July-August 2015

Page 1

July/August 2015

Volume 112, Number 4




Syncing gears in a competitive health care marketplace

Award-winning publication of the Colorado Medical Society


Colorado Medicine for July/August 2015

contents July/Aug. 2015, Volume 112, Number 4




Syncing gears in a competitive health care marketplace

Cover story Colorado’s insurance

market is fiercely competitive with nearly two dozen companies chasing market share and the lowest price point. This intense competition comes with consequences as they employ tactics to control costs. Read more starting on page 8 about how the machine works to give patients access to health care and what CMS is doing on physicians’ behalf.

Inside CMS 5 7 32 34 35 37 40 42 43

President's Letter Executive Office Update ICD-10 Continuing Medical Education Foundation Focus 2015 Annual Meeting Reflections COPIC Comment Looking Forward

Departments 44 48

Medical News Classified Advertising

Colorado Medicine for July/August 2015

Features. . . 14

Network adequacy–Peter Ricci, MD, talks about a new CMS working group that will help develop public policy on network adequacy and care by out-of-network providers.


Beyond SGR–H.R. 2 does more than just repeal the SGR.


Practice data–CIVHC discusses an initiative to provide


Practice transformation –Colorado primary care


AMA meeting report–Colorado physician leaders and staff


Cost commission–Jeffrey Cain, MD, talks about the work


Physician hero –CMS recognizes Larry Kieft, MD, MPH, for


Legal update–John Conklin writes about rule changes in the Colorado Supreme Court to streamline discovery and minimize or resolve disputes that arise.


Workers’ comp–In the 18 months since Phil Kalin became president and CEO at Pinnacol Assurance, his efforts to improve workers’ comp insurance are starting to bear fruit.


Final Word–Leo Tokar of the Lockton Companies talks about the conflict between health care providers and health insurance companies in health care delivery.

Additional measures in the law will relieve administrative burden and consolidate quality reporting programs. information to primary care physician groups on their cost and efficiency performance.

physicians can access funding to help them adapt to changes underway in the health care system.

traveled to Chicago in June for the AMA Annual Meeting to weigh new AMA policy.

of the Colorado Commission on Affordable Health Care, which is examining health care cost drivers. his service traveling abroad to train indigenous health care providers with tactics to reduce maternal mortality.

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


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


2014/2015 Officers Tamaan Osbourne-Roberts, MD President Michael Volz, MD President-elect Katie 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 John L. Bender, MD, FAAFP Immediate Past President

Board of Directors JT Boyd, MD Charles Breaux Jr., MD Laird Cagan, MD Cory Carroll, MD Joel Dickerman, DO Greg Fliney, MS Curtis Hagedorn, MD Jan Gillespie, MD Kendra Grundman, MSS Mark Johnson, MD Richard Lamb, MD Tamara Lhungay, MS Lucy Loomis, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD Daniel Perlman, MD Scott Replogle, MD Floyd Russak, MD Charlie Tharp, MD Jennifer Wiler, MD Andrea Vincent, MSS Harold “Hap” Young, MD

AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Katie Lozano, MD Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD CMS Historian W. Gerald Rainer, MD CMS Connection Mary Rice, President


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

Division of Communications and Member Benefits

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

Kate Alfano, Communications Coordinator, Kate_Alfano@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Executive Legal Assistant, adrienne_abatemarco@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.


Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Chet Seward, Assistant Editor. Colorado Medicine Printed by Spectro Printing, Denver, Colorado

for July/August 2015

Inside CMS

president’s letter Tamaan Osbourne-Roberts, MD President, Colorado Medical Society

In the center of the storm One would need to be near comatose to not have noticed that the recent Colorado weather appears determined to demote the majority of our “weather forecasters” (a dicey job in our state at the best of times) to “weather fortune tellers” (and inaccurate ones, at that). We have experienced thunderstorms and wall clouds brewing from clear skies so quickly that the reporting on social media is more accurate than the reporting on network news; pelting hail so thick that it looks like snow; flash floods running down city streets and drowning cars and basements; and even multiple urban tornadoes, including a very recent one that touched down about 40 feet from my car, about six blocks from my Denver address while I was driving my children home from the swimming pool. “Daddy, look, a tornado!” was not exactly the sort of experiential lesson in the natural sciences that I was hoping to give my kids that day. To put it simply: things have been a bit crazy, with a lot of time spent in hallways, bathrooms and basements. Most people I know are ready for a respite. Frustratingly, Colorado’s health care climate looks eerily similar to the actual climate for many physicians. A sudden move from the bright sun of SGR repeal one day pivots to a storm of narrowing networks the next, driving sheets of new coverage products, each with its own rules and frustrations. We’ve experienced the looming flood of ICD-10 transition, along with the whipping, swirling winds that push our practices from payers to hospitals and regulatory bodies, threatening to uproot us and to land us who-knows-where.

