May-June-July 2022 Colorado Medicine

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COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE

Medical school

BUILDING THE WORKFORCE OF THE FUTURE Practice

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P E A C E

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B E YO N D C O V E R A G E

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Prac C O NTE NT S

BUILDING THE WORKFORCE OF THE FUTURE The Colorado Medical Society supported a constellation of bills this legislative session that aim to build the health care workforce the state needs to care for patients now and in the future by investing in medical education, supporting

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health care providers and effecting change in the health care system. PAGE 6 ⊲

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D E PA R TM E NT S

INNOVATION SUMMIT

SOCIAL SERVICES

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OPPORTUNITIES FOR PHYSICIANS TO IMPROVE ACCESS AND SHARING OF HEALTH DATA

GRANTS AND FUNDING

NFORMATION EXCHANGE

S-HIE

The Colorado Office of eHealth Innovation is implementing a new health information technology strategy for Colorado and they are calling on physicians to help advance its goals.

18 COPIC Comment: COPIC Medical Foundation – 2022 grants 20

Reflections: Tired

20 Reflections: Professor Rounds 21 Introspections: The Physician 22 Partner in Medicine Spotlight: The perfect storm

10 PHYSICIAN BURNOUT: CALL TO ACTION In part three of a three-part series, Alexander on Hafften, MD, and Jeremy Lazarus, MD, present recommendations and resources for physicians and medical students to promote health and wellbeing and to reduce burnout.

16 REPORT ON THE 2022 LEGISLATIVE SESSION Advocacy is consistently ranked No. 1 in member priorities, and the Colorado Medical Society navigated another session to protect quality patient care and physician practices.

24 FINAL WORD: PRIOR AUTHORIZATION HURTS PATIENTS Robin Mulroney shares her heart-wrenching story of a serious surgery made worse by care delays and denials by her health insurance company. A bill CMS supported that would have helped patients like her failed to pass the legislature this year.

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President’s Letter: Calling for a new Flexner Report to end scope fights

14 Photos from the April Regional Summit and CMS Board of Directors Meeting


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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF 2021-2022 OFFICERS

BOARD OF DIRECTORS

AMA DELGATION

Mark B. Johnson, MD, MPH President

Brittany Carver, DO Enno F. Heuscher, MD, FAAFP, FACS Rachelle M. Klammer, MD Chris Linares, MD Evan Manning, MD Zachary Miller, MS Michael Moore, MD Edward Norman, MD Lynn Parry, MD Leto Quarles, MD Kim Warner, MD Hap Young, MD

David Downs, MD, FACP Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR A. "Lee" Morgan, MD Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MD Brigitta J. Robinson, MD Michael Volz, MD

Patrick Pevoto, MD, RPh, MBA President-elect Hap Young, MD Treasurer Bryan Campbell, FAAMSE Chief Executive Officer Sami Diab, MD Immediate Past President

AMA PAST PRESIDENT Jeremy A. Lazarus, MD

COLORADO MEDICAL SOCIETY STAFF Bryan Campbell, FAAMSE Chief Executive Officer Bryan_Campbell@cms.org

Amy Berenbaum Goodman, JD, MBE Senior Director of Policy Amy_Goodman@cms.org

Crystal Goodman Executive Director, Northern Colorado Medical Society Crystal@nocomedsoc.org

Kate Alfano Director of Communications and Marketing Kate_Alfano@cms.org

Emily Bishop Director of Government Affairs Emily_Bishop@cms.org

Ms. Gene Richer, M Ed, CHCP™ Director of Continuing Medical Education Gene_Richer@cms.org

Susanna Barnett Membership Coordinator Susanna_Barnett@cms.org

Dianna Fetter Senior Director of Business Development Dianna_Fetter@cms.org

Chet Seward Chief Strategy Officer Chet_Seward@cms.org

Paige Brophy Director of Membership Services Paige_Brophy@cms.org

Dean Holzkamp Chief Operating Officer Dean_Holzkamp@cms.org

Tim Yanetta Manager of IT/Membership Tim_Yanetta@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. Bryan Campbell, Executive Editor; Kate Alfano, Managing Editor; and Dean Holzkamp, Assistant Editor. Design by Scribner Creative.


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Calling for a new Flexner Report to end scope fights Mark B. Johnson, MD, MPH

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vividly remember the feelings of awe, anxiety, reverence and responsibility I felt the first time I took scalpel to skin and made an incision in another living human being. There were multiple layers of trust behind that seemingly simple act – both the patient’s and my teachers’ trust in me, my trust in the skills I had acquired, and society’s trust in the medical profession. It is in regard to the latter that I now write. Throughout history, societies have put their trust in those who have been called “healers,” allowing them rights and privileges that would be considered criminal in any other situation. It is an awesome honor and responsibility, and the provision of medical care today depends on the continued trust of society in the training and trustworthiness of physicians.

In Colorado, we seem to be at something of a crossroads in that relationship. For the past 30 years, I have testified almost yearly at the Colorado Legislature in regard to medical scope of practice issues. This has usually involved non-physicians seeking to expand their clinical privileges in what has been called “scope creep,” but there have also been conflicts over words and titles, such as the use of “licensed,” “registered,” and even “physician.” Those wishing to increase their rights have been relentless. The main point of contention is always a dispute over the quality and quantity of training. Those seeking changes argue that their training is adequate for the expanded scope of practice they are seeking, and some claim it is comparable to that of physicians. Knowing what legislators want to hear, they argue that they can provide equal quality health care for a lower cost, and they promise that if they are allowed to practice more independently, they will focus on more effectively meeting the needs of the rural and underserved populations in the state. Unfortunately, no one, including our legislators, really knows the full extent of training that is being provided in every field of health care. Along with “scope creep” in practice, it appears that there has been “scope creep” in educational programs. Some health care profes-

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sionals now claim their training includes more than they are allowed to legally use in practice. Each of us tends to feel our training is superior to that of others, but if our main concern is patient safety, we should be advocating for health care teams that are configured in such a way so that each member’s knowledge, skills and abilities are utilized to their fullest, while professional and individual weaknesses are compensated for by the training and supervision of other team members. How might that be accomplished? In the mid-19th century, medicine in the United States was a chaotic collection of medical sects with poorly trained “doctors,” medications and nostrums of dubious content and efficacy, and “treatments” that were reminiscent of medieval torture. Training, for the most part, was by apprenticeship, with no prerequisite education, no standard curriculum of study, no universally accepted body of knowledge, and no regulation or oversight of practice at the end of the course. Most pharmaceuticals were proprietary and included secret ingredients, often with high levels of alcohol, cocaine or opium. Surgical procedures were done without adequate anesthesia and often had massive resections, significant blood loss and high rates of infection.

It was in this medical milieu in 1847 that the American Medical Association was founded by a group of physicians who were deeply concerned about the state of medical training and knowledge; the relation of physicians with patients, the public and each other; and the loose, or nonexistent, standards of ethical conduct in the profession. In an attempt to improve medical practice and gain the trust of the public, they adopted four primary goals for the organization: (1) the advancement of the scientific underpinnings of the profession, (2) the establishment of standards for medical education, (3) a uniform program of medical ethics for physician behavior, and (4) the improvement of public health. Although some progress was made over the following decades, in 1910, Abraham Flexner was hired by the Carnegie Foundation to study the still questionable state of medical education in America. He found it greatly wanting. Most medical schools were still proprietary businesses, with no set standards for prerequisites or the teaching of a generally accepted body of medical knowledge. After an exhaustive study of the situation, he proposed five main recommendations: (1) decrease the number of medical schools from 155 to 31; (2) set standard prerequisites for medical training; (3) train physicians to practice in a scientific manner;


Today’s solution to Colorado’s health care workforce shortage and the statewide provision of safe medical care cannot rely on once again “overcrowding” the state with “doctors” of questionable training and educational achievements. (4) give medical schools control of clinical instruction in hospitals; and, (5) strengthen the regulation of medical licensure in states.

tional programs, requirements and products of all of the health care professions by an independent and unbiased team of qualified professionals.

