July-Aug-13 by Colorado Medical Society

July/August 2013

Volume 110, Number 4

What physicians need to do to improve the care experience and provide greater value for the premium dollar

Colorado Medicine for July/August 2013

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Colorado Medicine for July/August 2013

cont n ent nt ns nt July/Aug 2013, Volume 110, Number 4

Features. . . 16

Legislative roundup–CMS’ advocacy team advanced organized medicine’s agenda, including top issues like prior authorization reform and Medicaid expansion.

Connect for Health Colorado–Your questions answered: Colorado Medicine sits down with the CEO of the new health insurance exchange, Patty Fontneau.

Colorado Beacon Consortium–Primary care practices on the Western Slope are making improvements in HIT and quality with the help of federal grant funds.

Collaborative adaptation–Kaiser tailors new model to meet the needs of southern Colorado physicians and patients to achieve real results.

Physician practice innovation–Colorado physician practices are again the focus of national attention in an AMA/RAND research project.

Farewell address–Jeremy A. Lazarus, MD, reflects on his year as AMA president and predicts a bright future in his final speech before the AMA House of Delegates.

2013 AMA Annual Meeting report–Colorado leaders set policy and won election to national office at this year’s AMA meeting in Chicago.

Final Word–Author and innovation strategist Jason Hwang, MD, MBA, discusses why embracing change will mean healthier patients and a better health care system.

Cover story

The 2013 Spring Conference featured a host of experts who gave attendees action steps to transform their practices with proven techniques to identify weaknesses in processes, improve efficiency and, ultimately, improve career satisfaction and their bottom line. Coverage starts on page 8.

Inside CMS 5

President’s Letter

Executive Office Update

2013 Annual Meeting

Reflections

COPIC Comment

Departments 47

In Memorium

Medical News

Classified Advertising Editor’s note: Articles appearing in Colorado Medicine without a byline represent the collaborative work of CMS leadership and staff.

Colorado Medicine for July/August 2013

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OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2012/2013 Officers Jan M. Kief, MD

President

John L. Bender, MD, FAAFP President-elect Kay D. Lozano, MD

Treasurer

M. Robert Yakely, MD Speaker of the House Brigitta J. Robinson, MD Vice-speaker of the House Alfred D. Gilchrist Chief Executive Officer F. Brent Keeler, MD Immediate Past President

Board of Directors Susan Bauer, MS Amy Beeson, MS Charles Breaux Jr., MD Joel Dickerman, DO Naomi Fieman, MD T. Casey Gallagher, MD Jan Gillespie, MD Ripley Hollister, MD Johnny Johnson, MD Richard Lamb, MD Alisa Lee Sherick, MD Lucy Loomis, MD Donald Luebke, MD Randy Marsh, MD Gary Mohr, MD Edward Norman, MD Tamaan Osbourne-Roberts, MD Bianca Pullen, MS Scott Replogle, MD Floyd Russak, MD Ranee Shenoi, MD Stephen Sherick, MD Julia Tanguay, MS

Board of Directors Michael Volz, MD H. Dennis Waite, MD Michael Welch, DO Jennifer Wiler, MD Harold “Hap” Young, MD AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Immediate Past President Jeremy Lazarus, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Mark Laitos, MD Tamaan Osbourne-Roberts, MD CMS Connection Mary Rice, President

COLORADO MEDICAL SOCIETY STAFF Executive Office

Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Mellott-Yost,Director, Professional Services, Dianna_Mellott-Yost@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org Janine Hahn, Administrative Assistant, Janine_Hahn@cms.org

Division of Health Care Policy

Chet Seward, Senior Director, Chet_Seward@cms.org JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

Division of Information Technology/Membership Tim Roberts, Senior Director, Tim_Roberts@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org

Division of Communications and Member Benefits

Division of Government Relations

Division of Health Care Financing

Colorado Medical Society Education Foundation Colorado Medical Society Foundation

Brad Pierson, Art Director/ Manager, Communications, Brad_Pierson@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Chris McGowne, Program Manager, Chris_McGowne@cms.org

Mike Campo, Staff Support, Mike_Campo@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colorado, 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.

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Colorado Medicine for July/August 2013

Inside CMS

president’s letter Jan Kief, President Colorado Medical Society

Driving the future of medicine With summer in full swing, we are able to shift into a lower gear, but cruising is definitely not an option. At the last CMS Board meeting we heard a progress report on our 14-page work plan; directors were amazed at the breadth and depth of issues that are handled by your leadership, staff and committees to advocate for you and our profession. These CMS initiatives, coupled with your efforts in your communities, underscore the strength of the voice of physicians in Colorado. Our new website, which I encourage you to visit at www.cms.org, will make it easier to access information, provide feedback and remain apprised of CMS initiatives and programs. Our goals are to increase the voice of our members, foster grassroots activity, provide support to you as you swerve to avoid the pitfalls of health care reform, allow you to embrace evidence-based innovations, make your participation on our committees easier and more meaningful, and develop leadership in the physician community.

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• When I speak to physicians around the state, I advise you to look at the varied issues we are working on, find the one that is most meaningful to you, and then get involved to help find solutions to these challenges. Here are some areas that might pique your interest: • Your Council on Practice Evolution has been working to define the measures that will be used to monitor physicians in the All Payer Claims Database (APCD) through CIVHC. • Your Workers' Compensation/Personal Injury Committee and a special task force are tackling the huge issue of prescription drug abuse and participating in the governor’s discussions around the epidemiology, prescription drugColorado Medicine for July/August 2013

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monitoring program, drug disposal, and patient and physician education in this area. This problem affects us all; awareness and even small efforts on our part are necessary NOW. This will likely be an area of action in the legislature next year. I would recommend that all physicians become more aware by taking the Opioid Prescribing course webinar developed by the School of Public Health. The link is on cms.org. More than 600 physicians have been certified in this course so far! We are actively working on your behalf with regard to Maintenance of Licensure and Certification (MOL and MOC) and you will see much more about this in the near future. The rollout of the Choosing Wisely Initiative is underway in collaboration with Kaiser and the specialty organizations around the state. Remember, we were the first state medical society to endorse Choosing Wisely, which now includes recommendations from 35 specialties. We have several surveys in the field and I thank CMS members who participate in them. Your feedback provides useful and actionable information to us on many topics. A unique initiative, One Colorado, is underway with CMS and Denver Medical Society to identify and educate physicians and patients regarding healthcare disparities in the LGBT community. To help your practice in its day-to-day operations, our prior authorization bill (now a law) and our leading work on clean claims and standard edits continues. Physician leadership training is becoming an important tool. As we begin to recruit for our next Advanced Physician Leadership Course, let us know

your interest and whether the practice or organization in which you work may be interested in sponsoring you. • I have had the pleasure of talking with the residents on their weeklong rotation through COPIC about the importance of engagement with organized medicine throughout their careers. This has been a valuable two-way conversation in which they learn what we

“These CMS initiatives, coupled with your efforts in your communities, underscore the strength of the voice of physicians in Colorado.” do for physicians and I learn what the residents’ visions are for practice in the future, as well as what they perceive to be problems today. These are the leaders of tomorrow, and with their “fresh eyes” approach I believe our students and residents will be the key to solving many of our challenges in health care delivery. • Your CMS membership becomes even more valuable with our new CMS “member-only” programs, such as DocbookMD. Our membership drive is underway: tell your colleagues that CMS works diligently and effectively for you and our profession. Let’s keep revving up this summer. I appreciate your participation as health care evolves. It is important we take this ride together and that we choose to be in the driver’s seat. n

Inaction vs IN ACTION We understand the difference The Litigation Center of the American Medical Association and the State Medical Societies fights to protect doctors and uphold the highest standards of patient care. In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession. Whether we are challenging managed care organizationsâ&#x20AC;&#x2122; payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physiciansâ&#x20AC;&#x2122; rights. Learn more on how The Litigation Center can help you.

ama-assn.org/go/litigationcenter

Membership in the American Medical Association and the Colorado Medical Society makes the work of The Litigation Center possible. Join or renew your memberships today by calling the CMS at (800) 654-5653.

The Litigation Center is proud to have Alfred Gilchrist, CEO of the Colorado Medical Society, serve on its executive committee.

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cms.org Colorado Medicine for July/August 2013

Inside CMS

executive office update Alfred Gilchrist, Chief Executive Officer Colorado Medical Society

The thrill of Democracy There is a tendency to review a legislative session postmortem as though it were a freestanding episode, with no prequel or sequel. In fact, most legislative sessions run along a continuum that builds on its predecessor’s actions or inactions and is philosophically guided by the previous election cycle. Even with Colorado's term limits, institutional memory can reach back for a decade or more, assuring all forms of karma and payback, and, thankfully, the wisdom borne of sometimes-painful experience. In this session alone, we saw legislators switch positions after exhuming a simmering resentment against us that had its origins in fights over the previous decade. Legislators also walked the plank for us under considerable lobby pressure because of the unwavering support shown by CMS and physician constituents during previous election cycles. The point is that relationships cultivated at the grassroots level – whether homegrown or organic, ambivalent, hostile or collegial – are the essence of the legislative dynamic. The policies CMS offers to the legislature have to be internally settled by consensus, grounded in experience and clinically sound reasoning, then framed in a context that is appealing to a lay legislature that processes our proposals against counter proposals or determined adversaries. It is a combustible mixture of pragmatism and ideology. These interactions are cumulative, by definition political, and embedded in a rational process that is neither moral nor immoral. As George Bernard Shaw observed, “Democracy is a device that assures we shall be governed no betColorado Medicine for July/August 2013

ter than we deserve.” It is not a fixed game, as some cynics might insist when their ideas can't get past the bill filing or public hearing phase. It is a game of chance, opportunity, and skill. How well we prepare from the political and policy development phases and into the legislative process that will make those policy choices, and how well we sustain homegrown relationships with elected officials who will influence the outcomes, is paramount. In other words, timing can be everything, but we can make our own luck by concentrating on evidence-based policies, grass-roots political involvement, smart message framing and hard work. Medicine's agenda runs both right and left of center. I have had the luxury of advocating on behalf of the medical profession in political environments that have been dominated by Republican and Democrat governors, as well as Republican and Democrat governing majorities. The viability of our health care policy “ask” mix will vary on the relative voting strengths of the majority party and its respective ideologies and leadership. A Democrat-centered body will tend to support financing and delivery system innovations – Medicaid Expansion in Colorado moved along party lines – but also be sympathetic to “fairness” arguments for expansions of civil and governmental liability. A Republican-centered body will generally reject liability expansions while tending to resist health care funding expansions. It is of course more complicated than that. Conservatives can view some types of health care expenditures as an infrastructure investment more than social welfare, and liberals have rejected the trial attorneys’ often one-dimensional asks to expand liabil-

ity. Local constituencies do not always give their elected officials a clear signal on health care policy. Notwithstanding the challenges for those willing to cross the partisan divide for the sake of policy, Colorado still manages to find a bipartisan sweet spot on health care issues more often than

“Democracy is a device that assures we shall be governed no better than we deserve.” – George Bernard Shaw some more sharply divided states. We are farther along in the development of a Health Insurance Exchange and an entire range of system reforms that encourage collaboration and patient safety than most of our counterparts because of a pragmatic center that can still gel when offered rational options and compromises. Over the course of many sessions, Colorado’s political culture has proven to be durable and reasonably open to the competition of ideas, and tends to default to evidence-based policies. It is responsive to strategies that take the longer view, as we emphasize in tracing the origins of the legislative progress in health policy in this recently adjourned session. It is a process that endures, despite the best efforts of some to thwart or disable it. n

Cover Story

What physicians need to do to improve the care experience and provide greater value for the premium dollar Kate Alfano, CMS contributing writer

Colorado Medicine for July/August 2013

Cover Story Editor's note: The 2013 CMS Spring Conference brought experts from across the country to share their opinions and to dialogue with CMS members on what physicians need to do to improve the patient care experience and to provide greater value for the premium dollar. This extended cover story recaps the presentations and discussions from the conference. Action steps to transform your practice and thrive in an evolving system Health care in the United States must change. No longer will anyone dispute that the system is expensive, wasteful and exclusionary and, in some respects, harmful to patients. Physicians’ quality of life has suffered as they have endured increased administrative burden, steep costs and learning curves for new technology, and increased regulations – a patchwork of small answers to a big problem. With the health care system at a breaking point, it is imperative to study and redesign the entire cycle, from preventive medicine to care delivery and from coordination to payment for services, using methods that will move the system closer to the goal of lower costs, increased efficiency and improved value. A group of experts gave physicians action steps for health system reform at the 2013 CMS Spring Conference in Vail, and the record-setting attendance of physicians from around the state validates the demand for these strategies. As CMS president-elect and conference host John Bender, MD, said: the

Mary Holden, RN, MS, and Charles Little, DO, FACEP, discuss team-based care.