Colorado Medicine for July/August 2015

Given all of this, I can understand the instinct to head for the basement and wait it out, hoping that water doesn’t rise in the window wells. But, much like a real storm, these transitions in our practice environment will not necessarily pass peacefully leaving our shelter unscathed – unless that shelter is well built. Thankfully the Colorado Medical Society is working hard to shore up our walls. Having successfully advocated for an interim study on the overall insurance marketplace (including narrowing networks), we wasted no time moving directly into in-depth study and advocacy on this remarkably important issue. As physicians and payers sit down together at the table working to find solutions for consumers, we are ensuring that such a conversation will be productive for both physicians and patients. Our staff has also been working at various levels in regulatory and judicial venues to educate those who implement and interpret the law, clarifying laws and rules that can either support our practices or drown them. As always, we continue to achieve great success in these arenas. COMPAC, our affiliated Political Action Committee, has already begun vetting candidates and giving endorsements for the upcoming election cycle, including endorsing our very own Steve Sherick, MD, an emergency medicine physician, former CMS board member and tireless advocate for Colorado’s doctors and patients.

through a deep dive into a governance reform process and communications audit, both of which promise to create the medical society framework of the

“Much like a real storm, these transitions in our practice environment will not necessarily pass peacefully leaving our shelter unscathed – unless that shelter is well built. Thankfully the Colorado Medical Society is working hard to shore up our walls.” 21st century: expanding opportunities for member involvement, allowing us to move at the speed of the Internet, and democratizing the organization in a way not yet achieved by any other medical society in the country. We may not be able to keep the storms from coming or from showing up so suddenly but we can ensure that no matter how strong the winds, our house will still be standing when the wind stops blowing. Until next time. Stay safe out there. n

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

Perhaps most important, CMS is going


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Colorado Medicine for July/August 2015

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Post King vs. Burwell: back to work After nearly 50 stabs by the U.S. House of Representatives at repealing the Affordable Care Act and the second Supreme Court ruling to sustain this still divisive body of law, the coverage debate is once again settled for the time being and Colorado’s hard work in the real world of care delivery and payment reform continues. Health policy leaders in Colorado, who probably gave the recent ruling confirming federal premium subsidies for federally-run exchanges not more than a glance, are back at their desks and negotiating tables. Their focus continues to be on making the ACA work for patients and providers – seeking program and cost efficiencies, new delivery models, and patient education about health plan charges, payments and networks. Make no mistake, cost is in the crosshairs, and the transition of linking payments to quality measures embedded in the bipartisan H.R. 2 (the SGR repeal and replace), state government-based initiatives, and Colorado’s competitive insurance marketplace dynamics (see cover story on page 8), are more immediately relevant. While most of Colorado’s delivery system leaders and innovators already understand these dynamics, not everyone may be up to speed or shovel-ready. On the public policy front, the challenge is determining rational state policy on how networks are formed, maintained, trimmed or expanded, and how prices should be determined, disclosed or possibly arbitrated when the services are out-of-network. These issues are at the heart of the transparency discussion and we aren’t talking about a white paper exercise. Both sides of the aisle Colorado Medicine for July/August 2015

and multiple stakeholders are actively engaged. Sen. Tim Neville (R-Littleton), speaking in June to our recently appointed, multi-specialty Work Group on Managed Care, promoted as a starting point “plain English” price disclosures for the most common services, and building out from there in future years. The senator supports market-based solutions to bending the cost curve and emphasizes that some rational level of transparency is needed or the default is “government only,” to use his words. Sen. Neville also notes that he prefers to have physicians fix the disclosure issue rather than default to a “fix” crafted by the state legislature. Neville’s philosophical opposite and Senate colleague, Irene Aguilar, MD (DDenver), advocates protecting consumers from surprise out-of-network medical bills and excessive charges without harming providers who are operating ethically. These concepts are simple to explain and difficult to operationalize. Both senators operate from a common

denominator – consumers have a right to know the cost before they purchase when and if possible. Both senators fortunately acknowledge that these policy shifts are complicated and will require a soft landing, perhaps a transitional period to allow market stakeholders to adjust and refit their business plans and operations. Our starting point is to understand that this public policy debate is not in the abstract, or in some distant convening of the General Assembly. These policy options are being developed right now. CMS surveys continue to reveal payer issues a close second in importance only to maintaining the state’s relatively stable liability climate. During the month of July, we’ll poll our members to get an even better understanding of physicianpayer marketplace dynamics. The data will be shared with public officials and with our friends representing the insurance industry. It will enhance our evidence-driven approach to public policy (see related Q&A with Peter Ricci, MD, on page 14) and ensure that we bring ideas to the table that have long-term, positive consequences for you and your patients. n

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?

Email: Letters to the editor dean_holzkamp@cms.org





Syncing gears in a competitive health care marketplace Kate Alfano, CMS Communications Coordinator


Colorado Medicine for July/August 2015

Cover Story STORY HIGHLIGHTS • Colorado’s health insurance market is robust and competitive. More than 1,200 medical plans were submitted for review and approval by the Division of Insurance for 2016. Twentythree carriers propose to offer individual and/or small group medical plans in the state. • The Affordable Care Act has drastically changed the health insurance landscape over the past few years by taking away some of the strategies previously used by insurers to set premiums. • Insurers are turning to other tactics to control costs, including narrowing provider networks, which worries some physician and consumer advocates. If there was ever any question about the competitiveness of the Colorado health insurance market, with insurance companies chasing market share and the lowest price point while also facing the challenges of radically different payment models, that uncertainty was dispelled with the Division of Insurance’s June 15 announcement of proposed plans for 2016. A total of 1,221 medical plans were submitted. Of those, 425 are proposed to be offered through Connect for Health Colorado, the state’s health insurance marketplace created under the Affordable Care Act (ACA): 239 individual plans and 186 small group plans. Overall, 23 carriers propose to offer individual and/or small group medical plans in Colorado in 2016 and, of those, 11 propose to offer individual and/or small group medical plans through Connect for Health Colorado. “As in 2014 and 2015, it is great to see so many carriers offering plans in Colorado,” said Commissioner of Insurance Marguerite Salazar in a DOI news release about the proposed plans. “We have such a competitive market, with many choices for Colorado consumers.” Colorado Medicine for July/August 2015

