May-June 2019 Colorado Medicine

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COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE

HARD-FOUGHT LEGISLATIVE SESSION ADJOURNS

C O NTE NT S

Cover story: Legislative report The Colorado General Assembly adjourned on May 3, concluding a legislative session that arguably had the most sweeping and contentious focus on health care law and policy in recent memory. The Colorado Medical Society and allies defended multiple fronts, pushing our advocacy bandwidth to its limits, and secured major victories in reenacting professional review without breaching its privileged nature, reenacting the state’s Medical Practice Act, passing prior authorization reform, and more.

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F E ATU R E S

14 PATIENT SAFETY POLLS: A TALE OF TWO STATES

CMS and allies succeeded in protecting professional review this legislative session. Twin patient safety polls of Colorado and Florida physicians reveal strong confidence in Colorado’s peer review system and the nearcollapse of the system in Florida since it was opened to discovery of records relating to adverse events.

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18 COLORADO MEDICAL STUDENTS GO TO WASHINGTON

Colorado medical students traveled to the nation’s Capitol to learn about top health care issues before federal lawmakers and how the American Medical Association is working to address them.

19 CMS MSC HOSTS MEDICAL STUDENT DAY AT THE CAPITOL

Students from both Colorado medical schools descended on the Gold Dome to learn about effective lobbying and top health care issues at the state level, and meet with lawmakers and their staffs.

22 ACCURATE CODING AND DOCUMENTATION

Changes are coming to Anthem’s payment for evaluation and management services with modifier 25. Read about when the modifier applies and how to get paid appropriately for services provided.

23 IMPROVING AFFORDABILITY OF HEALTH CARE IN COLORADO

HCPF Executive Director Kim Bimestefer outlines the impactful health care affordability policies that passed in the 2019 legislative session and calls on physicians to work with the department to help make them work for all Coloradans.

36 FINAL WORD: THE CASE FOR PROTECTING PROFESSIONAL REVIEW

A Florida legal expert reveals why protecting privilege in professional review was so crucial for Colorado and how quickly confidence in the system can evaporate when records become discoverable.

20 MORAL INJURY IN MEDICINE

Burnout is bigger than an individual physician’s wellness activities.

Resourceful doctors are suffering moral injuries from the direct conflict between their Hippocratic oath and an increasingly business-oriented health care system that turns a profit on the sick and vulnerable.

I N S I D E

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C M S

President’s Letter

D E PA R TM E NT S

30 Medical news

13 CMS Corporate Supporters and Member Benefit Partners

34 Classifieds

24 COPIC Comment

34 Letter to the Editor

25 2019 Presidential Celebration and Gala 26 Introspections 28 Reflections

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 Stephanie Salazar, Coordinator stephanie_salazar@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance.

COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified.

Alfred D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor. Design by Scribner Creative.

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P R E S I D E NT ’ S

LE T TE R

My story of policy, politics and possibility

Debra Parsons, MD, FACP President, Colorado Medical Society Now that the 2019 Colorado General Assembly has concluded, I am able to take a step back, breathe and contemplate the incredible things we accomplished this session. The Colorado Medical Society amplified the voice of all physician members in Colorado, and we would not have accomplished this without your participation in Central Line and surveys.

Starting back in February, I was honored to represent Colorado at the American Medical Association’s National Advocacy Conference. As I set out with my CMS colleagues to visit our federal legislators I pondered: “What is my role in engaging the political process to lead positive change in health care policy for the sake of our patients and our profession? How is this best accomplished? Why do this?” The AMA prepped physicians on

four major federal issues – gun safety, opioids, surprise billing, and transparency and competitiveness in drug pricing – and we took our message to Capitol Hill for engaging Hill visits.

During the week in Washington, I recalled the proclamation by our CMS CEO, Alfred Gilchrist, that “politics is the process that drives policy.” I realized that our role as physician leaders is to broaden our responsibility to our patients, communities and our profession beyond our clinical role and engage in the political process. I learned that we do this best when we show up respectfully, professionally and with a unified voice; and demonstrate that we do this because we deeply care. When we engage our heart and soul in a personal and rewarding way, we are empowered to act and there is no stopping us.

1 David Markenson, MD, CMS president-elect, expresses physicians’ concerns with U.S. Rep. Doug Lamborn.

2 Sami Diab, MD, meets with U.S. Sen. Cory Gardner.

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3 From left: Sara Lipnick, executive director of the Aurora-Adams Medical Society; Chet Seward, CMS chief strategy officer; Liz Lowdermilk, MD, Denver Medical Society president; Kathy Lindquist-Kleissler, DMS executive director; Deb Parsons, MD, CMS president; U.S. Representative Jason Crow; and Dave Downs, MD, AMA delegate.

4 From left: Jason Kelly, MD, president of the Arapahoe-Douglas-Elbert Medical Society; Tonya Wren, MD, president of the Mesa County Medical Society; and Deb Parsons, MD, meet with U.S. Sen. Michael Bennet’s policy staff, Rita Habib (far right).

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P R E S I D E N T ’ S LE T T E R

As the Colorado legislative session kicked into gear, I joined company with physicians who are not experts in providing testimony but who are experts on the health care issues important to our profession and in the interests of our communities. My first testimony was in support of HB19-1083, the Athletic Trainer bill, concerning a reclassification of the regulation of athletic trainers from registration to licensure. Athletic trainers are often the first-responders for athletes and, as a former member of the Colorado State University’s collegiate women’s swim team, I know firsthand the importance of athletic trainers in the life of an athlete. With this testimony, I learned that involvement in the legislative process is an exciting and rewarding experience that connects our profession to our community.

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2,3 Denver Broncos football players, with CMS President Deb Parsons, MD, and Past-president David Downs, MD, support the athletic trainer bill.

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The legislative session is a fast-paced environment where a great deal of information is condensed into a short period of time. I learned that meeting with legislators and giving testimony are two of the most effective ways to educate our policymakers about the impact, either positive or negative, that proposed legislation or legislative change might have on our profession and our patients.

Deb Parsons, MD, CMS president, learns the first two steps in effecting meaningful change: “showing up” and “relating a personal story,” as she gives testimony on the athletic trainer bill.

The participation of Rep. Shannon Bird (center) on the Committee on Business Affairs and Labor helped pass the athletic trainer bill, which subsequently became law.

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1 Deb Parsons, MD, right, shares professional review data with Senate President Leroy Garcia during the sunset of the Colorado Professional Review Act. 2 CMS physicians educate legislators through their testimony about the impact on patient access and private practice physicians from proposed legislation on surprise medical bills and out-of-network policies.

From left: Anna Weyland, MD, member of the CMS Council on Legislation (COL); David Downs, MD, Chair of the CMS Workgroup on Health Care Cost and Quality; Bruce Waring, MD, COL member; and Nathanial Hibbs, COL member.

As I reflect on the 2019 session of the Colorado General Assembly, I deeply appreciate that it is critically important for medicine’s unified voice to be heard on those laws that affect day-to-day medical practice, improve patient care, support rewarding medical careers and improve the overall health of our communities.

I recall the wonderful book from my friend and colleague Jack Cochran, MD, “Healer, Leader, Partner: Optimizing Physician Leadership to Transform Healthcare,” in which he writes, “When physicians aggregate around the needs of patients to create and improve a system that prioritizes issues like clinical quality, efficiency, affordability and safety, there develops a unified voice worthy of an audience.” … “It’s our time, it’s our turn and patients need us.”

The CMS physicians made good on this directive by standing up and opting in to lead. We showed up, shared personal stories, fought hard for our patients and our profession, and built relationships and trust with our legislators. For this I am deeply proud. ■

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C OV E R

S TO RY

Hard-fought legislative session adjourns Big wins in patient safety and prior authorization and big changes in out-of-network billing Susan Koontz, JD, General Counsel, Senior Director of Government Relations The Colorado General Assembly adjourned on May 3, concluding a legislative session that arguably had the most sweeping and contentious focus on health care law and policy in recent memory. The multiple fronts of professional review and Medical Practice Act (MPA) sunset, the opioid crisis, out-of-network (surprise medical bills) reform, prior authorization and funding challenges within state budget deliberations were all anticipated and strategized by the Colorado Medical Society before the session convened. As expected, these multiple fronts completely absorbed the advocacy bandwidth of CMS and an impressive array of physician allies, often forcing near-impossible choices as pressure converged from both parties and various outside interests. Success in this formidable political environment can be objectively measured not just by fair laws passed but also in terms of so-called “opportunity costs” – bad policies that were unrealized by adversaries despite a wealth of policy targets.

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“Colorado may have replaced states like California or Oregon as a health policy hotspot,” said CMS President Deb Parsons, MD, FACP. “Never have we been engaged across so many fronts by so many divergent interests on such a range of diverse issues. I am proud of the excellent work of our lobbyists, staff and fellow physicians who worked within our culture of collaboration and allowed us to make real gains in what could have been a catastrophic session.”

Others involved in public policy agree, noting that CMS’s political and legislative success this session was accomplished through methodical, sustained engagement of local physicians and their advocates before legislators convened in Denver and throughout the session.