While there were significant problems with the Flexner Report in its treatment of female and BIPOC students, the overall results of its implementation were revolutionary. All state medical boards eventually adopted and enforced the report’s recommendations. More than half of all medical schools in America merged or were closed. Almost 90 percent of the schools remaining were affiliated with universities. Prerequisites and curricula were standardized, and medical research flourished. Treatments improved, the public’s trust in the profession skyrocketed, and the average expected length of life doubled over the next 90 years. (Association, of course, does not prove causation.)

In 2019, health care costs in the United States approached $4 trillion, or 17.7 percent of our Gross Domestic Product. The nation deserves to know if it is getting an adequate return on investment for the training of Doctors of Medicine, Doctors of Osteopathy, Doctors of Pharmacy, Doctors of Nursing, Doctors of Acupuncture, Doctors of Physical Therapy, Doctors of Chiropractic, Doctors of Naturopathy, Doctors of Dentistry, Doctors of Occupational Therapy, Doctors of Optometry, Doctors of Podiatry, Doctors of Health Administration, etc. It may be that such a report would recommend the cessation of certain training programs or their exclusion from reim-

bursement. Scopes of practice would hopefully be aligned with need, training and experience. The most important recommendation that could come from this study, however, would be a focus on the building of a coherent and comprehensive national structure for health care teams that maximizes the quality and safety of patient care while minimizing unnecessary and conflicting overlap in scope and authority issues among the various professions. This would both increase the value of our health care expenditures and help take politics out of decisions regarding medical scopes of practice. I strongly believe that medical education would do very well in such a study. I also believe it would, for the foreseeable future anyway, put to rest the yearly legislative battles over clinical scope of practice issues in Colorado. ■

In the Flexner Report’s section on Colorado there was an interesting comment: “The state is overcrowded with doctors.” It must be remembered, however, that the term “doctor” in 1910 described a group of individuals with widely divergent backgrounds and questionable training and educational achievements. Most would not be allowed to practice medicine today and, even at that time, many of them were considered to be charlatans and quacks. Today’s solution to Colorado’s health care workforce shortage and the statewide provision of safe medical care cannot rely on once again “overcrowding” the state with “doctors” of questionable training and educational achievements. The health care that is provided to the rural and underserved residents of the state should meet the same standards of care that are available in the state’s more populous regions. To reach that goal, I believe health care in America needs something like an updated Flexner report, but instead of focusing only on medical education and individual institutions, this report needs to include an in-depth study of the educa-

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Building the workforce of the future Kate Alfano, CMS Director of Communications and Marketing

Residency A decade ago, the number of health care providers in the state was already lagging need as Colorado’s population rapidly grew. Medically underserved areas and medically underserved populations were found throughout the state and overrepresented in our rural areas. Then the COVID-19 pandemic hit, stretching the health care workforce almost to its breaking point. As the crisis phase of the pandemic ends, those interested in ensuring the state can recruit and retain qualified, diverse health care workers now and for the future are re-evaluating the state’s workforce and sounding the alarm.

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Economic modeling (EMSI) data cited by the Colorado Hospital Association projects a deficit of 54,000 “lower wage” health care occupations such as medical assistants, home health aides, and nursing assistants, and a deficit of more than 10,000 registered nurses by 2026. In just over seven years Colorado is projected to need 2,400 more physicians. A Washington Post- Kaiser Family Foundation poll found that 61 percent of physicians reported experiencing burnout in 2021, up from 40 percent in 2018. 57 percent reported inappropriate feelings of anger, tearfulness or anxiety because of the COVID-19 pandemic. A staggering 1 in 5 respondents said they know of a physician who has either considered, attempted or died by suicide during the pandemic.

Because building the right workforce for Colorado is a multifaceted problem, it will take a multifaceted solution – from selection and training of students, to innovation in graduate medical education, to supporting health care providers and affecting change in the health care system.

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54,000 DEFICIT in lower wage occupations

2,400 NEEDED PHYSICIANS

61% EXPERIENCE BURNOUT

The Colorado Medical Society helps in this effort through our advocacy in the legislature as bills are debated and in the regulatory arena after they become law. We supported a constellation of workforce bills considered by the 73rd Colorado General Assembly in 2022 that aim to build the workforce of the future, and opposed bills that offered shortsighted solutions. BUILDING UP RURAL AND FRONTIER COMMUNITIES Senate Bill 22-172, a bill CMS strongly suppor ted, seeks to increase t he health care workforce in Colorado’s rural communities by funding rural track training programs. It is modeled after the rural training track that is run by Mark Deutchman, MD, at the University of Colorado School of Medicine (CUSOM). Widely known as a national model, the program has shown that students trained in the unique challenges of servicing rural communities are more likely to remain in these communities and lead successful careers. Funding will be available for a host of higher education institutions across the state that of fer degree and credentialing programs for health care professionals.


Lindsey Paulson, MD, a family physician in Wray, Colo., has medical students and residents rotate through her clinic through the CUSOM rural training track program. “This works because the physicians come here, their families come here, and they become part of the community,” Paulson said. “I have kids in the school system. It’s the same with my partners. Where you put down your roots is where you’ll end up staying. … Encouraging the rural track to expand makes a lot of sense because if we’re going to get students in these communities long term, they have to get a sense for how it is to live and work in a community like this.” Paulson continued: “In some of the other towns, they have staffed the hospital by having physicians commute in three days a week from the Front Range. That can fill a shortage in the short term but it’s not the best. If you have to sit next to the person you’re treating in the emergency room at your kid’s basketball game the following week, you have more skin in the game. That’s why our staffing has been more successful than in some of the other smaller areas and that’s one of the biggest benefits for the rural track.” Rep. Dylan Roberts (D), co-prime sponsor of SB22-172, commended the bipartisan approach to workforce bills in the 2022 session. “I am so proud that the legislature was able to come together in a bipartisan way this year to pass the Rural Health Care Workforce Initiative. This program is exactly what my part of the state and all of rural Colorado needs and deserves: dedicated resources to recruit, train and place doctors, nurses and other health care professionals into rural communities, and to allow the state’s higher education institutions the opportunity to be a part of this exciting initiative. We can all look forward to this initiative expanding our rural health care workforce over the coming years and that is great news for all of Colorado’s providers and patients.” INCREASING THE NUMBER OF PROVIDERS Encouraging diversity in the workforce

is a priority goal for CMS, as increasing cultural competency has been shown to improve patient care. CMS advocated for a bill, HB22-1050, to support international medical graduates (IMGs) interested in completing their medical degrees in Colorado and join the health care workforce. The IMG assistance program will provide direct services to IMGs, including evaluation and technical support through credentialing and medical licensure. A clinical readiness program provides curriculum for and assessments of IMGs to help them build the skills necessary to enter a medical residency program. Colorado will have a larger pool of medical students in the state with the opening of a third medical school. Passed unanimously, SB22-056 authorizes a new osteopathic medical school at the University of Northern Colorado. UNC plans to enroll its first class of medical students in 2025. INVESTING IN THE PRECEPTORSHIP PROGRAM More on medical education, preceptorships offer real-life experience in medical fields, helping medical students decide which specialty to pursue and in what setting. HB22-1005 expands Colorado’s rural preceptor tax credit program, offering a $1,000 income tax credit for health care preceptors working in rural and frontier areas to help recruit more to these areas and retain those already volunteering. Christie Reimer, MD, coordinates the preceptorship program for the CUSOM branch campus in Fort Collins. “We know that the students have positive experiences in the program. The physicians say having the students in their clinics enhances their professional careers. And patients who the students have followed longitudinally feel like they have an advocate in the health care system. There are benefits to patients, preceptors, students and the medical community as a whole.”