Intense health plan competition comes with consequences, however, such as the move to narrow networks, without-cause physician de-selections, increased utilization and prior approval requirements, among others. A 2013 study conducted by the American Medical Association and the RAND Corporation found that physician workplace dissatisfaction is high and on the rise, and much of this dissatisfaction is the direct result of third-party payers making it difficult for physicians to provide good care. All of this makes the goal of achieving the Triple Aim of higher quality care, lower costs and a better experience for patients even more challenging. The Colorado Medical Society is following these issues with public and private payers closely and actively participating in interim discussions on network adequacy to ensure physicians’ voices are heard. Read more on page 14 about CMS’s preparation for the interim discussions, which came about after debate in the 2015 legislative session on Senate Bill 259. Breaking down the components Taking a closer look at health insurance trends over the past few years since the ACA became law, it’s important to understand the different segments, cogs that work together to cover Coloradans: government plans like Medicaid and Medicare, the individual market, the small group market and the large group market, and within large group, fully insured and self-funded. Leo Tokar is senior vice president in the health care practice for Lockton Companies. He explained how each segment has been affected by the ACA and state-based health reforms. Starting with the government plans, the Medicare insurance market has been largely unaffected, other than serving as a platform for experimental payment models. The biggest impact on Medicaid has been Colorado’s decision to expand the eligibility threshold, which created many more insureds. “That benefits not only individuals but also providers in the form of having less bad debt; receiving something, even in a lower payment rate, is better than receiving nothing while attempting to

collect a higher payment rate,” Tokar said. “It has significantly helped boost hospital profitability and has generally lowered bad debt for providers.”

“The biggest unknown is what is truly going to happen with rates in the individual market. The first two years of the exchange were to some extent the Wild, Wild West because it was a new marketplace. ... I think in years three and four there’s going to be a lot of pricing rationalization and shaking out of the market as insurance companies understand who actually enrolls.” – Leo Tokar, Lockton Companies The ACA similarly reduced the number of uninsured patients in the individual market, standardized benefit offerings and helped eliminate gaps in coverage that were previously allowed. On the other hand, it eliminated the option for individuals to access “skinny products,” or true catastrophic health plans. “It has also greatly inflated the charges that we’re seeing for catastrophic cases, not just in the individual market but really across all commercial insurance,” Tokar said. “Where previously hospitals would limit their billings because they knew there were annual and lifetime maximums in policies that limited coverage, now you have a much higher prevalence of $2 million, $3 million, even $8 mil-


Cover story (cont.) lion cases because there’s a funding mechanism for it.” At least in the short term, the small group market has not really been affected, Tokar said. The ACA pushed rates up somewhat because of added benefit mandates but it has also standardized the way groups have to be rated, which took away variation. As a result, rates have been squeezed toward the middle; groups that previously paid a much lower rate because they had a certain profile are now paying a higher rate, and vice versa. The provision of the ACA that has affected the large group market the most is

“A key factor in the cost of health insurance is something that the division and insurance companies have no control over, and that’s the cost of health procedures and services. We all need to work together to figure out how we bring those costs down.” – Marguerite Salazar, Commissioner of Insurance the employer mandate, Tokar said, which requires groups to be in the heath care financing game one way or another – either an employer provides coverage to employees or pays the penalty and funds health care through the government. “In combination with that, it has created many other rules, significant administrative burden, and that has been incredibly onerous.” He explained: While the mandate has expanded coverage to people working more than 30 hours a week, it created an incentive for employers to manage some workers’ hours to fewer than 30 a week so they don’t have to provide health insurance coverage for them. 10

“The biggest unknown is what is truly going to happen with rates in the individual market,” Tokar said. “The first two years of the exchange were to some extent the Wild, Wild West because it was a new marketplace and carriers didn’t have a sense for the risk pool of people that they would receive, and even for the second year they had little experience to base the second year’s rates off of. I think in years three and four there’s going to be a lot of pricing rationalization and shaking out of the market as insurance companies understand who actually enrolls.” In some respects the rates have been lower than what they truly needed to be, he said. “Insurance is a very simple concept: It’s a pooling of risk. People pay in when they don’t need it and the insurer pays out when they do need it. No one can have a sustainable business by paying out more than they take in.” Calculating rates for 2016 and beyond In general, individuals who have enrolled on the public exchanges since the ACA took effect have a higher risk profile and higher health care utilization than what was originally expected, meaning many insurance companies are losing money on these products. That indicates that as pricing rationalization takes place – where insurers more accurately match prices with consumers’ risk profile – that is going to put upward pressure on rates. “The press around the country is that insurance companies are filing rate increases for 2016 that are well into the double digits pretty consistently,” Tokar said. At least in the preliminary announcement, Colorado appears to be an outlier. The DOI reported that some insurers in the state have requested lower rates and others are looking to single-digit increases. Tom Abel, head of DOI’s Rates and Forms section for life, accident and health insurance, said in the DOI news release: “Overall increases appear to be more than the average increases seen from 2014 to 2015; however these are just the premium rates requested by insurers, and are not the approved rates. Any requested rate has to be justified by the insurance carrier.” He attributed the