Colorado Medicine for July/August 2013

new reality of reform lives within the framework of the Affordable Care Act, which is the law of the land but still exists largely in statute. He identified five components physicians should consider to thrive in this environment: practice transformation and workflow redesign; team-based care; health information technology and interoperability; metrics reports and population management; and broadening health care access. Practice transformation and workflow redesign Bender shared his own story of practice transformation, demonstrating how staff at Miramont Family Medicine in Fort Collins stepped off the proverbial treadmill and improved workflow and processes to improve their quality of care. In 2002, he and his partners recognized that they were delivering a “lousy” product: “Test results were low, labor costs were high with a lot of non-revenuegenerating activity, there were no open appointments, no clinical data management, barely any financial data management and there was high variability in patient experience day-to-day. Documentation was illegible because we were still on paper and I couldn’t compete with retail clinics, urgent care or emergency departments,” Bender said. They changed their focus after a company retreat in 2007 when they decided that Miramont would offer local families the most convenient and highest value health care that would be delivered in a compassionate, modern and timely way in an environment that promotes patient and staff growth, health and happiness. The practice brought in coaches who examined Miramont’s processes, suggested ways to improve, and gathered data to measure progress and influence the next step. Bender said his model for success is built on two concepts: continuous improvement and respect for all people. “Continuous improvement can be thought of as never quite being good enough. We make small, continuous, incremental changes and as things get better we’re

satisfied for a time but we’re not ever permanently satisfied. We’re always looking for ways to improve.” Respect for people means trusting team members, encouraging them to take ownership in their part of the process and empowering them to suggest and implement changes to improve the final product, Bender said. “In 2013, we have five locations in four separate communities; we’re open Monday through Friday 8 to 8, Saturdays 9 to 1; we have 17 providers and 61 employees; we have more than 100 company computers operating in a terminal server environment with 30,000 patients; and in 2010 HiMSS named us

CMS President-elect John Bender, MD, FAAFP, leads the conference. the Nicholas E. Davies Award Winner, which acknowledges that we had the best implementation of IT in the U.S. for small, private sector clinics.” At the same time that Bender was moving his practice forward, 34 primary care physicians in his area left their practices, including eight who went bankrupt. He said the difference comes down to efficiency. “I pay my staff to do in 10 minutes what my competitors are paying theirs to do in 20. When we look back at the practices that bankrupted, they all folded for the same reason: cash flow. If you don’t have cash, you can’t pay your bills. And what was their cash flow problem? Their labor costs.” All other expenses are “chicken feed” compared to labor, Bender said. “Can I

Cover Story (cont.) be involved with patient check-in.”

pay my staff less and get away with it? They’ll go somewhere else. If anything, at Miramont we pay them a little bit more. But I’m paying them to be efficient and this is why you have to go back into your workspaces … and start leaning up the system to reduce the waste so that we can deliver health care to people.” Implementing lean processes “Lean” is a key word. The concept of lean processing, in brief, means maximizing customer value and minimizing waste, explained Ellen Batchelor, a health care quality improvement coach with Zeroth Blue and project manager with the Colorado Foundation for Medical Care. The customer is the recipient of the process. Value is something the customer wants and is willing to pay for, whether monetarily, with time or in another way. And waste is anything that adds cost or time without adding value. Waste can be found in every process in health care such as errors in billing or clinical work; unnecessary movement of

Ellen Batchelor shares how to achieve practice transformation using lean processing. staff or equipment during a processing step; too much or too little inventory; or when patients are waiting for services or staff are waiting for laboratory results. To “lean a process,” you must define your team and engage your leaders, Batchelor said. “Your team is not your best and brightest; it’s one person from every area of your organization that’s involved in that process. If you’re looking at your patient check-in, you’ll want your front desk person, maybe a billing person, a physician or primary provider, nursing staff and whomever else might

The team starts by assessing the process and determining the baseline. Then they diagnose the problem using “lots and lots of data,” she said. Along the way is problem-solving, which in lean involves using solutions tailored to a practice’s specific needs. “We have to remember that problems look a lot alike on the surface but blanket solutions and best practices do not always work, so don’t just take [another practice’s] solution and try it at your office.” “The next step is to treat. You have your data, you have it figured out, you’ve done some problem-solving and you’re ready to treat the problem. You might do some just-in-time training or workload balancing. There are a lot of tools in lean.” “Finally, you’re going to prevent. Once you have your process at a point where you think it’s going to work, this is where you really get the mindset of continuous quality improvement. You’re going to have some storyboards, some visual controls, things to keep you on track.” As a result, “you’re going to have fewer people and things sitting around waiting,” she said. “You’re going to have people working to their highest training. You’re going to have exam rooms that have what they need, when you need it, where you need it.” You’re going to have less motion waste. “You’re going to have people who have organized workspaces and employees who are satisfied because they’re working to their highest capacity. You’re going to have fewer errors. And, we don’t talk about this a lot in medicine, but you’re going to have a higher return on investment.” Another case study: Five levels of the virtual PCMH Dale Glenn, MD, chief of family medicine and medical director of information systems for Straub Clinic and Hospital in Honolulu, took five steps to build a virtual patient-centered medical home, “virtual” because members of the full care team don’t have to be present in the clinic and can serve multiple

Colorado Medicine for July/August 2013

Cover Story sites. Visually, the steps are represented in a pyramid with information systems as the base. “The first thing you absolutely must have is data. The new model of health care is based on information.” “Then you’ve got to go to the next layer, shared clinical protocols. This can be

Dale Glenn, MD, talks on how to build a virtual patient-centered medical home. tough,” Glenn said. “You have to do this rule by rule and layer by layer, at least agreeing within your practice that you’re all going to try to standardize a lot of your care because this will dramatically improve the quality you give your patients.” The next level, reporting and incentives, tracks the progress of transformation and rewards improvement. “Ideally you want your payment to be tied to that. The new payment system is really important; you can’t fund a lot of these changes under fee-for-service medicine.” “The next layer we went to was team care. Quality is a team sport. The idea of a single person being solely responsible for another human being’s health in this complex day and age is ridicu-

lous. It doesn’t mean you can’t be a solo practitioner; you can be financially independent. But we need to be more interdependent and that’s why organizations like [the Colorado Medical Society] are so important.” And those four steps lead to the most important, on the top of the pyramid: “the true patient-centered approach to health care.” Team-based care As Glenn and nearly all other Spring Conference speakers mentioned, teambased care is essential for practice transformation. They recommend allocating tasks among the various health care providers so each professional is working “to the top of his or her license” and in a collaborative manner. But employing this concept isn’t always easy. “It’s a fairly big culture change to empower teams and move toward a team-based care model,” said Nicole Deaner, MSW, program manager at HealthTeamWorks. “In a lot of senses, many practices have been very traditional or hierarchical in how they practice, and in this new world of patient-centered medical homes and medical neighborhoods, we have to move much more toward a team-based approach.” It requires engaging the whole team and empowering individuals to work at their highest level. “When you look at the roles within a practice, often people can expand much more than what they’re doing now. And you want to think about staff not only within their roles but as their individual skills and talents.” Glenn said “we practice the science of medicine in teams so we can practice the art of medicine as individuals. The main focus of this transformation is so that you can spend more quality time with your patients. Not doing paperwork, not being on the computer, not doing faxes and things back and forth.”

Nicole Deaner, MSW, discusses being an effective leader within a practice setting. Colorado Medicine for July/August 2013

“The standard model for thousands of years was the provider and the patient,” he continued. “Because medicine was

getting more and more complex, we added nurses and MAs to help do some of the work. It’s gotten even more complex so we needed even more help. We added care coordinators. We’ve added nurse educators; they’re a critical part of our team. Now we have nurse case managers; they help us with hospital transitions and help prevent readmissions.” The allied health professionals in Glenn’s practice have lists of protocols they must address before the physician

Marjie Harbrecht, MD, proves data management is key to the modern practice. enters the exam room. “Save the critical thinking for the things that really matter: Making the difficult diagnosis, understanding those complex systems, really taking a good history like you learned in school.” And once they examined quality reports comparing all physicians on a variety of metrics, they revealed that the highest scorers were the ones who embrace team care. “The doctors who are doing well are the ones who are using their staff. This is the transformation that we have to help physicians make if we’re going to get to team care.” But Glenn stressed that each team member must work under the physician’s authority and have the trust and permission of the physician to act on his or her behalf. “You have to have protocols that you both trust so you can let them do their jobs.” Constructing a medical neighborhood A broader application for team-based

Cover Story (cont.) care is the medical neighborhood. Health care has gotten so complicated that no physician – neither primary care nor specialist – can do it alone and that realization is pushing health care professionals into teams, said Marjie Harbrecht, MD, CEO of HealthTeamWorks. The typical primary care physician deals with 229 other physicians working in 117 practices, and the average Medicare beneficiary sees seven different physicians and fills more than 20 prescriptions per year. “We went into these various arenas because that’s what we wanted to do. Now we have to figure out how to get the patients to the right place at the right time for the right care, and align everybody so we can all move together toward the best quality, affordable care and best experience.” Building the medical neighborhood starts with a conversation with patientcentered care at its core, where all providers respect the skills each brings to the table, recognize the value of that differentiation, acknowledge the problem, and remain professional. Together, health care teams must establish a shared community vision, shared care plans and a plan for shared data that allows access to patient information at the point of care, individual outreach for patients needing care and for identifying trends in communities for targeted programs. Health information technology and interoperability Physician adoption of electronic health record systems has rapidly increased over the past few years due to fund-

Larry Wolk, MD, shares how CORHIO connects physicians to needed data.

ing opportunities from the private and public sector as well as upcoming penalties for those who don’t use their EHR to e-prescribe, produce quality reports or perform other tasks designated as “meaningful use.” Health information

neighborhoods, they are creating the framework for a safe, effective and efficient system where patients neither fall through the cracks nor receive duplicate services. A numbers game: metrics reports and population management Data is imperative in practice transformation. Gathering metrics allows physicians to set benchmarks and goals for process and quality improvement, and demonstrate value to payers and patients who increasingly demand this information.

Christina Ells walks attendees through how to use CORHIO's connection tools. exchanges provide the platform for shared data by connecting EHR systems and pushing clinical information back out to providers. Colorado has two Health Information Exchanges (HIE): the Colorado Regional Health Information Organization and Quality Health Network. CORHIO is the state-designated entity for HIE and covers most of the east and south regions: 40 hospitals and more than 1,800 office-based physicians and providers. QHN connects 10 hospitals, more than 800 medical providers and 140 other health care organizations in western Colorado. CORHIO has two products, one that integrates directly into a practice’s EHR system and a freestanding portal for physicians without an EHR, said Larry Wolk, CORHIO CEO. Both allow access to patients’ community health records at the point of care including test results, hospital admission and discharge alerts, care summaries, transcribed notes, and newborn screening results. And, particularly important for the medical neighborhood, physicians can make electronic referrals and send and receive information from any provider on the HIE’s network. Specialists can designate how they want referral direction delivered to them and their consultation notes go back to the primary care physician. As communities work to develop medical

While an EHR system may help consolidate large pools of clinical information for data mining, Spring Conference attendees learned a technique to gather information to increase efficiency using a simple stopwatch. Value-stream mapping, a similar method to lean, helps practices “get a metric around chaos,” said Jane Brock, MD, MSPH, chief medical officer for the Colorado Foundation

Jane Brock, MD, MSPH, describes the technique of value-stream mapping. for Medical Care. A practice can map three things: the process, the producer (the person delivering the service), or the product – which in health care could be considered a completed patient visit. “That’s really the role of value-stream mapping; it is a tool to help you learn in real time. Anytime you’re frustrated you can pull out a stopwatch and get some information. It’s meant to map materials and information required to bring a product or service to a consumer.” A practice leader might use this as a data-driven way to restructure staff re-

Colorado Medicine for July/August 2013

Cover Story sponsibilities “without getting into nastiness or the perception of unfairness,” Brock said. “It certainly empowers staff and maintains buy-in. It allows you to examine outliers; if it’s your perception that you have one physician who is very efficient and one who isn’t, by observing exactly what they do and looking at the proportion of time spent in physician work, you can adjust the schedule accordingly.” Measuring patient value-added time can also be used as an outcomes tool to validate a particular process change to staff, particularly “if you perceive that change is going to degenerate into finger-pointing about who’s not doing what.” Brock gave the example of wait time, which has been shown to be harmful to the patient. The best way to capture this data is to give the patients the stopwatch, she said. Tell them at check-in to click the stopwatch anytime something happens: when they are called back to the exam room, when a care provider comes in, when they leave the room. “If you can get patients to capture this data for you one day a month, you can really start to take a look at what works in your practice and what doesn’t.” The rise of big data and the All Payer Claims Database Besides tracking metrics for quality and process improvement, physicians also must know their own data to understand how they compare to others in the health care market and be able use this information to leverage their position. This was the message from Jay Want,

Jay Want, MD, encourages physicians to use data to leverage their market position.

Colorado Medicine for July/August 2013

MD, and Phil Kalin, both from the Center for Improving Value in Health Care – the nonprofit that’s administering the Colorado All Payer Claims Database, or APCD. Business and organizations already know a large amount of information about individuals and consumers, said Want, CIVHC chief medical officer. “The chances that they’re not going to know huge amounts about you as a doctor? An economist would say that value is statistically indistinguishable from zero.” “Information has become cheaper than zero,” Want continued. “The challenge

Phil Kalin emphasizes importance of physicians knowing their own data. today is not that you can’t find the information, the challenge is filtering the information and changing it into something that you can actually do something about.” Knowing your own data is going to be key, said Kalin, CIVHC president and CEO. Payment is starting to shift to different mechanisms. Payers are increasingly shifting to the highest-performing practices with narrower networks and providing incentives for providers to send referrals to these high-performers. “It’s only going to increase. The consumers, your patients, are going to know this; businesses are going to have this information. You need to have this information and understand how you are performing relative to your peers.” Starting in December 2013, CIVHC will make public on www.cohealthdata. org information that shows consumers how various physician practices compare to others on some cost and qual-

Saturday night's panel experts discuss bridging coverage gaps in Colorado. ity metrics and empowers them to take an active role in the cost of their care. CMS has been actively involved with the APCD since its inception. For a fee, physicians and other facilities can use the APCD as one place “where you can find a really big data set, draw statistically significant conclusions, and get better,” Want said. “And at the end of the day, we think that’s what binds us all together in this enterprise, which is a promise to get better all the time. We think databases like this give you one component.” It’s inevitable that information on physician practices will be made public, Kalin said. “All of you are familiar with Healthgrades and Vitals; you’re going to hear about Castlight and iTriage. They’re all getting data from various sources and presenting it for people to see: your patients and other providers who are deciding whether to refer to you or to someone else. So part of the message is about engagement. Better that you’re working with organizations like ours and others to have a chance to see how we’re shaping this because it is going to happen.” “We’re actually all on the same team,” Want said. “Our vitality now depends on us working on these problems to offer the best health care possible to optimize the state’s future. That’s a really tough message to internalize, but I have to say that working with CMS and with others at our table, they have demonstrated exactly that: an understanding, a belief, a loyalty to the state, which makes us a very special place in the country.”

