September-October 2018 Colorado Medicine by Colorado Medical Society

September/October 2018

Volume 115, Number 5

GUBERNATORIAL CANDIDATES SHARE HEALTH CARE PLATFORMS Award-winning publication of the Colorado Medical Society

contents Sept/Oct 2018, Volume 115, Number 5

Features. . . 10

2019 legislative preview–Learn the formidable issues facing the medical community in the upcoming legislative session and why it is so important to vote.

Western Slope update–AMA president Barbara McAneny, MD, joined CMS physician leadership to meet with Grand Junction and Montrose physicians.

A doctor’s perspective–The Grand Junction Sentinel published this editorial after meeting with AMA and CMS leadership during their visit to the Western Slope.

Organized medicine unites– CMS joined the AMA and 168 other medical groups to submit unified comments to fix a proposed federal payment rule.

Prescription drug abuse–The Colorado Consortium

Opioid clock–Incoming CMS President Deb Parsons, MD, unveils a new opioid clock she designed to educate physicians on the opioid epidemic.

6 President’s Letter 31 COPIC Comment 32 Reflections 34 Introspections

Guest editorial–CMS member Kenneth Finn, MD, submits a guest editorial sharing research on how marijuana will not fix the opioid epidemic.

Departments

COPIC position statement– COPIC endorses ballot amendments Y and Z to reform the federal and state redistricting process.

Final Word–Political analyst Floyd Ciruli analyzes the

Cover story Colorado is approach-

ing a potentially transformative election and Colorado Medicine invited both the Democratic and Republican gubernatorial candidates to share their health care platforms with CMS members and the broader medical community. Educate yourself on both candidates by reading their articles starting on page 7 and continuing through page 9.

Inside CMS

36 41

Medical News Classified Advertising

Colorado Medicine for September/October 2018

for Prescription Drug Abuse Prevention is hosting an education symposium Oct. 24.

factors influencing the 2018 election cycle in Colorado and highlights some of the choices facing voters.

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF

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

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

Katie Lozano, MD, FACR Immediate Past President

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

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

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

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

Colorado Medicine for September/October 2018

Inside CMS

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

Reflecting on an enlightening year as president As my term of president of the Colorado Medical Society comes to an end, I wish to express my gratitude to all the members of the society for allowing me to serve this organization. As you all know from your own experiences in life, when you give your time, your talent and your courage to solve problems in the service of others, you gain more than you ever give. I have always been a person who loves to learn new things. That is part of the reason I enjoyed the practice of urology. There were very few things I was doing in the operating room at the end of my career that I was taught to do during my residency. Isn’t that an amazing tribute to the scientific discoveries that have been made during my 50 years in practice? This position has allowed me to learn a great deal about the challenges our profession faces that I knew little about. The first and most heartbreaking problem was understanding the complexities of the opioid crisis. Working with our staff and leaders in this field, including a committed group of legislators and elected officials, we will bring change to help save lives and restore dignity to many broken individuals. A great deal of work remains to be done, so please take the time to learn what each one of us can do. The second, and perhaps an even more complex problem, is looking at how to reduce to cost of U.S. health care without sacrificing quality. Working with the CMS Cost Containment Committee and working with the committee on cost containment that the Denver Chamber of Commerce brought together has been enlighten 6

ing. We all want to have the ability to care for our patients with the highest quality care at the lowest cost, but often we have no idea what or where the lowest cost is for our patients. Identical services or pharmaceutical costs can vary widely in the marketplace. If we were able to obtain this information and make it available to our patients, we could help bend the cost curve. This is but one of the many facets of the cost problem we will continue to work to solve for the benefit of our patients. The last thing I will share with you is that I have learned how important our organization is to preserve the financial viability of our practices regardless of whether you are self-employed or employed by an organization. This organization’s advocacy efforts benefit all of Colorado’s physicians. Many physicians who are not members of

our society do not know that they directly benefit from the work of our talented staff. We recently hired a new staff member who will be taking the evidence of our achievements to nonmembers to help them understand why we need their dues dollars to maintain the long string of successes that we have achieved. We have a dedicated and talented staff that shoulders the majority of the burden of getting the work done from which we all benefit. Without the dues required to pay these salaries, we would be unable to achieve the successful representation from which we all benefit. Your next president, Deb Parsons, MD, is a talented and hard-working physician who has achieved much in her year as president-elect. I can confidently assure you that you will be well represented as I slip into obscurity. Goodbye and thank you. n

New member benefit for CMS members only! Know Your Rights database Physician practices have rights under Colorado law that can be exercised to mitigate health plan barriers to care. These rights have been summarized and incorporated into a members-only online database – Know Your Legal Rights – at www.cms.org/kylr for easy access. The members-only tool is searchable, and will help physicians and practice managers understand what their rights are in disputes with health plans. Colorado Medicine for September/October 2018

COLORADO GUBERNATORIAL CANDIDATES SHARE HEALTH CARE PLATFORMS

POLIS AND STAPLETON VIE FOR SUPPORT OF COLORADO PHYSICIANS

Colorado Medicine for September/October 2018

Cover Story

Candidate Perspective Rep. Jared Polis, Democratic candidate for governor

Colorado gubernatorial candidates present their health care platforms One of the biggest downsides of today’s polarized political climate is when we discuss the issue of health care, we sometimes get lost in the political stakes and ignore the costs to all of us – in both money and human lives. No matter your political beliefs, every single one of us has needed, and will again need, health care during our lives. Helping Colorado families and small businesses save money on health care and gain better access to quality services is one of the main reasons I am running for governor. I believe that more can be done to bring everyone to the table – community leaders, patients, medical professionals and insurance providers – to create workable solutions for health care in Colorado. Any proposal that lowers costs, expands coverage and improves the quality of health care for Coloradans is a proposal I will enthusiastically support. I am proud to be running for governor alongside my running mate, Dianne Primavera. As a mom raising two little girls, Dianne was diagnosed with breast cancer and given five years to live. That was 30 years ago. Since then, she’s not only fought cancer four times and survived – she’s dedicated her life to fighting for affordable, high-quality health care for every Coloradan. One of the first things we did as running mates was meet with families on the Western Slope to discuss the health care needs of families who have 8

been struggling to manage the incredible health care costs with limited coverage. We met with a woman whose daughter is on a five-month waiting list to see a specialist to manage her care. We heard from parents who fear they’ll never be able to retire because their savings were wiped out paying for their children’s medical needs, cancer survivors whose drug costs eat up most of their income and small business owners struggling under the costs of covering their employees. These stories show us Coloradans aren’t interested in ideology, partisanship or slogans. They’re interested in solutions. We have lots more listening to do, but here are some of the solutions Dianne and I will pursue if we earn the privilege of leading our amazing state. First, we need to immediately save Coloradans money. On the prescription drug front, we can tackle staggering costs by cracking down on pharmaceutical price gouging, requiring pricing transparency and enabling Coloradans to more easily import drugs from Canada, where the exact same medications often cost much less. Second, we need to embrace innovation to level the playing field between consumers and the corporate entities we depend on for care. One of the best ways to lower premiums and other costs is to partner with other states on a collaborative health

care system that creates the largest possible risk pool. Larger risk pools reduce costs for consumers and for small businesses providing benefits to their employees, and provide greater negotiating power to get better rates on prescription drugs and other services. And we should take advantage of innovation waivers available through the Affordable Care Act, which will allow us to build a Colorado-centered health system that meets the unique needs of our communities. Finally, it is critical to improve access and supply, especially in our rural communities. Too many Coloradans live nowhere near a provider for mental health care or other specialty services. Our plan calls for bringing more health clinics – including mobile clinics, community health centers, and satellite offices – and providers to rural and remote communities. And it calls for expanding access to telemedicine services that allow Coloradans to receive many kinds of care over the internet if they are unable to travel to meet with a provider in person. We are never more financially or personally vulnerable – and politics is never farther from our minds – than when we or our loved ones are sick. Let’s get to work on real solutions that will bring truly affordable, high-quality health care to Colorado families in every corner of our great state. Jared Polis is currently the U.S. Representative from Colorado’s 2nd district and the Democratic candidate for governor. n

Colorado Medicine for September/October 2018

Cover Story

Candidate Perspective State Treasurer Walker Stapleton, Republican candidate for governor

Colorado gubernatorial candidates present their health care platforms As I travel across Coloradoâ&#x20AC;&#x2122;s 64 counties, a key concern of many Coloradans is the rising costs of health care. There are no silver bullets in health care. Each policy decision will have its benefits and disadvantages. However, I steadfastly believe that we get the best medical outcomes when there are fewer barriers between patients and doctors. Moving to a singlepayer system will make it more difficult for doctors to be doctors. I will work to make reforms that ultimately streamline our public and private systems and allow doctors to focus on practicing medicine. As governor, I will focus on improving quality and reducing the costs of health care in Colorado by working with a variety of groups to drive innovation, increase transparency, and improve the delivery of care. Through these actions we can make health care more accessible and affordable. Across the board, our system needs to emphasize improving primary and preventive care. Many medical professionals have made clear the importance of taking proactive steps to monitor health conditions and take necessary actions through routine care before a patient ends up with a medical crisis in the emergency room. A key component of this preventive care is greater integration of mental, behavioral and physical health. According to a report prepared for the American Psychiatric Association in 2014, it is estimated that people with comorbid physical and mental health conditions have medical costs that are roughly twice as high as the general population.

