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VO LU M E 1 1 6     N O . 2     M A R - A P R 2 0 1 9

COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE


C O NTE NT S

Cover Story The rising cost of health care and health insurance continues to squeeze personal pay raises, business spending, and public-sector funding on Colorado priorities such as transportation and education. The cover story and accompanying features present examples of what providers, government agencies and physician practices are doing to address this critical issue. PAGE 6 ►

F E ATU R E S

10 RELENTLESS IMPROVEMENT Alan Kimura, MD, MPH, discusses how his practice has reduced health care costs while increasing quality, boosting patient satisfaction and building a case for better contracts with insurers. 14 BEWARE OF HCSM Bill Lindsay warns physicians of a new non-insurance, Health Care Sharing Ministries, and explains why they are not a solution to high insurance costs. 15 MOVING BOLDLY FORWARD HCPF Executive Director Kim Bimestefer outlines Colorado’s Health Care Affordability Roadmap to respond to the complex and pressing challenge of health care costs. 16 LOWERING COSTS IN PRIMARY CARE Debbie Chandler of the Matthews-Vu Medical Group in Colorado Springs speaks about reducing costs through risk stratification and case management. 18 LOWERING COSTS BEGINS WITH THE INDIVIDUAL Michael Pramenko, MD, shifts the cost discussion to the individual – his or her risky or unhealthy behaviors – and society’s incentives to pursue wellness.

A D D ITI O N A L

F E ATU R E S

23 Vaping is hitting Colorado youth hard 24 Photospread: Metro-area legislators and physicians convene for dialogue 26 Read a mid-legislative-session report on medicine’s top issues 28 Why peer review protections are critical to continually improving care 29 CMS and partners launch CO’s CURE to develop multispecialty opioid guidelines 32 AMA and CMS release progress report on the opioid epidemic response 34 Colorado medical students lead in AMA-MSS Region 1 meeting 35 Colorado showcased at AMA State Advocacy Summit 36 Climate risks to health vary across Colorado I N S I D E

C M S

4

President’s Letter

20 A SURGICAL GROUP’S SUCCESS IN REDUCING COSTS Kelly Baldessari presents four concrete actions – and results in real dollars – that SurgOne and TraumaOne have taken to reduce health care costs.

5

Save the date: 2019 Presidential Celebration and Gala

22 COLORADO TCPI PRACTICES RECOGNIZED FOR EXCELLENCE Two Colorado practices were honored for exemplary medical management and patient engagement.

40 Reflections

48 FINAL WORD: THE BUSINESS PERSPECTIVE ON COSTS Representing member-businesses, the Denver Metro Chamber of Commerce has worked for 18 months on a set of recommendations for reducing health care costs.

13 CMS Corporate Supporters and Member Benefit Partners 38 COPIC Comment 41 Introspections D E PA R TM E NT S

42 Medical news 43 In Memoriam: K. Mason Howard, MD and Steven Perry, MD, FAAP 47 Classifieds


CO LOR AD O M E D I CAL SO CI E T Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 720.859.1001 • 800.654.5653 • fax 720.859.7509 • www.cms.org

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF 2018-2019 OFFICERS Debra J. Parsons, MD, FACP President

David Markenson, MD, MBA President-elect

Patrick Pevoto, MD, RPh, MBA Treasurer

Alfred D. Gilchrist

Chief Executive Officer

M. Robert Yakely, MD

BOARD OF DIRECTORS

AMA DELEGATES

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

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

Immediate Past President

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

AMA PAST PRESIDENT Jeremy Lazarus, MD

COLORADO MEDICAL SOCIETY STAFF EXECUTIVE OFFICE Alfred Gilchrist, Chief Executive Officer Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer Dean_Holzkamp@cms.org Chet Seward, Chief Strategy Officer Chet_Seward@cms.org Dianna Fetter, Director, Professional Services Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting Tom_Wilson@cms.org DIVISION OF COMMUNICATIONS AND MEMBER BENEFITS Mike Campo, Director, Business Development & Member Benefits Mike_Campo@cms.org Kate Alfano, Coordinator, Communications Kate_Alfano@cms.org

DIVISION OF HEALTH CARE POLICY AND FINANCING Marilyn Rissmiller, Senior Director Marilyn_Rissmiller@cms.org Amy Berenbaum Goodman, JD, MBE, Senior Director, Policy amy_goodman@cms.org Gene Richer, Director, Continuing Medical Education Gene_Richer@cms.org DIVISION OF INFORMATION TECHNOLOGY/MEMBERSHIP

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

Krystle Medford, Director, Membership Krystle_Medford@cms.org Tim Yanetta, Coordinator Tim_Yanetta@cms.org Susanna Barnett, Coordinator Susanna_Barnett@cms.org

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


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P R E S I D E NT ’ S

LE T TE R

A real-life example of an individual member’s proposal on its way to public policy

Debra Parsons, MD, FACP President, Colorado Medical Society

CMS mission: To champion health care issues that improve patient care, promote physician professional satisfaction and create healthier communities in Colorado

As the AMA motto proclaims “Membership Moves Medicine,” so it goes for our Colorado Medical Society. We are standing up for you and tackling your hard-hitting priorities just as you directed us to do, and it’s making a difference for our profession and our patients. As a membership organization, the economic and human impact of your belonging to CMS amplifies the voice of Colorado physicians and affords influence on those important issues to our profession and our patients. We can only achieve our mission “to champion health care issues that improve patient care, promote physician professional satisfaction and create healthier communities in Colorado” with your support and it is with gratitude that we thank you for being CMS members. Two directives from the board of directors’ operational plan instruct leadership to enhance effective decision-making and maximize membership engagement through effective communication. I am proud to say that we are doing this most effectively through Central Line, CMS’s members-only virtual engagement platform, and can demonstrate a concrete example of one member’s idea sparking real legislative change below.

Since Central Line went live in 2017, it has been a game-changer for CMS and has garnered awards and the attention of other associations around the country. As I hope you’re well aware,

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this revolutionary application allows any CMS member to submit policy proposals or to give input on policy proposals submitted by colleagues, and to give input to the board of directors before and after votes are taken on policy.

• In the first year, 11 policy proposals were submitted by CMS physicians across the state through Central Line; more than 1,800 physicians from around the state voted on one or more of these proposals. • In 2018, the second year of Central Line, even more policy proposals were submitted and the number of participating physicians increased. Statewide in 2018, Central Line was used by 1,950 unique CMS members including nearly 300 students, casting a total of more than 9,200 votes on health care policy. The value of your participation in the Central Line process is that your representative on the CMS board of directors reviews your input on each policy before and after he or she casts a vote at the CMS board meetings. The importance of this, from a policy standpoint, is that all proposals approved by the CMS board of directors have had member input before they become official CMS policy. Some proposals become policy for future action, and other proposals are acted upon right away.


P R E S I D E N T ’ S LE T T E R

As a concrete example of Central Line’s effectiveness, last November, the CMS Board of Directors adopted a Central Line proposal about mandatory childhood vaccinations. The proposal sought CMS support for legislation to prohibit opt-out exemptions for childhood vaccinations solely for personal or religious reasons, which would prevent parents from putting their children and others at risk by declining recommended vaccines solely on these two reasons.

The mandatory childhood vaccination proposal was adopted with amendments by the board with 91 percent of Central Line participants voicing their support of the board action. In January, a bill sponsor was recruited and legislation was drafted for consideration by the 2019 Colorado General Assembly. CMS has already joined a broad coalition of organizations that advocate for children’s health, and the group will work to support the passage of the bill in 2019. ■

I encourage all members to continue their involvement in Central Line in 2019. It is through this platform that individual members can affect real change in health care public policy for the good of Colorado.

Save the date for the 2019 Presidential Celebration and Gala: Sept. 14 The Colorado Medical Society is pleased to celebrate the inauguration of incoming CMS President David S. Markenson, MD, MBA. Mark your calendar to join your colleagues on Saturday, Sept. 14 for an engaging day of exploration and education at the highly celebrated Denver Museum of Nature & Science – a delight to people of all ages that ignites passion for understanding and protecting our natural world through fascinating exhibits and interactive displays.

TENTATIVE SCHEDULE* 9 a.m. - 5 p.m.

Denver Museum of Nature & Science open

9 a.m. - 11 p.m.

CMS Children’s Activity Center open

12 p.m. - 1 p.m.

CMS Finance Committee meeting

The museum will be open to CMS members and their guests during normal daytime operating hours, with special evening access to the Gems and Minerals exhibit during the Inaugural Gala. COPIC programming in the afternoon will be geared toward the latest knowledge needs for members in all stages of their careers, from medical students and early-career physicians to late-career physicians and emeritus members. The event will culminate with the semi-formal Inaugural Gala, featuring dinner, music, dancing and the swearing in of 2019-2020 CMS President Markenson.

1 p.m. - 4 p.m.

CMS Board of Directors meeting

1 p.m. - 4 p.m.

COPIC educational sessions

5 p.m.

DMNS closes to the public

6 p.m.

Inaugural Gala reception

A modest ticket fee will be charged. Supervised child care will be provided throughout the event through the CMS Children’s Activity Center. Discounted hotel pricing will be available. Registration will open soon. ■

6 p.m. - 11 p.m. DMNS Gems and Minerals Exhibit open for CMS members and their guests only

6:30 p.m. - 11 p.m. Inaugural Gala

*subject to change C O LO R A D O M E D I C I N E    5 


C OV E R

S TO RY

Kate Alfano, CMS Communications Coordinator

Increasing alarm over rising health care costs – in the form of negative impacts on the health and finances of individuals and families and the crowding out of other priorities in state and national budgets – has put a glaring spotlight on elected officials and health care providers to take action to bend the cost curve. Not mincing words, newly inaugurated Colorado Gov. Jared Polis expressed in his January State of the State address that despite all the progress Colorado has made,

Health care costs are still rising today, and families are still being ripped off.” “It’s time for us to build a health care system where no person has to choose between losing their life savings and losing their life. It’s time for Coloradans to pay a fair price for the prescription drugs they need.”

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C OV E R

The Colorado Medical Society’s effort to develop and recommend new policy and study initiatives on cost containment and quality improvement falls under the purview of the CMS Work Group on Health Care Costs, chaired by past president Dave Downs, MD, FACP. “To paraphrase Warren Buffet, ‘health care costs are a tapeworm on American productivity,’” Downs said. “As physicians, we should act where we can to reduce the cost of care without compromising quality and work to collaborate and influence wherever we can to improve the efficiency of care delivery.” As reported in the November-December issue of Colorado Medicine, Colorado physicians are concerned about rising health care cost s and are ac tively

engaged in initiatives to address costs. An all-member survey conducted in summer 2018 showed that almost three-quarters of CMS physicians in active practice call the current health care cost situation in Colorado a “crisis that they hear about daily” (23 percent) or a “very serious problem” (50 percent), particularly those in small towns or rural settings.

Two-thirds of CMS members believe physicians can have an impact on reducing health care costs, with 30 percent saying they can have a great deal of impact, and another 36 percent saying they can have some impact. PAGE 8 ►

CMS members believe that physicians can have an impact on reducing health care costs

physicians can have an impact

2/3

great deal of impact

some impact

30%

36%

GOV. JARED POLIS ESTABLISHES HEALTH-COSTS OFFICE

As promised in his State of the State address on Jan. 10, Colorado Gov. Jared Polis signed the second executive order of his office, effectively creating the new Office of Saving People Money on Health Care. The goal of the office, led by Lt. Gov. Dianne Primavera, is to study, identify and implement policies that will lower health care costs while ensuring all Coloradans have access to affordable, quality care.

• Empowering the Division of Insurance to protect consumers and support rural and mountain communities working to lower their health care costs; and

Anticipating public pushback on health care costs, the CMS board of directors established the Special Work Group on Health Care Costs and Quality. CMS is poised to fully cooperate with the Office of Saving People Money on Health Care.

The office will also establish a statewide interagency collaborative effort to develop common policies and strategies to reduce the cost of health care; develop policies and strategies to support innovation and efficiencies in health care systems to reduce health care costs; work to ensure culturally competent and equitable access to health care; and improve health in Colorado by developing, promoting and implementing policies and strategies that reduce the costs of health care by promoting public health and addressing social determinants of health.