Cover Story (cont.) Broadening health care access As physicians move forward with practice transformation, they must also look to the horizon and prepare for an influx of patients gaining access to health insurance under the Affordable Care Act. “The demographics don’t lie,” said Patrick Gordon, associate vice president at Rocky Mountain Health Plans and director of RMHP government programs. “If you look at what’s coming

with respect to Medicaid and coverage expansion through the health insurance exchange, hundreds of thousands of people who lack access to coverage are now moving into the system. We need to create the capacity in the system so we can serve that population effectively.” An estimated 800,000 Coloradans are uninsured. Colorado’s health insurance exchange, Connect for Health Colorado, will open in October 2013 to al-

low individuals, families and small businesses to find health plans to fit their needs and to find out if they are eligible for federal financial assistance. Coverage through the exchange starts on Jan. 1, 2014. The Colorado Department of Health Care Policy and Financing estimates that the Colorado Medicaid expansion, also effective on Jan. 1, will allow more than 160,000 adults to gain access to health coverage. Gordon commended Colorado for tackling the challenges of delivery system reform and payment reform while others seem “paralyzed.” Susan Birch, MBA, BSN, RN, HCPF executive director, said Colorado is ahead because of the collaboration among state agencies, physicians, hospitals and consumer groups. She mentioned the work around service provision, coordinated care, the Regional Care Collaborative Organizations and the children’s medical home program. “Health care reform is a crazy process,” Birch said. “It’s like flying a jet while we’re rebuilding it from the outside in and keeping it all going.”

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“One of the biggest things I would beg you to pass on is that it has taken us decades to get into this situation in the United States and it’s going to take us decades to transform our health care system.” There will be bumps in the road and “we’re really counting on you all to feed that information up to us.” “What I would ask is that physicians step up and be a part of this change,” Gordon said. “There is no substitute for that leadership. Certainly in Grand Junction when we run into a problem or challenge with respect to any of the aspects of our delivery system, physician leadership is often the key in getting the breakthroughs and making progress. Shaping the future with innovation Continuing to broaden access to health care will mean embracing disruptions to the current model, said Jason Hwang, MD, MBA, an internal medicine physiColorado Medicine for July/August 2013

Cover Story cian, senior strategist for an innovation and strategy consulting firm in Massachusetts, and co-author of “The Innovator’s Prescription: A Disruptive Solution to Health Care.” Disruptive innovations – new products or services that improve upon and eventually replace incumbent products – have occurred throughout history and throughout all industries. He said disruption in health care involves a departure from the general hospital. “This is a business model built on the assumption that if you have a problem, you bring it here and we’ll fix it. All the expertise is here. The problem with that is that this gold standard is not necessarily affordable and accessible, certainly not in areas where you can’t sustain one of these behemoths.” Many

Ultimately “we need to put more and more power in the hands of consumers using technologies that allow this to be done safely. That’s the only way we can transfer our health care system into a setting that’s affordable and accessible to everyone.” Diagnostic tests must be easily interpreted and medications to treat these conditions must be made available over-the-counter safely or behind the counter “so you can really treat disease effectively as a public health problem.” We often stand in the way of disruption, whether inadvertently or on purpose, Hwang said. “This is no different from what we see whenever an incumbent is disrupted by a disruptive force. When disruption comes up from the bottom oftentimes the immediate reaction is to deride the quality and safety of the disruptive force.” Physicians can refuse to empower health care teams, embrace patient-centered technology, or implement new workflows, or they can agree to be the best

CMS member physicians seek clarification on effects of disruptive innovations. people can’t access the system as constructed, the so-called “non-consumers” of health care, because they live too far away, are too poor or lack health insurance.

Jason Hwang, MD, MBA, discusses the science behind changes in health care economics. provider of health care where they are needed most and allow other safe and effective innovations to come in. “We want to help make sure disruption is a good thing,” Hwang said. “It is good for our patients, it’s been slowly coming to health care and I think with all your help and support, we can make it happen.” n

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Physicians must ask whether care delivered in hospitals might be better suited in an outpatient facility, an individual office or “better yet, a kiosk, retail setting or at the patient’s worksite.” “But it’s not just about the venue, it’s about transferring skills. Whereas the general hospital is dependent on a lot of expensive experts trying to work together, can we take some of their skills, put them in a piece of software, a device or a training program and transfer them to an individual practitioner? Not just a physician, but perhaps a nurse practitioner, a physician assistant, pharmacist, or any of the other allied health care professionals who are tremendously underutilized.” Colorado Medicine for July/August 2013

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Features

Legislative roundup Susan Koontz, JD, CMS General Counsel

Bills standardizing managed care prior authorizations and the Medicaid expansion highlight successful year The Colorado General Assembly recently concluded a contentious session that resulted in the progression of medicine’s agenda launched several years ago. Key issues included historic Medicaid expansion, the enactment of a model law standardizing managed care prior authorizations and innumerable public health reforms ranging from reimbursement for end-of-life counseling to vaccinations for needy children and expansion of outpatient dialysis treatment. Colorado Medical Society’s Strategic Plan, now in its ninth year, anticipated and outlined those categorical goals for long-term advocacy. They are still a work in progress, and are now moving into preparations for the 20132014 election cycle and into the 2014 legislative session. Pundits point to legislative ideas as “turtles on fence posts,” meaning that they don’t get there by themselves. “The remarkable health-care-related successes of this session, and those that preceded their efforts, don’t spring up spontaneously when legislators are sworn in every January,” explained CMS President Jan Kief, MD. “The groundwork that preceded these considerable advances in public health are the result of methodical, long-term planning and political engagement at the most intimate, grassroots levels.” “Medicaid expansion, and the almost completed work of the State Health In16

surance Exchange had its roots in the 208 Commission, and now moves into the impending and ambitious agenda of the Governor’s Healthiest State Report, which builds on that institutional memory and momentum,” said CMS CEO Alfred Gilchrist. “The politics that drives the process that determines the policy results are complex, interdependent and mutually inclusive.” CMS leaders from the grass roots to the grass tops were involved as these ideas were germinating, and are still involved now as fully formulated law and prospective legislation are being implemented or mobilized for enactment. The standardization of prior authorizations evolved from a yearlong voluntary collaboration between CMS and the health plans, working from a well researched and developed model provided and guided by AMA health attorneys, and had its antecedents in a long list of first-in-the-country managed care initiatives – standardized contracts, profiling-rating rights, clean claims reforms, physician rights in plan mergers or acquisitions, and prompt payment standards, to mention a few. “We have a near-decade-long history of engaging the plans, through ongoing advisory committees and ad hoc collaborations that continue to produce reforms to these vital but often contentious relationships,” said CMS Senior Director of Health Care Financing Marilyn Rissmiller, who has served on

CMS’ physician advisory committee to UnitedHealthcare care since its inception in 2006. The ongoing and successful resistance to trial lawyer lobbying for expanded malpractice causes of action and their relative value have been countered over the last seven years with patient safety reforms, a complex rewrite of Colorado’s professional review laws, several amicus briefs before the Colorado Supreme Court, and highly localized political engagement in swing districts where the trial attorneys were choosing sides. “We continue to counter the trial attorneys by reframing this almost ritualized debate in terms of the demonstrable failures of the tort system – i.e., to reduce the risk of an adverse result, to compensate a patient promptly and fairly, or to reduce the disproportionate number of meritless prosecutions,” said CMS General Counsel Susan Koontz, JD. “But this political environment gives the other side more leverage.” Colorado’s state political environment has been edging more toward the Democratic side of the aisle for several elections, culminating in a substantive shift to solid majorities in both chambers in 2012. That transition generated tensions that allowed for more expansive views of health care financing and delivery. Similarly, expansive views in terms of patients’ rights, expanding damages from $150,000 to $350,000, along with Colorado Medicine for July/August 2013

Features an index that can escalate those limits in a lawsuit against public entities, or a new law allowing for a private right of action against an employer with 15 employees or less under instances of discrimination. “This is their marker to make the case for ‘updating’ Colorado’s non-economic damage cap, breach peer review immunities, and an array of related changes to ease the process for filing and pursuing a malpractice suit next session,” said John Conklin, JD, of the Martin Conklin law firm. Similarly, barring a significant reversal of the current legislative composition in the next election, CMS leaders and advocates anticipate a vigorous, wellinformed debate on how best to reduce the incidence of opiate abuse during the interim and into the next session. “Gov. Hickenlooper is part of a sevenstate pilot created by the National Governor’s Association that has rounded up key stakeholders to set a policy course that is still sorting through the epidemiology of opiate abuse and successful case models,” said Gilchrist. CMS Council on Legislation Co-chair Lee Morgan, MD, emphasizes the importance of the set up in the legislative process and the cyclical nature of policy development and enactment. “There is a quote adapted from Shakespeare’s “The Tempest” inscribed on a sculpture in front of the National Archives Building in Washington that says, the ‘past is prologue.’ Any given state legislative session is an episodic manifestation of the politics and policy work that grew from earlier sessions and elections. Even as our lawmakers have returned home to their private lives, we are setting the stage for the next legislative act, if you’ll excuse the double entendre,” she said. n

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Q&A

Features

Q and A with Patty Fontneau, Executive Director/CEO, Connect for Health Colorado

Connect for Health ColoradoTM will open a new online marketplace in October for health insurance and access to new financial assistance for individuals, Patty Fontneau families and small employers in the state. In advance of the official launch, the Colorado Medical Society asked Connect for Health Colorado Executive Director and Chief Executive Officer Patty Fontneau a few questions regarding details of the marketplace and where health care professionals and their patients can get more information. Colorado Medicine (CM): What is Connect for Health Colorado? Patty Fontneau (PF): We are a new health insurance marketplace and support network opening this October with the mission of increasing access, affordability and choice for individuals, families and small employers across the state. CM: Health insurance is complicated. How do you intend to help Coloradans understand their choices and find the health plan that meets their needs? PF: Connect for Health Colorado will provide a broad support network to help consumers, including online decisionsupport tools, online chat, assistance by phone with customer service representatives, certified Health Coverage Guides who will be available to provide in-person help in your community, and licensed and certified health insurance agents and brokers. Connect for Health Colorado recently selected 57 organizations across the state to serve as assistance sites. CM: How will the Assistance Network Colorado Medicine for July/August 2013

work in October? PF: Starting in October, the network will provide local, in-person assistance to individuals, families and small businesses looking to shop for health care coverage through the marketplace, to apply for new tax credits to reduce costs and for other insurance affordability programs. Health Coverage Guides will provide impartial assistance and will also be able to connect customers with a licensed agent/ broker, a customer service center representative, insurance carriers and other resources when appropriate. CM: How many carriers will be offering health plans through the marketplace? PF: Ten carriers requested approval from the Colorado Division of Insurance to provide about 150 health plans for individuals and families through Connect for Health Colorado. Six carriers requested approval to provide nearly 100 health plans to small employers. Final details about the costs and features of the health plans will be known in August. CM: Does Connect for Health Colorado play a role in negotiating reimbursement rates with providers? PF: No. Connect for Health Colorado cannot negotiate rates and does not play a role in the agreements that are made between carriers and medical providers. We are a resource to help Coloradans compare competitive health insurance plans from the leading carriers and decide which plan best protects their family and meets their budget. We encourage providers to work with carriers, including new companies that are entering our marketplace, to complete agreements. CM: What resources are available for health professionals looking for additional information to share with patients? PF: We encourage health professionals

to refer patients to our website, www. ConnectforHealthCO.com. We also have a toll-free number, 1-855-PLANS4YOU, where interested Coloradans can ask general questions. CM: What advice do you have for people who want to help educate Coloradans about the new marketplace or who want to get additional educational materials? PF: Participation from health care professionals will be a critical component of providing information about the health insurance marketplace to consumers. People interested in volunteering or in learning more through webinars or outreach events can contact info@ConnectforHealthCO.com (no hypen in the email address) or go to http://www.connectforhealthco.com/connect/. Key takeaways â&#x20AC;˘ Connect for Health Colorado, a new health insurance marketplace for individuals, families and small employers, opens in October. â&#x20AC;˘ The marketplace will include a highquality support network of customer service center representatives, Health Coverage Guides and licensed health insurance agents and brokers to make finding the best health plan a faster and simpler experience for Coloradans. â&#x20AC;˘ Consumers will have a broad choice of health plans. Ten carriers requested approval to offer 150 health plans to individuals and families through Connect for Health Colorado and six carriers requested approval to provide nearly 100 health plans to small employers. Providers should be negotiating contracts with carriers now. n

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Colorado Medicine for July/August 2013

Features

Western Slope consortium featured for improvements in HIT, quality Kate Alfano, CMS contributing writer The Commonwealth Fund published a case report in April spotlighting the Colorado Beacon Consortium (CBC) and how its culture of collaboration and integration of health information technology has increased quality and reduced the cost of care for patients on the Western Slope. CBC is one of 17 regions across the country participating in the three-year, federally funded Beacon Community Program, which aims to demonstrate that strengthening local HIT infrastructure can support care coordination and population health management. But CBC isn’t just about technology, said Patrick Gordon, associate vice president at Rocky Mountain Health Plans (RMHP) and director of its government programs. While one objective was to spread HIT and strengthen the HIE infrastructure to support analytic capabilities, the other was to help redesign primary care practices by bringing them together in a learning collaborative that focuses on the effective use of electronic health records and analytics tools to implement team-based quality measurement and improvement. The consortium brings together 51 primary care practices in seven largely rural counties spanning 17,500 square miles. The region’s predominant payer, RMHP, is the lead sponsor of the consortium and of CBC’s clinical transformation activities, one distinction from the other communities. They place heavy emphasis on primary care, population-health management and shared registry technology, and have “a very high level of engagement, particularColorado Medicine for July/August 2013

ly with independent, old-fashioned, private and network practices,” Gordon said. “Then, last, we actually have moved some quality metrics. There’s nothing all that sophisticated about it, we just focused on coaching and other resources to create a metric-driven component for the transformation process.”

the free text tool, there’s no way that we can push that information out into the registry to document that the activity occurred. So the physicians really had to relearn how to document a number of things they were doing in an encounter so we were all reporting in the same manner and the reports were more accurate.”

Improving care The Commonwealth Fund’s report shows in preliminary results that participants improved quality of care in eight objective quality metrics, with relative improvements of 17 percent to 75 percent between the first and last three months that cohorts of primary care practices participated in the collaborative.