The care for this segment accounts for over 30 percent of total health care spending, and is probably under-reported because of the stigma associated with mental health. We need to work to integrate health services through co-location, telehealth, and any feasible route to help reduce the barriers for Colorado families to access care. Taking a holistic approach and promoting more of a one-stop-shop for primary, physical and mental health will help improve the lives of patients and lower our costs. Medicaid is also an important part of the health care landscape and provides services to the most vulnerable in our population. We must mitigate the cliff effects and work to make private insurance more affordable. Medicaid covers nearly 1.4 million people in Colorado and is one of the largest parts of our state budget. As the associated costs have grown, it has crowded out funding for our schools and roads. More can be done to improve our administrative processes, delivery of care and patienteducation to make improvements without sacrificing quality. We must focus on outcomes-based systems for our publicly administered programs and work to reduce costs. We will work with a broad coalition of partners across the health care landscape, from patients and doctors to hospitals and payers, so as to not shift costs from the governmentâ&#x20AC;&#x2122;s programs onto consumers. No family should be stuck with the decision of paying their mortgage or paying

Colorado Medicine for September/October 2018

for health care. Too often these rising costs are preventing Coloradans from fulfilling the American dream of owning a home. We must create more choice and access for families in the types of coverage they can purchase. We have the ability to be creative and find solutions that work for Coloradans like the expansion of association plans, shorterterm plans, and catastrophic coverage options. In addition, new services like mobile clinics and telehealth will help patients gain access to care, especially in underserved communities. Make no mistake, I will defend patients with pre-existing conditions and continue to allow young adults under 26 to stay on their parentsâ&#x20AC;&#x2122; coverage. Any proposals to roll back these provisions will be rejected by my administration. The good news is that today over 93 percent of Coloradans have coverage and over 79 percent are satisfied with the care their families receive through their employers or state programs. But more must be done to reign in costs and help find solutions to expand coverage to those still struggling to gain access. We must do this in a way that does not throw out what works in our system. Simply put, a government-run, single-payer health care program will result in higher taxes and less choices. It will bankrupt Colorado and drive families, businesses and physicians out of our state. Walker Stapleton is currently the Colorado state treasurer and the Republican candidate for governor. n

Features

2019 legislative preview Susan Koontz, JD, Senior Director, Division of Government Relations

Upcoming elections to set the stage for a challenging legislative session The legislators we elect to the General Assembly Nov. 6 will consider a wide range of sharply divisive proposals and amendments that will, as a matter of law set the conditions of licensure, peer review, and medical malpractice. In addition, we expect debates regarding Medicaid funding and operations, opioid abuse interventions and treatment, and other public health concerns. Colorado’s trial attorneys will be pressing their case to expand the value and frequency of medical malpractice suits, breach the confidentiality of records and activities of professional review committees, and impose other new, creative causes of action under both the

Medical Practice Act and medical liability statutes. For the last several months local physicians have briefed and screened incumbents and candidates across the state for two mutually important objectives: to inform and prepare legislators for the often-complex issues they must consider, and to garner a local medical community consensus on levels of support for an incumbent, challenger or candidate. That support comes in the form of contributions from the Colorado Medical Political Action Committee (COMPAC) and the Small Donor Committee as well as the in-kind support from phy-

What is the Medical Practice Act and why is it important? The Colorado General Assembly first passed the Medical Examiners Act in 1881, which established the Colorado Medical Board to regulate the practice of medicine and was the precursor to the Medical Practice Act (MPA). Over the years, the MPA has been updated to include laws controlling the licensing and practice of physician assistants (PAs) and anesthesiology assistants (AAs) in addition to the licensing standards for medical doctors and doctors of osteopathy. The MPA, administered through the Colorado Department of Regulatory Agencies, is once again up for sunset 10

review by the Colorado Legislature in 2019. It is inefficient and unrealistic for the average consumer to research the credentials of an individual physician, PA or AA to determine competency. The depth of knowledge and level of skill required to practice as a competent health care provider is more efficiently determined by the medical board. All Coloradans share a long-term, common interest in a fair marketplace where the health, safety, and welfare of consumers are protected by properly licensed and regulated health care providers.

sicians. Those combined efforts raise the threshold levels of informed legislators committed to medicine’s views. Legislators and candidates have been briefed by their local doctors on three broad issues that will occupy most of medicine’s advocacy work in the capitol next year: professional accountability, coverage and cost, and the range of issues provoked by Colorado’s opioid crisis. Key issue 1: Medical professional liability and physician accountability The 2019 legislative session is a once-ina-decade opportunity for lawyers that sue physicians to more easily amend the laws governing professional (peer) review, the legal conditions that define a medical license under the Medical Practice Act, and to expand the value of a professional liability lawsuit. The 2019 General Assembly will be compelled to reconsider the substantive body of law governing: 1. Medical licensure under the allencompassing Medical Practice Act and the protected peer review activities that assure both patient safety and advanced practice standards under the Professional Review Act, both undergoing sunset review; and 2. The statutory limits and related conditions regarding medical malpractice litigation under the 1988 Health Care Availability Act. These anchors to physician liability and accountability will provide a series of

Colorado Medicine for September/October 2018

Features opportunistic conflicts between Colorado’s medical malpractice lawyers and their prospective defendants – physicians, hospitals and other caregivers caught in that crossfire. The Colorado Trial Lawyers Association (CTLA) will seek to amend these laws in ways intended to expand both their leverage in those lawsuits and monetary value. Taken together or separately, disturbances to the stability and continuity of these highly sensitive processes will compromise proven patient safety measures, spike health care costs, and subsequently restrict the supply and distribution of physicians in high-risk practices and provider shortage areas of Colorado. CMS has made the case to the legislative candidates and incumbents, as well the gubernatorial candidates to uphold the confidentiality provisions in the Medical Practice Act and Professional Review Act, maintain the current monetary value of malpractice suits, preserve the legal protections afforded physicians engaged in professional review, and assure adequate funding for the Colorado Medical Board and provisions that strengthen their investigative and intervention capacities in order to detect, mitigate and remediate questions of professional conduct. Key issue 2: Coverage and access, cost and value Colorado has consistently shrunk the pool of uninsured individuals living in the state, which are otherwise a significant burden to safety net providers, local tax bases and private sector premiums. Several factors have contributed to this decrease: 1. The adoption and implementation of Medicaid expansion; 2. The regionalization of Medicaid services through the Accountable Care Collaborative program; and 3. A state-run insurance exchange. All of these measures have been sustained while further federal reform efforts have stalled. Future efforts will need to focus on maintaining current coverage gains and protections like es-

sential benefits and bans against preexisting condition exclusions, while working to expand coverage to those still uninsured where possible. Like most states, Colorado struggles with escalating cost of care. Patients, as well as physicians, lack transparent, actionable information on pricing and cost. Supply chain middlemen and other side deals in care delivery further complicate efforts to encourage market forces or government actions to isolate the predators and outliers. CMS has been fully engaged since the earliest health care community efforts decades ago to restructure and realign health care delivery into a more rational, harmonious system. The successes and failures of those efforts are first experienced by physicians and the patients they serve on the front lines of the exam room. The 2019 General Assembly will consider a comprehensive package of measures related to health care costs and

coverage brought by a coalition of business and trade organizations. CMS is actively participating in these efforts and supports bringing all stakeholders to the table to engage and adopt legislative, regulatory and market-based strategies that advance the ideal that Coloradans can get the right care at the right place, time and value. All stakeholders have responsibilities, culpabilities and priorities. A specific focus of CMS for the coming session will be to support specific steps to decrease the cost of care and ease the administrative burden on medical practices, which account for hundreds of millions of unnecessary expenditures by physicians and are a significant contributor to physician burnout. CMS has asked gubernatorial candidates and legislators to support efforts to maintain current levels of insur-

What is professional review and why is it important? Professional review (sometimes referred to as peer review) is a process to review and evaluate the competence, professional conduct of, or the quality and appropriateness of patient care provided by a physician, physician assistant, or advanced practice nurse. The majority of voting members of a professional review committee must be physicians actively engaged in the practice of medicine in Colorado. With governing boards, there are exceptions to this requirement. If an APN is being evaluated, the review committee must have one APN as a voting member or must have an independent review by an APN with a similar scope of practice as the APN being reviewed. In addition, a professional review committee can evaluate whether a professional could benefit from further education, or if the committee must take an adverse action which must be reported to the state licensing board.