The office will create and implement a roadmap for lowering the cost of health care including: • Reducing the cost of individual health insurance by working with the General Assembly to authorize a reinsurance program in Colorado; • Developing proposals for new, lower cost health insurance options;

• Increasing hospital price transparency and establishing programs to reduce prescription drug prices.

“During my battle with cancer, I was lucky to be in the care of incredible medical professionals with my family by my side,” said Lt. Gov. Primavera in a news release. “We want to make sure that every Coloradan can afford the same support system I did.”

Read the full executive order at

www.colorado.gov/governor C O LO R A D O M E D I C I N E    7 


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

Physicians are and have been taking active steps to control costs in parallel with proposals in the legislative and regulatory arenas. As last summer’s survey showed, significant percentages of CMS physicians are implementing or will soon implement various technologies, systems or strategies to contain costs while ensuring quality. This issue of Colorado Medicine features the concrete actions being taken by just a few of the many practices across the state, as well as perspectives by government and business stakeholders. ■

The tipping point on health care cos

arrived,” Downs said. “Together phy sicians can work with others across the bro ad health

care sector to promote cost-conta inm

solutions that are data-driven and

centered, to influence reductions

ent

patient-

in the

cost of care while ensuring quality. ” - Dave Downs, MD, FACP

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F E ATU R E

RELENTLESS

IMPROVEMENT

Specialty practice demonstrates high-value care while relentlessly pursuing continuous improvement in patient-centered care and cost reduction Alan Kimura, MD, MPH, President and Managing Partner, Colorado Retina Associates

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F E AT U R E S

The physician and administrative leadership of Colorado Retina Associates (CRA) understands that the highest-value care is delivered by physician-led organizations that strive for excellence in clinical care with person-centricity and modern business practices.

CRA is the dominant retina practice in the Rocky Mountain West and western Great Plains, with 12 physicians working alongside 128 staff seeing 24,000 unique patients per year for an annual workload of 64,000 visits. From a population perspective, our practice is the final hope for persons with both very common sight-threatening conditions such as age-related macular degeneration and diabetic retinopathy, as well as very rare inherited or inflammatory diseases. My own Master’s of Public Health training exposed me to a larger perspective on health care that medical training alone did not provide. Coinciding with my degree was the passage of the Af fordable Care Act – and the growth of the larger dialogue on how to improve health care quality while reducing costs. While the ACA addresses cost and value to a point, true transformation of the fragmented health care ecosystem can more easily be accomplished starting with physicians and patients. To meet quality and cost goals, CRA knew we had to evolve our entire leadership and operational processes. We explored peer practices across the country to see that they were solving the same clinical and business challenges that we faced, but they were doing it better.

In the 21st century physicians must know the business skills of finance, data and outcomes, and human relations, but I would also argue that you ideally need the “big picture” and forward view obtained by having fluency in health care policy, to “skate to where the puck is going to be.” I continued my training in leadership and management through the Johns Hopkins School of Public Health, the American Academy of Ophthalmology Leadership Development Program, the Medical Group Management Association, and also the American Association of Physician Leadership, and became involved in committees and workgroups at the Colorado Medical Society relevant to public policy and quality improvement. Our practice signed on to the Transforming Clinical Practice Initiative (TCPi); we were the first practice in Colorado to have completed the TCPi certification and have since been named an “exemplar practice.” Our involvement with TCPi has further demonstrated the value of developing data and outcomes measures to redesign care with patient-centricity – all to improve quality of care and reduce waste and inefficiency.

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


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

We analyzed our basic practice metrics: From 2012 to 2017 we had experienced a 27 percent growth in clinic visits and a 37 percent growth in new patient visits but we had not addressed the need for more robust staffing, revenue cycle management, IT and clinical infrastructure to meet administrative burden. What gets measured gets managed; what gets measured, managed and rewarded gets repeated. We needed a major overhaul with better oversight and performance metrics.

prescribing lower cost, off-label pharmaceuticals for first-line therapy. CRA physicians perform 64 percent of their major surgeries in ambulatory surgery centers whenever medically appropriate. CRA also saves payers by providing same-day access with their physicians on call 24/7 including nights, weekends and holidays, thereby avoiding emergency room visits. In early 2018, CRA transitioned to a cloudbased EHR that allows on-call doctors access to patients’ charts and images for higher quality triage.

C R A commi t te d to our cul ture of patient-centered care built on a foundation of continuous quality improvement. We constantly challenge ourselves to be a high-performer clinically, providing excellent care to patients and holding surgical rounds to shorten the post-fellowship learning curve. CRA was an early adopter of the AAO IRIS Registry (Intelligent Research in Sight), which aids in quality tracking, and our practice is in the second year of deploying Lean Six Sigma to drive continuous process improvement using metrics, benchmarks and internal feedback loops, resulting in care well above peer practices, while demonstrating improvement over baseline.

The next projects we are working on are, as specialists, attempting to integrate with primary care in the larger medical neighborhood to improve communication and patient referrals from and back to primary care, and to begin to leverage our data and outcomes to generate a performance story that makes the business case for quality and cost-effective delivery of care to payers, changing the discussion from arguing for another few dollars on a given code to reworking how value-based care would look for both the provider and payer. For instance, with data demonstrating “exemplar practice” status, how can a practice get relief from the inefficiencies of prior authorization and the revenue cycle? Showing payers how we have implemented data-driven care redesign, beating benchmarking of peers to demonstrate high-value care with high quality, and that we are aligned with their interests will hopefully translate into better contract terms.

My experience with Lean Six Sigma has been overwhelmingly positive: Our subject matter experts guided us through a remarkable process of self-discovery unique to our organization. Innovation bubbles up from the front-line workers rather than command-and-control directives pushed from above. Lean is a fundamental reordering of how the work is done. The efficiencies created are more respectful of patient time, allowing more patient interaction to discover their values and preferences to guide care. Another clear benefit is a reduction in stress of staff and physicians, in turn positively feeding back upon patient care. It has been an eye-opening, transformative experience. In addition to data to support excellent clinical outcomes, CRA contributed $20.3 million in cost savings in 2017 to the health care system, with a projected $23.5 million in cost savings for 2018, by

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I believe that physicians in all practice settings do not have to choose between taking care of your business and doing the right thing for the health care system. You can do both by studying your own clinical and business operations to wring out the waste. ■

COST SAVINGS MEASURES

AT A GLANCE PRESCRIBING

LOWER COST PHARMACEUTICALS

2017

20.3

MILLION

2018

(PROJECTED)

23.5

MILLION

SURGERIES PERFORMED IN AMBULATORY SURGERY CENTERS

64%

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Carr Healthcare Realty 303-817-6654 or visit carrhr.com Dynamic Physician Billing Solutions 303-913-0508 or visit dynamicphysicianbilling.com Eide Bailly 303-770-5700 or eidebailly.com/healthcare Favorite Healthcare Staffing 720-210-9409 or medicalstaffing@favoritestaffing.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com *CMS Member Benefit Partner MINES & ASSOCIATES 800-873-7138 or visit www.minesandassociates.com *CMS Member Benefit Partner Officite 866-508-9176 or officite.com/webcheck/cms *CMS Member Benefit Partner RainTech 844-TEL-RAIN or visit https://rain.tech Rx Security 800.667.9723 email: info@rxsecurity.com or visit www.rxsecurity.com The Legacy Group 720-440-9095 or visit www.legacygroupestates.com TSYS 877-841-0606 or visit transfirstassociation.com/cms *CMS Member Benefit Partner Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net C O LO R A D O M E D I C I N E    1 3 


F E ATU R E

Beware of new, desperate attempts to help local residents afford health care coverage Bill Lindsay

This brief article is intended as a warning to all physicians in Colorado. You may have in your practice today individuals who participate in Health Care Sharing Ministries as an alternative to health insurance. This is of concern because under these arrangements there is no guarantee that you will ever be reimbursed for the services you perform. History has demonstrated that when the cost of goods or services get to a boiling point, people seek any alternative that will make that good or service more affordable. Examples include what happened during the gas shortages that we had in the mid-70s (when OPIC raised the cost of a barrel of crude to all-time highs), or when rents in New York City rose during the 1980s (before rent controls were put in place in 1997). Now we are seeing this phenomenon with health insurance. For the past several years Colorado has been one of the leaders in the promotion of what are referred to as “Health Care Sharing Ministries” (HCSM). What are HCSMs? When did they start? Think for a moment of being in church when the pastor remarked about Mrs. Jones who was recently diagnosed with a horrible disease, and asked to pass the plate to help her family pay for their out-of-pocket costs, or even their final expenses. We have all been exposed to that concept of “sharing.” Well, although that approach may have had its origins with the Bible, with a charitable intent, the new version is not the same.

The HCSMs provide no such assurances. They are unlicensed entities that do not provide insurance. Moreover, they do not cover claims that may be related to an individual’s behavior or actions if those behaviors or actions are excluded by the contract. Examples would include conditions related to alcohol, drugs, etc. They also do not cover mental or behavioral health.

HCSM

HCSMs are pools of individuals who pay into a third-party administrator to pay for each other’s care. This is where the aforementioned “pass the hat” parallel ends. In the modern version what is being proposed is an alternative to buying health insurance. Why should I be concerned? The greatest concern is that the individuals who participate in these sharing ministries believe that they have found an alternative to the very expensive private insurance that they had previously, or were considering

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purchasing. Why is this an issue? Private insurance plans in Colorado have to file their rates with the Colorado Division of Insurance. Those rates have to be approved by the state as being adequate and sufficient to enable the insurer to pay their claim obligations. Furthermore, the state maintains regulatory oversight over the operations of those insurers to ensure they are fair and appropriate and follow the terms of the policy that has been sold. Finally, the state maintains a guarantee fund for insurers (non-HMO plans) to ensure that if an insurer fails financially, the other insurers will be able to pay the claims that have been incurred.

Our warning is to encourage you to consider individuals with HCSM coverage as self-pay and thus to use existing practice policies (i.e., to require they pay cash for their care, or at least sign a promissory note acknowledging their obligation to you for the services provided). For hospital-based care this circumstance might be more difficult and thus additional concern should be taken.

Colorado is one of the nation’s leading states in terms of the sale of these plans and some Chambers of Commerce have even promoted them as a way to offer an alternative to the high cost for traditional insurance. The governor legislature, and the various state departments are hard at work to address the very real issues with private insurance costs. HCSMs do not provide a solution. They are not insurance. ■


F E ATU R E

Moving boldly forward on a shared goal, improving affordability of health care in Colorado Kim Bimestefer, Executive Director, Colorado Department of Health Care Policy and Financing It is my privilege to lead the Department of Health Care Policy and Financing (HCPF). We are the state’s largest health plan, serving about 22 percent of the population through Health First Colorado (Colorado’s Medicaid program), the Children’s Health Plan Plus (CHP+), and other safety net programs. Our focus has been working with providers and other key partners on improving the health outcomes and quality of care; improving health plan operations and service to providers and members; identifying opportunities to control Medicaid claim trends; and driving health care affordability to employers and consumers served in the private insurance arena. Over the last year, we collaborated with health care thought leaders to craft and roll out Colorado’s Health Care Affordability Roadmap to respond to one of the state’s and the nation’s most complex and pressing challenges – controlling health care costs. We’ve engaged employers and their representatives; consumer advocates and union leaders; providers and their representatives (including Colorado Medical Society leaders); innovators and their associations; Regional Accountable Entities; commercial payers and more. The Roadmap is designed to be customized by geographic communities across the state under the philosophy that all health care is local. Given Medicaid’s size and budget ($10 billion, 25 percent of the state’s general fund), the Roadmap informs Medicaid cost control strategy, and Medicaid learnings inform the Roadmap. The Roadmap’s ability to drive efficiencies across the continuum of Medicaid spending directly impacts the budget dollars available to invest in other key areas of state government such as transportation and education. By providing insights, the Roadmap is also an effective tool to inform health care policy.

The Roadmap’s initial focus areas were chosen because of their impact and consistent relevance to the health care cost equation, as well as our ability to lower health care costs to the benefit of all Coloradans by creating effective strategy in each category.

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Constrain prices, especially hospital and prescription drugs.