RMHP collaborated with other sponsors to obtain the $11.9 million federal grant, including Quality Health Network, the health information exchange for the region; Mesa County Physicians IPA, representing roughly 85 percent of the county’s physicians; St. Mary’s Hospital and Regional Medical Center, a 277-bed facility in Grand Junction; and Club 20, an association of business and civic leaders. Community hospitals, mental health agencies, long-term care facilities, homehealth agencies and allied health providers serve as collaborating and supporting organizations.

The biggest challenge was geography, said Gregory C. Reicks, DO, FAAFP, a family physician at Foresight Family Physicians in Grand Junction and president of the Mesa County Physicians Independent Practice Association (IPA). The quality improvement advisers had to travel long distances to reach the practices in the remote areas. The second challenge was the technology, or more specifically learning how to use it better. These practices were the ones that perhaps needed the outreach the most, as rural practices tend to lag behind in their adoption of technology, he said. “When we first started the project, many of the physicians were just doing free text transcription about preventive care activities. For example, ‘I talked to the patient about exercise; here’s what we talked about.’ Or, ‘I talked to the patient about diet; here’s what we talked about.’ Using

Gordon said he appreciates the flexibility of the Beacon program. “It really did live up to the billing as a public-private partnership with the federal government; they allowed the communities to define their own projects. We were held accountable for performance for achieving certain benchmarks, but we had a lot of latitude in how we chose to get there.” “It gave us the ability to put a coaching resource in place in the workforce, and data extraction and supports for care management at the point of care,” he added. “Then, all of that allowed us to create a region-wide learning collaborative struc-

CBC (cont.) ture with a lot of engagement and leadership that will provide a nice frame for the future.” Framework for the future The first opportunity to leverage these lessons came in the form of the Comprehensive Primary Care Initiative (CPCi), a separate multi-payer initiative to strengthen primary care. Using their foundation in the Beacon program, some CBC practices were able to move to more rigorous care management and population health management objectives and will receive additional compensation from payers. Reicks’ practice qualified for CPCi and he anticipates the funding will allow them to expand their resources further in care coordination, health coaching, and patient engagement and activation tools, which they believe will continue to improve out-

comes in their patient population. As the Commonwealth Fund case study concludes, CBC’s approach “drew upon universal principles of collaboration, physician leadership, and community action to help empower each medical neighborhood to define its own approach using common tools and technology.” To be replicated in other communities, they will also need to adapt these principles to their local needs. Gordon’s advice to others is just to jump in and start. “Start with a project, be willing to work outside your own walls, be willing to try something new, be willing to accept failure as a positive part of the learning process and it will be possible to get this kind of transformation on a much broader basis.” n

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Colorado Medicine for July/August 2013

Features

Collaborative adaptation Kate Alfano, CMS contributing writer

Non-traditional Kaiser model in southern Colorado designed to meet needs of area physicians and patients When it comes to practice transformation, physicians are increasingly realizing that “business as usual” is no longer viable and that they must adapt a collaborative approach to medicine. Many private practicing physicians in southern Colorado are finding help from a perhaps unexpected ally, Kaiser Permanente. Kaiser has been in southern Colorado since 1997, but the model in the area encompassing El Paso, Pueblo, Fremont and Teller counties isn’t the typical fully integrated model seen in the Denver/Boulder area and in other parts of the nation. “We operate down here primarily through a network model,” said Clinton R. (Rocky) White, MD, a practicing primary care physician and chief of outpatient network services for Kaiser Permanente, Southern Colorado. “We contract with fee-for-service physicians, just like a regular insurance company.” In 2010, when Kaiser leadership noted disparities in quality between Denver/Boulder and southern Colorado, they embarked on a collaborative care model. “We were trying to take the best of the integrated system and think creatively about how to apply that in a fee-for-service network model to create more integration in care, create more connectivity and improve a few defined quality metrics,” White said. Paying for value That’s where the new pay-for-value initiative came in. Central to the collaborative care model, pay-for-value provides a stipend to physicians to help with population-based care and improve quality 24

across nine quality measures, including five for diabetes, one for hypertension and three for prevention focusing on colorectal, breast and cervical cancer screening.

were contracted with in adult primary care understood that they could improve that care – measurably improve it – we knew they would work with us in a collaborative way.”

Though it may not sound different from other pay-for-performance programs, the twist to the Kaiser initiative is in its bottom-up approach. “First we went into each individual practice to see where they were at that time,” White said. “Each group is unique and all are individual. We told them where we see the future going and then asked what we could do to help them get there.”

“Eventually, the pay-for-value program will evolve to include a set of valuebased criteria in the categories of data connectivity, quality and service that encompass the values we feel these adult primary care practices should have,” Spurlock said. “We are approaching this as a long-term program, understanding that transformation takes time. We will continue to engage the practices and help them with the resources to be successful.”

The second part of the strategy focuses on working with the practices to improve performance on those metrics. Once baselines are determined across the nine metrics then the practices report quarterly on their metrics for diabetes and hypertension. The prevention bundle is pulled from claims data on a yearly basis. If the practices meet their goals, they get a bump on top of their fee-for-service payment. The stipend, based on an attribution formula that makes up roughly 6-8 percent of the practice’s revenue from Kaiser, is intended to help support them as they invest in the various components of practice transformation, said Richard Spurlock, MD, MBA, medical director for Kaiser Permanente, Southern Colorado. “Most physicians don’t practice population medicine because they don’t have the tools and the resources to do that. They don’t have the EMRs, the registries or the nurse navigators to help them. We felt that once physicians we

The approach appears to be working. There are currently 24 primary care or multispecialty groups involved in a pay-for-value contract, plus one pediatric group, three OB-GYN groups, and three cardiology groups. This translates to roughly 250 providers caring for 25,000 Kaiser Permanente members in southern Colorado. David Hoover, MD, a pediatrician and board president of Mountain View Medical Group in Colorado Springs, said the model is favorable for the area. “El Paso County has a different personality than Denver/Boulder and this sort of model is more acceptable to the other physicians and patients than the integrated model would be.” Providing support to achieve targets Above simply providing bonuses, Kaiser also provides tangible staff support, Colorado Medicine for July/August 2013

Features outreach and registry functionality. Through Kaiser Permanente Care Connections, or KPCC, a team of nurses identifies gaps, provides a quarterly gap list to physicians and also reaches out to the patients themselves to encourage them to seek care. “If a provider has 500 Kaiser members and of those 75 are women over age 50, we give that list to them and say, ‘look – out of these women who are eligible for a mammogram, there are 20 who have not had theirs. Can you reach out to them and get them in for a physical?’” White said. Kaiser also provides case and care management for complicated patients. Physicians in the pay-for-value initiative can refer the patients to the Kaiser Population and Prevention Services (PPS) team who then can reach out to the patient on a weekly basis to help with myriad issues, from compliance issues to helping to titrate their medications, under the physician’s orders. “Not only are we giving them a target, we’re providing resources behind them to wraparound and support them to help them reach their target,” White said. Additionally, Kaiser collaborates with HealthTeamWorks in southern Colorado to help physician practices make these transformations. White said that when they created the pay-for-value program, practices needed individualized help with things like their EHR or with population management. He would refer the practices to HealthTeamWorks who would provide an on-site quality improvement coach. BJ Dempsey is one of these coaches. Under a three-year grant from the Colorado Health Foundation, she meets with practices twice a month, working on everything from basic skills to more sophisticated strategies. The HealthTeamWorks model is based on the principles of the patient-centered medical home and the seventh aspect is payment reform. “That’s the piece that’s been missing for most of the practices. Most in this area recognize the benefit and the need to provide patient-centered care, but without the payment reform aspect,

Colorado Medicine for July/August 2013

frankly, they just can’t afford it,” said Dempsey. That’s the nice part about the Kaiser Permanente program, Dempsey said. Under pay-for-value, the practices receive enough financial benefit to offset some of their costs so they can start the transformation process. Ideal Family Healthcare in Manitou Springs has received assistance with data gathering and replacing some registry functionalities they were struggling with. “Without Kaiser’s lead we wouldn’t be getting as far as we have,” said Greg Sharp, MD. “I think they have been rather unique in their involvement. I sure would like to see other payers take as active an approach as Kaiser has in their pay-for-value program. I see this cooperation between payer and provider as the future in terms of requiring more incentive change in the insurance marketplace and for providers to demonstrate they’re providing quality care.” Seeing results Since the program’s inception, the hemoglobin A1c screening rate has improved 13.1 percent; blood pressure control in their diabetics has improved 11.7 percent. The number of diabetics who have had an LDL screening has

improved by 8 percent and the number of diabetics whose LDL is at target or below has improved by 14 percent. Diabetics with hemoglobin A1c less than 8, the hardest metric to move, has improved by 1.2 percent. And control of hypertension in the general population has improved by 12.6 percent. “It’s a testament to several things: To the fact that the practices are beginning to understand population management and to the fact that I believe our support services are supporting them in doing that,” White said. “It’s also a testament to the fact that the smaller groups know their patients; they have a strong personal working relationship with them and it’s easier for them on that scale to see progress. We have some groups that are outperforming Denver/Boulder in some of these metrics – not in all metrics or in every group, but some.” “What we like about Kaiser is that we’re moving in the same direction toward becoming a patient-centered medical home,” Hoover said. “We’re figuring out how they can help us provide better care for our patients, keep them out of the hospital, make sure they’re getting in for services they need. Physicians are great about providing one-on-one care. What we’re trying to learn to be good at is how to mange a population of patients.” n

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Features

Physician practice innovation Kate Alfano, CMS contributing writer

AMA partners with RAND to study efficient delivery and payment models in Colorado Colorado physician practice innovations are once again the focus of national attention. The American Medical Association and the RAND Corporation have teamed up for a research project to study models of practice that deliver efficient and effective patient care and high physician professional satisfaction. Thirty physician practices across the nation are participating – five in Colorado – that represent a broad spectrum of specialties and practice settings. The Colorado Medical Society is collaborating on the project and hopes that the results will help physicians across Colorado better cope with changes and lead reform in how care is organized, delivered and paid for in the future. This project falls under the AMA’s fiveyear strategic plan, which aims to ensure that enhancements to health care in the United States are physician-led, advance the physician-patient relationship and ensure that health care costs can be prudently managed. One of the strategic plan’s three core areas of focus is “enhancing physician satisfaction and practice sustainability by shaping delivery and payment models.” The goal of this study is to identify and better understand models of practice that deliver efficient and effective patient care while simultaneously sustaining the physician practice and improving physician professional satisfaction. The study began in December 2012 and will be completed by fall 2013. RAND’s experts collect data from the practices through three methods: a questionnaire 26

for administrative and clinical leaders to examine the staffing, finances and overall structure of the practice; on-site visits for facility tours, to observe staff meetings, and to conduct in-person interviews with administrative leaders, clinicians and staff members; and a clinician experience survey. After collecting and analyzing the data, each practice will receive a detailed practice assessment benchmarked against the other 30 practices as a population providing customized feedback on the practice’s efforts to transition and transform the way they provide and are paid for providing care. Practices will receive their reports in the summer of 2013 and a de-identified public report will be released in early October. One of the Colorado practices is a selfemployed internist group in Parker, which is actively positioning for health care reform by working toward NCQA certification for the patient-centered medical home as well as NCQA recognition for diabetes care and cardiovascular disease prevention. Another of the Colorado practices, a large group providing general surgical care, says their delivery model involves continually evolving their “successful approaches to patient care with successful navigation of increasing financial and regulatory hazards.” A physician with the internist practice, kept anonymous at the AMA’s request, said he/she hopes that by participating in the study, the practice will gain perspective on its progress and understand

which component of practice transformation to pursue next. “When we receive our results it will be interesting to see if we fit the norm or if we’re on one side or the other. That may give us a better sense of where things are headed and what other practitioners are doing. I think if we find that the majority of practices are doing something very different than we are, then we’d look at that and rethink our methods if that were appropriate,” the physician said. Through research partnerships like this one, the AMA provides data, analytics and tools that can be used to improve critical indicators of physician satisfaction and practice sustainability. Additionally, the AMA will promote successful models in the public and private sectors, create tools that enable physicians to adopt proven models that fit with their respective practices, and work with hospitals and health plans to incorporate the findings and tools into their own operational models. “As the nation’s health care system continues to evolve, the AMA is dedicated to helping physicians navigate the environment successfully by ensuring sustainable physician practices that result in good health outcomes for patients and greater professional satisfaction for physicians,” Jay Crosson, MD, group vice president of physician satisfaction and care delivery payment said in a statement. “Because practice sustainability and physician satisfaction are essential to improving the health care system, Colorado Medicine for July/August 2013

Features health outcomes and patient satisfaction, the AMA wants to identify, support and grow the models of care delivery and payment that promote the long-term sustainability of and satisfaction with medical practice and that lead to improvement in the cost and quality of health care in the nation.” n

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Farewell address Jeremy A. Lazarus, MD, President, American Medical Association

Every day is a winding road can now report to you that nothing can completely prepare someone for all of the challenges encountered as the public face of the AMA. Naturally, I had my expectations – and suspicions – of what it would entail.

AMA President Jeremy A. Lazarus, MD, delivers farewell address at annual meeting. Editor's note: Dr. Jeremy Lazarus was just the second Colorado physician and the first in 91 years to serve as president of the American Medical Association. The following is a complete transcript of his June 15, 2013 farewell address delivered to a packed AMA House of Delegates at the start of the AMA annual meeting. Mr. Speaker, members of the Board, delegates, colleagues and guests – and our international friends. I’m honored to speak with you for the last time as president. This is a bittersweet moment. I’ve long been involved in organized medicine – most of it associated with the AMA – and I want you all to know, I have truly loved serving this past year as your president. Of the many posts I’ve held: President of the Colorado Medical Society and the Colorado Psychiatric Society, Speaker of this House of Delegates, I 28

But after 12 months seeing up close the breadth and depth of this amazing organization, I better understand – and appreciate – our role in the minds of the public, physicians, and the political landscape that can so often undermine the best of intentions.

Affordable Care Act Just after my inaugural, the Supreme Court ruled that personal responsibility to obtain health insurance coverage – the so-called individual mandate – is constitutional. It cleared the path to extend health insurance coverage to millions of people – many of whom will become our new patients. At the same time, the Court struck down the Affordable Care Act’s mandatory Medicaid expansion.