Colorado Medicine for September/October 2018

In 1975 the Colorado General Assembly determined that, to uphold the standards of quality, professional conduct and appropriateness of patient care as well as encourage professional reviews within health care to support these, protections were needed for the professional review process. These protections have been reaffirmed several times during the last four decades by the General Assembly and upheld in Colorado’s highest court as a means to protect the public health, safety and welfare of Colorado’s citizens. The protections afforded for this process by the Colorado Professional Review Act (CPRA) encourage reporting of potential unsafe care, willingness to be reviewed, and open, honest and objective discussion among the reviewers.

Legislative preview (cont.) ance coverage, support and improve the Medicaid Accountable Care Collaborative program, appoint an insurance commissioner who will enforce Coloradoâ&#x20AC;&#x2122;s array of patient protections and insurer fair business practice standards, examine current laws governing the business practices and medical necessity decisions by commercial health plans, and continue to study and address the drivers of health care costs.

nities have worked closely with public officials and the highly regarded Colorado Consortium for Prescription Drug Abuse Prevention over the course of the last several years to successfully slow the pace of opioid and other substance abuse, there is still a substantial cohort of Coloradans with substance abuse disorder who require sustained effort to mitigate the enormous costs to families and their communities.

Key issue 3: Opioids Colorado Medical Society remains 9258_CMJClinicalGuidelinesAd_Resizes_060718_x1A.pdf 3 6/7/18 4:49 PM While Coloradoâ&#x20AC;&#x2122;s health care commu- committed to the community-based

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work of the consortium and prioritizes patient access to care, physician education, and continuing to limit opioid use as the crucial next steps. Colorado Medical Society is currently convening a multi-specialty, statewide work group of physicians at the invitation of the consortium to develop their perspectives, ideas and an ultimate consensus on guideline development and other physician activities to present to the consortium as a future strategic pathway to accelerate reversal of the crisis. CMS is also currently partnering with the American Medical Society (AMA) on a joint collaboration with Manatt Health, a fully integrated, multidisciplinary legal, regulatory, advocacy and strategic business health care practice to focus on comprehensive, multidisciplinary pain care and comprehensive, high-quality and evidence-based treatment for opioid use disorder. Colorado Medical Society has urged the candidates for governor to continue the gains toward mitigating the opioid crisis started by the previous administration, support the Colorado Consortium for Prescription Drug Abuse Prevention, and work to address the crisis in rural and underserved communities that face provider shortages. Stay tuned for more updates on these and other issues as the November elections are decided and the new governor and General Assembly begin their work in January 2019. n

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Colorado Medicine for September/October 2018

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Features

Western Slope update Krystle Medford, Membership Director

AMA president, CMS leaders visit Grand Junction and Montrose American Medical Association President Barbara McAneny, MD, made two stops in Colorado in September to hear directly from physicians on the Western Slope on unique issues they are facing and to discuss areas of focus currently being addressed by the AMA: confronting the increasing chronic disease burden, attacking dysfunction in health care that interferes with patient care and reimagining medical education. McAneny listened carefully to each physician and reassured them by stating, “We [AMA] are listening. We support our colleagues in the care of

their patients and listen to the concerns that affect their communities.” Accompanied by Colorado Medical Society leaders – President Robert Yakely, MD; President-elect Deb Parsons, MD; past president and CEJA Chair Lynn Parry, MD; and past president Dave Downs, MD – McAneny met with the Mesa County Medical Society membership at their monthly meeting on Sept. 4 and then traveled to Montrose for a Curecanti Medical Society meeting on Sept. 5. As a practicing oncologist/hematologist who founded the New Mex-

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AMA President Barbara McAneny, MD, meets Montrose physicians to share AMA goals and to listen to local issues.

ico Cancer Center in Albuquerque – McAneny’s career has centered on serving minority and underserved populations including rural, Native American and Hispanic patients. Over the course of her medical practice she has recognized the need for systemwide change in health care. Following her installment as AMA president in June, she has pledged to work to address patient access to care, the high cost of care and regulatory burdens on physicians. In this short time she has already overseen the creation of the Coalition to Reform Prior Authorization following an AMA survey that revealed 91 percent of physicians believe prior authorization delays care, causes patients to abandon treatment and negatively affects outcomes. The coalition aims to eliminate and streamline federal rules and regulations for prior authorization and improve usability and interoperability across electronic health records (EHRs). She also addressed Medicaid expan-

Colorado Medicine for September/October 2018

Features sion, acknowledging that while it is a state-by-state issue, the AMA believes that the program is an important safety net for patients – particularly for women, children and low-income elderly. She and others at the AMA recognize that Medicaid seldom pays for the cost of providing care and she assured the audience that they are working to address this.

Mesa County Past President Patrick Pevoto, MD, moderates panel with AMA President Barbara McAneny and CMS leadership.

“None of us can do what we do without a lot of other people doing what they do,” McAneny said. “That is why we are stronger when we work together.”

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The AMA president and CMS leaders also spent time with the editorial board of the Grand Junction Sentinel (newspaper) to discuss the opioid crisis on a national and local level and how the reporters could translate the issue to their audience. The physicians shared their thoughts on how organized medicine is working to address the epidemic through partnerships and collaborative efforts. “We are working in tandem to tackle the opioid crisis,” Yakely said. “We are deeply concerned about the issue and we are working to educate our members.” n

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Features

A doctor’s perspective The Grand Junction Daily Sentinel editorial board

AMA president, CMS leaders’ Grand Junction visit prompts editorial by largest newspaper in Western Colorado Editor’s Note: The following editorial was published in the Sept. 5, 2018 edition of the Grand Junction Daily Sentinel, the largest daily newspaper in western Colorado, with distribution in six counties. 2018 marked 120 years of publication since the newspaper’s founding in 1893. If you’re frustrated being a patient in today’s health-care environment, try being a doctor – especially a primary care physician.

How we do IT

Doctors are trained in a hospital setting, which is actually alien to their mission of keeping people healthy through pre-

vention. They learn through exposure to failures in the system that land people in the hospital, often from chronic, yet preventable conditions like adult-onset diabetes and high blood pressure. Once they fulfill their residency requirements to practice on their own, federal laws against self-dealing create hurdles to form a team-based system of care utilizing shared resources that is actually proving to lower costs and deliver care more efficiently than hospitals. Adherence to long-held ethical guide-

“The AMA’s overarching mission is to promote the art and science of medicine and the betterment of public health,” said AMA President Barabra L. McAneny, MD. But Wednesday’s discussion focused on three key areas:

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• Confronting the increasing chronic disease burden. The AMA wants to eliminated preventable cases of type 2 diabetes, help all adults meet their blood pressure goals, and end the opioid epidemic.

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lines, like making sure patients don’t suffer undue pain, have contributed to an opioid epidemic that the system doesn’t have the capacity to treat. Doctors spend half as much time seeing patients as they do logging data meant to measure quality – but doesn’t. And Medicaid patients, with their low reimbursement rates, create a financial challenge that many doctors take on as a matter of conscience to avoid creating a two-tiered system of care in this country. These are just a few observations that doctors representing the Colorado Medical Society and the American Medical Association shared with the Sentinel’s editorial board Wednesday.

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• Removing barriers to care and emphasize patient-physician relationships over paperwork. The AMA supported the Affordable Care Act, in part because it improved access to care. It continues to work for Medicaid expansion and make it a more robust system. • Reimagining medical education. “The AMA commits to speeding re-

Colorado Medicine for September/October 2018

Features search into practice – making medical knowledge easy to consume, medical technology easy to use, medical evidence easy to apply and medical education easy to access across a lifetime.” McAneney, an oncologist practicing in Albuquerque, makes these visits all over the country, comparing strengths of local health-care systems. She said she’s “fascinated” by the Grand Valley’s “mainstreamed” Medicaid model – an example of how “all health care is local.” There’s no one-size-fits-all model to making health care affordable and accessible. Representatives of the Colorado Medical Society touted efforts to lower the number of opioids being prescribed in the state and the growing number of physicians accessing prescription drug monitoring programs, or PDMPs to curtail instance of “doctor shopping.” “Even if we do everything we can to reduce prescribing opioids and increase takeback locations, we may still see the death rate continue to climb for the next six or seven years,” said CMS President M. Robert Yakely, MD. More addiction specialists are needed in the state, along with more treatment centers. Medical schools should adopt curriculum about opioid use and addiction. Insurance companies should cover the expense of alternatives to pills, such as physical therapy. Citizens can do their part by getting rid of pain meds in their medicine cabinets. And society must stop stigmatizing those who grow dependent on opioids “and recognize that opioid-use disorder is a chronic relapsing disease and not a moral failing,” McAneny said. Meanwhile, doctors are encouraged by how Colorado’s business community is pushing for non-legislative ways to lower costs. “They’ve taken the reins, which is good from our perspective,” said past CMS president Dave Downs, MD. “They have the legs to move things through.” n

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Organized medicine unites Staff report