It relies on volunteer physicians – who for now are available in northern Colorado – but studies show the pervasiveness of physician burnout. “For physicians who are preceptors, it adds professional satisfaction and professional identity. But as much as they enjoy it, it can be another thing to add to their day.” The hope is that the tax credit will help provide a small, much-needed incentive to continue serving as a preceptor. SUPPORTING THE CURRENT WORKFORCE In addition to the pipeline initiatives, CMS advocated for support for those already in practice. Lawmakers listened and passed SB22-226 – a bundle of initiatives that makes large investments to support the current health care workforce. A top priority for CMS is a measure in the bill that creates a health-care workforce resilience and retention program to ensure that Colorado’s health care workforce receives the support they need in resilience, wellbeing and retention. Additionally, the workforce bundle will expand the number of clinical training slots to clear the backlog of students waiting for placement, provide tuition assistance to make entering allied health professions no-cost, allocate funding to recruit workers who have recently left the field back into health care professions, establish a grant program to recruit and hire school nurses for Colorado public schools, create a statewide data-sharing system to better allocate resources, and inform decision-makers of health care workforce planning initiatives. Prime sponsor of SB22-226, Rep. Kyle Mullica, RN (D), said, “This bill is focused on workforce development and protection. CMS has played a big role in the mental health component of this initia-

However, even with great benefits, Reimer describes the state of the preceptorship program as “fragile.”

Encouraging diversity in the workforce is a priority goal for CMS, as increasing cultural competency has been shown to improve patient care.

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tive. I am proud of this bill because it will be transformational and Colorado is going to be better because of it.” THE TEMPTATION TO ALLOW “SCOPE CREEP” CMS opposes inappropriate scope of practice expansions of nonphysicians, which every year have tempted policymakers seeking a quick solution to workforce shortages. This year CMS secured a major victory in scope of practice, as well as a defeat. CMS led the charge against HB22-1095, a flawed and dangerous bill that we also defeated in 2021. It would have drastically expanded the scope of practice of physician assistants by striking all physician supervision from statute. CMS believes multidisciplinary teams led by physicians can provide the highest quality care and that independent practice outside of team-based care will further fragment health care delivery. Physician members answered our call to action and legislators around the state were inundated with patient-centered concerns with this bill. Combined with an

intense lobbying effort across the House of Medicine, Colorado physicians helped to drive a bipartisan defeat of the bill on the floor of the House of Representatives. In an interview with Colorado Public Radio, the bill’s sponsor placed the “blame” for killing the bill squarely on the Colorado Medical Society. While some may resent this, CMS will always stand up for the interests of physicians and the patients they serve. CMS President Mark Johnson, MD, MPH, pledged to work to improve collaboration on health care teams and join other interested parties to find needed improvements – as we have demonstrated on the other workforce initiatives we supported this session. Defeat came af ter HB22-1233, the optometrist sunset, passed. Despite a robust public information campaign and outreach by Colorado physicians and lobbyists, legislators approved allowing optometrists to perform injections around the eye, surgically remove chalazion, perform corneal cross-linking, surgically repair lid lacerations, and perform certain laser procedures.

At Key, we’re devoted to providing our clients with insights and solutions that help navigate what’s coming next. To learn more about the trends shaping the future of healthcare, visit key.com/healthcaretrends. Contact: Shelly Doan 913.406.4479 shelly_doan@keybank.com

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Ensuring Colorado has the workforce needed for the next crisis: Forming a Health Care Services Reserve Corps At the request of the Colorado Department of Public Health and Environment (CDPHE), the Colorado Medical Society helped coordinate a series of virtual listening sessions with Colorado physicians so the state and its health care workforce can better prepare for a future health crisis.

The future will be different. So will healthcare.

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OUR WORK CONTINUES A benefit of the Colorado Medical Society is the ability to affect change through a host of platforms, and we aim to do this with programs initiated at CMS that are driven by our physician leaders and volunteers, in the legislature and regulatory arenas, in partnership with others in the House of Medicine, and beyond. Your membership in CMS matters and makes our work possible. CMS is here to support Colorado physicians in your careers now and in the future, and to support future generations of physicians. ■

These listening sessions were developed following the passage of a bill last year, House Bill 21 -1005, which created a task force at CDPHE with the charge to develop a Health Care Services Reserve Corps. The reserve corps will allow medical professionals to cross-train to be able to serve the state in an emergency. During the listening sessions, CDPHE asked physicians about staf f ing and func tion def icits, throughput challenges, supplemental staf f ing, and potential incentives/benefits for participants in a reserve corps. The input of physicians is vital to this effort and CMS was honored to be involved.


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Opportunities for physicians to improve access and sharing of health data Stephanie Pugliese, Director of the Office of eHealth Innovation

In November 2021, the Colorado Office of eHealth Innovation (OeHI) and eHealth Commission released the 2021 Colorado Health Information Technology (IT) Roadmap, the state’s health information technology strategy. The Roadmap addresses the evolving needs of health IT to support health and behavioral health care providers and community organizations supporting whole-person care. The Roadmap reflects input from stakeholders statewide who expressed a need for more streamlined technology infrastructure to provide accessible patient records and minimize time spent on data entry and administrative burden. The Roadmap includes the following opportunities for physicians and health IT enthusiasts to improve access and sharing of health data, develop recommendations for more coordinated policy, and advance digital health equity.

INNOVATION SUMMIT, JULY 21-22: Hosted annually in partnership by Prime Health and the OeHI, the Innovation Summit connects innovators and health care leaders from a variety of backgrounds, including federal and state leadership, urban and rural health systems, inves tors, funders, entrepreneurs, technologists, and more. Go to www. primehealthco.com/innovation-summit to register for this exciting event! S-HIE: A major initiative working toward this vision is the development of a SocialHealth Information Exchange (S-HIE) infrastructure, defined as a vendor-agnos t ic f lex ible inf r as t r uc ture t hat supports coordinated whole-person care across the physical, social and behavioral health domains.

opportunity for technical solutions, from electronic screening tools to resource databases. This will allow providers to use the tools that are most useful in supporting their patients, while still exchanging relevant data across health and social systems. This data-driven infrastructure will reduce administrative burden and promote efficiencies across systems, paving the way for improvements in health equity. OeHI plans to begin the process for building this statewide solution in Fall 2022, and welcomes input and partnership of members of the health care community. GRANT OPPORTUNITY: OeHI is working with state and community partners to offer grant and funding opportunities in support of increased broadband connectivity, technical infrastructure, and connection to the state health information exchange network. Colorado House Bill 21-1289 appropriated monies to increase access to broadband services for providers, non-profits, correctional facilities and county jails, and other telehealth service providers who lack

S-HIE is an innovative model meant to include the social determinants of health in a person’s primary care. Through this model, when an individual shares their social needs with their physician, the provider can make a referral directly to a social program in the community. To connect patients to social services from a health care setting, multiple steps are required: screening and assessing for a need, finding a program in the community, referring and connecting the individual to the program, and conf irming and SOCIAL-HEALTH INFORMATION EXCHANGE recording the referral result (known as closing the loop). Each step presents an

quality internet access and devices for the delivery of telehealth visits. Eligible applicants that receive this grant shall use the funds to meet the telehealth delivery needs of its patients, providers and other staff. The Request for Applications (RFA) is currently open through June 20, with awards being made in August 2022. For more information on applying, please visit the ColoradoVSS website (https:// co d p a - v s s .c l o u d .cg i f e d e r a l .co m / webapp/PRDVSS2X1/AltSelfService); click the Public Access button on the left, and type HB21-1289 Project Broadband Grant into the keyword search. Submission instructions can be found on page 10 of the RFA. G o to w w w.oehi.colorado.gov to learn more about Colorado’s health IT efforts and how to get involved or contact Stephanie Pugliese, Director of the Office of eHealth Innovation, Stephanie.Pugliese@state.co.us, for more information. ■

INNOVATION SUMMIT

SOCIAL SERVICES GRANTS AND FUNDING

S-HIE

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Physician Burnout: Call to action INDIVIDUAL PHYSICIANS ARTICLE 3 OF 3

This is the third of three articles on physician burnout. Burnout is a syndrome of emotional exhaustion, depersonalization, cynicism, detachment, and sense of low personal accomplishment.1 Approximately 50 percent of physicians and medical students were experiencing burnout prior to the COVID pandemic. 2,3 Burnout is an individual response to a systemic problem and interventions focusing solely on individual physician resilience are inadequate and miss the national, organizational and practice environment contributors to physician burnout. Organizational and practice environment interventions were the focus of the second article. This article summarizes recommendations and resources for physicians and medical students to promote health and wellbeing and to reduce burnout.