At times, I was surprised and occasionally blindsided by the whims of Washington politics and the world’s random savagery. Each time, I proudly witnessed the AMA rally and rise to the occasion.

At the AMA, we believe Medicaid expansion is necessary for needy citizens to get the care they deserve. But for the program to be viable, I believe we all agree, physicians must be adequately reimbursed.

In these 12 non-stop months, I’ve learned that one of the few constants is change – and that you never know what life – or the government – or science – or Mother Nature – will throw at you.

Fortunately, the provision in the ACA that calls for raising Medicaid pay to Medicare levels for primary specialties from 2013 – 2014 will help.

Expecting the unexpected has helped me become a better dancer – because the course of advocating for medicine and promoting the AMA’s agenda has more twists and turns than a tango danced during an earthquake.

That’s why, when proposals surfaced to eliminate this increase at the end of last year, the AMA organized 261 state, national and specialty medical societies in a letter of opposition.

Were it a song, it might be Sheryl Crow’s “Every Day is a Winding Road.”

And guess what – Congress actually listened! Yet another example of why it’s important to proactively confront these problems with a unified voice.

In it, she sings about “swimming in a sea of anarchy,” but it’s important to remember, every day, we are getting a little bit closer to the goal. For me, those first steps were a doozy.

As states began wrestling with Medicaid and Health Insurance Exchanges, the AMA mobilized – working with medical and specialty societies to assure access to care for as many as posColorado Medicine for July/August 2013

Features sible, despite the patchwork of state approaches. But whether state or federally run, exchanges will start operating early next year. And countless physicians – including many in this room – will participate in and benefit from these exchanges. The AMA is working to minimize whatever burdens they might create. For instance, we made inroads in the federal rules to help physicians.

So we went to work on initiatives to remove the stigma still present against those with mental illness and to offer better treatment options for those affected. Shortly after Sandy Hook, we met with administration officials in Washington to discuss a strategy to address gun regulation, mental illness and public education. And though legislation has not passed this year, we remain committed to seeing it happen.

And we continue to work with groups such as the National Association of Insurance Commissioners and the National Conference of Insurance Legislators to cement these hard-fought gains.

We also believe strongly that physicians must be able to have frank discussions with their patients and families about firearm safety issues and risks. Maybe fewer 4-year-olds will accidentally shoot a parent or sibling.

Gun regulation, mental illness and public education Other policy debates raged outside the halls of power.

And we are pleased also that the CDC will again be able to begin epidemiological research on gun violence to better inform the ongoing debate.

A month after my inaugural, in my home state of Colorado, a gunman opened fire in a movie theater, killing 12 and wounding 58 more. In December, a different young man, in a matter of minutes, killed 26 people – 20 of them children – at a Connecticut elementary school.

Sunshine Act The tragedy in Newtown isn’t the only high-profile event that has sparked AMA action. We recently reiterated our ethical position opposing physician involvement in force-feeding hunger strikers.

First there was shock. And then, dozens of physicians, physician organizations and other health care professionals mobilized within days – even hours – to again denounce the plague of gun violence. It also brought to the forefront problems with our mental health system – and our capacity to prevent at least some of these tragic events. And as a psychiatrist myself, I was at the same time all too aware of the potential backlash against mental health patients. Some may paint them all with the same broad brush of potential violence – but we know that the vast amount of violence – whether guns are involved or not – has no relation to mental illness. Colorado Medicine for July/August 2013

That takes me from the search for more information – to the subject of TMI – too much information. In February, my travels took me to a Senate hearing on the Sunshine Act, the new transparency regulations regarding interaction between physicians and representatives from the pharmaceutical, medical device and other industries.

Now for the hard work – to get the word out. CMS starts tracking this information on August 1 – and not everyone’s aware of it. So we’ve launched a Sunshine Act resource page on our website to educate physicians on the requirements, and we’re offering online modules and webinars to explain it in detail. As dermatologists tell us, sunshine might feel good but it's also important to apply some good sunscreen. Physician satisfaction/patient sustainability In another practice issue, the AMA has launched the Integrated Physician Practice Section to help physicians shape policy that enhances physician satisfaction and improves practice sustainability. It’s now crystal-clear to me that the future of medical care depends much on how well physician-led integrated practices work to keep patients healthy, and how well they function for their physician members. In my practice, I've seen thousands of patients one at a time. Now we can leverage what we can do for so many more patients by working more effectively together. That’s what the IPPS is all about. It will address the issues and needs facing physicians in group and integrated practices, and provide a forum for those who have moved into the many new non-traditional types of practice.

This provision will require those companies to report any payments or other “transfers of value” they make to physicians on an annual basis – and to publish that information via a public database.

To you, I say “Welcome to our House of Delegates.”

The AMA has long supported greater transparency between physicians and industry, but as I declared to the Senate directly – we want the law implemented appropriately and physician rights to challenge false or misleading reports protected.

Will Rogers said, “If you want to be successful, it's just this simple. Know what you are doing. Love what you are doing. And believe in what you are doing.”

Legislative successes Our work isn’t just among individual physicians, of course.

Lazarus (cont.) Following that credo is why – in the past year – the AMA earned more than 125 legislative victories at the state level – from insurer transparency to preserving medical liability reforms – by working with state medical societies across the nation. For instance, AMA support and resources, combined with the tireless advocacy efforts of the Kentucky Medical Association, led to legislation to expand access to quality medical care while ensuring physician leadership of health care teams. Georgia enacted a state physician shield act based on AMA model legislation. The AMA was proud to help the Maryland State Medical Society, Nevada State Medical Association and Texas Medical Association successfully push for legislation based in part on the AMA’s model bill on Truth in Advertising. And in a major decision earlier this

week, the U.S. Supreme Court ruled that individual physicians can come together as a group to fight the unfair business practices of large health insurance companies. Sutter v. Oxford Health Plans concludes a dispute that alleged the company systematically bundled, down-coded and delayed payments for 20,000 physicians in its network. The AMA-led brief with the Medical Society of New Jersey noted that health insurers know that arbitrating disputes with individual physicians works to their advantage. They allow contract violations and underpayments to persist and leave physicians helpless to fight them. But thanks to this ruling, thousands of physicians will be allowed to use class arbitration against a health insurer that has underpaid them for more than a decade. This finally gives physicians a weapon to challenge unfair payment practices.

Thursday, June 13 the Supreme Court ruled again and affirmed the AMA position opposing patents on the human genome. To ensure the Supreme Court heard our voices loud and clear, the AMA joined with other health care organizations to file a brief to defend a federal court ruling that invalidated gene patents. This ensures that scientific discovery and medical care based on insights into human DNA will remain freely accessible and widely disseminated, not hidden behind a thicket of exclusivity. And in the interests of a free flow of information, we established the JAMA Network, which provides easier access for physicians to vital, breaking medical news. For the next few months, access will be free with the new JAMA app – a tremendous service for all physicians in the U.S. and around the world. Continued progress Then there were issues that can be neither sparked nor solved with a single gesture or action – but that require ongoing attention. We made progress improving the health insurance billing and payment system. At the AMA, we didn’t wait for Congress to act on this issue on behalf of consumers and physicians. Our efforts to tame the chaotic health insurance billing and payment system has cut in half the number of incorrectly paid medical claims, according to our fifth annual National Health Insurer Report Card. I’m also happy to report significant progress in our long campaign to convince Congress to eliminate the Sustainable Growth Rate (SGR) physician payment formula in Medicare. Thanks in part to the relentless education efforts of the AMA and those of more than 100 physician groups and

Colorado Medicine for July/August 2013

Features others, we see a light at the end of this tunnel. The House Energy and Commerce Committee recently released a draft of legislation to repeal the SGR and replace it with a fair and stable physician payment system, building on a framework jointly developed with the Ways and Means Committee. The Senate Finance Committee is also making progress toward developing legislation to reach this goal. In our discussions with each of these panels, we are hearing the messages delivered by medicine echoed back to us: That one size does not fit all; that in addition to a viable fee-for-service payment option, physicians in their diverse practice settings, specialties and communities must be free to choose new payment and delivery models that work best for them and their patients. Finally, we might have the right prescription to put this issue to rest.

Finally, I’m gratified for the rave reviews for our initiative to improve health outcomes. Our initial targets are cardiovascular disease and Type 2 diabetes and to improve health outcomes for people with these conditions. As physicians, we know the devastation these and other chronic diseases impose on our patients and the system. This will allow all of us to join this effort. Toward this end, the AMA is also supporting the Medicare Diabetes Prevention Act, which provides coverage for the National Diabetes Prevention Program as a Medicare benefit. It’s estimated an expansion of community-based diabetes prevention programs like this one would save $191 billion over 10 years. So call your member of Congress and ask them to cosponsor S. 452 or H.R. 962.

Madara will provide a more detailed update on our plan. But these are big issues – and big stakes. On the table is a better health care system, better outcomes for our patients, better training and education for tomorrow’s physicians, and a brighter practice picture for physicians today. And throughout, our compass for our Strategic Plan is the AMA Code of Medical Ethics. It tells us that we must recognize responsibility to patients first and foremost, as well as to society, to other health professionals and to ourselves. Compassion and bravery To witness ethics in action, think back on the response to a deadly turn in the winding road just two months ago, with two horrific incidents involving explosions. Two bomb blasts detonated at the Bos-

I’ve just scratched the surface, and Dr. Strategic plan Fixing the SGR is of course a big issue. I’ll turn my attention now to the big picture. I would like to note the positive reaction I’ve seen to the AMA’s new strategic plan. Like the enthusiastic response to our $11 million grant-funded initiative to accelerate change in medical education for the 21st century. Last night, it was my honor to announce the 11 grant recipients. I look forward to their important work to bring needed change to how we educate and train future physicians. We’re also making progress in our work in our strategic focus area aimed at enhancing professional satisfaction and practice sustainability. Our work will enable physicians to make more informed choices about their practice environment.

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Lazarus (cont.) ton Marathon finish line and still another in a fertilizer plant in the town of West, Texas. Personally, the Boston tragedy struck especially close to my heart. I’ve run that race many times. I know exactly what it feels like to cross the finish line, exhausted and yet exhilarated. I can tell you that as a psychiatrist and runner, this is one of those events that challenges a doctor’s best training. In the Washington Post, columnist Mike Wise, who also runs marathons – described why this tragedy captured hearts and headlines around the world. “Of all places to ruin and end lives,” he wrote, “where the runners work so hard to embrace a pure and noble goal. Of all places to attack the majesty of the human spirit: At the finish line.” So many enter this race to overcome a personal loss or reach a personal goal as an act of therapy. To attack it, Wise wrote, “is so wrong and personally destructive, it’s almost unspeakable.” For runners throughout the country – as well as those who support their loved one’s ambitious goals – this was an attack on our spirit as much as upon the fragility of human flesh. Those who came to the finish line exhilarated to complete this grueling race fell from the highest high to the lowest low. Our hearts sank with them. Yet at the same time, many brave people exemplified who we are as Americans. I watched this violent violation on the news – and then, on a rainy, gloomy night, flew to Boston to do a television interview to offer perspective on this nightmare.

it’s an institution embroidered into the fabric of the city.

And I have rarely been more proud to be a physician.

And it reminded me, too, of an event almost 40 years ago when I flew to Boston to take my oral exams in psychiatry.

In the New Yorker, George Packer noted that when we look around at this country, we see many institutions that don’t work. In Boston, the institutions of civilization met our highest standards of courage, competence and humanity.

It rained that night, too. And when I arrived at my hotel, a helicopter circled the block, shining a spotlight on the crowd in front of my destination, I never found out who or what it sought. I was already anxious about my tests, and this sure didn’t help. It tells me that stresses and traumas that happen to us are often relived and stay with us a long time, and we may never know in advance what might trigger it. We know what the immediate reaction is to an explosion, however – and that’s paralyzing shock. But in Boston, instead of being frozen in horror, bystanders fashioned tourniquets from their own clothing and carried casualties to safe havens for medical attention. One pediatric resident who ran the race, without hesitation jumped over the barricades and evaded the police cordon to attend to the injured. A surgeon who had finished the race an hour before the bombings was at home and was called in to the hospital. He didn't hesitate for an instant. Volunteers turned a medical tent near the finish line into a triage station, and a network of nearby hospitals was ready in minutes, expertly executing disaster plans to quickly treat the 180 people injured in the blasts.

It was also the same night the second suspect was chased down and cornered.

Many said they were “just doing their jobs.” I don’t see it that simply. These were images that are only seen during the worst of war, not on the streets of a major city.

Soon after the tragedy, I spoke to the Massachusetts Medical Society. I was reminded how the Boston Marathon is not just a competition among runners,

This level of bravery and presence of mind, saved many lives. It reminded me that as Americans – this is who we are as a people.

We saw it in the fertilizer factory explosion in West, Texas. And we saw that same human compassion again in the quick, effective response for the injured in Moore, Okla. after a tornado last month. For the victims – and for physicians – the marathon – West, Texas – Oklahoma, if the unexpected happens we want to be ready. And as you saw in our video tribute earlier – they were. An incredible journey This year’s Boston marathon reminded me of another thing – that as AMA president, I may have spent the year negotiating these twists and turns – amid unexpected events and the milestones of our advocacy achievements – but I wasn’t alone either. While any marathon is an individual effort – I always knew my journey was part of many support teams. Through the dedication of AMA staff – of the members of state and specialty societies I met in my travels – to my friends and colleagues in this House of Delegates – and the insights and inspiration I received from everyone in my travels – and especially the support from my wife Debbie – each one of you was right alongside me. The degree to which successes are possible during an AMA presidency are as much the result of your efforts as mine. One of the most uplifting moments of this past year was giving the commencement address at my alma mater, the University of Illinois-Chicago medical school, just across the Loop from Colorado Medicine for July/August 2013

Features where we’re gathered today. The faces of these bright young graduates and the many languages they spoke – told me we're well on the way to enhancing diversity among physicians and being better equipped to tackle disparities. And I saw JAMA Executive Editor Dr. Phil Fontanerosa hood his own son, who graduated with an MD/PhD. I also had the honor to hood my own son Ethan and my daughter-in-law Melissa. These are moments when one generation is blessed by the next. As parents, we must have done something right.

restoring a hopeful future to their lives. You are making a difference and I'm very proud of you. Just like all of you sitting here – at every age, at every stage of career – who work every day to improve the health and lives of your patients. The passing of years gives us more than grey or thinning hair. It also brings clinical advances, new technologies like electronic health records and increasingly complex administrative requirements.