“The four months legislators are in the pressure cooker under the dome are preceded by eight months of briefings and conversations with elected officials, allies, and prospective adversaries that delineate medicine’s concerns and priorities,” said CMS President-elect David Markenson, MD. “In some cases, legislators have never considered the complexities of health care policy and it is our task to present it clearly long before they are in a committee hearing or considering floor amendments. This is our long game.”

LEGISLATORS MAINTAIN COLORADO’S PATIENT SAFETY CULTURE, REJECT LAWSUITS AS THE ANSWER Colorado’s stable liability climate stayed intact, while plaintiff attorneys focused their attention instead on making professional review records discoverable. Plaintiff attorneys engaged in a session-long campaign to breach the privileged nature of professional review activities, and at times threatened to persuade legislators to allow this vital body of patient safety law to lapse under the state’s sunset review process. This most serious threat of the session was not successful.

CMS, COPIC, the Colorado Hospital Association, and specialty and component medical societies joined forces in a strategic coalition that was well coordinated and executed throughout the session, and strengthened by the many physicians who responded to CMS’ Code Blue legislative alerts.

In Florida – the only state in the country to permit discovery of these records – physician confidence in professional review has virtually collapsed since a state Supreme Court ruling in October 2017.

CMS President Deb Parsons, MD, FACP, met with Senate President Leroy Garcia (D-Pueblo) late in the session to reinforce the message that lawyers cannot sue Colorado into a safe patient environment. She emphasized the result of a CMS-commissioned survey of Florida Medical Association (FMA) members demonstrating a virtual abandonment and loss of confidence in the peer review system where medical errors are now going unidentified and uncorrected, presumably waiting for a lawsuit to punish a compensable event.

In the last days of the legislative session, House Majority Leader Alec Garnett (D-Denver) played a key role in the bill’s passage by mediating discussions involving CMS, COPIC, CHA and Colo-

rado Trial Lawyers Association (CTLA). The basis for medicine’s strong resolve throughout the session resided in CMS and FMA survey results (see page 14). Fully 79 percent of CMS members surveyed said that it was “extremely important” that protection for documents from professional review be kept in place.

The day before adjournment, the 2019 General Assembly passed SB19-234, reenacting the body of law governing professional review. Significantly, the renewed Professional Review Act maintains the professional review privilege for all documents and information privileged under the current law for the next 11 years.

“I was proud to have a small part in helping get this critical, life-saving piece of legislation through the General Assembly,” Garnett said. “Peer review is a time-honored practice that helps better patient outcomes and, thanks to this bill, will be preserved long into Colorado’s future.”

Another top priority was reenacting the Medical Practice Act, which reauthorizes the Colorado Medical Board and its vital functions of licensure, investigation of complaints, taking disciplinary actions and imposing fines, and aiding law enforcement in the enforcement and prosecution of any person or entity charged with the violation of any of the MPA provisions.

The bill to continue the MPA, SB19-193, implements some of the recommendations in the 2018 sunset report by the Department of Regulatory Agencies. It will continue the MPA and Colorado Medical Board until 2026; eliminate the restriction on the number of days that a physician may practice in a calendar year with a pro bono license; repeal the requirement that the board send a letter of admonition to a licensee by certified mail; and make other technical amendments.

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C OV E R LE G I S L ATI V E S E S S I O N : C O N T

LEGISLATORS RESPOND TO PRIOR AUTHORIZATION “HASSLE FACTORS” Driven by CMS member survey data demonstrating that getting approval for prior authorization (PA) requests has gotten harder since 2014, CMS took the lead in the fight for HB19-1211, “Prior Authorization Requirements Health Care Service.” It will streamline the overall PA process by reducing the time for response to a non-urgent request from 15 days to five days; ensuring that services that have been approved cannot be retrospectively denied; and ensuring that an approved prior authorization request remains valid for at least 180 days and continues for the duration of the prescribed course of treatment, among other provisions.

The Colorado Academy of Family Physicians took the lead for organized medicine on the Candor Act (SB19-201), which will provide legal protections for confidential communications between a health care provider or facility and a patient after an unanticipated health care outcome. CMS and COPIC supported CAFP’s advocacy efforts. The final act promotes open discussions after an adverse health care outcome so patients and their loved ones understand what happened and what steps may be taken to prevent similar outcomes, if possible. Under certain circumstances, optimal resolution may include an offer of compensation.

“We had doctors who wanted to shorten the prior authorization experience and streamline clinical guidelines.

We had insurance companies who were worried about significant enough time to follow their own internal guidelines for medical review,” said bill sponsor Rep. Dafna Michaelson Jenet (D-Commerce City), in an email to her constituents. “How do we get to an agreement? The answer: a lot of patience and a lot of negotiation. Perhaps some elevated blood pressures and a hearty handshake at the end. I am very grateful for all of the people who agreed to come to the table and work on this with me, and for representative and doctor Yadira Caraveo to make this a possibility and improve the health care costs and experiences for patients in Colorado.”

“The Candor Act provides a framework for physicians to offer compassionate, honest, timely and thorough responses to unexpected health care outcomes,” said CAFP President-elect and CMS member John Cawley, MD, FAAFP, of Fort Collins. “CAFP championed SB19-201 to provide a better system both for patients and physicians.

It is confidential and entirely voluntary, but it is an option that can lead to a resolution far faster than the current tort system, allowing patients to learn about what happened and what might be done to prevent a similar outcome in the future.”

OPIOID INTERIM STUDY COMMITTEE PRODUCES 2019 CMS-SUPPORTED REFORMS For the past six years, CMS has been working with partners in the Colorado Coalition for Prescription Drug Abuse Prevention to develop policies, enact laws and make important strides to reverse the opioid epidemic. All the bills from the Opioid and Other Substance Use Disorders Interim Study Committee were introduced and worked their way through the legislature, as did other opioid-related bills introduced earlier this year.

HB19-1287, “Treatment for Opioids and Substance Use Disorders,” directs the Department of Human Services to implement a centralized, web-based behavioral health tracking system to track available treatment capacity at behavioral health and treatment centers to support treatment access. It also directs the Department of Human Services to implement a care navigation system and expands treatment capacity in rural and underserved areas.

HB19-1009, “Substance Use Disorders Recovery,” focuses on expanding housing vouchers for individuals recovering from a substance use disorder and the licensing of recovery residences. It also creates an opioid crisis recovery fund for money the state receives as settlement from opioid litigation.

SB19-227, “Harm Reduction Substance Use Disorders,” carries a variety of harm reduction measures; including allowing school districts to carry naloxone; specifying that hospitals can be a syringe access site; creating a naloxone bulk purchase fund; 8 C O LO R A D O M E D I C I N E

expanding the medication take-back system to include sharps;authorizing naloxone to be available where an automated external defibrillator (AED) is available; and establishing criteria for how a program must verify the identity of individuals seeking treatment, including those without identification and those experiencing homelessness.

SB19-228, “Substance Use Disorders Prevention Measures,” has a variety of components related to prevention. Most significantly for physicians is a requirement of health care providers who prescribe opioids to complete substance use disorder training as part of continuing education required to renew their license.

CMS opposed a mandatory CME provision but ultimately did not oppose the bill given other pressing legislation.

“We view this session as a win because we were able to get additional funding to address the opioid epidemic and achieve much of the agenda of the interim committee,” said Robert Valuck, PhD, RPh, executive director of the Colorado Consortium for Prescription Drug Abuse Prevention. “Regarding mandatory CME, there was a very strong appetite at the legislature this session. Legislators felt that while there has been a lot of success with voluntary CME, there are more prescribers we can reach with this requirement. We at the consortium worked with bill sponsors to make the mandate as rational and reasonable as possible.”

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C OV E R LE G I S L ATI V E S E S S I O N : C O N T

OUT-OF-NETWORK AND REINSURANCE DELIBERATIONS CHART NEW COURSES The legislative scrutiny regarding surprise medical bills aligned a trifecta of payers, consumers, and purchasers/employers – a perfect political storm for physicians. Much like the contentious debates in multiple other states, local and national media pressure was unrelenting, producing storylines that profiled billing excesses by outliers rather than the more complex picture of how plans game networks. Throughout the session, CMS and specialty medical society allies pressed the case for fair-minded reforms.

In the end, HB19-1174 passed into law. CMS and specialty societies were successful in narrowing the scope to emergency situations and inadvertent treatment by an out-of-network provider at an in-network facility. The bill also added “baseball arbitration,” where the carrier and provider both submit, in writing, their final offer and an arbitrator considers the provider’s level of training, education, experience and specialization as well as the previously contracted rate if the provider had a contract with the carrier that was terminated or expired within one year of the dispute.

Despite citing multiple data sources, the final bill does not establish medicine’s preferred payment benchmark. For covered services at an in-network facility from an out-of-network provider or for out-of-network emergency services with some exceptions, the carrier will pay the provider directly the greater of 110 percent of the carrier’s in-network reimbursement

rate for the same service in the same geographic area or the 60th percentile of the in-network reimbursement rate for the same service in the same geographic area for the prior year based on commercial claims data from the all-payer claims database (APCD).