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Champion alternative payment models.

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Align and strengthen data infrastructure.

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Improve our population and behavioral health.

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Maximize innovation.

We are now implementing a few Roadmap concepts through Senate Bill 18-266, Controlling Medicaid Costs. Specifically, this bill provided funding to roll out provider cost and quality tools like Prometheus and the Prescriber Tool, to launch an inpatient hospital review program that will help us target those who need the most support when transitioning out of a hospital and modernize our claim edits to match commercial payer standards. For those new to it, Prometheus can identify potentially avoidable complications and inform referrals based on quality. The new physician Prescriber Tool offers payer and patient costs for alternative drug therapies while also offering “health improvement programs” available under the patient’s unique medical plan design. Finally, doctors will have a single tool that aggregates health improvement programs and cost-effective prescription therapy insights, inclusive of all payer reimbursement and program information. Gov. Polis has asked us to be bold. Thank you for engaging in the affordability conversation, and for being thought leaders. We appreciate your partnership, and we look forward to moving boldly forward together to respond to the voices of the Coloradans we jointly serve. ■ C O LO R A D O M E D I C I N E    1 5 


F E ATU R E

Colorado Springs primary care practice lowers cost through risk stratification and case management Kate Alfano, CMS Communications Coordinator

Q&A

Colorado Medicine sat down with Debbie Chandler, CEO of Matthews-Vu Medical Group, to talk about their efforts to contain costs. MVMG is a primary care practice with three locations in Colorado Springs and specialists in pediatrics, family medicine, internal medicine, behavioral health and dermatology. Their vision is to provide exceptional health care for children and adults, and they achieve this by investing time in their patients and focusing on providing quality care to improve health outcomes. As the practice grows, they look to continue to fulfill their mission to provide compassionate and individualized care for patients and their families.

CM: Where did you start in your efforts to address health care costs? DC: Matthews-Vu currently cares for over 30,000 Medicaid patients in the Pikes Peak Region. Dedicated providers and clinical resources continuously work to improve Medicaid patient access to primary care and health outcomes, and control spending growth. We fully embody the medical home concept and provide integrated physical and behavioral health for our patients and their caregivers. When other primary and specialty care physician practices have closed to new Medicaid and Medicare patients, we have continued to accept new and attributed patients. Last year, we acquired a second practice and location in the primary care underserved region of downtown Colorado Springs; we have opened to new Medicaid patients and are providing unprecedented access. In early 2019, we acquired a practice in the Rockrimmon region and are focusing on improved access for Medicaid and Medicare.

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CM: How did you come to be concerned about costs and why did you decide to act?

CM: What other initiatives have you pursued to reduce costs to the patient and the system overall?

DC: All indications from the federal and state governments indicate a continued shift in the way primary care physicians and other health care providers will be paid. New payment arrangements reward advanced, coordinated care for populations of patients, and provide incentives to improve qualit y outcomes (KPIs) for these populations and reduce the overall cost of care through appropriate reduction in utilization, emergency room and hospital visits. Our Population Health Department makes this possible and we believe Matthews-Vu Medical Group will be well positioned for this shift in reimbursement models.

DC: MVMG has a comprehensive risk stratification process that is applied to all population health patients and documented in our patient registry. This includes giving a patient a calculated score (HCC correlation) based on health conditions, then applying clinical intuition to the score and placing the patient in a high-, moderate- or low-risk category. High-risk patients are engaged by phone or by direct contact when they are seen for an appointment. Case management is offered to the patient at this time and, if accepted, a comprehensive assessment and care plan is written with the patient’s input. These patients are discussed with the patient’s care team on a weekly or monthly basis to ensure their goals are being met. The minimum contact with each patient who is in case management is at least monthly with an RN Case Manager (4 FTEs), although these patients typically require more frequent outreach and contact.


F E AT U R E S

Our three full-time care coordinators perform outreach to MVMG population health patients to schedule them for their annual wellness visits or to establish care with our practice when they show up on our attribution lists without having previously been seen. Annual wellness visits often help these patients achieve optimal wellness to prevent unnecessary ED visits and hospitalizations. Our care coordinators also prepare wellness visit information for our direct patient care staff to ensure all preventative screenings and tests are addressed. Then our care coordinators follow up after each visit is completed to ensure the ordered screenings and tests were completed.

CM: How does your practice arrangement as a multi-specialty group assist in your cost-containment efforts? Could other practices (solo, small group, physician-owned, hospital-owned, etc.) adopt these strategies? DC: Each MVMG patient that visits the emergency department or who has an inpatient stay is contacted by our PHM staff within two business days from the time of discharge. Our case managers obtain discharge information daily from each hospital’s elec tronic medical record system so there is no lag in our office receiving discharge information. During these calls we talk with the patient about discharge instructions, perform a medication reconciliation and schedule a follow-up visit, usually within two weeks, to ensure they are not re-hospitalized, and they are safe until they are seen by their MVMG PCP. Through patient education and follow up, we have seen a quarter-over-quarter documented decrease in our ED/inpatient utilization.

For those patients who do not qualify for longitudinal care management, our case managers spend many hours finding resources and coordinating care for MVMG patients. This could be anything from transportation to housing, psych services, addiction support, medication management, advanced placement, Department of Human Services, etc. We provide a very comprehensive service to this population of patients. Our case managers often spend several hours searching for resources and advocating for this population of patients. CM: What have you learned from your experiences that would be valuable to other groups who may or may not be addressing health care costs? DC: It is important to be aware of the many ongoing changes in health care. We consistently monitor health care costs, trends and service lines. Being proactive rather than reactive has been a valuable tool for MVMG. ■

Have you heard? The TMF Physician Practice Quality Improvement Award Program online application is live! Physician practices in the state of Colorado with one or more licensed physicians providing care for Medicare fee-for-service patients is eligible to apply for an award.

Get the recognition your practice deserves. Visit https://award.tmf.org to review the criteria and apply. The deadline to apply is May 31, 2019.

You and your team should be recognized for your hard work. Apply today! C O LO R A D O M E D I C I N E    1 7 


F E ATU R E

OPINION

Behavior is the most modifiable component of health costs Michael J. Pramenko, MD

“Let food be thy medicine and medicine be thy food.” - Hippocrates Ask government officials, the business community, the media or even individual physicians to identify the greatest driver of health care costs and you’ll likely get 10 different answers. And while the issue of cost is certainly complex without a one-size-fits-all solution, there is one large root cause that is often overlooked: patients’ risky or unhealthy behaviors and our society’s incentives to pursue wellness. If our individual communities, the state of Colorado or the nation want to effectively address health care costs, we simply must align the various elements that guide our behaviors from commercial interests to social norms.

If not, even the world’s best designed health care system will fail under the weight of preventable chronic disease, substance abuse, mental health problems and poverty. Societies throughout human history have fallen into decline or collapsed altogether. Just like a business, if a society fails to adapt or respond to challenges over time, it will fail. An advanced society of the future will align its commercial, governmental and civil interests to navigate the incredibly high cost of modern-day health care.

Commercial determinants of health, as defined by Kickbusch et al. in an article in the medical journal “Lancet,” are “strategies and approaches used by the private sector to promote products and choices that are detrimental to health.” Pick your poison, from alcohol to marijuana, from tobacco to firearms, our society spends more energy and resources advocating unhealthy behavior than we do advocating healthy behavior. It is no wonder we are losing ground. Life expectancy in the United States is falling. Nicotine abuse is making a comeback with vaping. Type 2 diabetes is exploding with the obesity epidemic. Alcohol abuse continues to devastate lives and families. And of course, everyone is aware of the tens of thousands of lives lost each year to firearms. Ignore the commercial and social determinants of health at your own peril. We are drowning in them. Good health begins with the individual and not the health-care system. However, the decisions made by each single individual are heavily influenced by the society in which that person resides. Recent research has shown that your ZIP code is the best indicator of your health status.

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F E AT U R E S

While the private sector appropriately demands a control on the high cost of health care, components of that same private sector continue to market products that push us in the opposite direction of affordable population health. The same is true for the general public. We are demanding a more affordable healthcare system but do we truly support the alignment of policies that will be essential to reach that goal? Would you support greater sin taxes on tobacco? Would you support alcohol rehab and payments to the health care system financed by sin taxes on alcohol? Would you support a sugar tax? While some groan at the very idea of such policy, remember that we are all paying an increasingly large “tax” every month with your insurance premiums. Purchase a health insurance premium or pay taxes to cover Medicaid and Medicare and you are increasingly paying a tax to treat preventable chronic disease. So, in the future, private industries distinctly linked to poor health outcomes must help lower health insurance premiums via sin taxes. At the same time, we should offer discounted health insurance premiums to individuals who commit to healthy living. After all, auto insurance and home insurance companies have marketed these types of policies. In essence, we would market healthy behavior. Once we market healthy behavior more aggressively than we market unhealthy behavior, we can expect to see real progress. True innovative disruption of the American health care system will address the commercial and social determinants of health. After all, human behavior makes up the most modifiable component of health care costs. ■

Michael J. Pramenko, MD, is the executive director of Primary Care Partners in Grand Junction. He is chairman of the board of Monument Health and is a past president of the Colorado Medical Society.

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F E ATU R E

Success stories in health care costs: SurgOne/TraumaOne Kelly L. Baldessari, Director of Managed Care Contracting and Quality, Physician Practice Management (PPM), SurgOne PC, TraumaOne PLLC The 41 physicians of SurgOne PC, a comprehensive multi-specialty surgical group serving patients from Castle Rock to Lafayette and Aurora to Littleton and Englewood, pride themselves on high quality of care, demonstrated by thorough preoperative and postoperative evaluation and successful surgical outcomes. The patient has always been the center of what we do. Our providers recognized early on that duplicative testing and being out of network did not benefit our patients. That led to another focus: bending the cost curve for the benefit of patients and the system overall.

Consider four actions we have taken to reduce costs over the past few years.

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Providing self-funded employer group-bundled payment

At SurgOne we started working with self-funded employer groups to allow for bundled payments two years ago. It has been very successful in giving patients an opportunity to get the procedures they need without having to pay any out-ofpocket cost. They continue to keep their traditional employer-paid insurance but can use the surgical rider that the employer purchases for certain surgical procedures. We not only save the patient money but also the employer as these services are provided at a significantly discounted rate because the providers have no administrative cost for providing these services; i.e. no pre-authorizations, referrals or claims challenges. We agree on the bundled amount and get our check seven days after they receive our HCFA reimbursement form. In the last four months I have been in discussions with three more of these types of companies. It’s a simple concept with a huge result in savings.

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Ensuring an in-network trauma group

In 2014 TraumaOne PLLC, a subsidiary of SurgOne, started one of the first in-network trauma groups to give patients who seek care in the emergency room a guaranteed in-network physician. In most hospitals the emergency department and trauma physicians are out of network after 5 p.m. and use a different tax identification number to bill for their services. Hospital executives have told us that they have no choice but to let these physicians practice in their hospitals or they will lose their elective cases during the day when they do use their commercial contracts and are considered in network. We use freestanding ambulatory surgery centers (ASCs) whenever possible, which offer significant savings over a hospital set ting – creating cost savings for patients and the system. We were able to improve from 65 percent of cases going to the freestanding centers to 85 percent within one year. This allowed us to participate in shared savings opportunities with UnitedHealthcare and Cigna. In just three months we have even moved cases out of certain high-cost freestanding ASCs into a much more cost-effective one. In addition, our physicians are now using conscious sedation instead of Propofol when appropriate so that no bills from anesthesia are generated.

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Keeping surgical site infections down

The Centers for Disease Control and Prevention estimates that four percent of surgery patients get surgical site infections post-operation. If we take a conservative estimate that we perform approximately 18,000 procedures annually, approximately 720 patients should have surgical site infections. With our rate of 2.3 percent, only 414 patients develop surgical site infections. The average cost of a surgical site infection is $15,000. If you calculate the difference between expected and actual infections and multiply by the cost per infection, our group is saving the system $4.6 million dollars each year.