170 medical groups submit unified comments on federal CMS payment rule The American Medical Association, Colorado Medical Society and 168 other medical groups sent a letter to Seema Verma, administrator of the Centers for Medicare and Medicaid Services, regarding the administration’s proposals included in the 2019 Medicare physician payment rule. In an effort to reduce documentation, the Centers for Medicare and Medicaid Services proposed collapsing payment rates for eight office visit services for new and established patients down to two each. While the organizations strongly sup-

port reducing administrative burdens on physicians so they can devote more time to patient care, they oppose the proposed collapse of payment rates as “it could hurt physicians and other health care professionals in specialties that treat the sickest patients, as well as those who provide comprehensive primary care, ultimately jeopardizing patients’ access to care,” the letter states. In an effort to help the federal CMS work through the nuances of appropriate coding, payment and documentation requirements for different levels

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of evaluation and management (E&M) services, the AMA rapidly convened a workgroup on Current Procedural Terminology (CPT) and Relative Value Scale Update Committee (RUC) on E&M comprising physicians and other health professionals with deep expertise in defining and valuing codes, who also use the office visit codes to describe and bill for services provided to Medicare patients. Through an aggressive meeting schedule, the workgroup plans to develop a CPT proposal by early November. The CPT editorial panel would then vote on the recommendations in February 2019 and the RUC would develop revaluations by May, in time for implementation in the 2020 Medicare Physician Fee Schedule. Regarding reducing administrative burden, the organizations urge immediate adoption of three documentation policy changes included in the proposed rule. 1. Changing the required documentation of the patient’s history to focus only on the interval history since the previous visit; 2. Eliminating the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or by the patient; and 3. Removing the need to justify providing a home visit instead of an office visit. “We encourage the administration to adopt in the final rule the documentation changes outlined above. These changes reflect significant progress in your Patients Over Paperwork Initia-

Colorado Medicine for September/October 2018

Features tive. Such policy modifications will significantly reduce the documentation burden so health care professionals can spend more time with patients. We also urge the administration to set aside its office visit and multiple service proposals, fully embrace the assistance of the workgroup and work together with the medical community on a mutually agreeable policy that will achieve our shared goal of simplifying E&M documentation burdens while mitigating any unintended consequences.â&#x20AC;? n

Serving the Continuing Medical Education needs of Colorado physicians Your bridge to quality improvement in health care Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720-858-6309 Colorado Medicine for September/October 2018

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Prescription drug abuse Michael Davidson, Communications Professional, Colorado Consortium for Prescription Drug Abuse Prevention

Colorado Consortium for Prescription Drug Abuse Prevention hosts education symposium on Oct. 24 It’s hard to find good news when discussing the opioid crisis – but for health care providers looking to make a difference, there are reasons for hope. A renewed focus on multimodal, integrated pain management can provide patients with effective pain relief, and Colorado providers are ramping up treatment capacity for people with opioid use disorders. Those are messages Lesley Brooks, MD, and Josh Blum, MD, would like to share with health care providers across Colorado. Brooks and Blum are the co-chairs of the Provider Education work group for the Colorado Consortium for Prescription Drug Abuse Prevention. The Consortium is hosting the first Colorado Consortium Education Symposium: Best Practices for Pain Management and Addiction Treatment on

Wednesday, Oct. 24. This free event at the University of Colorado Anschutz Medical Campus in Aurora is for physicians and other providers who want to learn the latest in evidence-based pain management and opioid addiction treatment. Registration information is available at www.consortiumo pioidsymposium.eventbrite.com. Continuing medical education credits are available for MDs and DOs. Certificates of completion will be available for all others.

Useful information about opioid alternatives The goal of the symposium is for health care providers to leave with valuable information they can incorporate into their practices. The event will feature keynote presentations and focused breakout discussions about non-opioid pain management and best practices for treating addiction.

Unfortunately, the need for better prevention and treatment strategies increases. Although fewer prescriptions for opioids are being written, the overdose death toll increases. According to the Colorado Department of Public Health and Environment, 560 people died of opioid overdoses in Colorado in 2017, up from 504 in 2016 and 108

“We’re learning more and more about pain relief and ways to address substance use disorders. Much of it is applicable to how we can treat patients in our emergency rooms and offices,” said Blum, a primary care and addiction specialist at Denver Health who works with opioid and injection drug users. “We need to get the word out.”

Best Practices for Pain Management and Addiction Treatment Join healthcare providers from across Colorado for an evening of education and networking. Experts in pain management and addiction treatment will be discussing the latest research and best practices for treating patients with chronic pain and opioid use disorder. CME credit is available for MDs and DOs. The event is free. Register soon — space is limited! https://consortiumopioidsymposium.eventbrite.com/ Wednesday, Oct. 24, 5 to 9 p.m. University of Colorado Anschutz Medical Campus Education 2 North 13120 East 19th Avenue Aurora, CO 80045

in 1999. A total of 1,112 people died of overdoses in Colorado in 2017, up from 1,032 in 2016 and 432 in 1999.

One big lesson is that non-opioid analgesics work for many forms of acute pain. A study published in the Journal of the American Medical Association (JAMA) in 2017 showed that a combination of ibuprofen and acetaminophen was as effective as oxycodone, hydrocodone and codeine when it came to relieving acute pain caused by an arm or leg sprain, strain or fracture. Another JAMA study published in 2018 showed that treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

Colorado Medicine for September/October 2018

Features Instead, holistic approaches that include topical treatments such as ice, heat and massage, movement therapies like yoga and tai chi, psychobehavioral therapy and complementary modalities including acupuncture all play a role in pain management. Among other references, a 2017 back pain guideline from the American College of Physicians highlights this approach. Treatment approaches that don’t involve medication, such as physical therapy, cognitive behavioral therapy and yoga are also effective. Better options for treating opioid use disorders Helping patients avoid opioid use disorders is ideal, but providers also have tools to help patients who have developed disorders. “Medication-assisted treatment is proven to save and improve lives. Patients and physicians have more options now, such as buprenorphine and naltrexone, which are game changers in addiction treatment,” Brooks said. Brooks is a family medicine physician in Greeley where she serves as the chief medical officer for Sunrise Community Health and assistant medical director for the North Colorado Health Alliance. She led the implementation and manages the medication-assisted treatment (MAT) program at Sunrise Community Health. The symposium will cover those medications in depth, highlight how providers can be trained to administer

MAT, and share practical information doctors can use to incorporate MAT into their clinics. “An important thing to know about these medications is we can prescribe them or administer them from our offices,” Brooks said. “That greatly simplifies the treatment process both for us and our patients.” And they are effective. Administered within a structured environment, methadone, buprenorphine and naltrexone lead to decreased relapse rates and all-cause deaths, decreased acquisition of infectious diseases and, most importantly, increased retention in treatment. Physicians who want to offer MAT need to complete eight hours of training and advanced practice providers need 24 hours of training to receive a waiver allowing them to prescribe buprenorphine. “The training and waiver process is easy to complete and we offer guidance to physicians who are interested. We don’t want that to be a barrier for anyone,” Brooks said. Symposium speakers also will cover the latest scientific research about use disorders and treatment best practices. Attendees who want more information about the state’s response to the opioid crisis are welcome to attend the Colorado Consortium for Prescription Drug Abuse Prevention’s annual meeting the next day, Thursday, Oct. 25. n

Colorado Medicine for September/October 2018

Features

Opioid clock Staff report

CMS leader develops visual to educate physicians on the opioid epidemic The Colorado Medical Society is featuring a new graphic and interactive online tool to educate the public on the opioid epidemic. Designed and developed by incoming CMS President Deb Parsons, MD, FACP, the clock – available as a onepage graphic and interactive online tool with links to evidence-based resources and references – displays six drivers of the crisis from the positions of one o’clock to six o’clock and six categories of solutions from seven o’clock to 12 o’clock. A link for patients lies in the center and a real-time counter at the end “ticks” off 12 deaths/

minute. The clock is not meant to be chronological and will continue to evolve. Parsons created the idea for the opioid epidemic clock out of her “deep concern with the staggering statistics of opioid deaths and addiction,” she said. Like many physicians, she frequently heard stories of lives lost and lives affected by opioids. She worked on the opioid clock as a fellow of the Regional Institute for Health and Environmental Leadership (RIHEL) program.

vidual to use the opioid clock to spread knowledge and understanding of the causes of and the necessary solutions of the opioid crisis. She urges stakeholders to use the clock during crucial conversations with everyone from the uninitiated to topic experts and specifically with the lay public, affected individuals and families, legislators and health care professionals. “Key points to understand are that addiction is a chronic disease and is not a moral failure. Everyone has a role and everyone can help reverse the crisis,” she said.