increases to “the number and types of claims…as well as medical inflation.” DOI staff will examine each plan to make sure it complies with ACA requirements and state and federal laws, and meets the federally defined tier coverage levels, and staff will review the information that carriers submitted to support and justify the proposed rates. They will complete their review and analysis by September. “A key factor in the cost of health insurance is something that the division and insurance companies have no control over, and that’s the cost of health procedures and services,” Salazar said in the DOI release. “We all need to work together to figure out how we bring those costs down.” Shifting costs As stated in a June 2015 report by the Colorado Health Institute, “Narrow Networks in Colorado: Balancing Access and Affordability,” the ACA has done away with many strategies previously used by insurers to set premiums. “Insurers in nearly all individual and group markets must sell plans to everyone, even people who already have health conditions. And they are required to extend many preventive services…with no out-of-pocket costs. Insurers in the individual and small group markets must offer a standard set of benefits. And they are allowed to charge higher premiums for only one healthrelated behavior – smoking.” As a result, many health insurance plans purchased through the ACA marketplaces offer a limited selection of providers in their networks – so called “narrow networks.” CHI defined narrow network plans in the report as those contracting with 25 percent or fewer of the doctors and hospitals in the community. “Narrower networks are one of the tools available to insurers trying to lower their costs in order to compete for price-conscious consumers who are comparison shopping through the marketplaces,” the report’s authors wrote. “We’re not driving towards narrow networks as the only network we see, which would have an adverse impact on all Colorado Medicine for July/August 2015

Cover Story kinds of stakeholders,” said Robert Ferm, head of Hall & Evans’ Regulatory and Public Policy Practice Group in Denver. “This is a fully and highly regulated environment. There’s prior approval on all rates and there are limitations in terms of profit that carriers can hope to see if everything works in the appropriate way.”

doctor is in their network and, if they take prescription drugs, what that looks like for them. That’s what they want to know: cost, doctors, drugs. We have a lot of education to do on health insurance literacy: in network, out of network, deductibles, coinsurance. We need to help consumers navigate these complexities.”

“Maybe there is bigger concern than need be as to whether [narrow networks are] a real problem,” he said.

However, many physicians and their staff are already feeling the pressure of being asked to be “benefit counselors” for patients who just don’t understand their coverage; it is impossible for practice staff to recall or access up-to-date information at the point of care on the thousands of insurance plans available to their patients.

But CMS President Michael Volz, MD, said the rising prevalence of narrow networks is, in fact, a big problem. A 2015 report by McKinsey & Co. found that plans with narrow networks make up about half of all ACA exchange networks in the U.S., and about two-thirds of the networks in the largest cities. “Insurance companies should be compelled to negotiate in good faith with physicians in order for them to provide appropriate and reasonable care to their patients,” Volz said. “Consumers need assurance that when they go out and purchase insurance they have adequate coverage and have access to the physician specialists they expect.” “The larger issue is this: Insurers must be transparent in what they’re offering. Some patients truly want a narrow network plan for the lowest premium. However, some patients purchase these plans without fully understanding that they will lose access to their doctors or have to go to a hospital that is less convenient for them. In the most extreme cases, patients are forced to consider and act upon financial decisions that they thought were prearranged through their insurance coverage, shifting a significant burden onto patients at the time when they are most vulnerable.” User error Transparency and health insurance literacy remain real challenges in the effort to empower consumers to comparisonshop for insurance plans and then feel confident accessing health care services. Debra Judy, policy director at the Colorado Consumer Health Initiative, said that when choosing a plan, “consumers will look at their premium, whether their Colorado Medicine for July/August 2015

Media reports have highlighted cases where policyholders discovered after purchasing a plan that their provider was not in their network, that providers in the plan were not accepting new patients, or that they had limited access to specialists at sought-after medical centers. A 2014 survey by McKinsey & Co. found that 26 percent of those purchasing a plan through a marketplace did not know whether they had bought a narrow or broad network plan. “It is clear that many Coloradans are more than willing to trade wider provider networks for lower premiums,” said the authors of the CHI report. “For example, 40 percent of Colorado’s marketplace enrollees in 2014 opted for the lowest-price bronze plans, a rate second only to Hawaii. It is likely that many of these plans have narrower networks. It is also likely that some of the bargain shoppers may not be fully aware of the trade-off they are making.” Citing a 2014 Kaiser Family Foundation Health Tracking Poll, CHI asserted that customers shopping for coverage through the marketplaces prefer narrow networks that cost less to broader networks that cost more, and that these cost-conscious consumers are more likely to be low-income and uninsured compared with the total population. Elisabeth Arenales, director of the Colorado Center on Law and Policy’s Health Care Program, identified other trends in health insurance that she

finds concerning for consumers, including the rising number of people covered by high-deductible plans; cost-sharing for access to high-cost drugs, which she said “virtually every plan in Colorado” moved to in 2014; and strategies she’s seeing among the plans to try to control utilization of services in the interests of controlling costs. “We certainly have continued to see an increase in high-deductible plans, high levels of cost-sharing, and I think it’s a struggle we’re going to have about what

“Forty percent of Colorado’s marketplace enrollees in 2014 opted for the lowest-price bronze plans.... It is likely that many of these plans have narrower networks. It is also likely that some of the bargain shoppers may not be fully aware of the trade-off they are making.” – “Narrow Networks in Colorado: Balancing Access and Affordability,” June 2015, Colorado Health Institute the balance is between creating a low-cost premium which then has a very high outof-pocket obligation,” she said. “Frankly, I think we need to have a conversation in the state about high-deductible plans and whether there are any policy interventions that would be appropriate to tackle the question of their affordability. Highdeductible plans have consequences for physicians, hospitals and patients, and it’s an increasing problem.”