I’m also happy to tell you, at this meeting Ethan debuts as a new delegate from the American Society of Bariatric Physicians. Way to go, Ethan – and welcome!

For those who pursue a career in medicine, it can be a lot to juggle and maybe more than was bargained for. But for all of the challenges and frustrations – medicine above all is a profound calling – one that helps people when they need help the most.

Your determination and talent is helping patients get off medications for diabetes, hypertension and cholesterol and

That, dear friends and colleagues, is something worthy of pride and optimism at any age, or any stage – in one’s

career. And I can assure you that we all have even something more to offer. For me, these past 12 months through airports, countries and Capitol Hill, the winding road of medicine has been an incredible journey. Though sometimes lonesome and sometimes uncharted, it presents some pretty spectacular views along the way. And for that, I will always be very grateful. Now it’s up to you to keep on running. Our profession is worth it. This country needs us to be our very best, and together, this generation and all that follow, will cross every finish line together! Thank you. n

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Colorado Medicine for July/August 2013

Features

2013 Annual Meeting of the AMA House of Delegates Report Colorado leaders elected to national office, set ICD-10 policy Delegates and leaders representing the Colorado Medical Society traveled to Chicago June 15-19 to attend the annual meeting of the American Medical Association House of Delegates. Coloradans experienced great success in elections and policymaking, particularly among residents, students and young physicians. ICD-10 safety net for physicians The four Colorado delegates to the AMA – M. Ray Painter Jr., MD, and A. Lee Morgan, MD, delegation co-chairs; Lynn Parry, MD; and Brigitta Robinson, MD; along with the four alternate delegates – David Downs, MD; Jan Kief, MD; Mark Laitos, MD; and Tamaan Osbourne-Roberts, MD – worked hard to carry an important resolution to passage through the House of Delegates. It involved the transition to ICD-10 code sets to report medical diagnoses, which is set to take effect Oct. 1, 2014. The AMA’s current policy is to delay or stop the new diagnosis system.

claim payments for diagnosis codes that lack ICD-10/11 specificity, including through Recovery Auditors Contractors, or RACs. As the head of a company that helps physicians correctly code and bill, Painter understands the critical nature of this issue. He said that physicians would still need to prepare for ICD-10 but wouldn’t be penalized in payment for not being completely accurate in their diagnosis and would receive crucial information on correct ICD-10 codes. The new code set adds thousands of additional codes and most do not have a direct correlate to an ICD-9 code. “We had to work to make sure everyone understood the resolution, but in actuality it was passed unanimously. For a House divided by many philosophies, we all came together on this issue. Some of the AMA leadership said this may have been the most important policy passed at the meeting,” Painter said.

Colorado successfully added a clause to Resolution 236, “Action to Eliminate Implementation of ICD-10,” that would enact an “implementation period” should the AMA fail to stop or delay ICD-10. The clause would direct the AMA board to seek federal legislation to enact a two-year period during which payers would not be able to deny payment based on the specificity of ICD-10 or ICD-11 diagnosis.

New leaders Carolynn Francavilla, MD, who is finishing her second year of residency with the University of Colorado Family Medicine Residency at Rose, was elected to the alternate delegate position of the AMA Resident and Fellow Section (AMA-RFS) Governing Council. RFS comprises more than 38,000 resident and fellow members of the AMA and the seven-member governing council is the leadership of RFS.

Payers would be required to provide feedback for an incorrect diagnosis. Additionally, no payer would be able to re-

In her role as alternate delegate, Francavilla will work with the RFS delegate to advocate for RFS resolutions in the

AMA House of Delegates and organize the delegation’s positions on all of the items of business at the House of Delegates. Francavilla says she recognizes the unique perspective residents and fellows bring to the AMA on patient care and the health care system and looks forward to working to make residency a better experience for her colleagues. Steve Sherick, MD, is the current chair of the AMA Young Physicians Section (YPS). In this position, he serves as the spokesman for young physicians nationwide and is charged with directing the policy creation, national meetings, intra-AMA politics and outreach operations for YPS. Through his term ending in June 2014, he hopes to create at least 10 resolutions with the support of his section that will “help push the envelope of AMA policy,” he said. Paul Pukurdpol, a third-year medical student from the University of Colorado School of Medicine, was elected to the position of vice speaker of the AMA Medical Student Section (AMA-MSS) Governing Council. The eight-member council is responsible for appointing the remainder of the MSS leadership, carrying out policies and actions items adopted by the MSS Assembly, and directing the MSS agenda and strategy. In his role as vice speaker, Purkurdpol will work in collaboration with the speaker to develop programming and preside over two national meetings of the assembly, oversee and enforce campaign rules, and organize and lead orientation for new delegates and alternate delegates at the assembly. Colorado Medicine for July/August 2013

Features A Colorado native, Purkurdpol attended the University of Colorado for his BA, MPH and now MD and is passionate about developing the next generation of health care leaders to confront the challenges of a rapidly changing health system. “The MSS is the largest gathering of future health care leaders in the nation and I am proud to lead our annual meetings,” he said. Bianca Pullen, a medical student finishing her first year at the University of Colorado School of Medicine, was elected to the position of region chair for Region 1 of the AMA MSS. She will be responsible for fostering communication among individual school sections and state sections, as well as helping a host school produce a successful region meeting. “Working in this role presents me with the challenge of engaging schools that are typically absent from MSS activities,” Pullen said. “My passion for serving people extends beyond my patients. I would like to know how we can better serve all sections in Region 1. The AMA MSS provides many students with leadership training and community service involvement.” Dean Drizin was selected to represent medical

students nationwide on the Council on Medical Service. This council studies and evaluates the social and economic aspects of medical care and suggests means for the timely development of services in a changing socioeconomic environment. Drizin recently finished his third year at the University of Colorado School of Medicine where he served as the CUSOM chapter president of the Colorado Medical Society and the AMA, and represented medical students from the western states in the AMA House of Delegates. He is pursuing an MD/ MBA dual degree from CUSOM and the Wharton School at the University of Pennsylvania. “My involvement in the Colorado Medical Society and the American Medical Association has been a highlight of my medical education,” Drizin said. “I particularly value the relationships I have developed with physicians from across Colorado, whom I look up to as role models, mentors and friends.” Lazarus completes year as president The 2013 meeting marked the comple-

tion of service for AMA President Jeremy Lazarus, MD, of Denver. He now becomes immediate past president and will continue to serve on the AMA Board of Trustees. In his final presidential address before the House of Delegates, he reflected on events including the Supreme Court’s ruling on the Affordable Care Act, the gun tragedies in Colorado and Connecticut, and the bombings at the Boston Marathon. He emphasized that physicians rallied following these events to ensure as many patients as possible had access to care, and to address gun violence and mental illness. Physicians continually prove their strength and commitment in how they care for patients, he said. He referred to the AMA’s legislative victories and progress in long-term goals such as addressing health insurer practices and repealing Medicare’s sustainable growth rate formula and predicted a bright future for the AMA. “On the table is a better health care system, better outcomes for our patients, better training and education for tomorrow’s physicians, and a brighter practice picture for physicians today,” Lazarus said. n

Colorado ICD-10 Coalition pledges to help physicians prepare for coding switch The Colorado ICD-10 Coalition, a statewide organization of interested educators, consultants, physician and practice representatives, has pledged to help Colorado physicians prepare their offices for the scheduled implementation of the ICD-10 diagnosis codes by the Oct. 1, 2014 deadline. Though the AMA is actively lobbying to stop or delay the implementation of ICD-10, physicians and their staffs would be wise to continue their preparations so they don’t feel overwhelmed should the deadline stand, said Marilyn Rissmiller, CMS senior director of the Division of Health Care Financing. The coalition’s resources include a series of webinars, educational events, worksheets, task lists and apps that are available on the group’s website, www.cms.org/icd-10. The two most recent webinars, Project Planning Phase 1 and 2, provide viewers with information on how to jumpstart this transition. To learn more and to access resources to help you navigate the ICD-10 maze, go to www.cms.org/icd-10.

Colorado Medicine for July/August 2013

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2013 CMS Annual Meeting September 20 through 22 Vail Marriott Good friends, good food and good music: CMS bringing best of Mardi Gras to the mountains for annual meeting The 143rd Colorado Medical Society Annual Meeting and convening of the CMS House of Delegates (HOD) takes place Sept. 20-22 at the Vail Marriott Mountain Resort. The weekend event will be injected with a touch of Cajun spice, humor and joie de vivre. â&#x20AC;&#x153;Mardi Gras in the Mountainsâ&#x20AC;? will feature fun, friends and interactive programming on issues important to physicians and patients. The House of Delegates will conduct business inte-

gral to the continuing success of CMS, electing a new slate of officers and establishing CMS policies. New this year, the main events of the annual meeting will span two days instead of three. Schedule streamlining mostly affects the business portions of the meeting. All proposed resolutions for the House of Delegates must be submitted by Aug. 11, which will allow the reference committee to hold two meetings and submit their report to be posted

online prior to the annual meeting. The report will be distributed to delegates upon arrival Friday evening or Saturday morning. Registration for the annual meeting opens Friday at 3 p.m. All annual meeting registrants and their families are encouraged to attend the Mardi Grasthemed exhibitor welcome reception Friday evening to socialize and enjoy giveaway drawings, live music and a free photo booth for the whole family.

Colorado Medicine for July/August 2013

Inside CMS The HOD convenes Saturday at 8:30 a.m. Caucus meetings will be held between 7 and 8:30 a.m. During the morning session, delegates will hear speeches from the officer candidates and consider items on the consent calendar. Saturday’s AMA-COMPAC luncheon features top elected officials who will participate in an interactive discussion on health care, the state-federal working relationship, and other issues important to physicians. During Saturday afternoon’s interactive programming, attendees will explore the topics of opioid abuse and maintenance of licensure, as well as hear a presentation from CMS-member medical students. That evening, attendees have the opportunity to meet the candidates for CMS president at a reception before heading to the presidential gala to celebrate the installation of 2013-2014 CMS President John Bender, MD, of Fort Collins.

Our’s

NITROGEN

We hope to see you in Vail this September. Register by completing the forms on pages 39 and 40 or by visiting www.cms. org. Reserve your room by calling (877) 622-3140 or online at https://resweb. passkey.com/go/comedical.

Their’s

LN177201

Throughout the annual meeting representatives from various industries will be on hand to speak with attendees about the latest medical products and services. Don’t forget to visit with the 2013 sponsors and exhibitors to thank them for their involvement, which keeps attendee event fees low. The exhibitor area will be located outside of the meeting rooms.

Which one are you using?

The HOD reconvenes Sunday morning to elect officers and all attendees can participate in additional programming such as COPIC educational sessions and lectures on the liability climate, Medicaid expansion, the All Payer Claims Database, Choosing Wisely, ICD-10 and the 2014 legislative session.

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Colorado Medicine for July/August 2013

Inside CMS

2013 CMS Annual Meeting September 20 through 22 Vail Marriott CMS thanks the following sponsors and exhibitors for their support of this yearâ&#x20AC;&#x2122;s annual meeting Presenting Level Sponsor:

COPIC

Gold Level Sponsors:

UnitedHealthcare Wells Fargo Silver Level Sponsors:

CIGNA Healthcare Colorado Drug card

J. Bryan Sexton, PhD, MA Johns Hopkins University School of Medicine

Robert M. Wachter, MD University of California, San Francisco

Exhibitors: American Medical Association athenahealth Center for Personalized Education for Physicians Colorado Physician Health Program Doctors Office Systems Harmony Foundation

Exhibitors: Life Care Centers of America Medical Telecommunications PCLS Project C.U.R.E. Purdue Pharmaceuticals Solve IT TransFirst

2013 CHA Patient Safety Leadership Congress October 22, 2013 Hyatt Regency Denver at Colorado Convention Center

Thank you to our 2013 event sponsors

Eric A. Coleman, MD, MPH University of Colorado Anschutz Medical Campus

With additional support from the Colorado Medical Society Colorado Medicine for July/August 2013

Inside CMS

Accommodations Reservation Form Annual Meeting of the Colorado Medical Society/Connection Vail Marriott Mountain Resort • September 20-22, 2013

Reserve your room online at https://resweb.passkey.com/go/comedical, by phone at 877-622-3140 or through this form by remitting by fax to 970-479-6956. This form can be used for one room only. ROOM PREFERENCE Please indicate your first (1), second (2), third (3) and fourth (4) choices.

TYPE Standard Room Studio King Room Deluxe King Room Jr. Timberline Suite

RATE $149 $179 $179 $239

OCCUPANCY MAXIMUM 4 2 4 4

CHOICE

q q q q

The above rates do not include 9.8% tax. Check-in is 4pm and check-out is 11am. Rollaways are not available in Standard and Deluxe King rooms. No pets allowed. NOTE: Hotel reservations must be received by Wednesday, Sept. 4, 2013, to be eligible for the group rate. This is a non-smoking facility.

REGISTRATION INFORMATION Arrival Date/Departure Date ________________________________________________________ Name(s) ______________________________________________________________________ Address ______________________________________________________________________ City_____________________________ State_______ ZIP___________ Phone _______________ Special Needs/Requests ___________________________________________________________ Email Address __________________________________________________________________ PAYMENT Card Type ___________________ Card #_____________________________ Expiration ________ Name of Cardholder ______________________________________________________________ I authorize Vail Marriott to charge my credit card for the deposit for accommodations listed above.