If the out-of-network provider provides covered emergency services or nonemergency services and the provider receives payment from the covered person for which he or she is not responsible (i.e., the health plan has made a payment pursuant to this statute), the provider must reimburse the covered person within 60 days of receiving notification of the overpayment. If the provider fails to reimburse the covered person within the 60-day timeframe, the provider must pay interest on the overpayment at the rate of 10 percent per annum beginning on the date the provider was notified.

The Division of Insurance will work with the medical board and the Department of Health to develop rules outlining the language and timing of notifications to be used by all parties when informing a covered person about the possibility of receiving care from an out-of-network provider. Insurance Commissioner Michael Conway reached out to CMS on the day of the bill’s passage with an invitation to work on the law’s implementation and to discuss potential reporting requirements to track concerns raised in testimony by physicians.

1 CMS members Gary Ghiselli, MD, and Don Stader, MD, speak on behalf of the Colorado Orthopaedic Society and the Colorado Chapter of the American College of Emergency Physicians, respectively, to show the unified voice of medicine that came together to work on the out-of-network bill.

2 CMS Past President Dave Downs, MD, presented CMS testimony at the out-of-network hearing.

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A top priority of Gov. Jared Polis and Insurance Commissioner Conway, HB19-1168, the State Innovation Waiver Reinsurance Program, creates a reinsurance program for Coloradans in the individual health insurance market. The program will provide reinsurance payments to health insurers to aid in paying highcost insurance claims once an individual’s claims for the year reach a certain level (known as the “attachment point”) up to a cap determined by the commissioner.

As originally filed, the program’s funding mechanism used Medicare reference-based pricing for physicians and hospitals.

A physician-specialty forum convened by CMS leaders met with the commissioner in March to discuss the bill and express concerns. Amendments accepted in April and adopted in the final bill changed the funding mechanism so it no longer relies on rate-setting of physicians or hospitals.

“Not only is it a win that physicians were completely removed from the bill, but it is a win that this bill will not set any precedent for the DOI engaging in provider rate setting,” said Amy Berenbaum Goodman, JD, MBE, CMS senior director of policy.

A portion of the funding for the reinsurance program will come from what is known as pass-through funding from the federal government, pending approval, and through “special fees” assessed against hospitals, not exceeding $40 million, as well as several other funding sources.

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C OV E R LE G I S L ATI V E S E S S I O N : C O N T

IMMUNIZATION LEGISLATION STALLS ON ANTICIPATED VETO CMS supported HB 19-1312, “Modernizing Immunization Requirements for School Entry to Improve Vaccination Rates,” which aimed to increase childhood vaccination rates in Colorado by making it more difficult for parents to obtain a non-medical vaccine exemption. The original concept would have banned non-medical exemptions for any public school student. Even with compromises, Gov. Polis felt it still imposed an undue burden on families, particularly in rural areas, and announced that he would veto the bill. Time ran out for further negotiations and the bill stalled in the senate.

“The immunization bill may have been the most important bill this session for the safety and wellbeing of the public,” CMS President Parsons said. “While we are disappointed in its failure to pass, we physicians can continue to educate our patients and the public on the safety, efficacy and importance of vaccines in preventing serious diseases.”

CMS member surveys consistently show that advocacy is the No. 1 priority of Colorado physicians. It is our privilege to amplify your voice at the Capitol.

THANK YOU to all of the physicians around the state who served on the Council on Legislation, answered CMS surveys and responded to calls to action.

Your involvement is critical to our success. We need all members to stay engaged throughout the interim and into the 2020 Colorado General Assembly. ■

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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

Professional review polls Benjamin Kupersmit President, Kupersmit Research

COLORADO AND FLORIDA: A STARK LOOK AT PROFESSIONAL REVIEW WHEN PROTECTIONS ARE REMOVED The Colorado Medical Society regularly polls physician members to inform policy decisions, and our January 2019 survey shows wide-ranging confidence in patient safety systems in Colorado, high levels of comfort participating in professional review and significant concern about efforts to remove protections from the peer review system.

In preparation of a long-anticipated legislative move this year by Colorado lawyers that sue physicians to expand the opportunity for lawsuits by removing professional (peer) review legal protections, and since Florida is one of the only states in the country that has removed professional review protections, CMS also commissioned and funded a survey of Florida Medical Association (FMA) physicians to learn the effect of that change on physician confidence and participation in peer review systems.

The February 2019 CMS survey of FMA members probed Florida physician experiences in the wake of a 2017 Florida Supreme Court ruling removing protections for the state’s peer review system. This survey shows that Florida physician confidence in professional review has virtually collapsed, willingness to participate in the system has plummeted, and negative impacts are being seen across the health care system in terms of decreased patient access, increased defensive medicine and others.

The Florida survey results were shared with the physician members of the CMS Expert Panel on Professional Review, who noted that the Florida data starkly demonstrates that making documents from peer review discoverable has far-ranging impacts for patients and the health system, and delivers a critical blow to peer review and patient-safety systems that took years to develop and are not easily recovered.

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2019 PATIENT SAFETY SURVEY: COLORADO The survey of Colorado Medical Society members examined key aspects of the peer review system in Colorado.

The survey was conducted Jan. 16-31, 2019, and 902 CMS members completed the survey.

CMS physicians express confidence in the current peer review system: a solid majority of those familiar with the system say it is working, significant majorities would be at least “somewhat” comfortable going through peer review, and strong majorities would be comfortable serving on a peer review committee.

Physicians who have served on a peer review committee (and whom are thus most familiar with the system) have relatively more positive views of peer review, and would almost universally agree to serve on a peer review committee again.

Nearly all CMS physicians say it is important that protections for documents from peer review be kept in place, with more than three-quarters (79 percent) saying this is “extremely” important. If these protections are removed, upwards of 70 percent of CMS physicians believe there will be less reporting of mistakes and near misses; there will be more physicians hesitant to see risky and complex patients; and there will be more defensive medicine, higher insurance premiums and more lawsuits. Substantial majorities also say fewer physicians would be willing to sit on peer review committees.

F E AT U R E S

PROTECTING PROFESSIONAL REVIEW DOCUMENTATION CMS physicians agree overwhelmingly that it is important to protect professional review documentation from being discoverable in lawsuits

14% say this is very important

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F E AT U R E S P R O F E S S I O N A L R E V I E W P O LL S : C O N T

2019 PATIENT SAFETY SURVEY: FLORIDA The survey of Florida Medical Association members focused on the peer review system after the Florida Supreme Court 2017 decision in the Edwards v. Thomas case on the discoverability of records relating to adverse events. The ruling ended work-product privilege over records relating to adverse medical incidents, including the reports of an external peer review committee, fact-finding work by medical defense attorneys and potentially other documents that were previously protected from being used in a lawsuit.

The survey examined FMA member perceptions of the Edwards decision, perceptions of the peer review system, and impacts of the decision on peer review in Florida. The survey was conducted Feb. 28-March 19 and 928 FMA members completed the survey.

FMA physicians have a decidedly negative view of the October 2017 Edwards decision: 73 percent are negative, including 60 percent who have a “very” negative opinion. Physicians who practice in risky specialties – neurosurgery, obstetrics/gynecology, orthopedics, general surgery and urology – have an even more negative view, with 73 percent saying they have a “very” negative opinion and 80 percent negative overall.

FMA physicians paint a picture of a peer review system that has lost their confidence: even among those who have served on committees in the past, just one-quarter would feel comfortable serving again and few would feel comfortable going through peer review if they were involved in an adverse event. Fully 70 percent would not be comfortable going through peer review if involved in a risky event. By contrast, in Colorado, 9 percent of CMS member physicians would not be comfortable.

FMA physicians report that they have seen a wide range of negative impacts since the Edwards decision, most notably: • 55 percent report see more defensive medicine, • 52 percent see some physicians less willing to accept complex or risky patients, with 67 percent of those in risky specialties saying as such, and • 35 percent see fewer physicians willing to sit on peer review committees, with 46 percent of those in risky specialties saying as such.

Willingness of Florida physicians to serve on peer review committees is also quite low, with 46 percent saying they are not comfortable serving. In Colorado, 7 percent of CMS member physicians say they are not comfortable.

PHYSICIAN COMFORT IN THE PEER REVIEW SYSTEM Since 2017, Florida physicians’ comfort in the peer review system has plummeted.

11%

48%

In Florida, just 11%

In Colorado, 48%

of physicians would be totally or very

are totally or very comfortable going

comfortable going into peer review if

into peer review if they were involved

they were involved in an adverse event.

in an adverse event.