Cover story (cont.) Ferm said there have always been highdeductible options in the marketplace and they have served as a vehicle for entry into the health care system. “PreACA, for lots of people who are first-time entrants into the system, the most affordable potential product they could buy has always been a high-deductible product. That’s something that has been in play pre-ACA and now with the ACA.” Tokar said, “All of these things are meant to change the dynamics of health care delivery, understanding that insurance companies don’t deliver the care but at the same time they’re a gatekeeper to the financing of the health care in many respects. They get pressure from everyone – the consumers, the employers and the regulators – to manage costs. But since insurance is a pooling of risk, what they’re doing, aside from administrative costs, is just reflecting the cost of care in the provider community and in the patient base. All of these developments, like narrow networks, are an evolution that’s driven by the absence of tools that can help manage the cost side of the equation.”

The new machine, in practice All of these factors put tremendous pressure on consumers as they are being pushed to make good choices without necessarily having all of the information or understanding how to use the information. “Everyone can price shop when it comes to buying milk but when you’re talking about health care, it’s traditionally been a fairly black box when it comes to price,” Tokar said. While many new tools provide information for consumers to choose between providers and services, “they find it difficult because it’s just not something that they’re accustomed to and there isn’t necessarily clarity on what types of trade-offs they’re making.” Providers, in turn, are being asked to support trends in transparency and quality measurement, and are similarly under pressure to develop processes to help inform some of these trends. Arenales said stakeholders in Colorado have to come up with ways to measure performance in a way that’s meaningful to policymakers and to “real people” who are using

the system – both for physicians and for hospitals. “Right now it’s very hard to get meaningful data.” Judy said there are opportunities to educate consumers on health insurance trends and terms at the point of care, and that the responsibility to do so falls on everyone – consumer advocates, carriers and providers. “If there’s an opportunity we should be helping consumers understand what [a service] means in terms of their health insurance and what it’s going to cost them.” She continued: “I think we’re on that wave as people are learning more. That’s where we need to have that conversation for consumers: How do we weigh all these variables and what kind of tools are out there to help people pick the right plan for them? I think there is a lot of interest but we’re not quite there yet. We’re trying to figure out what is the information that consumers can take and run with to make the right decision for them.” Regardless of which cost-cutting approach takes the lead in the rapidly evolving health insurance marketplace, there are two approaches to take, Tokar said. “Either resist or figure out how you can support it and come out ahead in those trends. That requires investment in systems and processes, or alignment with other providers. It’s definitely requiring different business models than providers are traditionally accustomed to.” This is where the Colorado Medical Society comes in. “Physicians are going to need help developing different variations of business models that can help them continue to care for patients with these different financial scenarios like narrow networks and ACOs, as well as standardizing quality measures,” Tokar said. “I think it’s very difficult to have individual or small practices figure this out. CMS is in the perfect position to be a convener, to identify different models, to create partnerships that can help docs figure out how they align with other practices, share data, or identify efficiencies and manage risk.” n


Colorado Medicine for July/August 2015

Colorado Medicine for July/August 2015



Network adequacy Kate Alfano, CMS Communications Coordinator

Peter Ricci, MD

What's next for out-of-network charges and managed care reform STORY HIGHLIGHTS • The issues around network adequacy and care by out-ofnetwork providers are some of the hottest health care topics in state legislatures across the country. In Colorado it came up as a result of debate over Senate Bill 15-259, “Out-of-Network Health Care Provider Charges.” The bill was narrowly defeated in committee by a 5-4 vote. • CMS formed a Working Group on Managed Care, which held its first meeting in June. Colorado Medicine sat down with Peter Ricci, MD, chair of the CMS Committee on Physician Practice Evolution (CPPE) and a board-certified radiologist and president of Radiology Imaging Associates in Englewood, Colo., to talk about issues of increasing importance in Colorado: network adequacy and care by out-of-network providers. CPPE is the committee of CMS that studies issues related to the evolving health care system and how such changes affect the ability of physicians to deliver accessible, high quality, cost-effective patient care in an economically sustainable manner. Colorado Medicine (CM): Why is this issue receiving so much attention in Colorado? Peter Ricci, MD (PR): The issues around network adequacy and care by out-of-network providers are some of the hottest health care topics in state legisla 14

tures across the country. In Colorado it came up as a result of debate over Senate Bill 15-259, “Out-of-Network Health Care Provider Charges.” I was one of many physicians who testified in opposition to the bill. Our coalition felt that problems inside of systems with the complexity and magnitude of health care coverage and payment, both in and out of network, are best addressed through the type of collaboration that comes from an interim study. The bill was narrowly defeated in committee by a 5-4 vote. CM: Why did CMS and, ultimately, legislators pursue an interim study? PR: We asked for the interim study from the very beginning. There is a lot is at stake and this issue has broad interest among stakeholders, including state officials, physicians, facilities, insurance companies, consumers and business. All parties involved bring a different perspective and we all agree the subject is extremely complex with many interrelated parts. This is particularly true in Colorado because of our highly competitive health insurance market. While developing and gaining consensus on public policy solutions will not be easy, it needs to be done, and I think the legislature was willing to give stakeholders a chance to work it out. CM: How is CMS preparing for the interim study? PR: We have outstanding policy, communications and advocacy experts working for CMS and the specialty societies, and we have our most potent weapon – physicians at the grass-roots level. With the committed help of the AMA, we are