F E AT U R E S

Improving quality and reducing costs: Post-op outcomes data SurgOne performs significantly better than national averages. Data was collected on over 3,800 unique patients. Surgical site infections National average 4% SurgOne performing at 2.28%

Re-admissions

Developing pneumonia

Centers for Medicare and Medicaid Services (CMS) target is less than 15%

National average 2%

SurgOne performing at 2.60%

Unplanned return to the operating room

Developing DVT/PE National average 4% SurgOne performing at 0.48%

SurgOne performing at 0.21%

No national average available SurgOne performing at 1.38% Post-operative anastomotic leak No national average available SurgOne performing at 1.27%

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Reducing hospital length of stay

We have impressive data through Intuitive Surgical that proves when certain procedures are done robotically versus laparoscopically or open, it can reduce hospital lengths of stay by 1 to 4 full hospital days. With a group our size, reducing the length of stay by a couple of hundred days a year is a significant cost savings and huge patient satisfaction booster.

Through our affiliation with the Transforming Clinical Practice Initiative (TCPi), a federally funded support network, we teamed up with Radiology Imaging Associates (RIA). In our partnership, RIA shared data with us which showed that SurgOne providers order the right imaging study 99 percent of the time. It is estimated nationwide that 33 percent of tests ordered are unnecessary. That equates to a cost savings of $8 million for our group annually.

Though these cost-saving strategies take time and effort to grow, we continue to identify ways to improve quality and reduce costs. We made a hard push in 2018 to reduce the number of opioids we prescribe after surgery and have already seen a dramatic decrease in the number of pills dispensed. We will continue this effort in 2019. In addition, we plan to launch telemedicine services. We will grow TraumaOne to bring more out-of-network physicians in network and continue to pursue other cost saving opportunities as they arise. ■

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F E ATU R E

CO TCPi practices recognized on national stage Heather Grimshaw, Director of Communications, Strategic Partnerships Colorado State Innovation Model (SIM) Two Colorado Transforming Clinical Practice Initiative (TCPi) practices were recognized for the exceptional work they do for patients during the 2019 Centers for Medicare & Medicaid Services Quality Conference in January, which focused on “innovating for value and results.” Executives from SurgOne, Englewood, Colo., and the PIC Place, Montrose, C o l o. , p re s e n te d t h e i r s t o r i e s t o hundreds of attendees and were both selected “best in category” for medication management and patient and family engagement, respectively.

“It was an eye-opening experience for me,” said Rena Bach, chief executive officer, SurgOne, who represented the group. “It was great to see so many like-minded individuals,” she added, citing the diverse nature of attendees including SurgOne as well as smaller practices and Medicaid-based clinics engaged in practice transformation efforts to improve quality.

just day to day for us, but she makes it seem like I’m standing still.” Perspective is everything and looking at t he s tories t hat Bach and Hall presented, it is clear that no one is standing still. Both teams have ambitious plans to improve patient care, experience and outcomes.

Bach says she was especially inspired by the PIC Place story presented by Melanie Hall, executive director, during the conference. “She really inspired me to continue to get better,” Bach said. “It’s

TCPi work SurgOne obtained significant physician buy-in throughout the practice and cut its opioid prescriptions (number of pills prescribed) by 50 percent in 2018. In addition to a lower surgical infection rate, SurgOne’s use of ambulatory surgery centers saved $10 million dollars annually. The message conveyed to all physicians was to cut the number of pills in half. In other words, for physicians who were prescribing 30 the request was to reduce the number of pills to 15, and a

cut its opioid prescriptions

(number of pills prescribed)

process change so that all patients who requested refills had to be seen by a SurgOne physician. Despite initial fears that patients would complain or that the process change would diminish a physician’s quality of life due to last-minute or after-hours requests for refills, the change has been almost seamless, Bach says. The key is setting patient expectations. The new patient policy is as follows: Physicians explain to patients that there will be a certain amount of pain with a surgery

50%

and provide some perspective on what is normal pain and what’s not. They also explain that they’re prescribing a certain amount of painkillers, which should handle that pain and, if it doesn’t, they need to see that patient before refilling the script. “Our goal is to have fewer pills sitting on the shelf, fewer pills that could be taken by someone else and fewer pills that lead to heroin addiction,” Bach explains.

use of ambulatory $saved surgery centers 10 million dollars annually

Patient engagement Both SurgOne and the PIC Place have reassessed processes to meet patient needs and have seen positive results from their work. The PIC Place developed an internal, complex needs team that was recognized by the federal CMS for excelling in patient

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and family engagement work. This team engages patients by asking what their best version of health looks like. Regular reviews of these journeys engage the patient and provide opportunities to celebrate success and address health concerns before patients and providers

start to feel overwhelmed. Get more details about how PIC Place accomplished it s work and learn more about SurgOne’s approach to reducing opioid use and reducing surgical infection rates at www.co.gov/healthinnovation/ TCPisuccesses. ■


F E ATU R E

State CMO warns of youth vaping in Colorado and its connection to other risky behaviors A letter by Tista S. Ghosh, MD, MPH, interim chief medical officer of the Colorado Department of Public Health and Environment, was recently published in the New England Journal of Medicine. In the letter, “Youth Vaping and Associated Risk Behaviors — A Snapshot of Colorado,” also authored by CDPHE colleagues Rickey Tolliver, MPH, Alison Reidmohr and Michelle Lynch, Ghosh urged health care providers to screen youth specifically for vaping, along with tobacco, as many teens may not associate vaping with tobacco.

She wrote that Colorado has the “dubious distinction of leading the nation in the use of nicotine-containing vapor products (electronic cigarettes), or vaping, among young people under the age of 18 years.” According to the most recent national Youth Risk Behavior Survey, one in four high school students in Colorado reported vaping, a rate twice the national average. This makes Colorado No. 1 in the nation for youth vaping among the 37 states surveyed. According to the National Academies of Science, Engineering, and Medicine, there is substantial evidence that youth who vape are likely to later smoke cigarettes. There is also strong evidence that nicotine, which is found in most popular vape products, is harmful to the developing brain.

In her letter, Ghosh describes associations between vaping and other risky behaviors in youth, based on data from the Healthy Kids Colorado Survey of more than 40,000 high school students across the state. Analyses of that survey data revealed that youth who vape have a significantly higher likelihood of using prescription pain medicines that are not prescribed to them, binge drinking, using marijuana, and engaging in sexual activity. While these associations are not causal, they offer the opportunity to turn a vaping counseling session into one that involves screening and discussion related to substance abuse, pregnancy and HIV prevention. ■ Access the letter online at

www.nejm.org The Colorado QuitLine has made free coaching available for children as young as 12 who are attempting to quit any nicotine product. Refer patients to call 1-800-QUIT-NOW or visit www.coquitline.org.

Colorado has the dubious distinction of leading the nation in the use of nicotine-containing vapor products (electronic cigarettes), or vaping, among young people under the age of 18 years.

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F E ATU R E

Metro-area legislators and physicians convene for dialogue on liability and professional review Kate Alfano, CMS Communications Coordinator

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Members of the Colorado General Assembly and physicians met on Jan. 30 to discuss the anticipated efforts by lawyers that sue physicians to expand the value of a lawsuit by increasing the non-economic damage cap and changing some of the protections relating to the body of law governing professional review. Benjamin Kupersmit, president of Kupersmit Research, presented preliminary findings from a CMS all-member survey demonstrating that physicians strongly support protecting the confidentiality of professional review and maintaining the non-economic damage cap at its current level. View results of the survey in the May/June issue of Colorado Medicine. The convening was held at the History Colorado Center in downtown Denver and was hosted by the Colorado Medical Society, Denver Medical Society, Arapahoe-Douglas Elbert Medical Society, Aurora-Adams Medical Society and Foothills Medical Society.

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Attendees were welcomed by Senate President Leroy Garcia (D-Pueblo) and, following Kupersmit’s presentation, broke into small groups to discuss. ■

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Sen. Angela Williams (D-Denver) addresses the event’s attendees.

2. Guests enjoyed small plates and good conversation. 3. Rep. Colin Larson (R-Littleton) introduces himself. 4. Rep. Emily Sirota (D-Denver) introduces herself. 5. Small-group discussions focused on the top issues in medical public policy. 6. Rep. Larry Liston (R-Colorado Springs) poses with CMS members. 7.

Rep. Julie McCluskie (D-Dillon) addresses attendees.

8. Sen. Dennis Hisey (R-Fountain) thanks the doctors for sharing their perspectives. 9. Pollster Benjamin Kupersmit presents the results of the peer review survey. 10. Hisey poses with CMS members. 11. Sen. Bob Gardner (R-Colorado Springs), center, asks questions of the physicians in his small group. 2 4     C O LO R A D O M E D I C I N E

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I heard many compliments from physicians, executives and legislators about the value of the night and how well organized the event was,” said CMS President Debra Parsons, MD, FACP. “Everyone loved being ‘up close and personal’ at the table discussions and benefited from good mingling opportunities. Many stayed after the event concluded to finish their conversations!”

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LEGISLATIVE UPDATE

A mid-session report on medicine’s top issues Emily Bishop, Program Manager, CMS Division of Government Relations The 2019 session is almost to the halfway point and CMS is working hard to track legislation that affects the physicians of Colorado and their patients. With staff support, the CMS Council on Legislation (COL) is reviewing each relevant bill to understand its intent, possible outcomes and the political landscape to collectively determine how and at what level CMS should engage.

Still to come: Colorado’s Professional Review and Medical Practice Acts

CMS’s number one priority this session, preserving the Medical Practice and Professional Review Acts, is yet to have a bill number assigned. While CMS is poised to take the lead on this legislation, bills reenacting the acts will not be introduced until March.

Here are a handful of particularly interesting bills that align with CMS’s legislative priorities.

OPIOIDS SB19-008 Substance Use Treatment Criminal Justice System

HB19-1009 Substance Use Disorders Recovery

Senate Bill 19-008 concerns the treatment of individuals with substance use disorders who come into contact with the criminal justice system. Individuals receiving medication-assisted treatment in local jails are allowed to continue treatment when transferred into the custody of the Department of Corrections. The bill also requires the Colorado Commission on Criminal and Juvenile Justice to report on alternatives for filing criminal charges against individuals suffering from substance use disorders arrested for a drug-related offense and a process for sealing criminal records for drug offense convictions.

The 2018 General Assembly worked tirelessly to pass a suite of opioid legislation aimed at prevention, treatment and harm reduction. House Bill 1009 seeks to build on that foundation and expand the housing voucher program to include individuals with substance use disorders. The bill would also establish a licensing system for recovery residences to standardize treatment.

Under this bill, Colorado would also seek federal authorization under the Medicaid program for the treatment of individuals with substance use disorders in jails. The bill is a result of the 2018 Interim Study Committee on Opioid and other Substance Use Disorders.

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This is another bill originating from the study committee, CMS is encouraged to see more being done for individuals in recovery. SB19-079 Electronic Prescribing Controlled Substances The CMS Prescription Drug Abuse Committee worked closely with the sponsors of SB 79 to ensure the bill included exceptions to the electronic prescribing mandate that reasonably accommodated system limitations and the nature of providing care in Colorado. The bill requires podiatrists, physicians, PAs, APNs, optometrists, and dentists to prescribe schedule II, III and IV controlled substances electronically. The CMS lobby team continues to work closely with sponsors to ensure no unintended consequences or hardship result from this bill.


F E AT U R E S

HEALTH CARE COVERAGE AND ACCESS, COSTS AND TRANSPARENCY HB19-1004 Proposal for Affordable Health Coverage Option This bill concerns a proposal for implementing a state option for health coverage. The bill directs the Department of Health Care Policy and Financing and the Division of insurance, with a robust stakeholder process, to study the costs, benefits and implementation logistics for a state option. CMS is pleased to see a reaction to the inordinately high cost of health care in Colorado. The CMS Work Group on Health Care Costs and Quality is watching this legislation closely. SB19-134 and HB19-1174 Out-of-Network CMS has been focused on the issue of unanticipated treatment by out-of-network providers and surprise billing for the past five years and is pleased to see political momentum on the state and federal level to find a solution. Both bills seek to end the practice of balance billing and take the patient out of the middle. CMS is working with stakeholders and the bill sponsors to establish a clear system for notifying patients and to standardize fair compensation for providers. The CMS lobby team is confident an agreement can be reached between the two bills that effectively protects patients while maintaining physician negotiating power.