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F E AT U R E S

PHYSICIAN EXPECTATIONS AND EXPERIENCES WITH PROFESSIONAL REVIEW PROTECTIONS Should professional review protections be decreased or removed Colorado physicians expect, and since 2017 Florida physicians actually have experienced, a range of impacts: CO DOCTORS EXPECT

FL DOCTORS HAVE SEEN

Physicians hesitant to see risky or complex patients

78%

52%

Less reporting of mistakes and near misses

82%

26%

More defensive medicine

76%

55%

Less emphasis on process and quality improvement

59%

24%

Less willingness to serve on committees

73%

35%

We shared the results of the Florida survey with a panel of CMS physicians who have been active participants or in leadership in professional review in their facilities/communities. They were struck by the extent and depth of the negativity toward participation in the peer review system in Florida, and how quickly this shift had occurred (it has been just 18 months since the Edwards decision).

They noted that it has been a 20-yearlong movement to shift the culture in Colorado – in facilities and training of new physicians – to one where physicians feel safe reporting errors or near misses. The Florida data suggests that these gains can evaporate quickly. These experts also express pessimism that there would be a path back to openness after going down the punitive road. ■

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F E ATU R E

Colorado medical students attend 2019 MARC in Washington, D.C. Danielle Davis and Alysa Edwards, University of Colorado School of Medicine The Medical Student Advocacy and Region Conference (MARC) took place in Washington, D.C., from March 7-9 with medical students from 44 different states in attendance.

During the conference, students learned about three pressing political issues and how the American Medical Association is working to address them. The first day, students met with Colorado congressional representatives to ask for their support in addressing these issues, gaining experience in lobbying and the legislative process.

POLICIES DISCUSSED: PHARMACEUTICAL DRUG PRICES

GUN VIOLENCE

GRADUATE MEDICAL EDUCATION

Between 2013 and 2015 the net spending on prescription drugs increased by 20 percent. In 2017, more than 300 generic drugs had at least one price increase of 100 percent or more. Physicians see firsthand the burdens placed on patients by the rising costs of prescription medications. Many patients delay, forgo or ration their medications at the expense of their own health.

With over 38,000 Americans injured or killed by firearms in 2016¹, gun violence is considered a public health crisis. To help address this issue, the AMA supports the Bipartisan Background Check Act (H.R. 8), which would require a background check on every gun sale or transfer (with exceptions). This would expand current policy to include unlicensed sellers.

Additionally, the AMA supports funding the CDC to conduct epidemiologic research on gun violence to better inform future policy.

GME (residency training) positions, largely funded by Medicare, were capped in 1997. Since then, a mismatch in the number of medical school graduates and residency positions has developed, adding to the physician shortage crisis around the country. The AMA therefore supports the Resident Physician Shortage Reduction Act (S.348), which would expand GME positions by 15,000 over five years, particularly aiding states with new medical schools, current programs’ training overcapacity, and training in community-based/outpatient department s. The Communit y and Public Health Programs Extension Act (S.192) would provide funding to critical health programs offering affordable access to preventative services for underserved patients while providing scholarships for residents. ■

The AMA strongly supports legislation that addresses the anticompetitive practices of pharmaceutical companies.

Therefore they are in strong support of the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2019 (S. 340/ H.R. 965). This act would allow generic drug manufacturers facing anticompetitive delay tactics – such as failing to provide sufficient quantities of branded product samples for premarket testing – to bring an action in federal court for injunctive relief.

CONFERENCE HIGHLIGHTS:

WHAT’S NEXT?

Advocacy workshop

AMA Annual Meeting in Chicago

Teachings on effective lobbying techniques

June 6-8 | Stay tuned for more info!

Capitol Hill visits

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1. National Vital Statistics Reports. Vol. 67, No. 5. July 26, 2018. https://www.cdc.gov/ nchs/data/nvsr/nvsr67/nvsr67_05.pdf

F E ATU R E

Medical students descend on the state Capitol for day of advocacy The Colorado Medical Society Medical Student Component (CMS MSC) hosted Medical Student Day at the Capitol on Thursday, March 21. Thirty-six medical students from the University of Colorado and Rocky Vista University – many in their first year – attended the event for a crash course on effective lobbying and meetings with 12 legislators or their staff. Students also sat in on two committee hearings during the afternoon for a firsthand look at the legislative process.

Legislators attended the kick-off lunch and the closing reception, providing additional opportunities for interaction with students.

Feedback was overwhelmingly positive.

“

“Medical Student Day at the Capitol with CMS was my first experience with state legislators as a professional in medicine. As medical students, we gain tremendous influence when we don our white coats in a public forum; spending an afternoon at the Capitol was a striking reminder for the importance of advocacy on behalf of our profession and patients. Perhaps there is no better impact than having a group of youthful future doctors – 30 strong – descend upon Capitol Hill to show we care.”

Vincent Fu, University of Colorado School of Medicine

“

“It was empowering to advocate directly to lawmakers. The CMS lobbyists and executives helped me to prepare and practice my statements, which made me feel at ease when it was time for in-person meetings. After participating in Lobby Day, I feel ready to voice my opinions and share my insights on future legislation in an effective way.” ■

Sen. Rhonda Fields (D-Aurora)

CMS CEO Alfred Gilchrist

Jennifer Daniels, Rocky Vista University College of Medicine

C O LO R A D O M E D I C I N E 1 9

F E ATU R E

Moral injury in medicine Doris C. Gundersen, MD For the last decade, much attention has been paid to the alarming rates of burnout among physicians. Physician health programs, medical specialty societies and hospital wellness programs have aimed to address the epidemic by primarily focusing on what the individual physician can do to prevent it: exercise, meditate, eat nutritiously, practice mindfulness, take vacations, “unplug” from electronic health records on evenings and weekends. The list goes on and on. However, the concept of burnout resonates poorly with physicians who are in fact resilient and resourceful – traits necessary for successful entry and achievement in the medical profession. More recent scrutiny of the problem has revealed that the greatest driver of burnout is our broken health care system.

Most physicians enter medicine with a deep desire to help people, a willingness to make significant sacrifices (often including a disregard for one’s personal health) and a devotion to providing high-quality care and healing to patients. However, the house of medicine’s values and morals often conflict with the priorities

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of an increasingly business-oriented and prof it- driven health care environment. Physicians must contend with patients’ financial constraints related to the high cost of health care insurance and pharmaceuticals, sometimes limiting what care can realistically be offered. Physicians, while expected to be productive, are distracted by administrative burdens (prior authorization requests) and tasks unrelated to providing good medical care. The fear of discipline or litigation is constantly in the background. Patient satisfaction scores and online provider scores serve as additional sources of stress. The basic tenets of the Hippocratic oath conflict with the current business of health care in which the primary goal is making a profit from people who are sick, suffering and vulnerable.

The term “moral injury” historically was used to describe soldiers’ responses to their actions in war.¹ “Moral injury results when soldiers violate their core moral beliefs, and in evaluating their behavior negatively, they feel they no longer live in a reliable, meaningful world and can no longer be regarded as decent human beings.”²

Moral injury occurs when there has been a betrayal of what is right by someone who holds legitimate authority in a high-stakes situation. Moral injury is an injury to an individual’s moral conscience resulting from an act of perceived moral transgression, which produces profound emotional shame. More attention has been paid to moral injury in physicians as they experience failure in consistently meeting the needs of patients while attempting to ethically navigate intensely competing drivers.³ To stem the tide of physician burnout, compassion fatigue, depression, addiction and suicide, the concept of moral injury needs to be considered more carefully.

Those in leadership positions need to recognize that conflicting and competing demands (i.e. prioritizing profit over high-quality patient care) create moral exhaustion in physicians.

Eliminating or at least reducing some of these demands is one way of caring for physicians, which translates into better patient care and good business. ■ 1. https://www.statnews.com/2018/07/26/ physicians-not-burning-out-they-aresuffering-moral-injury/ 2. Rita Nakashima Brock and Gabriella Lettini, Soul Repair: Recovering from Moral Injury After War, 2012, p. 15 3. https://www.medicaleconomics.com/ med-ec-blog/beyond-burnout-realproblem-facing-doctors-moral-injury

F E ATU R E

Practice management update MODIFIER 25 – WHEN IT APPLIES AND WHAT’S CHANGING WITH ANTHEM Marilyn Rissmiller, CMS Senior Director of Health Care Financing Accurate coding and documentation are still important to ensure you receive appropriate reimbursement for the services you provide your patients.

The issues of coding accuracy and appropriate documentation are not just concerns of the federal programs; more commercial insurers are also taking a closer look at your claims as demonstrated by Anthem’s announcement concerning use of modifier 25.

Anthem announced in a bulletin earlier this year that they will deny an “…evaluation and management service with modifier 25 same day as a procedure when a prior E/M service for the same or similar service has occurred.” Colorado Medical Society President Deb Parsons, MD, FACP, and CMS staff met with Anthem’s medical director Elizabeth Kraft, MD, to gain a better understanding of how this policy will be implemented.

We were told that Anthem will look back in the patient’s claims history to see if the same physician has billed for an E/M visit for the same or similar diagnosis within the last 60 days. If there is a prior visit, and both E/M visits and the minor procedure all have the same diagnosis code (or one that is in the same “family” of diagnoses codes), the system will automatically deny the E/M visit that is reported with modifier 25. These denials can be appealed if the physician believes they were in error by submitting supporting documentation.