Parsons’ vision is to empower any indiParsons recently presented the clock at the Public Health in the Rockies conference. It can be seen on the following page and online at www.members.cms.org/clock. n

Health care professionals and patients share best practices and personal stories in fight against opioid abuse disorder

Deb Parsons, MD, FACP, recently presented the new opioid clock graphic and interactive online tool at the Public Health in the Rockies conference during a presentation of “Lift the Label,” a public awareness campaign that strives to remove damaging labels and stigmas that prevent those with opioid abuse disorder from seeking effective treatment. Parsons is pictured with the Lift the Label presentation team, Cristen Bates, director of Strategy, Communications and Policy, Office of Behavioral Health, CDHS; and Taylor Wright and Blair Hubbard, patients who presented personal stories about addiction and recovery.

Colorado Medicine for September/October 2018

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Colorado Medicine for September/October 2018

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Colorado Medicine for September/October 2018

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Guest editorial Kenneth Finn, MD

Marijuana will not fix the opioid epidemic Editor’s note: This article was originally published in the May/June 2018 issue of Missouri Medicine. Kenneth Finn, MD, is with Springs Rehabilitation, PC, Colorado Springs, Colo. He is board certified in Physical Medicine and Rehabilitation and Pain Management and Medicine. Currently, there is no widely available or accepted medical literature showing any benefit for pain with dispensary cannabis in common pain conditions. Marijuana has been used for reported medical purposes for thousands of years when the plant at that time had THC content of 0.5-3 percent. Currently, the most common reported medical use is for pain. As of this writing 30 states and the District of Columbia have some form of legalized marijuana, with eight states having legalized it for recreational use. The United States is currently in the grips of an opioid epidemic, which has been growing over the last 20 years and began with “pain” being termed the “5th vital sign.” At the time, it was reported that people in pain did not become addicted to opioids, and the number of opioid prescriptions started to increase over time, followed by an increase in opioid overdose deaths.1 There has been a lot of discussion about how the use of cannabis will help curb the opioid epidemic.2 It has been reported that medical cannabis laws are associated with significantly lower opioid overdose mortality rates, and others have suggested that legalization may result in less opioid overdose deaths.3 Other studies have reported that medical marijuana laws were

associated with a decrease in Medicare prescriptions, saving millions of dollars.4 The same authors followed up with another report suggesting that medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population.5 Cost savings in this day and age of health care is very important, but it was noted that “the researchers themselves cannot say if people switched from opioid prescriptions to using a medical marijuana product.” It is difficult to translate population-level analyses to individual marijuana-opioid substitutions, and this patient population is a rather small percentage of people who may be using opioids and/or medical marijuana. In 2017 Colorado had a record number of opioid overdose deaths from any opioid, including heroin and Colorado has had a medical marijuana program since 2001.6 In the face of the opioid crisis, the medical providers should utilize other ways for people to avoid the use of opioids. Treatments such as physical therapy, acupuncture, chiropractic, massage and cognitive-behavioral therapies are some of the standard treatments in the management of people with pain. Other naturopathic remedies have been suggested and tried but not proven.7 There is some evidence that there are components of the marijuana plant which may have therapeutic medical value.8 Cannabinoid and opioid receptors belong to the rhodopsin subfamily of G-proteincoupled receptors and are synergistic.9 Both are localized primarily at the presynaptic terminals and when activated reduce cellular levels of cyclic adenosine monophosphate (cAMP) by inhibition of adenylyl cyclase, which affects neurotransmission. Receptor activation of both also

Colorado Medicine for September/October 2018

modifies the permeability of sodium, potassium, and calcium channels and receptors of both systems coexist in the central nervous system, with overlapping distribution in the brain, brainstem and spinal cord.10 Both receptors co-localize on GABA-ergic neurons with potential coupling to second messenger systems, and receptor stimulation can suppress inhibition, suppress excitation and inhibit the release of several neurotransmitters, including L-glutamate, GABA, norepinephrine, serotonin, dopamine and acetylcholine, therefore modulating pain pathways and potentially provide antinociception. Opioids and cannabinoids share pharmacologic profiles and both can cause sedation, hypotension, hypothermia, decreased intestinal motility, drug-reward enforcement and antinociception. There are several reasons why any reported benefit will be outstripped by lack of benefit and increased risk of harm, and why cannabis is contributing to ongoing opioid use, and subsequently, the opioid epidemic. There is evidence in animal models showing adolescent rats exposed to THC will develop enhanced heroin self-administration as adults,11 which may be due to activation of mesolimbic transmission of dopamine by a common mu opioid receptor mechanism.11,12 More than 90 percent of heroin users report a prior history of marijuana use compared to a prior history of painkiller use (47 percent).13 Prospective twin studies demonstrated that early cannabis use was associated with an increased risk of other drug abuse.14 This particular study was conducted when the THC content was much lower than products today, which can reach 95 percent THC.

Guest editorial (cont.) The currently accepted body of evidence supporting use of cannabis in pain consists of 28 studies comprised of 63 reports and 2,454 patients.15 Additional articles relying on this primary paper misleadingly state that “there is substantial evidence that cannabis is an effective treatment for chronic pain in adults.”16 Both articles noted that products typically studied are not available in the United States (nabiximols, Sativex) or were with available synthetic agents (dronabinol, nabilone), and were studied in less common pain conditions: neuropathic and cancer pain. Currently there is no widely available or accepted medical literature showing any benefit for pain with dispensary cannabis in common pain conditions.17 Dispensary cannabis is a generic substance containing multiple components which may have physiologic activity in the body. The College of Family Physicians of Canada outlined potential prescribing guidelines of medical cannabinoids in primary care.18 They strongly recommended against use for acute pain, headache, osteoarthritis and back pain, and also discouraged smoking. There is currently a large and growing body of evidence showing that cannabis use increases, rather than decreases, nonmedical prescription opioid use and opioid use disorder, based on a follow up with more than 33,000 people.19 Concurrent use of cannabis and opioids by patients with chronic pain appears to indicate a higher risk of opioid misuse.20 Closer monitoring for opioid-related aberrant behaviors is indicated in this group of patients and it suggests that cannabis use is a predictor of aberrant drug behaviors in patients receiving chronic opioid therapy. Inhaled cannabis in patients with chronic low-back pain does not reduce overall opioid use; those patients are more likely to meet the criteria for substance abuse disorders and are more likely to be non-adherent with their prescription opioids.21 It has been found that patients with chronic pain participating in an interdisciplinary pain rehabilitation program using cannabis may be at higher risk for substancerelated negative outcomes, and were more likely to report a past history of illicit sub 26

stance, alcohol and tobacco use.22 A more recent study of 57,000 people showed that medical marijuana users are more likely to use prescription drugs medically and nonmedically, and included pain relievers, stimulants, tranquilizers and sedatives.23 There is also evidence that state medical marijuana laws lead to the probability people will make Social Security Disability claims.24 There is sufficient and expanding evidence demonstrating that medical marijuana use will not curb the opioid epidemic. There is further evidence that marijuana is a companion drug rather than substitution drug and that marijuana use may be contributing to the opioid epidemic rather than improving it. Although there are patients who have successfully weaned off of their opioids and use marijuana instead, the evidence that marijuana will replace opioids is simply not there. Medical provider and patient awareness, utilization of prescription drug monitoring programs, widespread availability and use of naloxone, and increasing coverage for atypical opioids and abuse deterrent formulations are only some of the other factors which hopefully be contributing to any impact on the opioid crisis. Education and prevention efforts as well as medication assisted therapies will be additional benefits to impact the opioid epidemic. Physicians should continue to monitor their patients closely, perform random drug testing to detect opioid misuse or aberrant behavior, and intervene early with alternative therapies when possible. Marijuana alone is certainly not the answer. n References

1. National Institute of Drug Abuse, Overdose Death Rates, Revised September 2017 2. Bachhuber MA, Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010 JAMA Intern Med. 2014; 174(10):1668-1673 3. Livingston, M; Recreational Cannabis Legalization and Opioid-Related Deaths in Colorado, 2000–2015; American Journal of Public Health; 2017; 107(11): 1827-1829 4. Bradford, AC; Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D; Health Affairs. 2016;35:1230-1236 5. Bradford, AC; Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population JAMA Intern Med. 2018; April 2, 2018: E1-E6 6. Colorado Department of Public Health and