Jeremy Lazarus, MD Past President, American Medical Association

EDUCATION AND AWARENESS Increasing awareness about physician distress and burnout is the first step. In 2015, the American Medical A s sociat ion ( A M A ) launched A M A Steps Forward, an online resource to help physicians learn about wellbeing, burnout, and resilience (https:// edhub.ama-assn.org/steps-forward/ pages/professional-well-being). Many physician organizations such as the American Academy of Family Physicians (AAFP), American College of Emergency Physicians (ACEP), American College of Physicians (ACP), American College of Surgeons (ACS), and the American Psychiatric Association (APA) have online information, resources, and continuing medical education programs (CME). How burned out am I? The National Academy of Medicine (NAM) website has links to several valid and reliable survey instruments (https://nam.edu/ valid-reliable -sur vey-instrumentsmeasure-burnout-well-work-relateddimensions/).4 Measure your well-being and burnout by completing the Oldenburg Burnout Inventory and the PHQ-9 (https:// www.apa.org/depression-guideline/ patient-health-questionnaire.pdf), both available without charge.

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Alexander von Hafften, MD Physician Health Committee, Alaska State Medical Association

WHAT IS RESILIENCE AND HOW TO ENHANCE RESILIENCE Myers defines resilience as the ability to confront adversity and still find hope and meaning in life.5 Tregoning defines resilience as the ability to bounce back or recover from stress.6 There are skills and mindset s that improve resilience. Psychological interventions such as Mindfulness-Based Stress Reduction (MBSR) and Cognitive Behavior Therapy (CBT) calm our mind and decrease negative rumination. These interventions improve wellbeing and resilience by reducing distress, anxiety, and depression. It is unclear if MBSR and CBT reduce burnout directly. This is understandable since national, organizational, and practice environment factors are primary contributors to physician burnout.

PEER SUPPORT Distress and burnout lead to isolation and isolation is more likely when accompanied by anxiety, depression, substance use, and thoughts about suicide. Isolation reinforces psychological distress. Preventing and overcoming the tendency to isolate are impor tant . Develop and foster

supportive relationships with colleagues at work and away from work. Colleagues, mentors, and physician coaches may help by recommending ways to manage workplace stress and communication. Meet with a group of colleagues to discuss the interpersonal aspects of clinical care. Balint training and Balint group participation lower rates of burnout in some physicians and residents. Form a group or participate in an online Balint group through the American Balint Society (https://www.americanbalintsociety. org/content.aspx?page_id=22&club_ id=445043&module_id=406070).7 Meet with a peer- coach. Physician coaching is a peer-to-peer/coach-to-client interaction; not a physician-patient clinical interaction. There is no medical evaluation, diagnosis, or treatment. Corinna Muller wrote an article for Alaska State Medical Association’s Heartbeat newsletter in December 2020 summarizing the positive evidence for physicians coaching physicians.8

SELF-CARE We have to care for ourselves to be able to care for others. Examples of self-care include nurturing our spiritual connections, investing in intimate relationships, seeing the good in others, extending


kindness to others, sharing experiences and vulnerabilities with colleagues, and reaching out to colleagues in response to adverse events and stressful situations. AMA Steps Forward has a seven-minute webinar titled Stress First Aid for Health Care Professionals.9

SEEK HELP The prevalence of depression in male and female physicians is 12 percent and 19.5 percent respectively.8 Approximately 400 physicians suicide each year.10,11 Suicide is 40 percent more common among male physicians and 130 percent more common among female physicians than the general population.12 Approximately 10 percent of physicians have a substance use disorder during their career.13,14 There is no replacement for medical evaluation and treatment when necessary.

OBSTACLES TO SEEKING HELP Even among physicians, there is a gap of understanding about the effectiveness of psychological and psychiatric care. Fear and stigma about seeking help are

barriers, too. Individual physicians are fearful of being ostracized by colleagues, jeopardizing their medical license, being excluded by employers and insurers, and having no privacy or confidentiality safeguards. Many medical boards, physician employers, and insurers ask about any history of mental or emotional conditions and substance use disorders, not whether the physician is currently suffering from a condition not being appropriately treated which impairs judgment or adversely affects one’s ability to practice medicine in a competent, ethical and professional manner.15 All stakeholders of the health care system should encourage physicians to seek and obtain help when needed, not discourage physicians from seeking help until after a crisis arises. In 2018, the Federation of State Medical Boards adopted a policy promoting physician wellness. The policy includes specific recommendations for state medical boards, state governments, Centers for Medicare and Medcaid Services, accreditation organizations, insurers, EHR vendors, hospitals, employers, professional medical societies, training programs and physicians.15

HELPING COLLEAGUES Sometimes we are approached by a colleague or observe a colleague struggling with burnout, anxiety, depression, substance misuse, or suicide. The Physicians Foundation has specif ic recommendations for conversations with a colleague. First: Be prepared. Second: Try to find the right time and circumstance so there won’t be interruptions, distractions, and lack of privacy. Third: Use language that communicates patience, understanding, and hope. Fourth: Listen without interrupting, judging, or trying to “fix” the colleague’s concerns. Fifth: Follow up with the colleague after the initial conversation. The colleague will likely have mixed feelings about having shared with you. The colleague’s ambivalence, withdrawal, and denial may increase.16 The Phy sicians F oundat ion has a one-page template to help physicians manage a personal crisis. The personal crisis management plan is built around answers to five questions.17 PAGE 12 ⊲

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P H YS I C I A N B U R N O UT: C O N T

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What are my warning signs?

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What are my healthy internal coping strategies?

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Who are a few people or social settings that can provide me with distraction?

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Who can I ask for help?

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Who are the professionals or agencies I can contact during a crisis?

The availability and comfort of telecoaching, telepsychology, telepsychiatry, and telemedicine have increased greatly since the pandemic. Resources are no longer limited by physical location. In fact, some people prefer telephone and video conferencing over in-person

meetings because of greater convenience and greater sense of privacy and confidentiality. The Colorado Physician Health Program (303-860-0122) is another resource. CPHP may help by providing local and national resources for physician coaching, peer support, and comprehensive evaluation if appropriate. SUMMARY

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Burnout is an individual’s response to a systemic problem.

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Interventions that focus solely on individual physician resilience are inadequate and miss the national, organizational and practice environment contributors to burnout.

Resources Colorado Crisis Services 1-844-493-8255 Colorado’s suicide prevention hotline https://coloradocrisisservices.org/ Colorado Physician Health Program 303-860-0122 https://cphp.org/ Accreditation Council for Graduate Medical Education (ACGME) https://www.acgme.org/what-we-do/initiatives/physician-well-being/ American Medical Association Steps Forward (AMA) https://edhub.ama-assn.org/steps-forward/pages/professional-well-being Association of American Medical Colleges (AAMC) https://students-residents.aamc.org/medical-student-well-being/ medical-student-well-being The Physicians Foundation https://physiciansfoundation.org References 1. Maslach C, Jackson SE: The measurement of experienced burnout. Journal of Occupational Behavior 2:99-113, 1981 2. Dyrbye LN, Shanafelt, CA, Sinsky PF et al: Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC, 2017 3. American Psychiatric Association. APA Wellbeing Ambassador Toolkit Physician Burnout and Depression: Challenges and Opportunities, Slide 16, January 2018 4. National Academy of Medicine https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/ 5. Myers MF: Why physicians die by suicide: Lessons learned from their families and others who cared. New York, Michael F. Myers, 2017. 6. Tregoning C, Remington S, Agius S: Facing change: developing resilience for staff, associate specialist, and specialty doctors. BMJ 348:g251, 2014 7. The American Balint Society https://www.americanbalintsociety.org/ content.aspx?page_id=22&club_id=445043&module_id=406070

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3.