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E/M services on the same day as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.

WHAT’S SIGNIFICANT AND SEPARATELY IDENTIFIABLE? If, in addition to the procedure, the physician performs an E/M service that is beyond the usual pre-procedure, intra-procedure and post-procedure associated care, the E/M may be reported with modifier 25 appended.

The E/M service must be appropriately documented and unrelated to the decision to perform the minor surgical procedure. In other words, the pre-procedure work includes explaining the procedure to the patient and/or family member and discussing possible complications; the post-procedure work includes applying a dressing, monitoring for immediate side effects, providing recommendations on activities/modifications, and counseling the patient and/or family member about signs and symptoms of possible complications.

The E/M service must be significant, the documentation must substantiate this, and the physician work must be medically necesA MODIFIER 25 REFRESHER sary. Did you perform all of the key components of You don’t just put a modifier 25 on an E/M visit and a problem-focused visit, report it with every minor procedure. Modifier 25 and could the E/M service is defined as a significant, separately identifiable stand on its own as a billEvaluation and Management (E/M) service by the able service? (Your docusame physician or other qualified health care mentation must meet the professional on the same day of the procedure requirements for the code or other service. level reported.) Did you perform work beyond that

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associated with the pre- and post-services associated with the minor procedure? Would the problem addressed require treatment with a prescription or necessitate another visit to address it?

These are some of the things to consider before billing an E/M visit with modifier 25 on the same day as a minor procedure.

Unlike Medicare, Anthem does require that the diagnosis code reported for the E/M service and the minor procedure are different. Be sure to report the correct diagnosis code associated with the problem addressed in the E/M visit and the correct diagnosis code for the specific procedure performed. This includes ensuring that the diagnosis pointer for the visit and the diagnosis pointer for the procedure are linked to the correct ICD-10 diagnosis codes on the claim.

(If this doesn’t make sense to you, ask your biller.)

IN NEWS FROM OTHER PAYERS UnitedHealthcare (UHC) announced that they will be eliminating reimbursement for consultation codes as part of an overall effort by UHC to “modernize” their physician contracts to align with Medicare. It was noted that the Centers for Medicare and Medicaid Services had made upward adjustments in E/M payments in 2010 to account for discontinuation of payment for consultation codes (hence, the “budget neutrality” of the federal CMS payment policy change).

The UHC reimbursement policy team indicated that they will be following this increase in E/M RVUs to balance out the elimination of payment for consultation codes. To ensure that you are recei v ing t he increased E / M RV U values physicians should make sure that your UHC contracted fee schedule is based on the federal CMS’ 2010 or later fee schedule. ■

F E ATU R E

Forward momentum on improving affordability of health care in Colorado Kim Bimestefer, Executive Director, Colorado Department of Health Care Policy and Financing My last message to you, in the March/April issue of Colorado Medicine, focused on the Health Care Affordability Roadmap.

Since then, Gov. Jared Polis outlined his administration’s health care priorities in the Polis-Primavera Roadmap for Saving Coloradans Money on Health Care, which offered short-, medium- and longer-term goals for Colorado. As well, policymakers from both parties, providers, consumers, employers and the broader community came together to have important and sometimes difficult conversations about driving health care affordability across Colorado. That good work resulted in a transformative 2019 legislative session.

I’m very pleased to report that many impactful affordability policies were passed, such as: HB19-1001 Hospital transparency HB19-1174 Out-of-network reform HB19-1168 Reinsurance HB19-1004 Affordable coverage option SB19-005 Import prescription drugs from Canada HB19-1320 Hospital community benefit accountability

At HCPF, we are also very excited that our legislative agenda items passed to extend our Breast and Cervical Cancer Care program for a decade (HB19-1302), allow more seniors to access dental care (HB19-1326), and enable additional grant funding to support nursing home innovation (SB19-254). In addition, legislation passed this year focused on helping those who need us the most: legislation passed to extend the in-home support services (SB19-164) and spinal cord injury waiver programs (SB19-197), and to give pregnant women in the Child Health Plan Plus (CHP+) program access to dental coverage (HB19-1038). Many behavioral health bills moved through this session as well.

WHAT’S AHEAD: FURTHER PARTNERING WITH YOU The initiatives passed this session and those already in the works will require the insights and expertise of partners like you going forward. You’ll be hearing more from us in the coming months as we work together on implementation and federal approvals where necessary. Specifically, we’ll be looking to partner with you on: • The new provider tools in development, which I mentioned in the last article.

Prometheus can help inform your referrals based on potentially avoidable complications (PAC insights), enable hospitals to address quality and cost opportunities, and frame Centers of Excellence conversations by procedure.

• The new physician prescriber tool we are working on will offer prescribers cost insights on Rx alternatives by payer, available health improvement programs that can complement or avoid drug therapy, and insights into patient-specific addiction risk as you consider opioid therapy and alternatives.

• Together, we will explore telehealth to improve specialty care access, serve members in rural communities, help members with mobility challenges and increase access to behavioral care.

We are looking forward to partnering with you to implement the new policies enacted this legislative session, to the betterment of the Coloradans we jointly serve. Thank you for the work you do to serve Health First Colorado members and for what you are doing to be part of the affordability solution across the state. ■

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

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C O P I C

C O M M E NT

Mentoring the next generation of physician leaders Gerald Zarlengo, MD Chairman & CEO COPIC Insurance Company

“Show me a successful individual and I’ll show you someone who had real positive influences in his or her life. I don’t care what you do for a living — if you do it well I’m sure there was someone cheering you on or showing the way. A mentor.”

— Denzel Washington I believe one of the most overlooked aspects of having a successful career in medicine is finding the right mentors.

Over the years, I have been fortunate to work with several outstanding physicians who invested their time to help me learn and grow. They were smart, tough, compassionate, and understood the importance of passing down pearls of wisdom from one generation to the next.

into. Like my mentors, I have taken this responsibility seriously and recognized the powerful impact I can have on younger physicians. Today, my advice to mentees is still rooted in some core elements that I learned when I was in their shoes.

The knowledge I gained from these mentors–from honing my technical skills to developing patient communication skills–greatly influenced the physician I became and who I am to this day. It also opened my eyes to the amount of valuable insight exchanged through mentor-mentee interactions and the bond that occurs because of the shared commitment to patients.

• Know your limitations and don’t be afraid to speak up when you feel in over your head.

A great example of a mentoring program is the Surgical Mentorship Pilot Project led by Bruce Waring, MD. The COPIC Medical Foundation recently provided grant funding that will be used for the implementation of this program designed for early-career surgeons to enhance the technical and leadership aspects of a safe and successful surgery practice. The goal is to improve early-career surgeon readiness for practice.

• Come prepared for interactions with your mentor; think about the questions you want to ask and what unique insight your mentor has to offer.

I remember the moment when I realized I was the most senior (a better way to say “oldest”) physician and had become a mentor. It was a transition that snuck up on me and a role I unassumingly stepped

I also have some advice for my peers who are mentors–recognize the differences that exist between you and your mentees and be open to the perspective they bring to medicine. I recently read the

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

• Be honest about the challenges you are facing and be specific about what type of help you are seeking.

• Don’t get defensive when you receive feedback that might sting your ego; good mentors enable you to see the areas where you can improve and become a better physician.

• Recognize that patients can also be great mentors with the feedback they provide.

• Observe, listen and learn.

2018 Physicians Foundation’s Survey of America’s Physicians. It asked physician respondents how they would describe their professional morale and feelings about the current state of the medical profession. More than 57 percent of physicians 45 years old and under said “very/somewhat positive,” while only 39 percent of physicians 46 and older had the same outlook.

“Younger physicians have been educated and trained in the era of electronic health records and value - based payment models and may not find these and other characteristics of contemporary medical practice to be as irksome as do older physicians. Or, they simply may not have been exposed to the stresses of medical practice as long as older physicians and are not yet as affected by them,” noted the survey.

Let’s face it, as senior physicians, we sometimes fall into being pessimistic curmudgeons. But, we need to remember that part of our role as mentors is to recognize the line between preparing younger physicians for the realities they will face and diminishing their enthusiasm for a career in medicine. Their energy can be contagious and help reignite our passion for being a physician. This is one of the most gratifying aspects of being a physician mentor: to be able to prepare the next generation and have confidence in their ability to improve health care as we have done. ■

INSIDE CMS

S AV E

TH E

DATE

Join us in a celebration of the precious role of physicians, Sept. 14 at the Denver Museum of Nature & Science Registration opening soon for the 2019 Presidential Celebration and Gala With all of the demands and stressors placed on physicians in practice today, it’s easy to lose track of what calls most to medicine–the desire to help people live full and healthy lives. This gift comes from our hands, hearts and minds and creates a precious bond that extends through the physician to the patient and his or her family to the larger community.

We are healers and leaders.

Framed by this unique role of physicians, the Colorado Medical Society invites all members to celebrate the inauguration of incoming CMS President David S. Markenson, MD, MBA, on Saturday, Sept.

14. CMS will mark the occasion with an engaging day of programing 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.

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, recognition of CMS and component leaders, and the swearing in of 20192020 CMS President Markenson.