Environment, Vital Statistics Program 7. Soeken, KL; Selected CAM therapies for arthritis-related pain: the evidence from systematic reviews; Clin J Pain. 2004 Jan-Feb; 20(1); 13-18. 8. Whiting, PF; Cannabinoids for Medical Use: A Systematic Review and Meta- analysis. JAMA 2015; 313(24); 2456-2473 9. Robledo, P; Advances in the field of cannabinoid--opioid cross-talk. Addiction Biology. 2008 13: 213-224 10. Scavone JL; Cannabinoid and opioid interactions: implications for opiate dependence and withdrawal; Neuroscience 2013; 284: 637654 11. Pickel VM; ChanJ,KashTL,etal.Compartment-specificlocalizationof cannabinoid 1 (CB1) and mu opioid receptors in rat nucleus accumbens. Neurosci. 2004;127:101–112. 12. Tanda G; Cannabinoid and Heroin Activation of Mesolimbic Dopamine Transmission by a Common µ Opioid Receptor MechanismScience 27 Jun 1997 (276); Issue 5321: 2048-2050 13. National Survey of Drug Use and Health, 2013 & 2014 14. Lynskey MT; Early onset cannabis use and progression to other drug use in a sample of Dutch twinsBehavior Genetics. 2006; 36(2): 195-200 15. Whiting, PF; Cannabinoids for Medical Use: A Systematic Review and Meta- analysis. JAMA 2015; 313(24):2456-2473 16. National Academies Press; The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research; 2017 17. Nugent SM; The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms, A Systematic Review; Annals of Internal Medicine; 15 Aug 18. Allan GM; Simplified guideline for prescribing medical cannabinoids in primary care Canadian Family Physician Vol 64, February 2018: 111-120 19. Olfson M; Cannabis Use and Risk of Prescription Opioid Use Disorder in the United States; American Journal of Psychiatry. 2018; 175(1): 47-53 20. DiBenedetto DJ; The Association Between Cannabis Use and Aberrant Behaviors During Chronic Opioid Therapy for Chronic Pain; Pain Medicine 2017; 0: 1-12 21. Smaga S; In adults with chronic low back pain, does the use of inhaled cannabis reduce overall opioid use?; Evidence Based Practice 2017; 20(1), e10 22. Craner SA; Medical cannabis use among patients with chronic pain in an interdisciplinary pain rehabilitation program: Characterization and treatment outcomes. J Subst Abuse Treat. 2017. Jun; 77:95-100 23. Caputi TL; Medical Marijuana Users are More Likely to Use Prescription Drugs Medically and Nonmedically; Journal of Addiction Medicine, April 2018; 1-5 24. National Bureau of Economic Research, February 2018

Colorado Medicine for September/October 2018

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

COPIC endorses ballot amendments Y and Z Representing the voice of voters matters to health care Over the last several years, the issue of drawing maps to establish congressional or state legislative districts has received significant national and local media attention. Courts across the country are being asked to weigh in and are pushing for decisions to be made at the state level and outside of the judicial system. In Colorado, Amendments Y and Z will be put before voters in November to address this very problem. You may be asking, “Why does this matter to COPIC and health care?” Competition is a fundamental principal of America’s representative democracy. This well-studied assertion is rooted in the idea that competition motivates politicians to stay in tune with the needs of their communities and vote according to the concerns of their constituents. And health care is a primary issue that should represent the voices of all people – from the patients who seek care to the medical providers who face challenges in delivering this care. Unfortunately, over time, legislative districts have been drawn to create “safe wins” by politicians who prefer to remove the threat of ideological difference to achieve their majorities. This process, known as gerrymandering, has created a growing number of non-competitive districts. This is highly relevant in Colorado. The Colorado General Assembly is comprised of the 65-member House of Representatives, of which only three districts are considered competitive. Of the 35-member State Senate, only six

are viewed as competitive. Even worse, at our federal congressional level in the last election, only one district was won with a margin of less than 15 points. So why does this matter? Health care in Colorado comes before the General Assembly every year. The ability to inform and perhaps influence our legislators on health care issues depends on the willingness of the legislator to understand the impact that a particular statute will have on the citizens within his or her district. Amendments Y and Z will improve the map-drawing process by establishing independent commissions to draw our political maps with an emphasis on fairness and better representation. Amendment Y will reform the federal congressional redistricting process, while Amendment Z will reform our state legislative redistricting process. These are common-sense solutions that

will strive to keep communities whole and districts more competitive. Competition will result in our legislators representing a broader community, and such representation will motivate our legislators to work across the aisle. This willingness to compromise will encourage solutions for bigger problems. COPIC supports letting the voters choose their representatives rather than having our representatives choose their voters. For the reasons mentioned above, COPIC has endorsed Amendments Y and Z. This fits within our broader legislative advocacy efforts, which focus on supporting ways that allow us to move forward to improve health care in Colorado. In our upcoming fall election, we hope you will consider supporting these amendments. n

Colorado Medicine for September/October 2018

The members-only tool is searchable, and will help physicians and practice managers understand what their rights are in disputes with health plans. 29

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Colorado Medicine for September/October 2018

Inside CMS

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

Certa Dose: A simple yet brilliant idea You’ve probably never heard of Certa Dose. The small medical device company is bringing its products to market this year. At first glance, the syringes it sells may seem pretty simple (more on these later). However, the compelling part of the Certa Dose story is not so much what it does, but more about how the company originated. It’s a story that reminds us how keen observations and a desire to improve health care can lead to great ideas that make a life-saving difference. Treating a child with an emergent condition is one of the most stressful and challenging situations that a medical professional can face. In 2005, Caleb Hernandez, MD, an emergency medicine physician, was attempting to resuscitate a little girl. In the process, a nurse almost injected the girl with 10 times the correct dosage of medication. Luckily, Hernandez stopped the nurse and the child recovered. Reflecting on that near tragedy, Hernandez realized that the medical space is set up for accidental overdoses because of a communication gap: doctors work in milligrams, or units of mass, while nurses use milliliters, which is a volume measurement. “We’re speaking two different languages,” he said. So, he came up with an idea to create color-coded syringes to simplify how much of a drug to give a child based on age and weight. Hernandez assembled a team to conduct a research study using simulated pediatric emergency resuscitation scenarios. The study was designed to evaluate the effectiveness of prefilled, color-coded medication syringes, compared with conventional medication administration. Among the partners that Hernandez reached out to for support was the COPIC Medical Foundation. Recognizing how well this project aligned with COPIC’s goal of improving quality of care, the Foundation provided grant funding for the team’s study in 2012.

seconds, respectively. • When 118 doses were administered using the conventional method, 20 critical dosing errors occurred. Using the color-coded approach, 123 doses were administered without a single critical dosing error. These results went on to be published in the Annals of Emergency Medicine1 and Resuscitation.2 The articles garnered national attention and were significant milestones that moved Certa Dose forward to become a viable company. In November 2017, Certa Dose won the Johnson & Johnson Innovation, JLABS Advancing the Safe Use of Healthcare Products QuickFire Challenge, which provides support for the “best ideas on how to educate, inform and provide clarity around health care product safety.” The company is now taking the first steps in rolling out its product to the medical community. Health care professionals introduced to the color-coded syringes can easily understand the benefits – they no longer have to do complex arithmetic under stress and, instead, simply draw up a dose to the appropriate color zone for the child. The first product released was a U.S. FDA-cleared syringe for use with the administration of epinephrine, and the company is exploring offering additional products in the future. There are several reasons why I love the Certa Dose story. First, it is a simple, but brilliant solution that is incredibly effective. Second, it demonstrates that with the right support and vision, innovative ideas can grow with the potential to transform health care. Finally, the story of Certa Dose’s success means that we are going to hear numerous accounts about how the distinct, color-coded syringes have saved the lives of thousands of our pediatric patients. n www.ncbi.nlm.nih.gov/pmc/articles/PMC4872869/ https://www.resuscitationjournal.com/article/S0300-9572(15)00347 0/fulltext

The study’s results were impressive: • Median time to delivery of all doses for the conventional versus color-coded delivery groups was 47 seconds and 19 Colorado Medicine for September/October 2018

Inside CMS

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

Elsa Alaswad University of Colorado School of Medicine

Elsa Alaswad is a second-year medical student at the University of Colorado School of Medicine, with aspirations to become a neurosurgeon. Elsa immigrated from Syria at the age of 9 and later graduated from George Washington University with a degree in psychology. Her father is an interventional cardiologist in Detroit and her mother is a thyroid cancer pathologist in Paris, but she has family all over the world as a result of the Syrian revolution. When she is not studying, doing neurosurgery research or shadowing in the OR, she enjoys classical piano, photography, cinematography, drawing, poetry, reading, independent films, languages and playing with her beloved female cat Xavier. With the aid of her medical degree, Elsa hopes to help the Syrian humanitarian crisis and all humanitarian crises in a big way.