a formidable force. The CMS board of directors voted on May 1 to make this project one of our highest priorities. We will spend the next eight months gaining a physician consensus on certain policies, and positioning ourselves to be successful in the 2016 legislature and beyond. CM: How will CMS leverage the opportunities the study presents? PR: The interim study presents opportunities but it also presents challenges. For instance, we anticipate greater media scrutiny of the issues under discussion. Fortunately CMS has an exciting vision. It is the enthusiastic view of the board of directors that the study can and should be used to open a broad front on the managed care pain points being experienced by all physicians, regardless of specialty, and also to serve to unify the profession. The board referred this issue to the CPPE, and the committee members fully understand the need to be proactive, solution-oriented, and unifying among our peers. We will demonstrate how we can use the power of strategic positioning right now to set the stage to help all of our members, and the patients they serve, over the remainder of the decade. At our first CPPE meeting on this issue members proposed expanding the committee to include specialty society and component society representatives and convening as the “Working Group on Managed Care.” The working group held its first meeting on June 17. Again, we want to convey to physicians that this project is about all physicians, regardless of specialty, and not just about issues related to out-of-network specialists. Colorado Medicine for July/August 2015

Features CM: What are your goals for the working group? PR: At our June 17 meeting we had a starting point discussion on definitions of and potential CMS policy on excessive charges and usual and customary fees, as well as language that non-participating physicians can provide patients on their billing statements to make them aware of the potential protections they may be afforded under existing Colorado statute. It will be imperative for us to develop meaningful policy solutions on these issues. If we can step up as a profession on behalf of our patients, we exponentially increase our chances of getting policymakers to help our profession on a broader array of managed care pain points. While we are working to develop policy solutions on the major issues relating to out-of-network charges and billings, we will work with longtime partner Kupersmit Research to survey our members on a broader array of pain points with managed care plans, including the impact of narrow networks and provider directories. This research is imperative and CMS will ask all members of all specialties to complete it. CM: Any final thoughts on this issue or the interim study? PR: There is a great deal of work ahead of us. We are already in discussions with the Colorado Association of Health Plans (CAHP) about the structure of the interim study. Together we are talking to the governor’s office about an oversight role. These discussions, which will be assisted by a professional facilitator, will be about new public policy and, as such, consumers, facilities and public officials will be involved including Sen. Irene Aguilar, MD, and Sen. David Balmer, chair of the Senate Committee on Business, Labor and Technology. CMS will work to determine who will best represent physicians. Our chances of success are greater if medicine is unified from a policy perspective, we know our bottom line and hang together. Gaining this consensus will be a big part of our job. n Colorado Medicine for July/August 2015



Beyond the SGR fix Kate Alfano, CMS Communications Coordinator

Additional changes under H.R. 2 will benefit Colorado When the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law in April, it permanently repealed the sustainable growth rate (SGR) formula and stabilized Medicare payments for physician services with positive updates from July 1, 2015, through the end of 2019, and again in 2026 and beyond. However, the bill contained other provisions that will impact how physicians deliver care now and in the future. Below are key provisions in the SGR repeal legislation that should be beneficial for Colorado physicians, as well as when the changes will take place. Quality reporting programs will be consolidated Medicare’s current quality reporting programs will be simplified into one merit-based incentive payment system, referred to as “MIPS.” This consolidation of the Physician Quality Reporting System (PQRS), meaningful use electronic health record (EHR) program and the value-based payment modifier (VBM) will reduce the aggregate level of financial penalties physicians otherwise could have faced. Beginning in 2019, physicians who score well in MIPS could receive substantial bonuses. Performance will be based upon four categories – quality, resource use, meaningful use and clinical practice improvement activities. MIPS also would build and improve upon current quality measures and concepts in existing programs. Physicians will be encouraged to report quality measures through certified EHR technology or qualified clinical data reg 16

istries. Participation in a qualified clinical data registry would also count as a clinical practice improvement activity. Alternative payment models will be rewarded Physicians who participate in qualified alternative payment models (APMs) will receive a 5 percent bonus starting in 2019. These physicians also will be exempt from participating in MIPS. $20 million per year, from fiscal years 2016 through 2020, will assist practices of up to 15 professionals to participate in the MIPS program or transition to new payment models. Small practices (up to 10 MIPS-eligible professionals) can also elect to report together as “virtual groups” and receive a MIPS composite score for their combined performance. MACRA creates an advisory panel to consider physicians’ proposals for new models and authorizes coverage for telehealth services in APMs, even if the service is not covered by the traditional Medicare program. Several Medicare accountable care organizations (ACOs) and other new payment models already serve the state of Colorado. Under this law, policymakers will build on this foundation and provide opportunities for all Medicare patients to benefit from new models of care delivery that will support physician-led initiatives to improve the quality of care while lowering costs. Physicians will have liability protections The law incorporates the Standard of Care Protection Act that will protect physicians by preventing quality pro-

gram standards and measures (such as PQRS or MIPS) from being used as a standard or duty of care in medical liability actions. Administrative burdens will be reduced. Physicians who choose to opt out of Medicare to engage in private contracting can elect to automatically renew their status instead of manually renewing their status every two years. By October, the Secretary of the Department of Health and Human Services must report to Congress with recommendations for safe harbors from fraud and abuse laws to permit gainsharing or similar arrangements between physicians and hospitals to improve care and efficiency while reducing waste. The law sets a goal of achieving widespread interoperability nationwide of EHR systems by Dec. 31, 2018. If the goal is not achieved by that date, the secretary can seek to adjust meaningful use penalties and/or decertify EHRs. The secretary must submit a report to Congress by April 16, 2016, on mechanisms that would assist physicians in comparing and selecting among certified EHR products. Funding has been extended for a host of programs Funding has been extended through 2017 for community health centers, the National Health Service Corps, and the Teaching Health Center Graduate Medical Education Payment Program, which provides residency training in community-based settings for family and internal medicine, pediatrics, OBGYN and psychiatry. Colorado Medicine for July/August 2015