There are individual physician interventions that may help reduce distress, anxiety, depression, substance misuse, and suicide.

4.

There are specific skills physicians may practice to promote resilience.

5.

There are specific actions and behaviors physicians may take to promote wellbeing.

6.

There are steps physicians may take to help colleagues who are in crisis. ■

8. Muller C: Physician coaching: Providing a cure for a silent pandemic. Heartbeat December:1-12, 2020 9. Westphal RJ, Watson P: Stress first aid for health care professionals: Recognize and respond early to stress injuries. American Medical Association Steps Forward. May, 2021 https://edhub. ama-assn.org/steps-forward/module/2779767 10. Gold KJ, Sen A, Schwenk TL: Details on suicide among US physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry 35(1):45-49, 2013 11. Schernhammer ES, Colditz GA: Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 161(12):2295-2302, 2004 12. American Medical Association Steps Forward: Physician suicide and support: Identify at-risk physicians and facilitate access to appropriate care, slide 2, 2015 13. Dupont RL, McLellan AT, White WL, et al: Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat 36(2):159-171, 2009 14. Flaherty JA, Rickman JA: Substance use and addiction among medial students, residents, and physicians. Psychiatr Clin North Am 16(1):189-197, 1993 15. Federation of State Medical Boards, Policy 2018. Physician wellness and burnout. 2018 Available from: https://www.fsmb.org/ siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf 16. The Physicians Foundation Vital Signs Attend To Your Wellbeing: Open your hear conversation starter https://physiciansfoundation. org/wp-content/uploads/2019/08/PF-Vital-Signs-ConversationToolkit.pdf 17. The Physicians Foundation Vital Signs Attend to Your Wellbeing: A personal crisis management plan for physicians https://physiciansfoundation.org/wp-content/uploads/2021/04/PhysiciansFoundation-Crisis-Management-Tool-for-Physicians.pdf This article was originally published in the Alaska State Medical Association (ASMA) bimonthly newsletter, Heartbeat. It has been edited slightly to include Colorado resources and has been reprinted with permission.


A mortgage program specifically for physicians That’s just how we operate You logged the hours. You earned your degree. You’re set with a job. You deserve to be rewarded for your hard work. Huntington’s physician mortgage program is tailored specifically to medical doctors, dentists, and veterinarians1. The program offers a wide range of options, including 100% financing up to $1,000,000, 95% financing up to $1,250,000, and 90% financing up to $2,000,0001. Other features include: • • •

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Mortgage Loan Officer NMLS# 410695 2690 W Belleview Ave Littleton, CO 80120 o: (720) 909-9980 e: john.wetzig@huntington.com www.huntington.com/mortgage/wetzig-john Program only available to medical doctors who have a minimum degree of M.D., D.O., D.M.D., D.V.M., or D.D.S. and proof of sufficient income or active employment contract with proof of sufficient income and reserves. Minimum reserves required vary depending on amount of the loan. Maximum loan amount at 100% financing is $1,000,000, at 95% financing is $1,250,000 and 90% financing is $2,000,000. Loan-to value (LTV) financing options vary based on customer FICO score. Maximum overall loan amount is $2,000,000 with a maximum overall cash out option of $250,000 for refinances. Program is limited to the purchase or refinance of a primary residence.

1

All loans are subject to application and credit approval, satisfactory appraisal, and title insurance. Terms, conditions, and loan programs are subject to change without notice. Other terms, conditions, and restrictions may apply. The Huntington National Bank is an Equal Housing Lender and Member FDIC. a®, Huntington® and aHuntington. Welcome.® are federally registered service marks of Huntington Bancshares Incorporated. ©2022 Huntington Bancshares Incorporated. NMLS ID #402436 (06/21)


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Back in person and energized to be together!

PHOTOS FROM THE APRIL REGIONAL SUMMIT AND CMS BOARD OF DIRECTORS MEETING Kate Alfano, CMS Director of Communications and Marketing The Colorado Medical Societ y was thrilled to host the April Regional Summit and CMS Board of Directors Meeting in Fort Collins April 22-24, 2022. We opened with the welcome reception with Partners in Medicine and exhibitors followed by “dine-arounds” in Old Town Fort Collins that brought together attendees for great food and conversation. Saturday featured the COPIC program “If I Told You Once, I Told You a Thousand Times: Recurring Issues That Get You Sued” with Alan Lembitz, MD; a legislative update with Chet Seward; and “Clinical Pearls for

Safe Opioid Prescribing” with Jonathan Clapp, MD. Attendees were impressed by the University of Colorado School of Medicine – Fort Collins Branch tour with Christie Reimer, MD, reminiscing of their years in medical school and how it has changed. Saturday night was our Board of Directors dinner and all-member meet-up at New Belgium – both highly regarded events. The event wrapped Sunday after the Board of Directors met to hear committee reports and set new CMS policy. ■

“Thank you for coming to Fort Collins, it was great to everyone again face-to-face.”

COLORADO MEDICAL SOCIETY

REGIONAL SUMMIT We are planning the July Regional Summit and Board of Directors Meeting in Denver, July 23-24, 2022, with meetings and education at the CMS office, 7351 E. Lowry Blvd, Ste. 110, Denver, Colo., and a Saturday evening reception at Wings Over the Rockies, 7711 E. Academy Blvd., Denver, Colo. Scan the QR code for more information and to register.

ANNUAL MEETING ge Breckenrid

Plus, save the date for the CMS Annual Meeting, Sept. 16-18, 2022, in Breckenridge, Colo.

1 CMS thanks our Partners in Medicine, exhibitors and sponsors for supporting the April Regional Summit. 2 Gene Richer, CMS Director of Continuing Medical Education and Recognized Accreditor Programs, welcomes members to the Regional Summit. 3 Members enjoy the welcome reception Friday evening. 4 Alan Lembitz, MD, presents a COPIC program. 5 Regional Summit attendees socialize before a presentation by Christie Reimer, MD, MACP, at the CUSOM-Fort Collins Branch.

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“It was very valuable as a medical student to be able to engage with local physicians, hear their stories, ask questions and build better connections.” 6

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6 Board members and their guests enjoyed a dinner together Saturday night. 7 Jonathan Clapp, MD, presented best practices in pain management for CME Saturday afternoon. 8 Members gathered at New Belgium Brewery Saturday evening for the all-member meet-up. CMS past presidents from left: Jack Berry, MD, Dave Downs, MD, and Deb Parsons, MD, MACP. 9 The CMS Board of Directors met Sunday morning. From left: CMS President-elect Patrick Pevoto, MD, MBA, CMS Treasurer Hap Young, MD, and board members Chris Linares, MD, and Rachelle Klammer, MD.

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Report on the 2022 legislative session

WHAT PHYSICIANS NEED TO KNOW AS THE COLORADO GENERAL ASSEMBLY ADJOURNS Emily Bishop, CMS Director of Government Affairs

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he Colorado General Assembly adjourned on May 11, concluding a legislative session defined by contradictions. The House of Medicine faced intense scope of practice battles, while simultaneously enjoying broad collaboration to find solutions for Colorado’s health care workforce. The Colorado Medical Society also engaged on important issues like prior authorization reform and mental and public health this session.