HB19-1211 Prior Authorization Requirements Health Care Service CMS was behind this legislation introduced in the House of Representatives at the end of February. The bill seeks to ease the administrative burden on physicians and streamline patient access to care by promoting safe, timely access to evidencebased care. The bill will standardize prior authorization among payers and utilization management organizations. Providers with 80 percent or higher approval rating on prior authorizations in the last 12 months will be exempt from further prior authorization requests. If a carrier or organization fails to make a timely determination on a request, the request is deemed approved.

Addressing physicians’ pain points: The Colorado Medical Society strongly supports prior authorization streamlining as outlined in HB19-1211. According to a 2018 CMS membership survey, nearly one-half of Colorado physicians (48 percent) say prior authorization has become harder over the past few years, including 28 percent who say it has become much harder and 20 percent who say it has become a bit harder.

SCOPE OF PRACTICE HB19-1095 Physician Assistants Supervision and Liability COL and the Scope of Practice subcommittee are working closely with PAs on this bill, which addresses supervision requirements and the number of PAs on the Colorado Medical Board. CMS is confident that a compromise can be found on this bill that suits both physician and PAs while improving patient access to care. The CMS lobby team expects many more bills relating to health care and physician practice in the state before the session adjourns May 3. Watch for a legislative wrap-up in the next issue for an update of this and other legislation. ■

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Peer review protections are critical to continually improving care Thomas F. Dwyer, M.D

The Colorado Professional Review Act or CPRA was established to promote patient safety through peer assessment. As physicians we are positioned to evaluate the care patients received much better than the court system. We not only have an obligation to care for patients, we have a duty to continually improve the care provided. We must learn from mistakes and system failures in a way that promotes safety and accountability of both people and systems. While one individual or a small group of individuals may benefit financially when care is evaluated through the court system, it is our patients, their families, our peers, our staff, our students and us as individuals who benefit when peer review is conducted in an effective manner.

A protected peer review process allows practitioners the opportunity to give and receive candid feedback. This feedback is shared peer to peer and, when appropriate, with the hospital and systems we depend on to provide care. This very important feedback provides education, it corrects system shortcomings, improves the environment, and promotes learning, growth and development. Best of all it helps keep our patients safe and allows us to practice high-quality medicine.

Without the Colorado Professional Review Act, physicians may be disincentivized to self-report. They may also choose not to report possible concerns regarding colleagues. This has the potential to stifle patient safety, limit reviews and squash the system we use to provide each other with candid, open and constructive feedback. As providers we spent our lives learning how to take care of patients, providing care to our community, and working to make a difference in the lives of our patients and their families. We do this work because we care about people and the quality of their lives. We value the trust placed in us and feel a great sense of responsibility to continually improve the care delivery system and to ensure that each person has the best possible outcome. The Colorado Professional Review Act helps us to learn from each

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other through a trusting, safe environment, where we know our peers have the same mission to provide great care and always strive to be better. Having frank conversations with our peers may seem simple and obvious but it takes courage to ask for help, advice and constructive criticism. The Colorado Professional Review Act allows for trusting, safe environment, where we can be vulnerable so our patients do not have to be. The legal protections provided by the act allow us to be open, collegial, reflective; without these protections physicians are more inclined to be defensive, guarded and reactionary. What type of provider would you want taking care of your loved one? I know I prefer my physicians to be open, to admit mistakes, to continually learn, to be reflective and to seek the advice of their colleagues. ■

Dr. Dwyer is a board-certified orthopedic surgeon who specializes in general orthopedics. He joined Western Slope Orthopedics in 2001 after completing residency and fellowship training at the University of Colorado. In training, Dr. Dwyer participated in, presented, and published award - winning research projects involving total knee replacement and spine care. He has extensive experience in the surgical treatment of arthritis, sports related injuries, fractures, and other disorders of the upper and lower extremities. Dr. Dwyer truly enjoys the Montrose community. Away from work, he enjoys spending time with his wife Tanya and their three boys fly fishing, hiking, skiing and riding horses.


F E ATU R E

Coalition launches opioid safety pilot programs in partnership with Colorado medical specialty societies Debra Parsons, MD, FACP

Darlene Tad-y, MD

President, Colorado Medical Society

Physician Advisor, Colorado Hospital Association

A coalition comprising the Colorado Hospital Association, the Colorado Consortium for Prescription Drug Abuse Prevention and the Colorado Medical Society launched a new safety initiative in January. The Colorado Opioid Solution – Colorado Clinicians United to Resolve the Epidemic (CO’s CURE) seeks to create partnerships between Colorado’s hospitals and the state’s medical specialty societies to develop the nation’s first

THE

4

pillers

1 LIMIT OPIOID USE

The first phase of CO’s CURE will be led by the Rocky Mountain chapter of the Society of Hospital Medicine, which represents the state’s hospitalists. The organization is currently working with the coalition to develop guidelines for hospitalists that can be piloted at a Colorado hospital later this year. This first phase will be funded by a State Opiate Response grant through the Colorado Office of Behavioral Health. Our goal is to continue the important work that Colorado hospitals and providers have already partnered on – treating pain while also reducing harm – through the development of additional opioid prescribing guidelines. This initiative continues the successful model of having clinicians help champion the work, which accelerates the rate of adoption and sustainability. We look forward to working with our state’s specialty societies to develop and trial these guidelines

comprehensive, multispecialty medical guidelines for limiting opioid use and increasing the use of alternatives to opioids (ALTOs). CO’s CURE will provide the resources to convene medical specialty society organizations to develop and implement new evidence-based opioid prescribing guidelines to pilot in Colorado hospitals and medical practices. The specialty-de-

2

rived guidelines will be built around four pillars that all specialties can adhere to – limit opioid use, use ALTOs for treatment of pain, implement harm reduction strategies, and improve treatment and referral of patients with opioid use disorder – while also allowing the specifics of each set of guidelines to be tailored to the nuances of each specialty.

3

4

USE ALTOS FOR

IMPLEMENT HARM

IMPROVE TREATMENT AND

TREATMENT OF PAIN

REDUCTION STRATEGIES

REFERRAL OF PATIENTS WITH OPIOID USE DISORDER

and ultimately help resolve the opioid epidemic in Colorado’s communities and lower costs for the entire health care system. In 2017, CHA, in partnership with the Colorado Chapter of the American College of Emergency Physicians (CO-ACEP), launched a six-month pilot study of the CO-ACEP opioid guidelines in 10 hospital emergency departments, which demonstrated an average 36 percent reduction in opioid administration and 31 percent increase in the use of ALTOs. By the end of 2018, those pilot sites had decreased the administration of opioids by 62 percent. The pilot has since been expanded into the Colorado ALTO Project and rolled out across the state and beyond. CO’s CURE was launched during the second annual Colorado Opioid Safety Summit in January. More than 400 medical professionals, double the number at

the 2018 event, attended the summit to address the opioid epidemic in Colorado. As our colleague Don Stader, MD, an emergency room doctor with Swedish Medical Center, told the audience at the summit, if the only place you could get medical care was the emergency department we would have made greater improvements in the opioid epidemic. Since that’s not the case, we must expand the program to areas where more people get medical help, like the office of their family doctor and with surgeons and dentists, to help them create guidelines of their own about opioid prescriptions so that there is a more uniform approach. The goal is to be more judicious with prescribing; opioids are no longer the first-line treatment for pain but can be used appropriately for severe pain if necessary.

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F E AT U R E S     C O ’ S C U R E :   C O N T

All specialty societies in Colorado are welcome and encouraged to join CO’s CURE by March 15 to continue moving this initiative forward. By providing robust support to specialty societies, Colorado can formulate the nation’s first comprehensive, multi-specialty medical prescribing guidelines that can help assure access to compassionate, evidence-based care for patients who suffer from acute and chronic pain, offer better treatment to those suffering with opioid addiction and significantly reduce the morbidity and mortality associated with opioid abuse and misuse. Together we can revolutionize the treatment of pain and improve the care of addicted patients, and serve as a model to the rest of the nation.

Key messages • CHA, CMS and the Consortium are launching a new initiative designed to reduce opioid administrations in the inpatient setting using the same model as the Colorado ALTO Project. • Because pain is one of the most common reasons for inpatient admissions and often leads to opioid administrations, it is important for specialties to create alternative pain management guidelines in order to reduce opioid exposures. • Because of the success of the Colorado ALTO Project, the initiative’s leadership is again partnering with specialty society organizations to develop prescribing guidelines that are tailored to the nuances of each specialty. This model will lead to clinicians helping champion the work, which accelerates the rate of adoption and sustainability. ■

CO’s CURE timeline

JAN MAR 2019

APR JUN 2019

Confirm all organizations’ participation by March 15, 2019

Review specialty literature, including current opioid guidelines and protocols to identify gaps specific to the Colorado Chapter of the American College of Emergency Physicians pillars

Finalize revised draft of guidelines

Complete first draft of guidelines by June 1, 2019

Identify pilot sites

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JUL SEP 2019

Attend mid-year in-person meeting in August to collaborate and discuss progress with other specialty societies participating in CO’s CURE

OCT DEC 2019

JANUARY 2020

Final draft of specialty guidelines due from specialty organizations by Dec. 31, 2019

Attend January 2020 Colorado Opioid Safety Summit Officially launch CO’s CURE guidelines Begin piloting guidelines


F E ATU R E

AMA, Colorado Medical Society and Manatt Health release study of Colorado’s efforts to reverse opioid epidemic Spotlight analysis finds progress made on numerous fronts, recommends next steps for policymakers, insurers and physicians Kate Alfano, CMS Communications Coordinator

The American Medical Association, Colorado Medical Society and Manatt Health released a report in January that shows Colorado has implemented meaningful reforms in response to the opioid epidemic though further steps are needed to save even more lives. The Colorado spotlight analysis found that progress is being made to increase access to evidence-based treatment for substance use disorders, several pilot projects have improved care for patients with pain, and increased access to the opioid overdose-reversing drug naloxone has resulted in thousands of lives saved. “We conducted this analysis because it’s essential that policymakers know what is working, and where additional progress can be made,” said AMA President-elect Patrice A. Harris, MD, who also chairs the AMA Opioid Task Force. “Colorado has implemented many important policies that are impacting patients’ access to care. Using this momentum, we think Colorado can go even further to save lives of those affected by opioid use disorder.” Colorado is the second in a series of individual state studies. The AMA released a study on Pennsylvania in December and also released additional analyses of North Carolina and Mississippi in early 2019.

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Based on available data, review of policies, and discussions with key policymakers, the analysis found four key areas where Colorado is succeeding: ADOPTION OF POLICIES AND FUNDING

INCREASING MEDICAID PATIENTS’

TO INCREASE ACCESS TO MEDICATION

ACCESS

A SSISTE D TRE ATME NT,

A LT E R N AT I V E S

including initial steps to reduce administrative barriers, increased funding to address workforce issues, and plans to increase Medicaid coverage in residential settings.

EX AMINING COMPLIANCE WITH MENTAL HEALTH AND SUBSTANCE US E D I SO R D E R PA R IT Y L AWS

through the Colorado Division of Insurance’s review of insurers’ conduct and the establishment of an ombudsman’s office to assist patients in accessing behavioral health care.

“This analysis comes at an important time for Colorado,” said CMS President Debra Parsons, MD, FACP. “Over the last six years, Colorado has developed policies, enacted laws and made important strides to have all stakeholders work together to reverse the opioid epidemic. While we continue these successful initiatives, we must closely evaluate how they are working so we can ensure we are putting our efforts in the right places.”

TO

NON-OPIOID FOR

PAIN

including coverage of non - opioid prescription medicat ions and al ternat i ve therapies such as physical therapy, occupational therapy and additional behavioral health care treatment options. MANAGEMENT,

EXPANDING ACCESS TO NALOXONE

with early legislation and implementation of a standing order for naloxone, Good Samaritan protections, and elimination of prior authorization for naloxone under Medicaid.

The analysis also highlighted the work of the Colorado Consortium for Prescription Drug Abuse Prevention, which has brought together several hundred stakeholders and continues to develop a data-driven, county- and state-level data dashboard that can be used to help direct resources to areas of greatest need.