Watch for registration opening soon, plus more information on the modest ticket fee, child care and discounted hotel pricing. ■

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 1 p.m. - 4 p.m.

CMS Board of Directors meeting

1 p.m. - 4 p.m.

COPIC educational sessions

5:30 p.m.

DMNS closes to the public

6 - 6:45 p.m.

Exhibitor reception

7 p.m. - 11 p.m. Inaugural Gala 6 p.m. - 11 p.m. DMNS Gems and Minerals Exhibit open for CMS members and their guests only *subject to change

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I NTR O S P E C TI O N S

Learning the importance of effectively coordinating and communicating treatment Yuina Sato

Yuina Satoh is a third-year medical student, aspiring to be an ob-gyn. Moving across the Pacific Ocean and from the East to West Coast a number of times, she has lived in many places including Japan, New York, Oregon, California, and currently, Colorado. Although she does not call any one place home, she has grown to love our gorgeous mountain state. After completing a BA from University of California, Berkeley, she began to pursue circus arts as an aerial straps and trapeze artist, and still continues to engage in the circus arts, as a performer and instructor.

START TIME 07:27.

Scalpel in hand, the ob-gyn makes the first incision into the skin. Within five minutes, the doctor is making the final incision into the uterus.

Standing in an operating room for the very first time, I watched in awe while the doctor orchestrated a Cesarean section.

It was almost robotic: efficient, orderly and flawless. On one hand, medicine seems to be clear-cut, with set guidelines to establish the correct care. On the other hand, medicine can often be ambiguous, with what seems to be no right answer. In reality, the practice of medicine is an art and there are diverse ways in which we can care for a patient. With such variation, it is especially critical that there is clear communication among providers and patient care is carefully orchestrated with a whole medical team. Within the same ob-gyn rotation, I witnessed just how crucial teamwork is to the art of medicine.

About two weeks into my ob-gyn rotation, we were consulted to the emergency department for a 30-year-old female

coming in with severe back pain and a pelvic abscess found on imaging. Interventional radiology (IR) immediately drained the abscess and, after a few days, the culture from the abscess was found to have grown E. coli, bacteria typically found in the gut. It soon became apparent that the abscess most likely formed due to E. coli spilling into her pelvic space from a bowel perforation accidentally created by a trochar during a laparoscopic ovarian cystectomy.

Although the abscess seemed to be draining less and she was put on a number of antibiotics, she became increasingly ill during her hospital stay.

The surgery team was unwilling to operate on her; they believed that the perforation would close on its own and there was no need for an invasive surgery. Other doctors, including the ob-gyn hospitalists,

thought that she needed an operation to close the bowel perforation. The patient became increasingly concerned and frustrated with the lack of answers to why she was not getting any better and the seemingly conflicting information from the different specialists. There were too many specialists – IR, surgery, internal medicine, ob-gyn, and infectious disease – involved in her case without clear communication among them.

The patient’s mistrust and lack of confidence in the medical community became increasingly apparent.

Watching on the sidelines, I could empathize with her confusion and frustration.

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.

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She had had a difficult year. She and her partner had undergone an abortion – a D&E – for an unviable fetus having multiple congenital defects, and now the patient was having complications from a cystectomy and becoming sicker. They were not getting clear answers regarding what needed to be done next for her to improve. Perhaps what was missing was centralized communication – a “team captain” who would gather all the information from the different specialists and be in charge of communicating this information and a single plan of action to the patient and her family.¹ Witnessing this case, the uncertainty and disagreement regarding the best course of treatment highlighted the need for teamwork with good communication in the practice of medicine.

In fact, there is much ambiguity in the practice of medicine. In our patient’s case, perhaps operating to close the perforated bowel may have led to a quicker recovery for her and prevented her from becoming sicker. On the other hand, the surgeon’s decision not to operate may have saved her from other complications from surgery in her future, such as scar tissue and adhesion formation that could lead to infertility or chronic pain. Knowing that the couple had hopes to have children, complications of surgery leading to infertility would have been detrimental.

Weighing the consequences of both sides, neither choice seems to be clearly the right choice. Moreover, with such variation in the practice of medicine and no unambiguously correct choice, clear communication and teamwork among providers and patient play a critical role in providing the best patient care.

My experience with this case gave me a chance to confront some of the more difficult aspects of medical practice and see how crucial our interactions with patients are to their outcomes. Of course the technical aspects of patient care are important, but I believe it is equally important that as medical professionals, we work together to effectively coordinate and communicate treatment in a way that patients are able to understand.

As I continue my path in the field of medicine, I must appreciate the practice of medicine as an art form, molding care to best suit my patients’ individual needs, to become an effective team member, communicator and physician. ■

References 1. Bono MJ, Hipskind JE. Medical Malpractice. [Updated 2019 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470573/

Have you heard?

The TMF Physician Practice Quality Improvement Award Program online application is live!

Any physician practice, accountable care organization or large system 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 August 16, 2019.

You and your team should be recognized for your hard work. Apply today!

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R E F LE C TI O N S

Gratitude Kelsey Repine and Oliver Bawmann

Kelsey Repine was born and raised in Denver, Colo. She graduated from the University of Notre Dame in 2014 with a major in Psychology and a minor in Peace Studies. She is a rising fourth-year medical student and will graduate from the University of Colorado School of Medicine in May 2020 with aspirations to become an anesthesiologist.

Oliver Bawmann was born and raised in Denver, Colo. He graduated from Santa Clara University in 2015 with a degree in Biology. He is a rising fourth-year medical student at the University of Colorado School of Medicine. Upon graduation he hopes to pursue further training in a combined internal medicine and pediatrics residency program.

“The real gift of gratitude is that the more grateful you are, the more present you become.”

When Robert Holden wrote those words, he may not have been thinking about “keeping health care human.” However, there is a connection between practicing gratitude and practicing compassionate patient care. Burnout is pervasive among physicians and trainees. Yet emerging data indicate that actively practicing gratitude combats burnout, promotes a culture of wellness and reminds us of the joys of medical practice. In 2019, in an effort to combat burnout, the University of Colorado School of Medicine will distribute gratitude journals to rising thirdyear students at the Student Clinician Ceremony – a ceremony that celebrates the transition from the preclinical to the clinical years of medical school. We will also distribute gratitude journals to our newest medical students at the August White Coat Matriculation Ceremony.

The goal is to foster resilience, reflection and humanistic clinical practice by future physicians.

We anticipate that distributing gratitude journals to incoming students will become a permanent part of the White Coat Ceremony. We remember well the gifts that we received almost three years ago during our White Coat Ceremony.

The School of Medicine presented us with stethoscopes, signifying the importance of clinical skills and patient care. We received new white coats, a symbol of the profession of medicine. Starting in August, incoming students will also receive gratitude journals, reinforcing the importance of student wellness and the humanistic journey they are beginning. By giving this triad of gifts to incoming students, we are prioritizing students’ future patients, their status as new members of this wonderful profession, and the immense importance of their wellness as they embark on this journey.

For the rising third-year students who did not receive gratitude journals previously, the gifts at the Student Clinician Ceremony will signify our commitment to them as they begin clinical training. As new fourth-year students, our hope is that presenting gratitude books will help students navigate the exhaustion and the emotional ups and downs of clinical rotations. In the introduction we prepared for the gratitude journal, we encourage new third-year students to take a few minutes each day to write down three things for which they are grateful: “No sentiment is too small. Be grateful for hot coffee, meaningful conversations with faculty, donuts in the hospital cafeteria, or peers helping you study for your next exam. Be grateful for the resident who spent time

teaching you, the patient who made you laugh, or the patient who thanked you for being her doctor. Take the time to share your gratitude with others, using the book’s tear-out pages.” The evidence is clear that gratitude is best shared.

The gratitude journals were designed by a team of students, faculty and administrators, and will feature quotations and words of wisdom collected by our faculty specifically for this project. As a gift from the School of Medicine faculty and the Society for Professionalism in Medicine, these journals signif y the facult y’s commitment to our success as learners and future physicians.

We believe that practicing gratitude and practicing humanistic patient care go hand-in-hand. Actively practicing gratitude, through reflection and journaling, encourages human connections – connections between students and their patients, between students and their peers, with residents and faculty members, with members of the health care teams and more. Patients and students alike will benefit, as gratitude promotes empathy, resilience and joy.

As David Steindl-Rast wrote, “It is not joy that makes us grateful; it is gratitude that makes us joyful.” ■

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

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Study: Less burnout seen among U.S. physicians but more needs to be done

The burnout rate among physicians in the United States dropped modestly in 2017 from a peak in 2014 and currently stands near 2011 levels, according to a triennial study conducted by researchers from the American Medical Association, the Mayo Clinic and Stanford University School of Medicine. While acknowledging progress, the AMA warned more needs to be done to reduce physician burnout and called on leaders in the health care system to remain focused on driving research, interventions, workflow and teamwork enhancements, policy changes, and technology improvements.