Features Funding has also been extended through fiscal year 2017 for the Children’s Health Insurance Program (CHIP), currently serving over 8 million children and low-income pregnant women; the Child Enrollment Contingency Fund, for states facing a shortfall that meet an average enrollment target; and the qualifying states option that lets states use CHIP funds to expand Medicaid for children rather than setting up a separate program. Colorado practices will have greater stability The new law will help the more than 54,000 employees of medical practices in Colorado and help preserve access to care for the more than 667,000 Medicare patients and 231,000 Tricare patients who were at risk due to the previously threatened cuts. The physician payment reforms in MACRA provide an additional $120 million to the balance of 2015 for the care of elderly and disabled patients in Colorado, and $1.5 billion over the next 10 years. n

Colorado Medicine for July/August 2015

MORE DETAILS ON THE MERIT-BASED INCENTIVE PAYMENT SYSTEM PROGRAM (MIPS) The merit-based incentive payment system program (MIPS) will take effect in 2019. This new payment system will consolidate and replace the Physician Quality Reporting System, (PQRS), Meaningful Use (MU) and Value-Based Modifier (VBM) quality initiatives. • Annual MIPS composite scores include four categories: quality (PQRS) – 30 percent; resource use (VBM) – 30 percent; MU – 25 percent; and clinical practice improvement activities – 15 percent. • The annual “performance threshold” is based on the median/mean performance of all eligible providers for a prior period. • The secretary may weight the categories differently. • Individual eligible providers can join “virtual groups” and report together. • Eligible providers with substantial revenue from qualifying APMs or with few Medicare claims are exempt from the MIPS program. • MIPS-eligible providers include physicians, dentists, podiatrists, optometrists, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists and nurse anesthetists. MIPS penalties and bonuses (for scores below or above the annual performance threshold) are on a sliding scale, with maximum MIPS penalties: Up to 4 percent in 2019, up to 5 percent in 2020, up to 7 percent in 2021, and up to 9 percent in 2022 and beyond.



Practice data

Jonathan Mathieu, CIVHC Vice President of Research and Compliance

Want to know how your practice compares on cost and efficiency? CIVHC can help! Data drives change. It serves as a foundation for better understanding of comparative performance and identifying opportunities for improvement. In our rapidly changing health care landscape, data is becoming more and more important to providers and is most valuable when it is accessible and actionable. Until now, primary care physicians (PCPs) have lacked access to information that demonstrates the value and efficiency of care provided relative to that of their peers. For the past 18 months, the Center for Improving Value in Health Care (CIVHC) has been participating in an initiative led by the Network for Regional Healthcare Improvement and funded by the Robert Wood Johnson Foundation. A main goal is to provide actionable information that allows PCP groups to understand their own cost and efficiency (or resource use) performance compared to other similar practices in Colorado. The data is intended to help PCP groups identify opportunities to bring about meaningful change and contribute to realizing the triple aim goals of better health, better quality and lower cost. The initial pilot included five states/regions – Colorado, Maine, Midwest Health Initiative (based in St. Louis, Mo.), Minnesota and Oregon – working together to achieve the following objectives: • Generate Total Cost of Care (TCoC) and Relative Resource Use (RU) measures based on a common methodology. • Develop regional, statewide and national benchmarks to facilitate meaningful comparisons. • Report results directly to PCP groups and engage them in using this information to help reduce health care costs and improve care. CIVHC conducted analysis based on 2013 commercial claims data from the 18

Colorado All Payer Claims Database (CO APCD). In May 2015, CIVHC provided 50 Colorado PCP groups with TCoC and RU reports reflecting patients from their respective practices. This initial distribution of reports is a modest but meaningful first step toward partnering with physicians to create actionable information based on the CO APCD. For the first time, PCPs across the state are able to see how costs and resources used in treating their patients compare to broader statewide averages. The reports are intended to highlight areas where individual PCP practices are performing well and where opportunities may exist to make changes that ultimately improve population health and reduce costs. A scatterplot graph (tinyurl.com/civhcgraph) illustrates the practice-level variation in cost and resource use based on the TCoC and RU measures uncovered by this initial analysis. Each point on the graph reflects the cost and resource use of an individual PCP group compared to (normalized) state average values. In general, low resource use index scores reflect greater efficiency in the delivery of health care and low price index scores indicate that care was delivered at relatively low cost. A practice in the upper left quadrant of the diagram is relatively efficient in delivering health care based on low resource use (compared to all PCP groups reflected in the analysis) but also has a relatively high price index (and thus costs). Moving forward, we would expect to see less variation among practices relative to statewide normalized values. Opportunities for improvement can be identified by looking at what PCP practices falling into the lower left quadrant are doing to provide relatively efficient and low-cost care. This information becomes actionable when a PCP group digs deeper into the results to understand what is driving com-