CMS’s positions on legislation are determined by the Council of Legislation, a diverse group of physicians who consider bill language, potential impact to physicians and their patients, CMS policy, and the political landscape to reach positions and allocate resources. “The Council on Legislation has an impactful role during the legislative session,” says COL Chair Kim Warner, MD. “Diverse physician voices by specialty and geographic location are invaluable to the workings and success of the Council. The power of COL lies in the grassroot physician involvement at every stage of the political-advocacy process.” THE FOLLOWING IS A SNAPSHOT OF SOME OF THIS SESSION’S KEY ISSUES. Legislators acknowledge physician-led, team-based care, reject PA bid for independent practice second year in a row. A perennial issue, CMS closely analyzes any attempt to expand non-physicians' scope of practice to defend quality patient care and stand up for physicians and their practices. CMS secured a key victory in defeating HB22-1095, which sought to drastically expand the scope of practice of physician assistants (PAs) and strike all physician supervision from statute. Proponents argued the bill would improve rural access and allow PAs to work at the top of their training. CMS, member physicians and House of Medicine lobbyists argued the move would fragment health care delivery.

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“Since the beginning of this debate, CMS and our House of Medicine partners worked tirelessly to convey the importance of PAs in the physician-led health care team,” said CMS President Mark B. Johnson, MD, MPH. “Expanding their scope of practice to be completely independent of physicians is not in line with PA training or the needs of Colorado patients.” Dr. Johnson lauded the defeat of HB22-1095 as a win for patient safety and the preservation of the team-based approach to care. CMS and House of Medicine partners suf fered a loss on HB22-1233, the optometrist sunset. Despite best efforts, the bill is expected to pass and will allow optometrists to perform injections around the eye and some surgeries. HB22-1384 was a late-in-the-game play by naturopathic doctors to expand their formulary beyond the nonprescription, biologics medicine class to which they’re currently limited. However, through great House of Medicine collaboration, specifically between the Colorado Academy of Family Physicians, Colorado Chapter of the American Academy of Pediatrics and CMS, the bill was postponed indefinitely to allow for a robust stakeholder process in the coming interim. Health care workforce solutions enjoy broad support. CMS supports physicians in all stages of your career, and initiatives to build the workforce for the future. A number of bills aimed at recruitment and retention of health care providers in Colorado, especially for those in underser ved

communities, passed this session. Read more in the cover story on page 6. SB22-172 will expand the University of Colorado School of Medicine’s successful rural track training program to other institutions and health care professionals across the state. CMS joined a group of health care organizations in supporting SB22-226, which focuses on the resilience and retention of our state's health care workforce. HB22-1005 expands Colorado’s rural preceptor tax credit program while SB22-200 establishes a grant program for rural hospitals. HB221050 establishes an innovative program for international medical graduates interested in completing their medical degrees in Colorado. Prior authorization “gold card” program and payment reform bills; legislators moved by patient stories. One of CMS’s highest priorities this session was expanding on our work to streamline and codify the prior authorization process for the sake of practices and patients. CMS has heard loud and clear from physicians and patients about the hassle and cost to patients of prior authorization. You can read one of these patient stories on page 24. The legislature ran out of time to approve a prior authorization "gold card" program for providers who demonstrate safe and consistent practices through their prior authorization approval percentages. However, work will continue to reduce cost and administrative burdens for patients and physicians alike.


A number of bills aimed at recruitment and retention of health care providers in Colorado, especially for those in underserved communities, passed this session. Primary care physicians currently using or considering integrated care models will be able to apply for a grant from the program established by HB22-1302. Watch for further information when those funds become available. This precedent-setting bill is one of the ways Colorado is on the cutting edge of payment reform. While CMS secured important protections for physicians in the bill, there is still important work to be done to ensure APMs work well for physicians and patients. Expect to hear from us in the coming months about how you can be involved with the implementation process. Mental and public health access see boost for second year in a row because of the COVID-19 pandemic. The legislature continued last year’s efforts to increase access to mental and

behavioral health. HB22-1278 established the behavioral health administration and tasked it with creating a coordinated, cohesive, and effective behavioral health system in Colorado. Several bills also addressed mental health services in the criminal justice system, including SB22-196, SB22-021 and HB22-1256. Once again, CMS opposed anti-vaccination legislation such as HB22-1200 and SB22-053, which sought to limit a hospital or facility’s ability to prohibit visitations to reduce the risk of disease transmission. CMS suppor ted HB22-1267, which emphasizes the importance of equipping physicians and other health care providers with culturally relevant training. The bill establishes a grant to fund a program that would be available statewide.

Finally, CMS supported HB22-1064, a bill that aimed to ban flavored tobacco and regulate synthetic nicotine products. While CMS and our partners knew this bill would be a difficult fight, it was important to show a united front of concerned physicians and health care providers. Stronger regulation of the tobacco industry is a long game and CMS remains committed to protecting consumers. CMS member surveys consistently show advocacy is the No. 1 priority of Colorado physicians and CMS is honored to be your voice at the Capitol. Grassroots engagement is critical to our continued successes on health care issues. Watch for updates in our Policy Pulse e-newsletter and invitations to interview candidates before the November election. We always welcome your involvement and feedback; email membership@cms.org. ■

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COPIC Medical Foundation—2022 grants Gerald Zarlengo, MD, Chairman & CEO COPIC Insurance Company

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stablished in 1991, the COPIC Medical Foundation has focused on providing charitable financial support to programs and initiatives that address health care issues. Over the years, it has provided more than $11 million to improve patient care and medical outcomes, primarily through grant funding. This year’s funding cycle continued to focus on initiatives designed to reduce fragmentation across care settings. Breakdowns in care from a fragmented health care system are a top concern in patient safety and can lead to readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and reduction in quality of care leading to general patient and provider dissatisfaction. “From youth with complex special needs to patients with predefined orders around life sustaining care to other scenarios where patient care is transferred, it is exciting to not only think of the impact our grant funding will have on these individual institutions and their patient populations, but the potential for widespread impact across regions,” said Sophia Meharena, DO, FAAP, COPIC Medical Foundation board chair. The 2022 cohort of grantees include five incredible organizations of varied size and scope that impact health care in communities across the country. This year, the COPIC Medical Foundation granted a total of $680,000 in grants focused on reducing fragmentation across care settings. Grants support the following projects:

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Children’s Hospital Colorado (Colorado)—The grant will be used for the rollout and implementation of the ImPACT Navigation Hub in care coordination for complex pediatric patients as they transition to adult care.

West Mountain Regional Health Alliance (Colorado)—Funding will support Community Resource Network West Mountain, a social information exchange platform in western Colorado that facilitates care coordination for individuals experiencing homelessness with coordination by hospitals, health and behavioral health providers, community organizations, and government agencies.

Bryan Health Connect (Nebraska)—Funding will support a project to expand the Bamboo Health clinical event notification system to additional locations across Nebraska.

Minnesota Medical Association Foundation (Minnesota)—Funding will be used for Project ECHO, which focuses on the challenge of transitioning youth with medical complexity to adult care in Minnesota.

Foundations of Orgon Providence Portland Medical Foundation (Oregon)—The grant will help a partnership between Providence and the Oregon Physician Orders for Life Sustaining Treatment (POLST) Registry to build a bi-directional interface which integrates Providence’s Epic electronic health record with the Registry. “The COPIC Medical Foundation is proud to support those in health care who are making a difference and pushing innovative ideas forward,” said Meredith Hintze, executive director of the COPIC Medical Foundation. “Our grant funding helps support solutions that can improve patient safety in ways that can be replicated across health care and/or create additional opportunities for expanded applications.” The Foundation plans to remain focused on funding projects that reduce fragmentation across care settings for its next grant funding cycle. We anticipate that the next Request for Proposals (RFP) will be posted in November 2022 with applications due mid-January 2023. For more details on the COPIC Medical Foundation, please visit www.copicfoundation.org.