Barbara L. McAneny, MD, in an AMA news release. “Despite improvements in the last three years, burnout levels remain much higher among physicians than other U.S. workers, a gap inflamed as the bureaucracy of modern medicine interferes with patient care and inflicts a toll on the well-being of physicians. There is a strong economic case for the health system to continue a comprehensive strategy to reduce the work-induced syndrome of burnout and caregiver fatigue among physicians. An energized, engaged and resilient physician workforce is essential to achieving national health goals.” ■

The study found 43.9 percent of U.S. physicians exhibited at least one symptom of burnout in 2017, compared with 54.4 percent in 2014 and 45.5 percent in 2011. In comparison, the overall prevalence of burnout among U.S. workers was 28.1 percent in 2017, similar to levels found in 2014 (28.4 percent) and 2011 (28.6 percent).

The AMA offers physicians and health systems cutting-edge tools, information and resources to help rekindle a joy in medicine. Explore the tools below by visiting www.ama-assn.org.

“The tide has not yet turned on the physician burnout crisis,” said AMA President

STEPS Forward™ The AMA offers a collection of more than 50 award-winning online tools that help physicians and medical teams make transformative changes to their practices and covers everything from managing stress and preventing burnout to improving practice workflow.

Institutional assessments The AMA assesses burnout levels within medical organizations to provide a baseline metric for implementing solutions and interventions that reduce system-level burnout rates and improve physician wellbeing.

American Conference on Physician Health The AMA, Mayo Clinic and Stanford Medicine will host a conference Sept.

19-21, 2019, in Charlotte, N.C. to promote physician health and wellbeing.

Debunking regulatory myths The AMA provides regulatory clarifications to physicians and their care teams to aid in their day-to-day practice environment.

EHRSeeWhatWeMean.org A collaboration between the AMA and MedStar Health to demonstrate the risks and challenges caused by poor usability in electronic health record technology that reduce time available for physicians to care for patients.

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Patty Skolnik and other patient advocates pen editorial calling to end the term “second victim” Four authors representing families and patients harmed by medical errors published an editorial in BMJ urging the health care community to abandon the term “second victim.”

The authors include Coloradans Patty J. Skolnik, president of Citizens for Patient Safety, and Carole Hemmelgarn, patient advocate in Highlands Ranch, as well as Melissa D. Clarkson, assistant professor in the Division of Biomedical Informatics at the University of Kentucky, and Helen Haskell, president of Mothers Against Medical Error based in Columbia, S.C. The term was introduced in 2000 to bring attention to the need to provide emotional support for doctors who are involved in a medical error. However, the authors assert that its use has become inappropriate; though patient communities and advocates do not question the need to support health care professionals who have been involved in an incident of patient harm, the term “victim” subtly promotes the believe that patient harm is random, caused by bad luck and not preventable.

“

It’s time to abandon the term second victim.

We know who the actual victims of medical errors are because we arranged their funerals and buried them.

ABOUT CITIZENS FOR PATIENT SAFETY Citizens for Patient Safety (CPS) was founded in 2005 by Patricia Skolnik after she and her husband, David, lost their only child to medical error and poor communication. CPS’ mission is to increase engagement and communication between patients/families and providers for better health care outcomes.

CPS provides curriculum, training and coaching designed to improve health literacy, strengthen person and family engagement as partners in their care and promote effective communication and coordination of care through shared decision-making and transparency.

“Preventable patient harm results from institutional systems factors and actions of individuals. The ‘second victim’ label obscures this fact and can deter the cultural changes needed to achieve a patient-centered environment focused on patient safety,” they write. It also seems to have reinforced an inward-gazing, professional-centered nature of health care systems that separates them from harmed patients and their families.

The authors conclude: “It’s time to abandon the term second victim. We know who the actual victims of medical errors are because we arranged their funerals and buried them.”  ACCESS THE EDITORIAL HERE: https://www.bmj.com/content /364/bmj.l1233.full

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Annual Holocaust Remembrance Week Program focused on medicine and morality in times of war, lessons from Syria program. The program included nine events across all four CU campuses during the federally designated “Week of Remembrance of the Victims of the Holocaust,” April 29 to May 3.

Matthew Wynia, MD, MPH, FACP welcomes the 200 attendees at “Medicine and Morality in Times of War.”

The ethics of health professionals in wartime was the theme of the University of Colorado’s 2019 Holocaust Genocide and Contemporary Bioethics (HGCB)

Keynote speakers were Zaher Sahloul, MD, director of the American Relief Coalition for Syria and past president of the Syrian American Medical Society, and Leonard Rubenstein, JD, director of the Program on Human Rights, Health and Conflict at the Johns Hopkins Bloomberg School of Public Health and core faculty at the Johns Hopkins Berman Institute of Bioethics.

In its fourth year, the HGCB program is one of the CU Center for Bioethics and Humanities’ most unique and anticipated

series of outreach events. It looks at the complicity of Nazi health professionals in facilitating the Holocaust and how that tragic histor y influences health care ethics today. This year’s program, Medicine and Morality in Times of War, addressed timely issues such as international laws of war, medical neutrality, the care of refugees and asylum seekers, and health care issues faced by those living in active war zones.

Sahloul, a critical care pulmonologist in Chicago, witnessed doctors in his native Syria committing war crimes. He has run multiple medical relief missions into Syria and along its borders to aid civilians and refugees. He has treated victims of gunshots, chemical weapons and chronic disease. Sometimes he has worked underground to decrease his chance of being bombed by a regime run by his former medical school classmate, Bashar al-Assad.

Rubenstein has spent more than two decades engaged in research and advocacy concerning the protection of medicine and medical ethics in war.

“We have to come to grips with the implications of counter-terrorism policy for health care and respect for medical ethics,” he said. “Protections established after World War II are very much at risk today, not only by rogue regimes but by nations that claim to respect long-established norms yet put them aside in the name of counter-terrorism.”

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The HGCB program was developed a decade ago by William S. Silvers, MD, a Denver-based allergist/immunologist whose parents were survivors of the Holocaust. Silvers, with other physicians and community stakeholders, created the original program to inspire health professionals to remember the lessons of the Holocaust – a time when the world’s leading scientific and medical community lent its power and skill to a perverse political ideology to turn healers into killers.

In 2016, Silvers partnered with Matthew Wynia, MD, MPH, a CMS leader who directs the CU Center for Bioethics and Humanities, and created an endowment to help support the program. “Nearly 80 years after German physicians and other health professionals were complicit in Nazi war crimes, health professionals continue to practice during times of war and political conflict. We face situations, even in this country, where health care professionals are asked to serve as

agents of the state,” Wynia said. “They serve in immigration detention centers or in collecting medical samples for use as evidence by law enforcement.

Our mission is to take lessons from the Holocaust and create opportunities for education and community engagement around difficult issues facing health care and society today.” ■

Left: Panel discussion with Janine Young, MD, Zaher Sahloul, MD, and Ved Nanda, LLB, LLM. Right: Matthew Wynia, MD, Janine Young, MD, and Zaher Sahloul, MD, during presentation.

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President-elect (two candidates running for one position) 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

Through observation of our culture and society over the past 40 years, and my own medical practice for more than 20 years, I might suggest that sugar and unhealthy fats in their connection to obesity create more morbidity and mortality than most, if not all, other causes. Our current American diet seems to accept and promote obesity, which is connected with heart disease, diabetes and chronic inflammatory diseases, all of which run up the cost of providing medical care in our society. This, along with the rise of nicotine and marijuana use, coupled with continued alcohol use, fall in a sphere of medical influence that we can use to improve population health.

I would like to see the Colorado Medical Society create a program to reduce obesity in the state of Colorado. I know that we are the “thinnest state” in the country; however this doesn’t say enough anymore. I commonly sense that my colleagues are afraid to bring up obesity to their patients as the main cause of their patients’ morbidities. Why is that? In part, many physicians may be too time-constrained to counsel their patients directly. Others may feel cowed into perceived political correctness by management.

Maybe the physician or staff are obese, creating a fear of being “the pot calling the kettle black.” Maybe the physician doesn’t know how to counsel for obesity.

Many people spend money on various diet plans and books, and spend social effort discussing diet plans and their success or lack thereof. Many people care about weight loss, but need help to achieve their most healthy weights. They need their own primary care physician to walk the journey with them. Why aren’t our medical offices partnering with weight loss programs, such as toward alcohol rehabilitation programs, as Dr. Pramenko suggests? Physicians could contract with health insurers to provide weight loss programs, with the insurer partnering in payment for the programs. Primary care offices could use the success they have with their patients in fighting obesity as a distinguishing marketing factor for their offices. I believe that if primary care offices committed to having various effective weight loss programs available, either by association with a weight loss clinic or by having weight loss advisors within the practice, the cost of health care and the health of our population would both improve.

I believe an unabashed, “full court” press needs to be put on obesity in our country.

Let’s have the CMS take this on as an initiative for patients and physician offices in the state, and help Colorado develop the model for other states to emulate. ■ Sincerely, Theresa A. Scholz, MD Dermatology, Denver, Colo.

