking care of patients. Our defense team is committed to helping build resilience and restoring confidence after a claim or lawsuit. And we do this in a timely manner: claims with COPIC are resolved 27 percent faster than other carriers (15 months compared with 20 months). ■

C O LO R A D O M E D I C I N E 3 3

D E PA R T M E N T S

M E D I C A L

N E W S

DOI issues cease and desist orders for Trinity Healthshare and Aliera Healthcare The Colorado Division of Insurance issued cease and desist orders for Trinity Healthshare and Aliera Healthcare on Aug. 12. Trinity represents itself as a health care sharing ministry. Aliera is the administrator, marketer and program manager for Trinity. According to a DOI news release, the division acted because of concerns about these companies and their interactions with Colorado consumers. Over the past few months, the DOI has received a number of complaints from consumers regarding these companies. The DOI is concerned that they may be using misleading marketing practices, blurring the lines between health insurance that complies with the requirements of the Affordable Care Act (ACA) and non-compliant insurance (like what is offered by health care sharing ministries, such as these companies). Because of this, the companies may be putting consumers at risk and violating Colorado insurance law, the DOI said. The orders require the companies to immediately cease and desist conducting insurance business in Colorado. However, the DOI has included provisions in the orders to protect Colorado consumers who are members of the health care sharing programs offered by these entities, requiring that the companies honor and maintain any existing contracts, plans or policies with Colorado businesses and consumers until the Commissioner of Insurance releases them from this obligation. Washington state and Texas have also issued cease and desist orders against Trinity and Aliera. If you or your patients have had problems with either of these companies, contact the DOI to let them know and to find out what recourse may be available. Call 303-894-7490 or 1-800-930-3745 (outside of the Denver metro area) or email DORA_insurance@state.co.us. ■

3 4 C O LO R A D O M E D I C I N E

D E PA R T M E N T S

M E D I C A L

N E W S

CMS president urges DORA to better define, discipline for injection-based investigational care Chiropractors should be barred from subjecting patients to injection-based investigational care and be subject to disciplinary action should they facilitate these activities, wrote CMS President Debra Parsons, MD, FACP, in a letter to the Colorado Department of Regulatory Agencies.

She requested that the sunset reports include recommendations that the relevant acts be amended to address the issues more explicitly and in a manner that subjects individuals to disciplinary action. For example:

In comments related to the sunset reviews of the State Board of Chiropractic Examiners and State Board of Nursing, Parsons wrote that it has come to CMS’ attention that “some chiropractors are utilizing nurse practitioners to perform injection therapies that are not standard of care and not part of an IRB-approved clinical trial such as ‘stem cell therapy’ or the use of amniotic or umbilical cord tissue, platelet rich plasma, or autologous or allogenic serum or plasma with or without vesicles to treat chronic pain or disease.”

• Informed consent must always be obtained, including an accurate assessment of the risks vs. benefits of any treatment, accurate information about the content of any therapeutic products (e.g. providers must not make inaccurate claims that allogeneic products contain “live stem cells” or “viable stem cells”), and accurate information about the efficacy of any treatment according to the current scientific literature.

• Providers administering injections must be appropriately trained. • Any therapeutic products provided/administered must be FDA-approved or exempt from regulation.

• All advertising and sales activities and materials must be accurate and supported by the current scientific literature.

The recommendations are in line with current CMS policy on stem cells. Go to www.cms.org/about/policies to access the online policy manual. ■

C L A S S I F I E D S

PROPERTIES FOR SALE/LEASE

Practice Consultants OB/GYN Practice for Sale - Colorado Springs, CO Revenue $2.1 million, up 30% in the past two years. At this location since 2000. Doctor-owned building would be available for purchase in the future. Offered at only $889,000. Contact info@MedicalPracticesUSA.com. 925-820-6758. www.MedicalPracticesUSA.com.