F E AT U R E S

The analysis also found areas where additional progress could be made: E L I M I N AT I N G B A R R I E R S T O

LEVERAGING SUCCESSFUL STATE

EVALUATING STATE POLICIES AND

TREATMENT,

PILOTS

PROGRAMS

EXPANDING ACCESS TO PROVIDERS

LINKING THOSE WHOSE LIVES HAVE

O F M E D I C AT I O N A S S I S T E D

BEEN SAVED BY NALOXONE

including further steps to increase enforcement of mental health and substance use disorder parity.

especially in the state’s rural areas. TREATMENT,

Further expand MAT treatment workforce

Remove barriers to high-quality, evidence-based SUD services

to increase access to multimodal pain care and comprehensive benefit and formulary designs.

to determine what is improving patient care and reduce opioid-related harms, including whether current policies may be resulting in unintended consequences.

with follow-up treatment to begin and sustain recovery.

Enhance comprehensive pain care, non-opioid alternatives

Strengthen mental health and SUD parity enforcement

Remove stigma associated with MAT

“This analysis comes at an important time for Colorado,” said CMS President Debra Parsons, MD, FACP. “Over the last six years, Colorado has developed policies, enacted laws and made important strides to have all stakeholders work together to reverse the opioid epidemic. While we continue these successful initiatives, we must closely evaluate how they are working so we can ensure we are putting our efforts in the right places.”

“Many of the recommendations in this report related to commercial insurance – such as strengthening our market conduct examinations to better enforce mental health parity and more comprehensive front-end reviews of the number of addiction professionals in insurers’ networks – are fair and reasonable approaches that are within our authority to immediately tackle,” said Colorado Insurance Commissioner Michael Conway, head of the state’s Division of Insurance. “We look forward to working with Colorado’s health insurers and physicians to implement solutions that help ensure consumers receive the care that they need to help end our state’s opioid epidemic.”

Colorado was chosen for the demonstrated ability of government and private stakeholders to work together to implement a coordinated state strategy in the prevention and treatment of opioid use disorders. The AMA recognizes the key role of states in responding to the epidemic and seeks to disseminate best practices in prescribing and treatment that are implemented in a coordinated way, demonstrating that there is a path forward that reflects the complexity and challenges of tackling this epidemic. The AMA has responded aggressively to the opioid epidemic, establishing an AMA Opioid Task Force, providing education and training to its members, and advocating for better policies and procedures with government leaders.

CMS has also responded aggressively, fully supporting and actively participating in the Colorado Consortium for Prescription Drug Abuse Prevention since its inception under former Colorado Gov. John Hickenlooper; convening the special CMS Committee on Prescription Drug Abuse comprising physicians and special advisors on this issue; providing education to physician members; and distributing best practices and education to members from other partners. ■ READ THE FULL REPORT AT

www.end-opioid-epidemic.org/ coloradospotlight

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F E ATU R E

EDUCATION IN ADVOCACY

Report from the AMA Medical Student Section Region 1 Meeting Fifty medical students from around the Western U.S. joined students from CU and RVU at the AMA Medical Student Section (MSS) Region 1 Meeting Jan. 4-5, 2019, at the University of Colorado Anschutz Medical Campus. The conference, which focused on physician advocacy, featured CMS leaders including CEO Alfred Gilchrist and past presidents Tamaan Osbourne-Roberts, MD, and Jan Kief, MD, in addition to Colorado MSS Region leaders Halea Meese (region chair, meeting chair), Adam Panzer (policy chair), and Krista Allen (advocacy chair). Students learned how to make a pitch to legislators, write testimony and engaged in a “Stop the Bleed” community service project. In addition to learning about advocacy during the day, the students networked at nightly social events and took a trip on Sunday to the Rocky Mountains. “The meeting was enjoyable and informative by all accounts and could not have happened without the valuable contributions of the Colorado students who served on the Meeting Planning Committee,” Meese said. ■

The planning committee members were: • • • •

Tosin Adebiyi Kiyomi Daoud Mary Wang Danielle Davis

• • • •

1

4

Jacob Leary Sofiya Diurba Danielle Davis Maggie Teets

• • • •

Mary Wang Lakshmi Karamsetty Kelsey Boghean Alysa Edwards

Register for Medical Student Day at the Capitol: Thursday, March 21, 12 - 6 p.m. Join your medical school peers at the Colorado Capitol on March 21. Fifty students from each school will attend special leadership development sessions and get face time with elected officials so they can gain perspective from the next generation of physicians before they debate and vote on matters of paramount importance to the profession. Register at members.cms.org/register

Find more information about the AMA Medical Student Section at www.ama-assn.org/membergroups-sections/medical-students. Find more information about student activities and opportunities for involvement in Colorado at www.cms.org/msc.

2

3

5

6

1. Region 1 Chair Halea Meese (CU) welcomes students to the meeting. 2. CMS CEO Alfred Gilchrist speaks to students about legislative advocacy. 3. Andrew Glerum and Sami Hourieh (CU) participate in a workshop on writing testimony. 4. Medical students from Rocky Vista University attended the MSS Region 1 meeting in Denver in January. 5. Rachel Landin (RVU), Iris Hardarson (RVU) and Kiyomi Daoud (CU) participate in the Stop the Bleed community service event. 6. CMS Past President Tamaan Osbourne-Roberts, MD, gave the keynote address, “Physician Advocacy in Action.” Shown here with Region 1 Chair Halea Meese (CU).

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F E ATU R E

REPORT FROM THE STATE ADVOCACY SUMMIT

Colorado showcased as a leader in combatting the opioid epidemic Halea Meese, Medical Student Component representative on the CMS Board of Directors Halea Meese, left, and Lee Morgan, MD, right, attend the AMA State Advocacy Summit.

Alethia (Lee) Morgan, MD, chair of the Colorado Delegation to the American Medical Association, and I attended the AMA State Advocacy Summit in Scottsdale, Ariz., Jan. 10-12. The Summit, entitled “Successful Advocacy in Turbulent Times,” focused on novel approaches to state advocacy amidst a very unstable federal regulatory climate. Attendees learned about using social media as to means to self-brand and influence legislative opinion and also received updates from the AMA advocacy staff and health policy leaders such as Len Nichols, Ashish K. Jha and Matt Salo. The summit prominently showcased Colorado’s efforts to combat the opioid epidemic, with Colorado’s interim Insurance Commissioner Michael Conway serving as a guest panelist along with the Pennsylvania Department of Insurance Chief of Staff Alison Beam. The panelists found many commonalities among the approaches the two states are employing, including establishing standing orders for naloxone and ensuring all insurance plans carry one medication on the lowest insurance tier for each class used for mediation-assisted treatment of opioid use disorder. Additionally, Denver and Philadelphia are the first cities in the nation to approve supervised injection facilities, which could be a major step forward for harm reduction in the states. Both states have been looking at insurers very closely to ensure opioid alternatives are being provided and that these insurers are closely following insurance regulations. ■

Members can download further information from the State Advocacy Summit, including the AMA-Manatt Spotlight on Colorado and presentations from the summit at

www.ama-assn.org/advocacy/physician-advocacy/ state-advocacy-summit

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F E ATU R E

Climate risks to health vary across Colorado Chrissy Esposito, Colorado Health Institute, Data Visualization and Policy Analyst Hear t disease, diabetes, asthma. Physicians are well acquainted with these maladies. But they might not understand how a warming climate can worsen health for patients with these conditions. New research from the Colorado Health Institute shows that patients in certain regions of Colorado are at an especially high risk for climate-related health impacts. Much of the public discussion on climate change in Colorado focuses on the mountain environment – impacts on snowpack levels, wildlife habitat and recreation. CHI’s research reveals that it’s a different story for human health risks related to the climate. While risks exist for mountain residents, people at lower elevations tend to be more vulnerable to climate change. The climate and health connection Climate change affects health in many ways. Colorado is experiencing rising temperatures, worsening air quality, and an uptick in environmental disasters such as wildfire and drought. The numbers tell the story. Colorado’s average temperature has risen two degrees Fahrenheit in the past three decades. Looking ahead, climate models indicate the state’s average temperature could be 2.5 to 5 degrees Fahrenheit higher by 2050. Extreme heat affects cardiovascular, respiratory and nervous systems. Heat also “cooks” pollutants already in our air into ground-level ozone, which harms cardiovascular health. Climate change is also felt in the environment. Last year was one of the worst on record for wildfires in Colorado. Smoke contains particulate matter that irritates the eyes, nose and throat, and aggravates respiratory problems. Wildfires can be deadly and survivors may experience symptoms of post-traumatic stress 3 6     C O LO R A D O M E D I C I N E

disorder, according to a study last year in the International Journal of Mental Health Systems. Who’s vulnerable Climate change is more than an environmental issue. It’s a threat multiplier that impacts social and health disparities in Colorado. For example, residents in lower-income communities are less likely to have financial means to cope with heat or extreme weather events, such as by installing air conditioning or having a place to evacuate to in case of a fire or flood. People with asthma or chronic obstructive pulmonary disease (COPD) struggle to breathe when air quality is poor. Older adults are more likely to have compromised immune systems and chronic ailments, conditions that can worsen when temperatures soar. CHI’s health and climate index Understanding the connection between our changing climate and health involves looking at this threat from multiple perspectives. Human health can be impacted by exposure factors, such as wildfires and heat. Demographic factors – age, health status, income level and more – also come into play. Health can also be affected by a community’s level of readiness, measured by perceptions about climate change and the political will to address it. CHI examined data on 24 factors involving exposure, sensitive populations and readiness to create its Health and Climate Index, a first-of-its-kind effort in Colorado to quantify local effects of climate change. Our results found that the northwest and southeast corners of Colorado are more vulnerable for exposure factors due to a high number of days above 90 degrees F. In the northwest, this increases the risk of wildfire; in the southeast, it’s drought.

Residents in southeast Colorado are most vulnerable in terms of demographics. The region has a higher than average proportion of residents who are living in poverty and have chronic health issues such as asthma, diabetes, COPD and cardiovascular disease. The northeast corner of Colorado is most vulnerable in terms of readiness. The region has the lowest proportion of residents who believe that climate change is occurring, and there are no public health or local government plans to address the issue. This Health and Climate Index is a snapshot of data from a given year. It does not track how Colorado’s climate is changing or who will be most at risk in the future. Rather, it is a tool that can be used by policymakers and health professionals to raise awareness and craft initiatives to protect the environment and the health of their neighbors. By acknowledging that climate change is occurring and enacting policies to combat it, we can reduce the negative impacts to human health and adapt to the changes we are already seeing. Physicians can use this tool to assess the relative risks for patients in their practices. For example, “treatments” for asthma or cardiovascular disease in Mesa County, which has more extreme heat days than most parts of Colorado, could include advice to avoid the outdoors on hot days and, if possible, install a home cooling system. The climate is changing, and our understanding of the drivers of health must change along with it. ■


INSIDE CMS

C O P I C

C O M M E NT

My professional review talking points Gerald Zarlengo, MD Chairman & CEO COPIC Insurance Company

Since becoming COPIC’s CEO, I’ve had several humbling learning experiences. Certain issues I thought I knew well have more depth and complexity when viewed through the lens of my new role. Professional review is one of these issues. As a practicing physician, I participated in professional review with my peers and there was a shared understanding about the value of it. Now, my conversations often look at this process from regulatory and legal angles and involve people who aren’t physicians. Luckily, I am surrounded by experts who know how to frame the issue in a broader perspective. And through my interactions with them, I’ve developed a few “talking points” to explain why everyone should support professional review.

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INSIDE CMS

The Colorado Department of Regulatory Agencies (DORA) has already recommended the reauthorization of professional review. The Colorado Professional Review Act (CPRA), which governs the professional review process, is up for review this year. The first step was an initial review by DORA and it recommended the full reauthorization of CPRA. This recommendation reinforces that professional review laws are necessary to protect patient safety, and that medical professionals are in the best position to monitor themselves because of the necessary knowledge needed to perform these complex reviews. The next step involves a review of CPRA by the Colorado General Assembly during the 2019 legislative session. Professional review doesn’t just relate to physicians in a hospital setting. In Colorado, professional review applies to those licensed under the Medical Practice Act – physicians, physician assistants and anesthesiologist assistants, as well as advanced practice nurses. In addition, CPRA allows medical practices to utilize professional review as long as certain requirements are met. This is supported by the federal Health Care Quality Improvement Act, which states that a “health care entity” includes group medical practices that follow a formal peer review process for the purpose of furthering quality health care.