_____________________________________________________ Signature

______________________ Date

DEPOSIT AND CANCELLATION INFORMATION A credit card is required at the time of booking. One night’s nonrefundable room rate plus tax will be billed on Sept. 4, 2013. After this date, cancellations or no-shows will forfeit one night’s payment. Any early departures will be billed for one night’s room rate plus tax. A confirmation is sent at the time of booking. Colorado Medicine for July/August 2013

Inside CMS

Annual Meeting Registration Annual Meeting of the Colorado Medical Society/Connection Vail Marriott Mountain Resort • September 20-22, 2013

Name (please print) _____________________________________________________________________________ Component Society ___________________________________________________________________________ Name of Spouse/Guest(s) ___________________________________________ CMS Connection Member q Yes q No Registration deadline is September 5, 2013. Registrations accepted on a first-come, first-served basis (may be limited for some

programs). For purposes of registration, Connection members and staff of county medical societies are considered members. You must indicate the number of attendees for each function so that we may be cost efficient with food/beverage orders.

Friday, September 20

member

spouse/guest

6:00 pm

Exhibitor Reception

Saturday, September 21 (Complimentary for member & one guest only)

CHARGES FOR ADDITIONAL GUESTS

6:45 am 12:15 pm 5:30 pm 6:00 pm

Breakfast Buffett AMA/COMPAC Lunch Candidate Reception Inaugural Gala Meat Dinner Vegetarian Dinner Vegan Dinner Gluten Free Dinner

Sunday, September 22 6:45 pm

Breakfast Buffett

q q q

#_______ @ $35/each_________ #_______ @ $35/each_________

q q q q

#_______ @ $105/each_________ #_______ @ $105/each_________ #_______ @ $105/each_________ #_______ @ $105/each_________

member

spouse/guest

TOTAL amount enclosed for non-members and additional guests.

#_______ @ $35/each_________

Please make check payable to: Colorado Medical Society and mail this form, or charge ❑ Visa ❑ Mastercard ❑ Am. Express #______________________________________ exp. date____________ Signature _____________________________________________________________________________________ Please mail this form to CMS at PO Box 17550, Denver, CO 80217-0550, fax to CMS at 720-859-7509 or scan and email to Dianna_Mellot-Yost@cms.org

Hotel reservation deadline is September 4, 2013. After that date reservations are on a space available basis.

Colorado Medicine for July/August 2013

Inside CMS

Reflections Reflective writing is now a regular portion of the CU School of Medicine curriculum, beginning in the first semester. All medical students participate by writing essays or poems that reflect what they have seen, heard and felt. This column is selected and edited by Henry N. Claman, MD and Steven R. Lowenstein, MD, MPH, from the new Medical Humanities Program

C. Kiersten Pollard

C. Kiersten Pollard is a visual artist and MIT-trained neuroscientist who is currently in her fourth year of medical school. She plans to combine her loves of delicate, tiny surgery, neuroscience, exciting emergency care, long-term patient relationships (and math and lasers!!!) as an ophthalmologist.

Ms. C The first thing I noticed about Ms. C was her chemo cap. Lots of women in the Gynecological Oncology clinic wear scarves or caps or hats or wigs once their scalps are abandoned by hair. Whether intended or not, a chemo cap ends up telling you a lot about the person underneath it, more than a hairstyle ever could. Ms. C’s looked like it was a part of her. It was a simple black cap with a bright red flower sewn on one side. Yet somehow on her head, it seemed like the ringed halos in medieval paintings. I knew she was a grandmother from the softness of her smile, and when I shook her hand a feeling of ease and peace went through my body, easing the stress

Have an idea you want to share? Do you like something CMS is doing? Are we heading on the right or wrong track with our strategic plan?

E-mail: Letters to the editor dean_holzkamp@cms.org

I didn't realize I carried. We had come in our white coats to tell her and her daughter that despite removing her uterus, ovaries, most of her bladder, fallopian tubes and part of her colon, and undergoing rounds of radiation and chemo, her cancer had recurred. She bowed her head slowly, like a samurai acknowledging an opponent, revealing more of the red fiery flower on her chemo cap. As her head came up and her eyes met mine, I felt like a planet watching another celestial body’s arc across my horizon, separated by the cold vacuum of space across which sound cannot travel. What felt like an eternity of silence passed between us and then, “what’s next?” is all she said with a smile. I realized her daughter was crying, staring at the knitting she’d brought to pass the time in the waiting room. The resident I was following began explaining that the options were to either do nothing, or to perform a pelvic exteneration to remove the parts of the pelvic floor harbouring malignant cells. He explained that this would mean an 8- to 12-hour surgery and adding an ostomy bag to the urostomy bag hanging on Ms. C’s belly and several weeks of recovery in the hospital. Ms. C’s daughter was clutching her knitting needles as though they were a tether to a previous cancer-free time, but Ms. C’s gaze never wavered, and she never cried. She quietly asked if she could take a few days to decide and if the surgery could happen after she got to spend Christmas with her grandchildren. I started in place as I felt my chest tighten, and asked if I could print out information about the surgery for her. I was relieved when she said yes and I could leave the room. I had seen similar situations all week in this clinic, and each time the talk of surgery and removing the cancer always made me feel confident, always made me feel like we were making a dent in the onslaught of cancer – maybe even curing in some cases. I had seen patients return to the clinic after extensive surgeries to receive good news, and I had seen the care and diligence with which the surgeons removed suspicious tissue. I never doubted their skills, and I never doubted the plan. This time though, as I walked back to the Colorado Medicine for July/August 2013

Inside CMS room with a packet explaining the process of pelvic exteneration, I felt a rock in my stomach instead of hope.

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Ms. C and her daughter took the information and thanked us for seeing them, shaking my residentâ&#x20AC;&#x2122;s hand and allowing him to leave the room to answer a page. I remained to shake their hands, and as I touched Ms. Câ&#x20AC;&#x2122;s hand for the second time, I felt the rock in my gut explode like a mass releasing millions of ravenous malignant cells. There were no sensible thoughts or words in my brain â&#x20AC;&#x201C; just the solid and undoubtable sense that this kind, fiery woman was going to die of complications if she chose this surgery. It knocked my breath out and I could only nod as they left the room, unsure if I should say anything. I told my resident about my feeling. He spared me a glance and a small, sad smile as he clipped his pager back into his belt, hung up the phone and simultaneously began scanning the next patient's chart as he waited for a review article to print. I wanted him to tell me everything would be okay, the way you tell a small child that there is nothing under the bed. But he didn't. Instead he handed me the article he thought would be useful for me to review, and all I could do was read. n

Colorado Medicine for July/August 2013

Inside CMS

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

COPIC’s medical resident program An inside perspective to help physicians maximize their knowledge to minimize risk As health care evolves so does the need for arming the next generation of physicians with insight to understand the challenges they will face. The COPIC Resident Rotation in Patient Safety and Medical Liability Program was designed to complement physicians’ medical school education as they are transitioning into clinical settings – an important time to recognize how medical liability issues impact the practice of medicine. Since 2004, COPIC has partnered with Colorado residency programs to offer a week-long rotation as a first-hand experience that draws upon the expertise of our staff. Each year, COPIC’s program hosts more than 170 participants and focuses on the following key areas: • An inside look at medical incidents, medical errors, medical liability claims and the world of medicallegal practice. • Patient safety initiatives – What they are, what are the opportunities for practice improvement and systems, and what are the barriers to implementation? • An understanding of the difference in the epidemiology of medical practice by specialty, and the epidemiology of medical errors and medical liability claims within different specialties. • The value of communication, early reporting and patient relationships in reducing claims and improving patient outcomes. The program also offers the following activities: • Group discussions with COPIC departments including Patient Safety and Risk Management, Claims, Legal, and Underwriting as well as time with members of our Senior Management team. • Chart reviews – Using a variety of specialtyspecific closed claim files, residents are exposed to important teaching points, the aspects of expert testimony and the process of analyzing a case. • Claims Department Round Table – Residents sitin as cases are discussed in an open forum that covers areas such as standard of care, defensibility, documentation and the overall process of managing a claim.

• Claims Committee – Residents are able to observe how this committee, a majority of which are practicing physicians, reviews cases and evaluates the quality of care through discussions that involve claims consultants and attorneys. • Half-day to full-day attendance at selected local venues where medical liability trials are taking place (when possible). • Video and online courses that cover topics such as medical errors, disclosure, documentation, handoffs and patient safety. The main purpose of residents participating in a rotation at COPIC is to provide them with real-world knowledge about all of the factors which can lead up to a claim or lawsuit as well as the factors which determine the defensibility of a claim or lawsuit and potential outcomes. We believe this gives residents a better idea of how a medical liability company operates and how they, as physicians, can minimize their risks and improve patient safety. And it demonstrates how COPIC is committed to being a trusted partner and resource for health care professionals, from the beginning of their careers through their retirement. So what do participants think of the program? Here’s what a few had to say after recently completing it: • “Very important, not only in the current culture, but also to provide better documentation and overall medical care.” • “[What I liked most was] having direct access to real cases to learn from as well as open, knowledgeable experts in this field.” • “This is an amazing experience for residents. No discussion, lecture or presentation given during residency can replicate going over real cases with real [claims] adjusters and real lawyers.” n

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Colorado Medicine for July/August 2013

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Colorado Medicine for July/August 2013

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Colorado Medicine for July/August 2013

Departments

In Memorium CMS remembers board member, family medicine leader Robert Brockmann, MD Robert Brockmann, MD, MS, FAAFP, a leader in organized medicine, passed away on May 10, 2013, from cardiac arrest. He was 58. Brockmann had served as a member of the Colorado Medical Society Board of Directors since 2008 and on the CMS Council on Legislation since 2005. He was also a past member of the CMS Peer Review Subcommittee.

Brockmann, MD, Student and Resident Scholarship Memorial Fund to benefit medical students and family medicine residents. Please send checks to the Colorado Academy of Family Physicians Foundation, 2224 S. Fraser St., Unit 1, Aurora, CO 80014, payable to “CAFP Foundation” and write “Bob Brock-

mann, MD, fund” in the memo line. He is survived by his mother, Lillian; brother, William; sister-in-law, Lorraine; nieces, Lindsey and Katie; and nephew, Charles. He was preceded in death by his father, Leonard, and sisters, Susan and Barbara Anne. n

“Bob was a tireless advocate for his profession and his specialty,” said CMS President Jan Kief, MD. “He worked to make health care better for his patients and peers through his numerous leadership roles and by serving as a mentor to many young physicians, residents and medical students. His enthusiastic participation in CMS will be greatly missed.” He was a board member and past president of the Arapahoe-Douglas-Elbert Medical Society (ADEMS), a board member for the Society of Hospital Medicine, and a board member and current president of the Colorado Academy of Family Physicians (CAFP). Additionally, Brockmann was a board member for HealthTeamWorks, a nonprofit collaborative working to redesign health care delivery. “We are sad at the loss of a great doctor who triumphed the cause of outstanding patient care through his work as a hospitalist and his many other hats,” says Marjie Harbrecht, MD, HealthTeamWorks CEO. Brockmann attended the University of Colorado School of Medicine and specialized in family medicine. Those wishing to honor his memory can make a charitable donation to the Bob Colorado Medicine for July/August 2013

Robert Brockmann, MD, MS, FAAFP. 47

Departments

medical news Michael Volz, MD, candidate for CMS President-elect

Michael Volz, MD I am running for President-elect of the Colorado Medical Society and am asking for your vote during our Annual Meeting in September. This decision was made several months ago after having served medicine in many capacities over 30+ years and in consideration that this position is demanding in representing the physicians of Colorado in arguably the most important physician organization in Colorado. Board certified in Allergy/Immunology and a native of Wisconsin, I eventu-

720-858-6306 or email tim_yanetta@cms.org 48

ally settled in Colorado because of its beauty and training available. Since beginning my career in medicine 32 years ago, I have seen many faces of medicine and in different venues. During my four years at the Medical College of Wisconsin, the school’s administration selected me as the medical student representative to the Association of American Medical Colleges and I also served as an AMA student representative. These positions led to many discussions of topics important to medicine with medical students and legislators in Wisconsin and Washington, D.C. The next step in my training was in Internal Medicine at the University of Miami, which I completed in 1988. Although this time focused on training, I was elected by my 52 peers to serve as one of two Internal Medicine training representatives to the Department of Medicine to voice concerns of residents. These efforts led to improved relationships with the administration and improvements of working conditions for resident physicians. Sub-specialty training followed in Allergy/Immunology (A/I). I was drawn to Colorado as a great place to live and trained at the National Jewish Center for Immunology and Respiratory Disorders in Denver from 1988 – 1992. I joined a Denver A/I practice in 1992 and soon after developed an outreach site in Colby, Kan. for this practice. Around this time I joined CMS and became a CMS delegate. After a few short years, as my interest in health care issues increased, I joined the Clear Creek Valley Medical Society Board of Trustees. In 2002 I launched my solo-based practice with two offices in Denver and travel to Colby twice per month.