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Visit www.cms.org/articles/ 2019-cms-elections to view candidate statements and CVs for all candidates The following CMS physicians have announced their candidacy for office.

E D ITO R

I read, cover to cover, the March-April issue of Colorado Medicine on health care costs and was particularly interested in Dr. Pramenko’s opinion piece about social culture guiding wellness and health. He seems to believe, and I also believe, that cultural change is the necessary element to wellness in our society.

2019 CMS elections page now available

• Sami Diab, MD • Patrick Pevoto, MD, MBA AMA Delegation (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 • Rachelle Klammer, MD, incumbent AMA Delegation • Tamaan Osbourne-Roberts, MD, incumbent AMA Delegation • Lynn Parry, MSc, MD, incumbent AMA Delegation • Brigitta Robinson, MD, FACS, incumbent AMA Delegation • Michael Volz, MD, incumbent AMA Delegation The election will be held in August and all ballots will be cast electronically. All CMS members are encouraged to use this opportunity to vote, affirming the significant commitment of our organization to engage all members in the governance process. We also ask you to consider seeking a leadership position next year. More details on the 2020 nomination period will be available in September.

Thank you for your participation in your medical society.

ADVOCATE. EDUCATE. NAVIGATE.

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Member benefits spotlight: Medjet HOW NOT TO GET STUCK IN A HOSPITAL FAR FROM HOME John Gobbels, COO, Medjet ity of choice at home for treatment and recovery, which your health or insurance company won’t cover, can also take a bite out of your savings.

This is where air medical transpor t memberships like Medjet come in.

As medical professionals, you know how important it is to be treated by physicians you trust in a facility you choose.

Yet many people, when faced with an accident or illness while traveling, find themselves stuck in a hospital far from home – at the mercy of health or travel insurance companies in determining the “acceptability” of a facility, and the “medical necessity” of a transfer home.

Not being able to get to a home hospital of choice for treatment can present a myriad of issues.

Care that is unacceptable to you, and facilities that don’t meet your standards.

Language barriers, if your hospitalization occurs during foreign travel, making treatment decisions difficult.

Capping out on travel insurance medical benefits if hospitalized abroad (even the high-end coverages can disappear quickly), and dealing with out-of-pocket payments and claims with an unfamiliar insurer can pose a financial risk.

The cost of having family members fly to your side to serve as your patient advocate and moral support (airfare, hotels, missed work) can also add to your financial headache.

A $30,000 (domestic) to $180,000 (international) medical transport, to your facil-

If you travel frequently, alone for business or on vacations with your family, it is vital to understand the fine print of your health and travel insurance coverage when it comes to getting home.

Travel insurance in its basic form usually provides trip cancellation, trip interruption, lost luggage, local hospital and treatment cost reimbursement, and limited medical evacuation benefits to the nearest acceptable facility – and what is deemed “acceptable” is determined by the insurance company, not the patient. While medical evacuation is a lifesaving benefit, it will not get you all the way back home, to your hospital of choice and doctors you know. Insurance typically waits for you to recover, where you are, and will rebook you home on a commercial airline.

Credit card travel benefits only sometimes cover injur y or illnesses that actually happen while you are on the common carrier that you bought the ticket for. Once you step off of that plane, your coverage ends. Far too many people mistakenly think they are covered for medical during their entire trip and are most definitely not.

Health insurance, for domestic travel coverage outside of your local network, typically covers emergency services and hospital and treatment costs, but it doesn’t necessarily get you home.

People don’t think too much about getting “stuck” in a hospital in another city, but it can cause some of the same financial and emotional stresses as getting stuck

overseas. It can be especially hard for families with children in school, where a spouse may have to choose between being bedside or remaining at home with the kids.

Air medical transport membership is a surprisingly affordable program that you join prior to traveling, and if you are hospitalized more than 150 miles from your home address, domestically or internationally, medical transportation back to your home hospital of choice is arranged regardless of medical necessity. You get to make the decision as to where you want to receive the remainder of your care, not an insurance company.

If you are transported, there are no claim forms or bills, no out-of-pocket expenses to seek reimbursements for; you pay only your initial membership fee and that’s it.

Many, like Medjet, have memberships that add security and crisis response protection. Access to a 24/7 crisis response line for travel safety threats like violent crime, disappearance, natural disaster and terrorism, can provide extreme peace of mind, especially if you travel alone a lot, or are sending children overseas to study.

I know it sounds like a lot of very boring reading, but understanding what coverage you have is vital. Over 10 million travelers are hospitalized abroad each year, millions more domestically. If the worst does happen, you will want to make sure you have the best options available to get yourself or a loved one back home. ■ Medjet is the premier medical transport and travel security membership program for travelers, recommended by hundreds of top travel experts and publications.

CMS members have access to discounted program rates by using the link www.medjetassist.com/CMS or by calling Medjet’s membership services team at 800-527-7478 (mention CMS). For group rates you can email slawson@medjet.com.

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FINAL WORD Congratulations, Colorado, on your tremendous win for patient safety Andrew Bolin, Esq, Bolin Law Group, Tampa, Florida The renewal of the Colorado Professional Review Act with changes to increase transparency and deter abuse of the confidentiality afforded by the professional review privilege was the strongest win of the session for the Colorado Medical Society, COPIC and other allies in the house of medicine. I speak from experience of the importance of this system and how quickly it can be damaged by being opened to discoverability.

Florida’s removal of peer review and quality improvement privileges for health care providers took place in November of 2004 after a strong and concerted effort by the plaintiff’s bar to have the initiative placed before voters. The provision, billed as the “Patient’s Right to Know,” gave unprecedented access to any records made or received by a health care facility or provider relating to “adverse medical incidents.” The initiative sought to roll back confidentiality and privilege that had been the cornerstone of quality improvement measures in the state’s hospitals for decades. An article in the March 2009 Florida Bar Journal noted, “Amendment 7 represent[ed] one of the most sweeping changes in law and public policy ever adopted in [Florida].”

PATIENT SAFETY SYSTEMS SACRIFICED FOR MORE LAWSUITS The 2004 initiative did not bring clarity or finality to how health care providers were to accomplish the function of making health care safer in the state. What is clear is how the “Patients Right to Know” initiative has been used by plaintiff attorneys as a tool for discovery in medical malpractice litigation. Self-critical analysis taken out of context and misinterpreted by judges and juries has wreaked havoc 3 6 C O LO R A D O M E D I C I N E

on quality improvement in Florida and resulted in dozens of battles in the courts throughout the state and federal system.

Litigation pitted legislative language and intent against the state appellate courts’ interpretation of how the new law should operate, striking limiting language as unconstitutional and continually broadening the scope of what items were discoverable in litigation. State trial and appellate courts were understandably ill-equipped to grasp the breadth of the information created by the various peer review and quality assurance committees to improve patient safety. Court decisions raised further questions and led to even more litigation in the ensuing 15 years, such that Florida health care providers continue to the present day to seek the court’s guidance on issues unforeseen by previous courts and the state’s legislature.

PROVIDERS’ RELUCTANCE TO PARTICIPATE IN EFFECTIVE PEER REVIEW NOT JUST THEORETICAL IN FLORIDA Health care providers in Florida are reluctant to participate in effective peer review for fear of retaliation and litigation.

From the date of the elimination of the privilege, providers immediately began to experience the impact of this new framework. Facilities immediately began seeing some providers resign from peer review committees and raise questions about what protections their facilities could offer them against eventual defamation or tortious interference claims that might arise from their involvement in the peer review process.

In an effort to comply with state and federal mandates for quality assurance processes, providers began searching for ways to limit or “explain” their findings in different ways. Many providers began moving toward “verbal” quality assurance and peer review methods only, attempting to eliminate written documents that would then be used improperly against

them. Unfor tunately, these methods limited the effectiveness of peer review and its uses. Providers became frustrated with an inability to communicate their findings and reliably recall and rely upon the recognition of the incidents experienced by others. Moreover, some providers suffered fines and increased exposure from licensing and accreditation boards for their new methods of quality assurance because those bodies found them to be less effective.

PATIENTS NOT USING ABILITY TO ACCESS PEER REVIEW AND QUALITY IMPROVEMENT RECORDS The newfound ability to access peer review and quality improvement records is not being utilized by prospective patients to make informed decisions about health care or raise the level of discourse about improved patient care. A large health care organization consisting of multiple hospitals and a large physician practice group in the Tampa Bay area estimates that, “less than one-half of 1 percent of any requests for such materials come from patients seeking information for health care purposes. The full balance of the requests come from plaintiff attorneys who are now seeking damages in litigation against providers.” Another provider on the east coast of Florida has estimated “seeing less than 10” total requests by patients who were not plaintiffs, while the law allowing access to these records is now a “standard request made in discover y in ever y medical malpractice case they face.”

Based on these experiences, it is not difficult to understand why a full 70 percent of physicians polled by the Florida Medical Association are not comfortable serving on peer review committees. I, again, applaud the Colorado General Assembly for considering Florida’s experience and refusing to enact legislation to make peer review and quality assurance information discoverable in civil litigation. ■

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