We participate in professional review to learn and ensure that all patients receive the best outcomes possible.

Professional review doesn’t just examine adverse outcomes. Within the medical community, professional review is recognized as a supportive process that encourages performance improvement. This means reviews are triggered not just when an adverse outcome occurs, but also when care could be improved to avert possible issues. Professional review benefits most from a multi-disciplinary team approach where everyone can understand and embrace the changes that may emerge and make a positive difference for patients. Professional review is a key aspect of the lifelong learning physicians embark on. We participate in professional review to learn and ensure that all patients receive the best outcomes possible. I have seen first-hand the impact professional review has on quality improvement, the value of in-depth, open discussions that occur, and how those involved recognize the responsibility associated with this process.

The ultimate goal of professional review is to ensure that qualified health care professionals are providing safe and appropriate patient care. As physicians, we need to educate those outside of health care about professional review. It promotes evaluating, learning and improving care delivery as an ongoing process. CPRA enables physicians and medical professionals to share information without fear of retribution from colleagues who are under review. Without these protections, important information would likely not be shared, and patients could be at increased risk of system failures or near misses. It is also important to point out that CPRA only affords protections if certain standards (e.g., registration, compliance and reporting) are met by participants. As the American Medical Association notes, “The peer review process is intended to balance physicians’ right to exercise medical judgment freely with the obligation to do so wisely and temperately.” COPIC strongly supports the value and role of professional review and I hope that we all voice how important this process is to health care. ■

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R E F LE C TI O N S

I wonder if you’ll know I’m human, too Gavriel Roda

Gavriel Roda is a second-year medical student at the University of Colorado currently interested in pursuing surgery. She planted her roots in Broomfield, Colo., after living in several different regions of the U.S., as well as abroad in Singapore. Between this time abroad and growing up in a family containing a multitude of cultures, Gavriel became fascinated by the qualities that make each individual uniquely human. Two of her greatest inspirations include the photographer Sebastiao Salgado and the chef Francis Mallmann, who highlight the interface between boldness, creativity and dedication. Today, she enjoys writing, reading, painting and trying her hand at new recipes.

I wonder if you’ll know

I wonder if you’ll know how much I’ll break with you,

I’m human, too.

As if it were my own battle. How I’ll go home each day

I wonder if you’ll think of who I was

Thinking of you

As a child in Minnesota

Your family

Running in the forest

Your life

Chasing toads with uncalloused hands

Who you are.

Collecting sawdust like glitter. I wonder if you’ll understand when I make a mistake The day my mother held my hand in hers

When I miss that diagnosis

Walking down the streets of Bangkok

When my education

Lined with poverty

My lab tests

And outstretched arms

My imaging

She told me:

My medicine

Not everybody has the same privileges as you.

Can’t save you.

I wonder if you’ll know where my love for humanity was born.

I wonder if you’ll forgive me.

I wonder if you’ll see my dedication to you.

And I wonder if you’ll know

The times I’ll spend in the hospital

I’m human, too.

On weekends

On holidays On call.

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I NTR O S P E C TI O N S

Cookbook medicine Logan Leavitt

Logan Leavitt is a second-year medical student who grew up in Salt Lake City, Utah. He is planning to pursue a career in physical medicine and rehabilitation. He received a Bachelor of Science in Biology from Utah Valley University. He enjoys spending time with his wife Alyssa, fishing and going to sporting events.

“Not every patient reads the textbook,” a physician once explained to me. I didn’t know what he meant until I gained firsthand patient exposure. Over the past two years I have been inundated with textbook information and clinical pearls. This caused me to presume that a patient with a specific disease will always present with characteristic telltale symptoms, and that a diagnosis could be found like a recipe in a cookbook. While shadowing Dr. Brown*, a specialist in pain medicine, I was able to witness firsthand that cookbook medicine is not feasible. Dr. Brown was scheduled to see Joanne, a patient who presented with debilitating chronic back pain stemming from a car accident many years prior. It was very apparent that she was in obvious discomfort as she talked about the effect on her overall quality of life. This was not the first time that Dr. Brown had seen Joanne; she had been his patient for several years. I listened as Dr. Brown asked Joanne about her family, job and hobbies. He took a sincere and genuine interest in her life. He went through Joanne’s various medications one by one and asked her how she was responding and if any changes or adjustments were needed. He discussed various treatment options for her conditions and sought her input and opinion. Due to her unique comorbidities, lifestyle, personality and

many other factors, Joanne required more focused attention and care than some of the other patients who simply needed a checkup or prescription refill. As I spoke with Dr. Brown after Joanne’s visit, I asked about their doctor-patient relationship. Dr. Brown explained that Joanne has been one of the most difficult patients in his career. While caring for her, he said there have been many times when he did not know how to proceed or what to do next. He wanted so desperately to alleviate even a small portion of her pain and suffering, but relief didn’t come easily. When he first saw her, he began with the standard treatments that he had been taught in his training, many of which he had used to successfully treat patients in the past. However, he reached a roadblock when none of these treatments worked with Joanne. He had to think outside of the box and seek input from other colleagues and medical professionals but, most importantly, from Joanne. In their 2015 opinion piece in JAMA, Ronald Epstein and Anthony Back explain that it is in these challenging scenarios that many physicians will “turn away” from their patients and throw their hands up in defeat.1 Rather than seeking alternative

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.

treatments and trying other options, they simply refer these particularly challenging patients to another specialist because they feel helpless and inept in their attempts to treat them. Dr. Brown did the opposite; he “turned toward” Joanne. He recognized that she was in distress and validated her concerns and worries. He expressed empathy for her condition. He was actively listening in hopes of gleaning any information that he could use in a personalized treatment. She understood that Dr. Brown was on her side and truly wanted to help her. Dr. Brown very well could have disregarded her or stuck with the same treatments that he had seen work in the past with similar patients. Instead, he empowered Joanne and made her feel important and cared for. I hope that as I go out to the clinics and hospital wards this coming summer, I can engage with patients and begin to broaden my medical understanding to tailor treatments to particular patients. Because every patient is inherently unique, “cookbook medicine” will never be possible. One of the only certainties is that no two patients will ever be the same and that each patient requires a comprehensive, individual and intimate approach. In the future, I hope to use my textbook knowledge to compliment my firsthand experience to empower a patient as Dr. Brown did to see them through a personalized treatment plan. ■ References 1. Epstein RM, Back AL. Responding to suffering. JAMA. 2015 Dec 22-29;314(24):2623-4. *names have been changed C O LO R A D O M E D I C I N E    41 


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STATE INNOVATION MODEL

New eCQM solution helps practices report measures for APMs Heather Grimshaw, Director of Communications, Strategic Partnerships Colorado State Innovation Model (SIM)

The Colorado State Innovation Model (SIM) team is funding an electronic clinical quality measure (eCQM) solution to help practices report eCQMs while reducing the administrative burden of doing so. The eCQM solution, which was launched last year for SIM practices, has been called the first to leverage blockchain technology for HIPAA-compliant data aggregation and reporting in Colorado.

Read more about the solution, blockchain technology, the press release for this new solution and apply today: www.colorado.gov/healthinnovation/sim-ecqm-solution

Three of Colorado’s clinical health data organizations have par tnered with Denver-based BurstIQ to enable aggregation, consolidation and sharing of clinical quality measures (CQMs) data across the state. The partners – Colorado Regional Health Information Organization (CORHIO), Quality Health Network (QHN) and Colorado Community Managed Care Network (CCMCN) – created Health Data Colorado as an umbrella organization to roll out the service. There are a limited number of spots open and practice representatives are encouraged to apply as soon as possible to secure a spot: www.surveymonkey.com/r/5CYV5CW.

This partnership will be the first collaboration of its kind to leverage blockchain for HIPAA-compliant data aggregation and reporting in the state of Colorado. BurstIQ’s secure blockchain-based platform will allow CORHIO, QHN and CCMCN to each maintain direct control over their respective data assets while enabling the consolidation and contextualization needed to report electronic CQMs for SIM.

The project is funded by SIM, a federally funded, governor’s office initiative that is helping hundreds of primary care practices and four community mental health centers integrate behavioral and physical health and learn how to succeed with alternative payment models (APMs).

“Health information technology is one of the foundational pillars of SIM, and it is rewarding to see this work come to fruition,” says Barbara Martin, RN, MSN, ACNP-BC, MPH, SIM director. “This solution will help reduce the administrative burden of reporting, and help providers prove their unique value to health plans, which is a core component to success with APMs.” ■

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SIM practices were the first to test this eCQM solution, which was designed to help providers extract eCQMs once and report data to multiple payers.

Software The eCQM solution, which automates extraction of field-level clinical data from SIM practice EHRs for eCQM calculation and validation, will be developed on a technical framework that enables re-use of extracted field level source data. This data will be leveraged to automatically calculate eCQMs and provide the foundation for future use cases. It will receive source data from EHRs and potentially other sources (flat files, registries, ADT, HIEs, the All Payer Claims Database, health plans, social determinants of health, lab vendors and other data sources), extract the appropriate data and synthesize it to accurately calculate eCQM numerators and denominators. Once calculated, the eCQM solution will relay extracted eCQM numerators and denominators in an industr y standard format to the state’s Enterprise Service Bus for Medicaid, the Shared Practice Improvement Tool (SPLIT), potentially the Centers for Medicare and Medicaid Services and other interested commercial payers.

Get more details at www.colorado.gov/healthinnovation/ sim-ecqm-solution


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K. Mason Howard, MD  1932 – 2019 COPIC’s first Chairman/CEO, an inspiring physician, and our friend K. Mason Howard, who was instrumental in the formation of COPIC and a great leader during the company’s early years, passed away in January. Howard grew up in Denver and attended medical school at the University of Colorado. After two decades in private practice as an orthopaedic surgeon in Englewood and Littleton, he became more involved with broader health care issues when he served as a trustee/director for the Colorado Medical Society from 1976-1979, and then as CMS president from 1980-1981. He also ser ved as president of the Arapahoe-Douglas-Elbert Medical Society and president of the Combined Medical Staff of Swedish Medical Center and Porter Memorial Hospital. At Swedish he was a trustee for many years, as well as board chairman from 1991-1993. He served as a trustee and chairman at HealthONE Alliance and was an HCA/HealthONE governor after the merger of several Denver-area hospitals.

“We were the Three Musketeers, or perhaps, the Three Blind Mice,” Howard said. “We were dedicated to the theory that physicians needed to have a lot more say about their malpractice coverage.” Discussions with the CMS Executive Committee ultimately led to the formation of COPIC in 1981. Howard became COPIC’s first chairman/CEO and served in this role until he retired in December 1994. In retirement, he remained involved, working on a study funded by the Robert Wood Johnson Foundation and COPIC to examine non-adversarial ways to fairly compensate injured patients. Besides Howard’s commitment to creating positive and lasting change, “…he loved a good game of golf, a satisfying smoke on his pipe and a fine glass of red wine,” his obituary stated. “Most importantly, he loved his family and making people laugh. He had a perpetual twinkle in his eye and often a sharp-witted comment on the tip of his tongue.” ■

During his time as a CMS leader, he also formed strong friendships with Robert Brittain, MD, and Roger Johnson, MD. The three of them took an interest in examining Colorado’s medical liability environment and pondered how things could be done differently.

Steven Perry, MD, FAAP  1964 – 2019 Pediatrician, leader, friend Steven Perry, MD, 54, died on Jan. 14, 2019 from complications due to cancer. He was an owner and pediatrician with Cherry Creek Pediatrics in Denver for 24 years. He served on the medical staff board of Children’s Hospital Colorado and concluded his presidency of the Colorado Chapter of the American Academy of Pediatrics last year. He was active in several nonprofit organizations and in immunization advocacy and other child health issues.