In addition to practicing full-time, I have served medicine in many positions during the past 20 years. Some of my roles have included serving on the American Lung Association of Colorado Board of Directors (2000-2005); ALAC summer asthma camp Medical Director; Colorado Allergy and Asthma Society Secretary/Treasurer (2006-2008), President (2008-2010), and as an Executive Committee member; many positions at CCVMS including President; charter member of the CMS Committee On Practice Environment and several other CMS committees including the Executive Committee, Finance Committee, a few ad hoc committees, the CEO Search Committee, and most recently chair of the Constitution and Bylaws Committee. I currently serve on the CMS Board of Directors. Although these positions occasionally take me away from my primary interest and source of fulfillment professionally – practicing medicine – these experiences have been exciting, interesting and have given me a perspective beyond direct patient care. As I spend more time in these activities I have become more aware of the needs and deficiencies in medicine and gained an awareness of where I can contribute. I have witnessed how CMS has benefitted the practice of medicine and see more opportunities to build upon the successes of CMS and its excellent and committed leaders. Medicine’s many challenges change with time and demand attention by CMS and its experienced leaders. I believe I have the necessary qualities to serve as your next President-Elect and ask for your thoughtful support this September. n

Colorado Medicine for July/August 2013

Departments

medical news Tamaan Osbourne-Roberts, MD, candidate for CMS President-elect "Rough waters are truer tests of leadership. In calm water every ship has a good captain." – Swedish Proverb In my travels throughout the state, I am often asked whether the rapid pace of change in Colorado’s health care system represents a liability or an asset. My answer is that it represents a wave, coming to wash over physicians and patients. But whether that wave will be a rising tide that raises all ships or a tidal wave that dashes all indiscriminately against the rocks will depend largely on the intervention of our profession, and the captain piloting our profession’s vessel. I ask for your vote to become the next president of the Colorado Medical Society precisely because I believe the strength, decisiveness, compassion and respect for diverse opinions fostered in me by my many life experiences will keep my hand steady at the wheel. I believe my greatest strength as your potential president is my substantial experience in medical policy. As a board member of the Colorado Medical Society, the Denver Medical Society and the Colorado Academy of Family Physicians, I have long worked to shape the nature of health care in our state. Most recently, as chair of CMS’ Membership, Unity and Relevance Task Force, I help to explore and envision how CMS might continue to serve all physicians in the state of Colorado, regardless of practice setting. As a member of Colorado’s delegation to the AMA, I work to bring ideas on how to improve health care from other states back to Colorado, as well as to spread the remarkable things accomplished here in Colorado to other places throughout the country. And in multiple meetings with legislators, bouts of testimony at the statehouse, and meetings of the CMS Council on LegisColorado Medicine for July/August 2013

lation, I fight to ensure that legal protections remain intact that make Colorado the best place in the country to practice medicine. Perhaps equally, my life experiences have prepared me well to captain the ship. With a father in the Air Force and a mother who was a teacher, I’d already learned much about leadership and service before my family settled here in Colorado when I was 10 years old. Growing up on bases as a “military brat” and child of two Caribbean immigrants instilled in me an appreciation for many differing points of view, and the ability to navigate diverse opinions to find an answer that works for all. These lessons serve me well in my clinical life; as a broad-scope family physician, the needs of my practice are exceptionally diverse. I treat privately insured, publically insured and uninsured patients; I deliver care in both inpatient and outpatient settings; I work with private practice and employed colleagues; and I refer to primary care, specialist, surgical and proceduralist physicians. My chosen career takes me to many places throughout the state, from urban centers like Fort Collins and Commerce City, to suburban municipalities like Brighton and Longmont, to rural communities like Fort Lupton, Frederick and Estes Park. In all of these different settings, and with all of these different patients and insurance constraints, I am challenged on a daily basis to find solutions that accommodate the diverse needs of those patients under my care. My success in plotting safe courses through this “rough surf” is a point of pride for me, and a skill that I will apply directly to the diverse needs of physicians throughout our state.

Tamaan Osbourne-Roberts, MD I encourage you to visit my webpage, http://www.tamaanforcms.org; to seek me out on Facebook at http://www. facebook.com/TamaanForCMS; or to follow me on Twitter, where my handle is @TamaanForCMS, to learn more about my qualifications and the specific steps I believe we can take to ensure that Colorado remains the best state for physician practice and patient care. Thank you for your time, your consideration and for everything you do for our profession and our patients. I ask for your vote; in the meantime, I wish you strong winds and full sails. n

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Departments

medical news CMS launches new website with enhanced member features The Colorado Medical Society has launched a newly redesigned website that increases its online presence and adds a variety of member benefits. Highlights include a robust member portal for profile management; improved navigation; site-wide search functionality; full access to Colorado Medicine articles; educational webinars; an updated events calendar; an improved online physician directory; and access to society bylaws and policies in HTML. CMS embarked on a redesign to help achieve our strategic goals, the most important of which is to ensure physicians thrive personally and professionally in the evolving health care system. The new site will allow for more focus on

and accessibility of resources and tools, members-only content and benefits, and a comprehensive online physician directory for the public that reflects information members can update instantly.

bers will need a member login to access it. Members should receive their login information by mail by mid-July. Contact CMS at (720) 859-1001 if you do not receive it.

All content on the site will be open to the public without the need for login credentials through the end of June. In July, portions of the site will be designated as members only and CMS mem-

CMS staff will continue adding features to meet members’ needs. Coming later this year will be an online membership application and dues payment system. Take a look by visiting www.cms.org. n

CMS.gov redesigns Physician Compare website In late June, the Centers for Medicare and Medicaid Services (CMS) launched a newly redesigned version of its Physician Compare website, which enables consumers to search

and compare information about hundreds of thousands of physicians and other health care professionals. The new site includes an overhaul of the underlying database and the addition of a new search functionality, making information more current and more easily found. Consumers can also find information about specialties offered by doctors and group practices, whether a physician is using electronic health records, a doctor’s board certification status, and affiliation with hospitals and other health care professionals. “Nearly a million physicians and other health care professionals serve the Medicare population,” said CMS Administrator Marilyn Tavenner. “This vastly improved website will provide new information in an improved, easyto-use format.” CMS plans to add quality data in 2014 to help patients choose a medical professional based on performance ratings, according to a notification from the U.S. Department of Health and Human Services. Visit the Physician Compare website at www.medicare.gov/physiciancompare. n

Colorado Medicine for July/August 2013

Departments

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

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Montrose, Colorado

Family Medicine Physician needed for Beautiful Southwestern Colorado Practice An exciting opportunity exists for a BC/BE Family Medicine physician in Southwestern Colorado. Montrose is near the San Juan Mountains and we have a golden opportunity for a physician interested in a practice in a growing community. • Exceptional 90-member medical staff representing 19 medical specialties • 75-bed general acute care hospital that underwent a major expansion within the last 5 years which included a new inpatient tower, a new ICU and telemetry unit, and a new emergency department staffed by board certified emergency medicine physicians • On-site emergency helicopter adds to our capability as a Trauma III medical center • The hospital is a joint venture partner in a cancer treatment center and an outpatient surgery center • Diagnostic and interventional cardiac services in our cath lab • Unassigned emergency room call is covered by an on-site hospitalist program • Highly respected accredited CME program with weekly case presentation conferences and guest lecturers Life in Montrose is made more inviting with easy access to skiing, fishing, biking, hiking, hunting and the majestic San Juan mountain range just to our south. We have family medicine opportunities for group practice or independent practitioner.

Contact Mary Snyder at (970) 240-7398 or email CV to msnyder@montrosehospital.com.See our website under Physician Services, Physician Recruitment at www.montrosehospital.com “Humana Clinical Resources is seeking an experienced Family Medicine Physician to provide full-time, outpatient services to active duty personnel in Fort Carson's Soldier Readiness Center. Fort Carson is home to the Air Force Academy and U.S. Olympic training center and resides about 8 miles south of Colorado Springs and 67 miles south of Denver. Provider will work Monday - Friday days, NO NIGHTS, NO CALL. Physician will be engaged as a Humana Government Business Independent Contractor and will be eligible for competitive compensation, a sign-on/retention bonus and paid time off. Requirements include: completion of an accredited residency program in Family Medicine, Internal Medicine or Occupational Health; Board Eligible or Board Certified in Family Medicine; a current, unrestricted license to practice as an M.D. or D.O. in any State; a minimum of four (4) years direct patient-care experience within the past six (6) years; current, unrestricted DEA registration; current BCLS certification through the American Heart Association (prior to start), and U.S. citizenship. For more information please contact Cindy Fitzpatrick toll-free at 1-888-241-1475 or by email at cfitzpatrick@humana.com or you can submit your Curriculum Vitae via facsimile to (502)322-8764 for confidential consideration.”

Features

the final word Jason Hwang, MD, MBA, co-author of The Innovator’s Prescription: A Disruptive Solution for Health Care

Resisting the status quo:

Today’s health care system must embrace change to move forward In business school, I read a memorable case study about a company that brought in an innovative piece of equipment that promised to transform its factories. This technology made it possible to utilize new types of workers to build an entirely different set of parts, attract new customers and ultimately grow the business. However, this potential was never realized. Instead, the new equipment was used sparingly, mainly by employees who had figured out ways the technology could be adapted to help them make the same parts they had always made, and even then only as a backup solution to traditional methods. Most people in the company viewed the new technology as inferior because it couldn’t match or elevate the production that was already in place – though of course preserving the status quo was not what the innovative technology was meant to do. In the world of health care, we often fall victim to this same mentality. When physicians talk about how to reform the health care system, too often we favor proposals that only preserve or reinforce the existing model of care delivery: tort reform, new and more generous payment codes, increasing the number of medical education slots, greater bargaining power through consolidation, and so on. Moreover, we routinely fight proposals that threaten to change the status quo and affect our historical roles in the system, perhaps most vehemently

when faced with the increasing scope of practice of nurses, pharmacists and other health professionals. However, we must recognize that preserving the status quo is not the only, nor likely the best, way forward. Certainly, with ever-increasing costs and unreliable quality despite our best efforts to date, we already have much evidence to confirm this. What we are putting into practice and routinely advocating does not amount to innovation – it is stagnation. Yet just like the company above with its many factories, our health care system has numerous opportunities to bring in innovative technologies and care models throughout its many components. Unlike the factories, however, we can ensure they are implemented successfully by actively promoting new delivery models that deliberately challenge our existing practices, rather than just the ones that sustain them. With this frame of mind, the medical home, for example, is much more than payment reform that protects primary care; it is a radical transformation in caregiving – empowering other members of the clinical staff (and engaging patients themselves), leveraging information technology and data analytics to manage population health, emphasizing and incentivizing patient wellness, and promoting communication across all stakeholders in the medical neighborhood.

Similarly, ambulatory surgical centers and specialty hospitals are not cherrypicking competitors that undermine the system; they are opportunities to rethink how some elements of care could be performed by more efficient entities. Retail clinics that use nurses to provide care are not threats to patient safety, but offer affordability and convenience that the current model lacks. Telehealth providers are not inferior substitutes deserving of low reimbursement; they reach patients that the traditional brick-and-mortar facilities cannot. Smartphone-based apps and consumeroriented health devices are not toys to be scoffed at; they hold the potential to put an “always-on” health care system in the hands of everyone. The pace of innovation in health-related technologies, and in the novel delivery models that accompany them, will only increase. Furthermore, business history informs us that those who suppress, resist or simply fail to recognize the inevitable changes that follow typically end up on the losing side. Physicians must not just become comfortable with this rapid and constant change; we should promote and be a part of it. We must move beyond managing patients as we have always done; we must also lead the people and shape the organizations that care for those patients. That is how physicians can promote innovation, and it is how we can ensure the health care system reaches its full potential. n

Colorado Medicine for July/August 2013

Patient care is your mission. And keeping your practice in top financial health is necessary to fulfill it. COPIC Financial Service Group brings an in-depth understanding to find the right insurance and financial planning products and services for doctors and health care organizations. These personal and business products not only help protect your practice now, they help to ensure a strong future for you and your staff. Experienced and resourceful, our professionals research the industry to find the best possible coverages and precisely tailor them to your unique needs. COPIC Financial facilitates the process from beginning to end, making sure you receive personalized, professional service.

Areas of service include: •Workers’ compensation •Property and casualty •Health and dental •Disability, life and long-term care •Cyber Liability •Personal lines: auto and home

While you’re taking care of patients, we’ll be taking care of you.

COPIC Financial Service Group www.copicfsg.com•(720) 858-6280/(800) 421-1834 Scan here to learn more about COPIC Financial Service Group. Colorado Medicine for July/August 2013

Member Member Benefit Benefit Partner Partner

Wells WellsFargo Fargo Healthcare HealthcareServices Services Whether Whether you’re you’re preparing preparing for for ownership ownership or planning or planning for for growth, growth, Wells Wells Fargo Fargo cancan helphelp youyou achieve achieve your your practice practice goals. goals. AreAre youyou working working withwith a specialized a specialized Healthcare Healthcare Banker? Banker? At Wells At Wells Fargo, Fargo, we have we have a dedicated a dedicated Healthcare Healthcare teamteam thatthat understands understands the unique the unique challenges challenges thatthat can can impact impact youryour practice’s practice’s bottom bottom line.line. To help To help you you establish establish a foundation a foundation for afor more a more sound sound future, future, we offer we offer an outstanding an outstanding variety variety of business of business products products designed designed to help to help you you meetmeet those those challenges. challenges. As aAs practice a practice owner, owner, you you havehave a single a single point point of contact of contact withwith a a dedicated dedicated Healthcare Healthcare Business Business Banker Banker whowho can can provide provide you you withwith “one-stop” “one-stop” access access to a to range a range of financial of financial solutions solutions thatthat will will helphelp youryour practice practice run run smoothly. smoothly. You’ll You’ll havehave more more timetime to focus to focus on on treating treating patients patients and and building building youryour business. business.

Chris Chris Strabala Strabala

Senior Senior ViceVice President President / Healthcare / Healthcare Market Market Manager Manager 303-863-6014 303-863-6014 | christopher.j.strabala@wellsfargo.com | christopher.j.strabala@wellsfargo.com

© 2013 Wells © 2013 FargoWells Bank,Fargo N.A. All Bank, rights N.A.reserved. All rightsWells reserved. FargoWells Practice FargoFinance Practice is aFinance divisionisofa Wells divisionFargo of Wells Bank,Fargo N.A. Bank, N.A. CommercialCommercial real estate real financing estateisfinancing providedisbyprovided Wells Fargo by Wells SBA Lending Fargo SBAandLending is subject andtois credit subjectapproval to creditand approval SBA eligibility and SBArules. eligibility rules. All practiceAllfinancing practiceisfinancing subject tois credit subjectapproval. to credit approval.

Solutions Solutions include: include: Practice Practice financing financing · Practice · Practice acquisition acquisition and and startstart up financing up financing · Expansion, · Expansion, relocation, relocation, and and renovation renovation projects projects · Debt · Debt consolidation consolidation and and business business refinance refinance · Commercial · Commercial real estate real estate financing financing · Practice · Practice equity equity loansloans Credit Credit services services · Business · Business credit credit cardscards and and rewards rewards programs programs · Unsecured · Unsecured lineslines and loans and loans · Business · Business real estate real estate financing financing · SBA· SBA loanloan programs programs · Equipment · Equipment financing financing Business Business services services · Business · Business payroll payroll services services · Merchant · Merchant services services · Patient · Patient financing financing · Business · Business insurance insurance Deposit Deposit services services · Business · Business checking checking · Business · Business savings savings · Comprehensive · Comprehensive treasury treasury management management services services

Colorado Medicine for July/August 2013