MISCELLANEOUS

Medical Waste Disposal that is affordable, reliable and 100% OSHA compliant. Request a quote in 10 seconds at http://www.biomedicalwastesolutions.com/ medical-waste-disposal/

C O LO R A D O M E D I C I N E 3 5

F E ATU R E

FINAL WORD We must work together to disrupt rising health care costs Robert Smith, MBA

Paul Presken’s environmental scan, featured in this issue’s cover story, could not be more correct or instructional than to begin with the observation that health care costs have reached a tipping point. As a Brookings Institution analysis of consumer spending quantified recently, total middle-class health care expenditures increased 24 percent from 2007 to 2014 while overall expenditures for necessities like food, housing and clothing actually decreased by more than 6 percent! By taking money out of families’ disposable incomes, out of classrooms (half of Colorado schools operate on a four-day week for lack of funding while family premiums can eat 25 percent of a teacher’s salary), and out of corporate earnings, health care spending probably represents the most critical socio-economic tipping point of our time. Presken also correctly calls out hospital costs. Although not the only issue in health care, economists across the United States seem to agree that hospital price increases enabled by consolidation present the central economic barrier to a more rational market. While excessive pricing for other services represents a problem, particularly in the profiteering world of

pharmacy, hospital payments represent the largest percent of the medical expense ratio at 2.76 times Medicare in Colorado statewide (and over four times Medicare for our four largest health systems). These payments distort hospital incentives and externally distort market dynamics. As MedPAC economists outlined in their March 2019 report to Congress, excessive commercial payments simply allow hospitals to increase administrative costs and duplicate services, thereby aggravating their Medicare losses. Case in point: The acquisition of physician practices by hospitals for the explicit reason of increasing leverage with insurers so as to be able to increase prices even further. Economists call this a negative feedback loop. It needs to be disrupted. Both because “health care is local” and because of Washington’s gridlock, states must take the lead in addressing such marketplace dysfunction. While several are doing so, Colorado seems poised to become the national leader. Gov. Jared Polis, by endorsing “a statewide model that essentially empowers the customers to have better negotiating leverage with the providers to negotiate better rates,” (see “Gov. Polis is looking to take innovative Summit County health insurance alliance model statewide” by John Ingold, Colorado Sun, Aug. 6, 2019), has facilitated just the sort of “involvement” by Colorado’s business community that Presken highlights. Now, assuming employers exercise the requisite courage and act on their fiduciary responsibility, health care marketplaces will become both more effective and efficient – instead of less and less so. In the end, if employers want to transform how care is provided, they must transform how they purchase it. But employers cannot change the dynamics alone. They must par tner with physicians – particularly independent physician groups and, because the majority of employee costs are directly or indirectly attributable to chronic disease, particularly with primary care physicians.

But employers cannot change the dynamics alone. They must partner with physicians... 3 6 C O LO R A D O M E D I C I N E

Any effort at reform must respect the patient-physician relationship. And the two parties in all of health care with the most aligned interests in making that happen are employers and physicians. Both seek the best outcomes for patients at the most affordable cost. Working together, preferably at the local or regional level but with an overall vision for a better health care system through the Colorado Medical Society, employers and physicians can take on pricing issues and address the three-headed utilization beast – underuse, overuse and misuse. An excellent example of this is taking place in nor thern Colorado where the Northern Colorado IPA is working proactively with several employers on a number of projects, each led by a separate employer group. Using reporting from CIVHC, employers and physicians are collaboratively addressing low-value services, emergency department use, advance directives and referrals to overpriced outpatient sites. While reasonable hospital pricing is important, it is this sort of collaboration that can transform health care in Colorado over the long term. The Colorado Business Group on Health is encouraged by the terrific work taking place in northern Colorado. And we are particularly excited to play the central role in the establishment of a statewide employer purchasing alliance that will seek to expand such collaborative relationships across the state. By working with physicians, both directly and through the Colorado Medical Society, we are committed to contributing to a more functional market that better serves our families and communities. ■ Robert Smith, MBA, is the executive director of the Colorado Business Group on Health. The Group is a purchaser-led, multi-stakeholder nonprofit coalition committed to collaboratively improving the health care value-proposition for all Coloradans and their communities.

ONLY OUR CMS MEMBERS CAN DO THIS

Advantage Partner

LET USFA HELP YOU GET INTO A NEW CAR

By special arrangement with commercial fleet purchasing requirements in Colorado, individual members are allowed to buy or lease a new car under this program.

• NO CAR SALES PERSON • OVER THE PHONE • TYPICAL SAVINGS $1,000-$7,100

Visit USFACORP.COM to find out more. Or call 303.753.0440

33 YEARS IN BUSINESS • 10,000 MEMBERS SERVED SINCE 1989 • LICENSED & BONDED