“Steve did so much to improve the lives of so many,” said Ellen Brilliant, AAP-CO executive director, in an email. “He not only made sick kids better, but we are all better because of his tireless commitment to do good. The inspiration Steve provided to children, families, and pediatricians across Colorado will be felt for years to come.” Perry attended medical school at Texas Tech University, and completed a pediatrics residency in Houston, at Texas Children’s Hospital and Baylor College of Medicine, serving as chief resident for one of the largest residency programs in the country. ■

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Prior authorization hurdles for patient care have led to serious adverse events, says AMA survey More than one-quarter of physicians (28 percent) report the prior authorization process required by health insurers for certain drugs, tests and treatments have led to serious or life-threatening events for their patients, according to survey results released in February by the American Medical Association (AMA).

• More than nine in 10 physicians (91 percent) said that the prior authorization process delays patient access to necessary care, and three-quarters of physicians (75 percent) report that prior authorization can at least sometimes lead to patients abandoning a recommended course of treatment.

The AMA survey of 1,000 practicing physicians found that prior authorization continues to have a distressing impact on both patients and physician practices. Despite widespread calls for meaningful reform during the last two years, the survey illustrates that prior authorization programs and existing processes remain costly, inefficient, opaque and hazardous in some cases.

• A significant majority of physicians (86 percent) said the burdens associated with prior authorization were high or extremely high, and a clear majority of physicians (88 percent) believe burdens associated with prior authorization have increased during the past five years.

“The AMA survey continues to illustrate that poorly designed, opaque prior authorization programs can pose an unreasonable and costly administrative obstacle to patient-centered care,” said AMA Chair Jack Resneck, Jr., MD, in a news release. “The time is now for insurance companies to work with physicians, not against us, to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality health care they need.” Critical physician concerns highlighted in the AMA survey include: • More than nine in 10 physicians (91 percent) say that prior authorization programs have a negative impact on patient clinical outcomes. • Nearly two-thirds of physicians (65 percent) report waiting at least one business day for prior authorization decisions from insurers – and more than one-quarter (26 percent) said they wait three business days or longer.

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• E ve r y we e k a m e d i c a l p r a c t i ce completes an average of 31 prior authorization requirements per physician, which take the equivalent of nearly two business days (14.9 hours) of physician and staff time to complete.

• To keep up with the administrative burden, more than a third of physicians (36 percent) employ staff members who work exclusively on tasks associated with prior authorization.

“The AMA is committed to attacking the dysfunction in health care by removing the obstacles and burdens that interfere with patient care,” Resneck said. “To make the patient-physician relationship more valued than paperwork, the AMA has taken a leading role by creating collaborative solutions to right-size and streamline prior authorization and help patients access safe, timely and affordable care, while reducing administrative burdens that pull physicians away from patient care.” ■


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Push pays off: DORA changes licensing application questions at urging of CMS and medical schools Following the urging of the Colorado Medical Society Medical Student Section, both of Colorado’s medical schools, the Colorado Physician Health Program (CPHP) and others, the Department of Regulatory Agencies (DORA) has changed questions on the physician professional licensing application regarding mental health and substance use disorders to focus on conduct and behaviors, rather than diagnosis. The revised application went live on Jan. 16 and DORA is in the process of updating the applications for other professions. “This should assist with the balance necessary for applicants to disclose information necessary for our mission of public protection, and focusing on what we are looking for which is behaviors or conduct

that have gotten the applicant in trouble,” a DORA spokesperson wrote in an email. Earlier in the fall and again in January CMS expressed concern with a question on the licensing application about whether the applicant has been diagnosed with or treated for a condition that may impair his or her ability to practice in a health care field, as well as a question about having “abused or excessively used” alcohol or other habit-forming drugs now or in the past five years. CMS and others stated that applicants should not be forced to report mental illness or neurologic conditions if the condition or behavior is already known to CPHP, and that overbroad questions should be written to directly target harmful

behaviors. An unintended consequence of poorly written application screening questions would be that physicians, medical students and residents could be discouraged from seeking needed care. The new questions very specifically inquire whether a potential licensee has engaged in conduct or exhibited behaviors that resulted in “an impairment of your ability to practice in a safe, competent, ethical and professional manner” or “abusing or excessively using any habit forming drug, including alcohol, or any illegal or controlled substance resulting in any discipline for misconduct, failure to meet professional responsibilities, or affecting your ability to practice safely and competently.” ■

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“Maintenance of Certification” is out: Commission recommends overhauling continuing certification The “Continuing Board Certification: Vision for the Future” Commission submitted its final report to the American Board of Medical Specialties Board of Directors on Feb. 13, 2019, thereby concluding their work to review the framework and purpose of the continuing certification of physicians. Their final report details a set of recommendations to overhaul the current certification process and create the principles, frameworks and program models of a new continuing board certification system. “As a community, we are committed to working with our stakeholders to improve the continuing certification process so that it becomes a system that demonstrates the profession’s commitment to professional self-regulation, offers a consistent and clear understanding of what continuing certification means, and establishes a meaningful and relevant program that brings value to a physician’s practice and meets the highest standard of quality patient care,” ABMS said in a statement. The foundational recommendation states that “continuing certification must integrate professionalism, assessment, lifelong learning and advancing practice to determine the continuing certification

Additional recommendations are as follows. • Continuing certification must change to incorporate longitudinal and other assessment strategies that support learning, identify knowledge and skills gaps, and help diplomates stay current. • The ABMS Boards must enable multi-specialty and subspecialty diplomates to remain certified across multiple ABMS Boards without duplication of effort. • The A B M S B oards mus t make publicly available the certification history of all diplomates, and facilitate voluntary re-engagement into the certification process for those not currently participating.

status of a diplomate.” The elements should be multi-sourced and based on the cognitive and technical skills and competencies required for optimal patient care in each specialty. The ABMS should develop standards that require ongoing diplomate engagement in activities that are relevant to current practice, rather than relegating engagement to every two, five or 10 years.

• ABMS must seek input from stakeholder s to develop consis tent approaches to evaluate professionalism and professional standing while ensuring due process for the diplomate when questions of professionalism arise. • ABMS should collaborate with expert stakeholders to develop the infrastructure to support learning activities that produce data-driven advances in clinical practice, and must ensure the certification programs recognize and document participation in a wide range of quality assessment activities in which diplomates already engage.

The commission recommended abandoning the term “Maintenance of Certification” in favor of a new term that better communicates the concept, intent and expectations of continuing certification programs to “reengage disaf fected diplomates and assure the public and other stakeholders that the certificate has enduring meaning and value.” The three -phase “ Vision Initiative” involved physicians, professional medical organizations, national specialty and state medical societies, hospitals and health systems, the general public, and the 24 ABMS member boards. Together, they comprised a commission that has led the ef for t throughout 2018 and early 2019. The ABMS Board of Directors will now develop a framework for addressing and operationalizing the commission’s recommendations over the next year, five years and beyond. ■ Download the final report at

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D E PA R T M E N T S

C L A S S I F I E D S

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Medical Director – Health District of Northern Larimer County The Health District in Fort Collins is seeking a Medical Director committed to improving community health. The Medical Director will work with staff and the community on designated priority projects, applying knowledge of general medicine, preventive medicine, and community and public health to enhance understanding of key health issues; and design, evaluate, manage, improve, and promote the most effective health services and other interventions for residents of the Health District. Qualified candidates must have a license to practice as an MD or DO in the State of Colorado; be board-certified in preventive medicine, family practice, or related specialty; have an MPH or MSPH and at least four years of experience as a manager or director in a health or medical setting. For the full job announcement and information on how to apply, visit www. healthdistrict.org/jobs

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Candidates announced for 2019 CMS All-member Election

Colorado Springs pain and occupational medicine practice for sale. Currently single medical practitioner with massage, therapy, chiropractic and X-ray. Turnkey operation. Continue lease.

The CMS Board of Direc tors approved the following candidates to run for CMS office. Final application packets, including personal statements and curricula vitae for each of the final candidates, will be posted on the CMS website and published in the May-June issue of Colorado Medicine as well as multiple issues of ASAP. The election will be held electronically Aug. 1-31, 2019. CMS must have your email address for you to vote. If you have not been receiving Central Line notifications or the ASAP electronic newsletter, contact membership@cms.org with your preferred email address.

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THERE ARE TWO CANDIDATES RUNNING FOR ONE POSITION

• Sami Diab, MD • Patrick Pevoto, MD, MBA

AMA Delegation THERE ARE EIGHT CANDIDATES RUNNING FOR EIGHT POSITIONS

• David Downs, MD, FACP, incumbent AMA Delegation • Carolynn Francavilla, MD, incumbent AMA Delegation • Jan Kief, MD, incumbent AMA Delegation

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• Rachelle Klammer, MD, incumbent AMA Delegation • Tamaan OsbourneRoberts, MD, incumbent AMA Delegation • Lynn Parry MSc, MD, incumbent AMA Delegation • Brigitta Robinson, MD, FACS, incumbent AMA Delegation • Michael Volz, MD, incumbent AMA Delegation

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F E ATU R E

FINAL WORD

Health care partnership takes on addressing cost of health care Kelly Brough

While health and wellness has long been a pillar of the work of the Denver Metro Chamber of Commerce, over the past 18 months, the Chamber has been intensely focused on health care costs for our members. We are acutely aware that Colorado businesses and their employees in urban and rural areas are struggling to pay for health care. According to the 2015 report by the Colorado Commission on Affordable Health Care, personal health expenditures have increased 327 percent over the past two decades in Colorado (compared to 216 percent nationally). The Denver Business Journal in 2013 reported that personal health care costs in Colorado stood at $36.3 billion, more than four times the level from two decades ago. Just since 2000, that spending is up 122.7 percent – 3.7 times the rate of inflation in the state. In 2016, over half of U.S. workers with single-coverage health insurance plans paid a deductible of $1,000 or more, up from 31 percent of workers in 2011. More urgent than the headlines was the feedback we heard directly from dozens of Chamber members who participated in focus groups last winter about how the cost of health care is impacting them. We learned directly from our members that the cost of health care is forcing tough budgetary decisions both personally and professionally. They shared with us that they don’t understand how health care costs and prices are set, which means they have a hard time predicting what they’ll pay out of pocket. Since those focus groups more than a year ago, we’ve been working hand in hand with many of our health care members and key stakeholders (who represent more than 20 organizations), including

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the Colorado Medical Society, to tackle these very issues. Together, we convened at the Chamber over six months through last summer and fall to develop legislative and private market strategies to increase transparency, ensure the open exchange of useful data, better educate consumers and set a foundation to tackle the cost of health care. We developed a roadmap with the help of CMS and others that includes market and legislative strategies that the Chamber will prioritize over the next months and years in an effort to help our members. The priorities include increasing the availability of data to help consumers make informed decisions and to help health care stakeholders better analyze trends and identify cost drivers. The key in this strategy is ensuring more ERISA-insured companies share their data, thereby providing a more complete picture of health care prices in Colorado. We also want to focus on making more information available to better understand pharmaceutical price increases and costs through transparency work at the legislature. Over the nex t year, we will develop educational tools to help employers better understand how to save money while maintaining quality. This could include sharing best practices for health insurance

plan design, effective wellness programs and how-to guides for consumers. In addition to education strategies, we hope to use the increased data collected to help the employer community negotiate higher value health care contracts. We know that value, access and quality are the keystones to a healthy community, so we also prioritized increasing provider capacity to ensure more Coloradans have access to quality preventive care and mental health services. This could come in the form of supporting workforce development programs or regulatory efficiencies, and supporting the expansion of telehealth in Colorado. We’re energized by this critical topic and know we have a role to play in helping our members navigate the complex world of health care. The partnership formed with health care stakeholders and our physician community informed our work, and while this only represents a starting point, we know it is as important as ever that we take action on health care in Colorado. ■

Kelly Brough is the president and CEO of the Denver Metro Chamber of Commerce. The Chamber represents 3,000 businesses and their 300,000 employees who work across Colorado.


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Profile for Colorado Medical Society

March-April 2019 Colorado Medicine  

Colorado Medicine is the award-winning publication of the Colorado Medical Society. This issue features articles about health care costs and...

March-April 2019 Colorado Medicine  

Colorado Medicine is the award-winning publication of the Colorado Medical Society. This issue features articles about health care costs and...

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