The cadaver as first teacher The first incision was like magic Running the blade across the faceless skin Dreaming of sulci and gyri hidden deep within the plastic wrapping Hacking and scraping Like a butcher 32

In another dimension Cutting deep into the spinal cord Sifting your thoughts into small imaginary cylinders All your memories draining away into metal foramen Were you a teacher? A nurse? A scientist? What brought you here before me? I wonder what your face looks like As I lose myself in your nerves, arteries, veins Empty space and lymph nodes Brushing against muscles and bones Tubercles, fascicles, trochanters, and processes I realize There are so many features to you But none of them tell me Who are you? What was your favorite dessert? Did you exercise on the weekend? Did you have grandchildren who worshipped you? Did you cook casseroles for Thanksgiving dinner? Thank you for being here Thank you for giving yourself to science To young minds To my blade As I pass my vibrating bone saw over your vertebral processes I remember I am dissecting a human being And treating her like a construction project Colorado Medicine for September/October 2018

Inside CMS Except it’s deconstruction I’m doing to you Taking you apart so I can put you Back together in my mind Then I will carry you with me And one day I will be you And blades will be cutting into me Fingers pulling apart my ligaments Hurting my tendons with their eager probes Unsheathing me like you Holding your hand through the plastic I feel as though you are my guide Helping me to understand the enigma That is you, me and everyone You will always be my first cadaver My posthumous teacher of anatomy and ethics You don’t have to tell me who you are But someday soon I will see your eyes and find parts of your soul And I will carry that with me too. n

Advice for the life you lead Invest in our experience Michael Caplan, CFP® Senior Vice President– Wealth Management Former fellow at Georgetown’s Institute of International Economic Law and adjunct law professor at Georgetown University Law Center Daniel Katz, CFA Senior Wealth Strategy Associate President of CFA® Society Colorado 2017 – present

Jessica Margetson, CFP® Senior Wealth Strategy Associate National Association of Plan Advisors’ “Top Women Advisors: 2016 Rising Stars” The Caplan Group UBS Financial Services Inc. 370 17th Street, Suite 4100 Denver, CO 80202 303-820-5144 michael.caplan@ubs.com

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As a firm providing wealth management services to clients, UBS Financial Services Inc. offers both investment advisory services and brokerage services. Investment advisory services and brokerage services are separate and distinct, differ in material ways and are governed by different laws and separate arrangements. It is important that clients understand the ways in which we conduct business and that they carefully read the agreements and disclosures that we provide to them about the products or services we offer. For more information, visit our website at ubs.com/workingwithus. Certified Financial Planner Board of Standards, Inc. owns the certification marks CFP® and Certified finanCial PlannerTM in the U.S. For designation disclosures, visit ubs.com/us/en/ designationdisclosures. © UBS 2018. All rights reserved. UBS Financial Services Inc. is a subsidiary of UBS AG. Member FINRA/SIPC. CJ-UBS-1957199270 Exp.: 06/30/2019

Colorado Medicine for September/October 2018

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

Lisa Moore Rocky Vista University College of Osteopathic Medicine Lisa Moore, OMS IV, grew up in Colorado Springs and attended Vanderbilt University where she obtained her Bachelor of Arts in Neuroscience. She is an aspiring neurologist and is excited to be an active member in the medical and research communities. In her free time, Lisa enjoys escaping to the mountains for hiking, painting with watercolors and playing board games.

Hidden in plain sight: The art of observation in medicine “Welcome to my practice,” my physician preceptor exclaimed as he ushered me into his office. “You might notice that we do things a little bit differently around here.” I nodded, halfexpecting my days in family medicine to revolve around diagnosis of viral respiratory infections and referrals to subspecialties. We spent the first hour of my first day poring over different art pieces. According to my preceptor, there is a difference between seeing and observing. I was asked to analyze the state of the subject’s marriage in John Singleton Copley’s painting Portrait of Mrs. John Winthrop. Though the subject sports a wedding ring, it is absent from the reflection of the table, subtly signifying that the state of her marriage is poor. I missed the subtlety. My mentor hinted: “The answer is hiding in plain sight!” On the second day of the rotation, I hurried inside the clinic. I was then asked to describe the appearance of the outside of the clinic. After failing to describe several key features, I was asked to step outside to observe the clinic’s exterior and then to report back with my findings. These exercises have 34

shown me that I struggle to take the time to recognize detail. The real difference between seeing and observing is the recognition and analysis of meaning behind what is initially presented to you. Despite sight being my greatest tool, as humans perceive up to 80 percent of all impressions by means of sight, I was failing to observe. A well-studied phenomenon known as the McGurk Effect shows how important our sense of sight is, in that it influences how our brain processes sound. The man’s mouth motioning “ba” and “fa” changes how we interpret the singular sound track. I was challenged to interpret more by slowing down and noting details of my environment and the people around me. I have found that this close observation skill is especially important when noting body language, deciphering precision of language and interpreting lab values. These initial teachings have returned throughout my few weeks in family medicine and have forced me to pause and synthesize. A 58-year-old retired businesswoman with Hashimoto’s came into the office. Her chief complaints were continued fatigue and weight gain, and she wanted to adjust her dosage of Levothyroxine. She appeared as though she had dressed hastily. Her hair, though brushed, showed signs of how she slept on it last night, and her make-up was caked on her face. As she discussed her troubles, I watched her fidget nervously in her seat. She wrung her hands and played with her nails. We then asked about life stressors. She came unraveled as she explained her elderly mother was now living with her, and that she was the sole caretaker. The only time that she could get some time to herself was after her mother fell asleep late at night. Knowing this, my physician preceptor urged her to get some help at home. We learned that her sister lived down the road and had not been much help. We helped her set a realistic goal for herself of having two hours to herself twice a week where she would ask either her sister or a member of her church to care for her elderly mother. The patient’s TSH lab values came back appropriate for her treatment. In her follow-up call, she reported feeling less anxious and guilty about leaving her Colorado Medicine for September/October 2018

Inside CMS elderly mother, and she had been sleeping better. Without noting her obvious distress, we might not have investigated what was stressing her out at home. By attempting to find the root of the problem and helping her set a realistic goal for herself, we offered more treatment than an increase in thyroid hormones would have. After other experiences like this, where I practiced the art of slowing down to observe, I’ve realized that family medicine is more than the art of prescribing medications and tests, but also being the first provider in line to really observe, listen and decipher the patient’s troubles. I’m grateful to my mentor who asked me to exercise observation. As he has pointed out, many things I wouldn’t have noticed were “hidden in plain sight.” All I had to do was look. n

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

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member. For more information, call Krystle at 720-858-6308 or email krystle_medford@cms.org

Colorado Medicine for September/October 2018

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medical news CMS members elect new president-elect and two AMA Delegation members for 2019 fiscal year Thank you to all the members who voted during the 2018 Colorado Medical Society election of officers. Thanks, also, to the physician-candidates for stepping up as leaders in the society. The following candidates were elected to office via an all-member vote. David Markenson, MD, elected CMS president-elect “This is both an exciting time and opp or t unity for the C olor ado Medical S o ci e t y,” Ma rkenson wrote in his candidate David Markenson, MD statement. President-elect

“Our society has embarked on a reorganization and structural change that is in my view groundbreaking amongst medical societies and exceptionally forward thinking. These changes have positioned our society to be better equipped to communicate with our members, hear grassroots ideas and feedback, and allow us to be nimble enough to address our members’ concerns and react to the ever and quickly changing health care landscape.” “Of all these benefits to me, the truly special aspect is that our members can be confident that their voice will be heard and their concerns will be addressed by the society,” he continued. “I am truly excited and humbled for the opportunity to serve as your leader at the time when our society has changed in such a positive way. I feel my skill set and experiences will allow me to help as we continue to improve this new and vastly improved model for a medical society.”

Katie Lozano, MD, FACR, and Lee Morgan, MD, re-elected to Colorado delegation of the American Medical Association “Effective work with and within the AMA is a long-term investment and I have i nve ste d m a n y hours, days and years in both the AMA and CMS,” Lozano wrote in her candidate statement. “One of the Katie Lozano, MD, FACR strengths I AMA Delegation will continue to bring to the Colorado delegation is broad networking contacts across the house of medicine in the AMA, given

Colorado Medicine for September/October 2018

Departments

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my partnership over years with physicians of all specialties when we worked together in the Young Physicians Section.” “I have the leadership experience, the experience of listening to multiple points of view and helping forge consensus, as well as strong interest and concern about the issues that affect the practice of m e d ici ne to d ay,” Morgan wrote in Lee (Alethia) Morgan, MD, her candidate FACOG, AMA Delegation statement. “This last decade has been a time of many changes and challenges for physicians. It is more important now than ever that we work together as a cohesive force in organized medicine on a local, state and national level.”

Nominate yourself or a colleague to run for CMS office next year. 2019 nominations now open. The nomination period for the 2019 CMS all-member election will is open through Jan. 31, 2019. 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), AMA Delegates (four positions open) and AMA Alternate Delegates (four positions open). The CMS Board of Directors would like to see contested elections and encourages multiple candidates at each position.

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 CMS COO Dean Holzkamp at dean_hol zkamp@cms.org if you have additional questions. n

Congratulations to these newly-elected CMS leaders. n

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

Colorado Medicine for September/October 2018

Compliments of:

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

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Milton Perkins - Program Director 38

mperkins@coloradodrugcard.com Colorado Medicine for September/October 2018

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Departments

medical news Celebrating achievements: Gordon Fleishaker, MD, celebrates 90th birthday and 50 years in medical practice Gordon H. Fleischaker, MD, a private practice physician with Wheat Ridge Pediatrics, celebrated his 90th birthday on Sunday, July 1, and was back in the office seeing patients the next day. He is the oldest activelypracticing member of the Colorado Medical Society and has been a member since 1960.

in a handwritten record era to a paperless era where smart phones and computers dominate our lives and the way we practice. He has kept up with the medicine and the technology, and logs a large number of CE hours each year to ensure he is current on medical practice and practicing the best medicine possible.”