All Medical Answering Service Within Normal Limits: Navigating Medical Risks—hosted by Eric Zacharias, MD, COPIC’s Director of Medical Education—now has more than 35 episodes available. Each episode is around 20-30 minutes and features a discussion with physician leaders and/or medical experts that offers insights to improve care and avoid medical liability issues. Recent episode topics include: • Managing Patients Who Bring in Wearable Device Data • U s i n g K e t a m i n e t o Tr e a t Depression • Preventing Surgical Fires and Injuries Related to Elec trical Surgical Units Within Normal Limits is available on popular platforms such as Apple Podcasts, Google Podcasts, Spotify, and Amazon. You can also go to www.callcopic.com/wnlpodcast for more information. ■

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Our Partners in Medicine program connects industry leaders and physician members of CMS to improve patient care and help physicians achieve personal and professional satisfaction. For more information, visit

www.cms.org/partners

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R E F LE C TI O N S

Tired

Valerie Gao

Valerie Gao is currently a third-year medical student at the University of Colorado School of Medicine. She is a proud Denver native and enjoys everything Colorado has to offer such as hiking, skiing and exploring the evolving food scene. She is interested in applying to internal medicine with a special interest in rheumatology and chronic pain management. It was 4 p.m., the end of another long clinic snapped up in surprise. I couldn’t believe with unvaccinated patients treating me day. Our last patient was late, of course, what I had just heard. My mind raced as like I was stupid, from getting interrupted and the sun was already beginning to I tried to think of what to say next: How by attendings, from tripping over my set before she was finally roomed and much did I actually want to engage with words on every presentation. I was tired ready for me to talk to her. The purpose this statement? Was she trying to compli- of answering the question, “No, where of the clinic visit was vague: “follow-up.” ment me? What do you even say to some- are you really from?” and having to thank Before I went in, my resident told me to thing like that? More than anything, I was people for their stuttering comments “try to keep things short” if I could. I was bewildered. Out of pure curiosity, I heard about how fascinating and exotic my tired, but I went in with a big smile and myself saying, “Um, why would you say culture is. I was tired of getting annoyed cheerily introduced myself to the patient. that?” She told me something about how at the grocer y store employee who She was an older woman and greeted too many Filipino people are in health acted like they couldn’t understand my me with a pleasant “Hello dearie.” As we care and “all of them are nurses.” At this dad’s English, even though he regularly began talking, she suddenly asked, “So, point, I knew it was useless continuing this publishes scientific papers in prestigious where are you from?” I knew exactly what line of conversation and tried to steer it journals. I was tired of hearing about the “rise of anti-Asian American violence” in answer she was looking for because she back to her visit. the news. I was tired of fretting about definitely wasn’t the first person to ask me this. I was born and raised in Denver, I didn’t feel any malice from this patient, my Chinese-American partner who lives but that never seems to satisfy people. I but I still felt slighted. I wasn’t expecting in New York City every time he gets on wearily decided in that moment I didn’t to end the day answering questions about the metro. I felt my shoulders sag with the have the energy to dance through the my ethnicity and, once again, feeling weight of this patient’s comments adding usual fake theatrics, and I responded that foreign in a place I called home. More than to the already existing pile of exhaustion I was Chinese. Usually, I get comments anything, I was tired. I was physically tired dragging down all my energy. I didn’t even about how wonderful China is or how from clinic all day, from starting rotations bother to bring it up with my resident when much “I love Chinese food/culture.” But in May, from studying for Step 1 since I came out of the room as I presented our instead, I heard today, “Oh, I’m so glad January. I was emotionally drained from interview, because I was tired. ■ you’re Chinese and not Filipino.” My head talking to patients all day, from dealing

Professor Rounds Andrew Willis

Andrew Willis is third-year medical student planning to pursue an MPH next year. He was born and raised in the San Francisco Bay area by journalist parents. His undergraduate years at UC Berkeley highlighted the need for collective political action, migrant justice and health care reform. After his MPH he plans to apply to family medicine and psychiatry combined residency programs. The late afternoon light filtered in reminding me – once again – that a balmy fall day had passed without me setting foot outdoors. I was gathered with four beloved classmates around a man suffering from ARDS, a sequela of SARS-CoV-2 pneumonia. On high flow oxygen, he had generously agreed to have each of us examine his lungs by ultrasound. Within moments his torso was coated in ultrasound goop. One of my classmates was driving the probe, while Dr. C, our attending, gave gentle instructions, inflected with ques20

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tions. I stepped back for a deep breath was all the rage when I was training!” or as I so seldom remember to do. I took in “COVID was brand new in my day, and we my classmates, recalling how much we braced ourselves against the coming of had laughed and suffered and grown each new variant." And, I wonder: What together (imperceptibly so!) over the past will I be like when I'm an attending? Where six months. Breath. I glanced at Dr. C, will I practice? How will I find meaning in motioning to the ultrasound findings, so my life and in my career? generous, unassuming, and wise in his way. Breath. Our patient, a calm eye at I search without knowing. I don't have to the center of our storm of curiosity. I felt I know right now. For now it's enough to was living in a sepia tone memory, already look around this hospital room, to see the faces in afternoon light, to breathe. To nostalgic for being a learner in this time. appreciate the little things. ■ I wondered what I’d tell the next generation of students: “Point-of-care ultrasound


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I NTR O S P E C TI O N S

The Physician Jonathan Evers Nadine Taher

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.

Jonathan Evers is a third-year medical student at Rocky Vista University College of Osteopathic Medicine. Originally from Plymouth, Minn., Jonathan is interested in pursuing a career in pediatric and adolescent psychiatry that integrates emerging interventional modalities into patient care. Student-doctor Evers previously penned the Vision Statement for RVU’s Class of 2023 and enjoys writing poetry and prose in his spare time.

Nadine Taher is a third-year medical student a Rocky Vista University College of Osteopathic Medicine. Nadine grew up in Saudi Arabia before moving to Colorado to attend medical school and intends to pursue a residency in pediatrics. Student-doctor Taher enjoys writing about current political topics, particularly those related to humanitarian crises being faced around the world.

And in the study of those ancient Machines of our great race I have Scarce seen a heart unfit for beating, Have never known lungs unworthy of breathing, Nor eyes infirm of love for seeing, Yet despots of clear spirits would throw That lead curtain over the perception of Our better angels, furiously washing The eternally perceptible marble of Justice marking that the hearts of All humankind are unfit to the dredge of slavery and Lean to the ceaseless march of due freedom, for I have sown a million wounds about the Rich and destitute alike, their blood runs and soothes the very same, I have been the lungs of the native and of the foreigner, both Laid still as I watched over their quiet breathing into the morning, Those fitful hearts I’ve jolted to steady beating leap sure enough

At sight of their beloved whether Black or white; and I know that Tremulous hands held through plastic feel the same whether Jew or Muslim. Long have I borne tidings both good and ill, the young Receive them as like the old; and I tell you that Even the hardest of wards is Fit with Jacob’s Ladder leading up and hereafter, For the timeless vow of Medicine Is a blind mother, she whispers and pacifies All that are equitably touched by her presence. My soul is Of that sightless realm and I am tied to Her endeavors as a capstone mired to the tumultuous sea, For every refrain of our profession is Justice Until all corners of the world and every people is awash With it; and physicians, being the lasting fiduciaries Of that inextinguishable torch of healing Peace Are bound endlessly to its success, and fixed In struggle against its defeat. ■

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The perfect storm Claire Schulte, SHJ Wealth Advisors

Over the past three months, a fusion of increased prices, talks of rising interest rates and the humanitarian crisis in Ukraine has created the perfect storm, which sent markets into volatile waters. The uncertainty has pushed investors away from equity exposure, and while traditionally bonds would serve as the safe haven, recent changes in monetary policy have prevented such protection. Because it has been some time since we have seen inflation at these levels, current conditions can feel foreign, and it is important to remember that we cannot control the wind; we can only adjust the sails.

Why so expensive? Inflation has been in the headlines for the past few years, as we navigate the aftermath of the COVID-19 pandemic. Recent price increases have been driven by issues on the supply side. The shock caused by COVID-19 and the subsequent shutdown highlighted long-term structural constraints within the trucking and port industry. The dependency on current supply-chain logistics needs to be reevaluated. This need for rewiring of the global economy puts pressure on companies to reassess how they deliver their products to the consumer. This could lead to great opportunities for innovation, but prices will remain elevated as companies navigate current logistical issues. In the meantime, individuals and companies

are sitting on an excess amount of cash due to decreased spending during the pandemic to combat higher prices. Oil, natural gas and commodities make up another piece of the inflation pie. Prices will most likely remain high with oil and commodity market disruptions provoked by the Ukraine crisis. The combination of demand for more space and low interest rates have pushed housing prices higher over the past few years. Groups are moving back to big cities af ter retreating from crowded streets during the pandemic, pushing rent prices up. The Federal Reserve is hoping that the increase in interest rates will work to stabilize housing prices and slow growth.

Federal funds effective rate 20% 18 16 14 12 10 8 6 4 2 0 1980

1985

1990

1995

Note: Data isn’t seasonally adjusted Source: Federal Reserve Bank of St. Louis

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2000

2005

2010

2015

2020


S&P 500: Worst Performance through 48 Trading Days (1928-2022)

Interest rates versus inflation On March 16, the Federal Reserve voted to raise interest rates by 0.25 percent, kickstarting their journey to bolster interest rates for the first time since 2018. The Fed also alluded to six more increases by year-end, possibly reaching 2.75 percent by the end of 2023.

Rank

Year

Price Return Through 48 Trading Days

Price Return: Day 49 to Year-End

1

2009

-16.9%

48.5%

2

2020

-15.1%

37.0%

Rocking the boat: Market volatility

3

1935

-14.1%

64.6%

Heading into 2022, the fear of rising prices and the uncertainty around the Federal Reserve’s strategy for addressing interest rates created nerves in the markets. Investor fear accelerated when Vladimir Putin announced Russia would be invading Ukraine, forcing 3.7 million Ukrainians (as of March 25, according to Pew Research) to seek refuge in over 20 countries. As the world tries to navigate these difficult hurdles, it is important to be reminded that panic is not an investing strategy.

4

2022

-11.8%

?

5

1933

-11.6%

62.9%

6

1982

-10.8%

28.3%

7

2001

-10.6%

2.7%

8

1960

-10.1%

8.0%

9

2008

-10.1%

32.6%

10

2003

-8.6%

38.3%

11

1948

-8.6%

8.6%

12

1942

-8.2%

22.4%

13

1968

-6.6%

15.4%

14

1978

-6.5%

8.1%

15

1984

-6.4%

7.7%

Looking back to 2020, the two-week stay-at-home order and mounting anxiety surrounding COVID-19 created a large market response. The S&P 500 dropped sharply in the month of March, losing a total of 24 percent from the beginning of the year. Heading into 2022, we see an eerily similar response, although the fear now centers around rising prices and the conflict between Ukraine and Russia. The S&P 500 dropped 12 percent by mid- March 2022 before star ting to recover. According to the chart below, when stocks begin a year in negative territory, they typically have time to recover. In the 14 years when the stock market started with a dip, 12 of the years recovered to some degree. We have already seen a slight recovery in the U.S. stock market as hope for resolution between Russia and Ukraine grows and companies begin to report positive outlooks on earnings. The S&P 500 has jumped from -12 percent to -5.3 percent over the past two weeks. Europe will most likely experience a slower recovery, as the Ukrainian crisis will have a more long-term impact on the surrounding countries that rely more heavily on Russia and Ukraine for exports. Because of this, our portfolios are currently underweight in international stocks.

The bond market has also had a difficult start to the year. With anticipation of rising interest rates, bond prices have declined. Bonds are still a diversifier in contrast to stocks and over the longterm decrease volatility in portfolios. Adding shorter-term bonds to the portfolios has helped stabilize returns and reduce interest rate sensitivity. Stay the course No matter the investment uncertainty in 2022, remaining disciplined is typically the best approach. In trying times like these, it can be difficult to maintain a long-term focus and not abandon ship. It is important to remember that this too shall pass. Maintaining a diversified portfolio and a long-term outlook will help this volatility feel more tolerable.

F or more content , v isi t w w w. shjwealthadvisors.com to watch our quarterly market recaps. ■ Any analysis of economic or market conditions are the opinions of SHJ Wealth Advisors and are conditional at the time they were made. Analyses could be subject to different interpretation if read at a later date and/or in a different environment. Any forward looking statements (i.e. expected sector growth, expected growth of a particular issuer, etc.) offered are the opinions of SHJ and should not be relied upon as any form of guarantee.

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

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F E ATU R E

F I N A L

WO R D

Prior authorization hurts patients like me Robin Mulroney

M

y story is about what goes wrong when health insurance company bureaucracy prevents patients like me from getting the medical care we need. My hope is that by sharing the nightmare I have gone through, the Colorado General Assembly will be motivated to act to spare others from having to endure similar care denials. I was in my late 20s when I was diagnosed with Essential Tremor, a movement disorder more common but less well known than Parkinson’s Disease that causes involuntary, rhythmic shaking in the body and gets progressively worse over time. The shaking began in my hands and over 30 years worsened to affect my face, tongue and vocal chords. I tried every medication I could, every medical device. I switched to weighted utensils so I could feed myself. Nothing worked, and my independence and quality of life were slipping away. It was a huge leap for me to agree to deep brain stimulation (DBS) surgery. It begins with an MRI under anesthesia to map the brain and is followed by a surgery to implant the leads (wires) into the brain. After a few weeks of healing comes the second surgery, to implant batteries and make small incisions behind the ears to connect the leads to the power source, which acts like a pacemaker to stimulate the brain and hopefully lessen the shaking after some adjustments. I knew this was going to be a difficult journey – but at age 62 and with plenty of life left, I decided to go through with the procedure. I discussed this with my neurologist and in December 2021 we made a plan. My doctor’s office submitted the required paperwork to my insurance company for approval, a process called “prior authorization.”

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In January I underwent the first part of the procedure by getting the MRI and having the surgery to implant the leads in my brain. A few days later I suffered a stroke that made me very weak and required that the final surgery be postposed by two weeks. Days before my second surgery, I received notification from my insurance company that they were denying the final surgery to place and connect the generators. Even though they had approved the first surgery, they stated the second surger y was “medically unnecessary.” I was aghast and very emotional given the toll the first surgery had taken on me. My doctor and his staff were stunned. They appealed the denial. It was denied a second time. An appeal was sent to a third party and was denied again. I just fell apart. My doctor requested a peerto-peer review; he gave the insurance company his personal cell phone number to discuss my case. They never contacted him. His staff spent hours on the phone, being transferred from person to person. I also spent hours on hold, with wires in my brain not connected to anything, told by the insurance company that they would not authorize a surgery for “just a twitch,” and I would be responsible for paying for any additional claims they received related to this procedure. The day before the second surgery, my doctor’s scheduler spent the entire busi-

ness day on the phone with the insurance company and my doctor asked the hospital to keep an operating room open for me just in case. They were doing everything they could to follow the mind-boggling health plan rules and get me the very best care possible. It was after business hours and still I waited to hear if I would be undergoing surgery or continuing to plead my case. At this point I felt like I had done something wrong. It was as if I were a prisoner on death row waiting for clemency. Finally, at 7:30 p.m. the night before the surgery, the insurance company finally granted approval on exception, still insisting it was not medical necessary. I am grateful that the second surgery was successful and after two calibrations I am seeing results. I celebrate the small but significant victories that others take for granted: I can eat soup using a bowl and spoon instead of drinking it out of a cup; I can eat with a fork and not have the food fall off; I can brush my teeth without jabbing my face or gums; the list goes on. My experience was stressful and, in some ways, humiliating, yet I am quite certain that it is common and more people are out there suffering like I did. This should not be tolerated. I am choosing to move forward to heal and share my story so we can change things. The Colorado legislature can make a difference by voting “yes” on a Senate Bill 22-078, which will lessen the burden of prior authorization on patients like me. ■

Our work continues

This article was written in April 2022 as Robin was preparing to testify in support of SB22-078. Unfortunately, time ran out on the session before this bill could pass. CMS will continue to work to reform prior authorization as we know Robin's story is not unique. If you know of a patient who has had a similar experience, please contact amy_goodman@cms.org to add to our arsenal for next session. ■

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