“Dr. Fleischaker has seen every single major childhood illness that we now vaccinate for and take for granted,” said Barb Heil, practice manager of Wheat Ridge Pediatrics. “In addition, when he started out he was making house calls in the middle of the night and took all of his own emergency calls. He went from practicing

Fleischaker was awarded his undergraduate degree from the University of Louisville and his medical degree from the University of Louisville Medical School. He served in the United States Air Force as a medical officer and flight surgeon on active duty from 1953-1956 and in inactive reserve until 1970. He

completed his residency at the Children’s Hospital in Denver, Colo. Dr. Fleischaker has been in private practice in the Denver area since 1960 and is board certified in pediatrics. Fleischaker has been a member of the faculty of the University of Colorado medical school since 1960. He also has been actively involved with the Colorado Medical Society, serving as president of Clear Creek Valley Medical Society in 2002-2003. In his spare time Fleischaker enjoys reading, gardening, bicycling, swimming and the company of his children, grandchildren and good friends. n

CMS past president Gary VanderArk, MD, steps down from leadership of charity organization he founded Thirty years after founding a nonprofit health care organization for south metro Denver patients in need, CMS past president Gary VanderArk, MD, has announced that he will step down as board chair. Doctors Care provides access to quality, affordable health care and services and celebrated its 30-year anniversary this summer. “What Doctors Care has meant to me for the past 30 years has been pure joy,” VanderArk said. “Doctors Care has done an incredible amount of good. We have provided more than $150 million in free care. We have met the needs of thousands of people. My message is today ‘Thank You’ to more than 1,000 physicians and six hospitals and many hundred volunteers and our wonderful employees. And Doctors Care will continue to carry out its mission in the future!”

Beginning in January, Ellen Burkett will assume the role of board chair with CMS past president Katie Lozano, MD, FACR, assuming the position of vice chair. Doctors Care began operating through a network of volunteer physicians who provided care on a sliding scale, targeting individuals whose earnings were above the criteria to qualify for Medicaid and other public assistance, but below the level to pay for health care or private health insurance. After the successful establishment of this network, Doctors Care opened a clinic to treat medically underserved children and young adults. Following the Affordable Care Act, Doctors Care responded to the needs of the underserved in new ways by adding programs designed to assist individuals in accessing health coverage, and with utilizing that new coverage.

Colorado Medicine for September/October 2018

Today, the Doctors Care clinic offers health care that includes integrated medical, behavioral health and dental hygiene services to more than 3,000 active patients through nearly 8,000 visits each year. For more information about Doctors Care, visit www.DoctorsCare.org.

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

Access the CMS website at www.cms.org to stay current on the latest news affecting your practice. Look for our website redesign early in 2019.

Colorado Medicine for September/October 2018

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

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

➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES MEDICAL DIRECTOR, CHIEF OF PSYCHIATRY The Colorado Mental Health Institute at Fort Logan is searching for a Medical Director/Chief of Psychiatry. The position is a clinical administrative position and this individual is a member of the hospital’s management team. A qualified psychiatrist must be board certified or be eligible to sit for certification examination with ABPN. Candidate must pass background and drug screen, and be eligible to practice in a State Institution. Interested candidates please contact Margaret Mason at margaret.mason@state.co.us or (303) 866-7086.

➤ OFFICE SPACE FOR LEASE OFFICE SPACE FOR LEASE ON CAMPUS Med. Ctr. Aurora, daily, weekly, etc. Unobstructed view of front range. Furnished. 1800 feet, 3 exam rooms, 1 minor OR. Available for any specialty or primary. Staff available as well. Flexible terms. info@apsmd.us

STAFF PSYCHIATRIST The Colorado Mental Health Institute at Fort Logan is searching for a full-time staff psychiatrist to provide inpatient psychiatric care for adult patients. Candidate should enjoy working in a multidisciplinary team-based setting to deliver compassionate, evidence-based psychiatric care for individuals with mental illness. This direct patient care position provides psychiatric assessment, diagnosis, and treatment of hospitalized patients and leads the coordination of care with members of the treatment team. Candidate must pass background and drug screen and be eligible to practice in a State Institution. Parttime, temporary/coverage opportunities are also available. Interested candidates please contact Margaret Mason atmargaret.mason@state.co.us or (303) 866-7086.

Support the CMS Foundation with your tax-deductible donation

The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997. We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans. The CMSF Board of Trustees is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. We need your help to meet our goals.

Consider giving a tax-deductible donation of $25, $50, or more to help CMSF continue its mission. Questions? Call 720-858-6310. Colorado Medicine for September/October 2018

Features

the final word Floyd Ciruli, pollster, political analyst, Director of the Crossley Center for Public Opinion Research at the University of Denver

Colorado in 2018: A transformative election Colorado is approaching a transformative election – one of those moments when the political environment becomes unstable due to a mix of surging new social movements, changing voter attitudes, rising unconventional leaders and shifting demographics. Like the earth’s surface, the plates slip and create a new configuration of politics. Nationally, the election of Donald Trump released that kind of new energy. Colorado has had ruptures of similar proportion in the last four decades, and we are heading toward one this November. The anti-Olympic movement of 1972 and Dick Lamm’s environmentalism, which captured the Democratic Party, changed the history of Colorado in the mid-1970s. The passage of the TABOR Amendment in 1992, accompanied by a surge of local Reagan Republicans, made Colorado a conservative redoubt through the 1990s and into the early 2000s. And now, after more than a decade of rapid growth, a rise of unaffiliated voters and a shift to more liberal politics, it appears another inflection point is approaching, and Colorado voters will decide a new direction for the state. It is easy to observe the shift in the state’s politics since early in this century when George W. Bush won Colorado in two presidential elections (2000, 2004) and Bill Owens gained his 2002 gubernatorial reelection with 65 percent of the vote. That year was the apex of Republican dominance. Colorado had two Republican U.S. Senators and both state houses, and five out of seven congressional seats were in Republican control. Contrast that with this year. Democrats have erased a 160,000-plus deficit in voter registration since 2000 and are now ahead. They had 119,000 more voters turn out in the June primary than the Republicans. Democrats have won the last three presidential races in Colorado. The party’s nominee for governor is currently 42

favored after an eight-year term by Democrat John Hickenlooper. And, of course, they may benefit from a wave of support this November due to the normal midterm election referendum on a new president. The party that dominates the state this November is likely to shift its politics dramatically. The major issues Colorado voters face in November’s election are starkly differentiated between the two parties and candidates for governor. Energy, education, transportation and health care have produced different analyses of the problems and contrasting solutions. Health care is rated the top issue today in national and Colorado polls. The state is one of the most engaged in the issue. When Obamacare was passed in 2010, Gov. Hickenlooper jumped on the program, setting up a newly authorized health care exchange and expanding Medicaid. Even voters have gotten involved. In 2016, Colorado voted on a single-payer system, but strongly rejected it. The issue is a significant focus in the governor’s race with Democrat Jared Polis endorsing a version of a single-payer system and Republican Walker Stapleton rejecting it. But, the issue has become much more complex since Obamacare first passed and both parties are being forced to adapt. The Republican battle cry to repeal Obamacare, which was so politically successful in the 2010 and 2014 elections and so pervasive in the 2017 Congressional deliberations, is now a liability in competitive elections. The public fondness for Obamacare grew just as it was most embattled, and Republicans are scrambling to deal with questions on pre-existing conditions, access to coverage and rising insurance rates. But, Democrats are finding limited support for single-payer proposals due to criticism about the cost, reduced choice in care and government control of the medical system.

After the 2018 election, significant changes in health care policies are likely to be implemented by the governor-elect. Health care is increasingly seen as a basic right, which won’t go away as a political challenge, whomever is elected. Although the Colorado electorate will also face choices that could significantly change the partisan makeup of the state Senate, constitutional statewide offices (attorney general, treasurer and secretary of state) and the congressional delegation, it may be ballot issues that could most alter the state’s trajectory. A ban on oil and gas fracking is on the ballot after almost making it on the 2014 ballot. Although it is gathering little establishment support, it could affect the general election as millions of dollars of oil and gas money may be spent to oppose the initiative and the Democratic Party is split on the issue. Billions in new taxes are proposed for the K-12 public school system. A massive school tax increase was rejected in the 2013 election, but supporters of the initiative are hoping the new proposal aimed at upper-income Coloradans has a friendlier electorate in 2018. Finally, on that ballot is another billion-dollar contest over how to fund transportation with either increased sales tax dollars or a diversion of existing state tax revenue (revenue which has been used for other programs, especially Medicaid expansion), which could control future state budgets as profoundly as the TABOR Amendment. It is possible Colorado voters will stay with their historically conservative position on new state taxes and fracking, yet will put a very liberal team in charge of state government. But, the odds are that the forces that have been building for a decade in Colorado are likely to be released, producing new politics and policies for the next decade. n

Colorado Medicine for September/October 2018