parative performance in specific service categories. For example, a PCP group may have high TCoC and/or RU in the Outpatient (OP) services category. The data generated can be used to identify whether minor surgical procedures, diagnostic testing, imaging procedures or other specific categories of OP services are driving the results. Armed with this information, they can identify opportunities to alter practice patterns to address the underlying cause(s) and improve relative cost and resource use performance in the OP category. CIVHC meets on a regular basis with the Colorado Medical Society Committee on Physician Practice Evolution to discuss issues related to the Colorado APCD both in general and for the TCoC and RU measurement project more specifically. Physicians interested in being more directly involved and providing ideas on how to make this information as useful as possible are encouraged to contact Chet Seward, senior director of health care policy, at chet_seward@cms.org. As administrator of the CO APCD, CIVHC is committed to making this resource as valuable as possible for all stakeholder groups. As we embark on the next phase of this project, CIVHC plans to expand the number of PCP practices receiving these reports as well as provide additional granularity in service categories such as inpatient, outpatient, professional services and prescription drug utilization. Over the next 18 months, we welcome your engagement, feedback and input regarding how to make the reports as helpful and actionable as possible. If you have other suggestions on how we can improve the use of this valuable state resource or if you have specific questions regarding the APCD or TCoC project, please contact Jonathan Mathieu, vice president of research and compliance, at jmathieu@civhc.org. n Colorado Medicine for July/August 2015

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Practice transformation Allyson Gottsman, Colorado Health Extension System

Practice redesign prepares physician offices for changes in the health care system State and federal programs are currently bringing trained practice facilitators and clinical HIT advisors into Colorado primary care offices to help them become examples of excellence in advanced patient-centered care. Practices should consider taking advantage of the many grant-funded programs that will help them move to the next level of patient-centered care. As the recent Colorado Primary Care Collaborative meeting made very clear, there are major changes underway in the structure of our health care system and the payment system. Our practices need to carefully track these developments and plan how they will effectively adapt to these changes. For those practices that have been holding off on practice redesign efforts in order to see whether the whole thing would just blow over – the time is now, and there are major risks inherent in not beginning work as soon as possible to redesign your practice. Making the needed changes to adopt advanced primary care approaches takes time, and practices benefit from outside support to be successful. Fortunately, funding is now available from state and federal groups to support these changes. There’s no need to reinvent the wheel when easily accessible programs are available to work with trained practice facilitators, clinical HIT advisors and peers to identify and share best practices. Multiple organizations are collaborating to offer these types of programs for free, but this won’t last forever. Under the leadership of Perry Dickinson, MD, a family physician from the 20

University of Colorado School of Medicine, 17 practice transformation organizations and health systems have joined the Colorado Health Extension System (CHES) to provide a cohesive, coordinated approach to practice transformation support services for primary care practices in Colorado. With more than 30 programs across the member organizations, there truly is an opportunity for everyone to get involved. CHES members will be working to deliver two of the largest statewide primary care practice transformation efforts in Colorado’s history: Evidence Now Southwest and the Colorado State Innovation Model. Evidence Now Southwest is part of a national program funded by the Agency for Healthcare Quality and Research that will assist practices in primary care capacity to rapidly deploy evidencebased interventions into practices with an initial focus on cardiovascular risk. The program will engage 260 small primary care practices (208 in Colorado and 52 in New Mexico) to build critical infrastructure to help smaller primary care practices apply the latest medical research in the care they provide to their patients. CHES practice transformation organizations will provide on-site practice facilitation and coaching, expert consultation, shared learning collaboratives and HIT support. Evidence Now is a great program for practices engaged in the early stages of redesigning their practices to build the foundation for advanced primary care and new payment

models, and/or for practices particularly interested in work on reducing cardiovascular risk factors in their patients. For more information contact allyson. gottsman@ucdenver.edu. The State Innovation Model (SIM), a significant statewide effort led by the governor’s office and funded by the Centers for Medicare and Medicaid Innovation, will engage 400 primary care practices over three years in practice redesign, with an emphasis on advanced primary care that includes behavioral health integration. The initial cohort of 100 practices will start in February 2016, and more information regarding the application process will be available to interested practices over the next few months. In addition to on-site practice facilitation and coaching, help with HIT and HIE needs, and shared learning collaboratives, business consultation is also available to help practices evolve to new models of compensation based on the value of care. SIM includes four interdependent bodies of work, all focused on achieving better population health, lower cost and a better experience of care for patients and their health care teams. The four interdependent pillars of SIM are practice transformation and delivery system redesign, compensation reform, data collection and reporting, and patient and community engagement. For more information, contact allyson. gottsman@ucdenver.edu. n

Colorado Medicine for July/August 2015

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Annual meeting report Kate Alfano, CMS Communications Coordinator

Colorado AMA Delegation leads way for new policy to seek ICD-10 grace period for physicians after implementation STORY HIGHLIGHTS • Colorado led the way on one of the most important policies passed at the meeting, which directs the AMA to seek a twoyear grace period for ICD-10 to allow physicians to avoid financial disruptions following implementation. • Two Colorado physicians representing the American Society of Bariatric Physicians hosted the first ever Obesity Caucus at the meeting to allow delegates from different states and societies to talk about what their groups are doing for obesity, and to brainstorm ways the AMA can help tackle the obesity epidemic. • Physicians gathered June 4-10 in Chicago to weigh new AMA policy. Colorado Medical Society sent four delegates, four alternate delegates as well as the CMS President-elect, staff and representatives from the medical specialty societies and AMA sections. Colorado led the way on one of the most important policies passed at the the 2015 AMA Annual Meeting, which directed the AMA to seek a two-year grace period for ICD-10 to allow physicians to avoid financial disruptions following implementation. The AMA will call on the Centers for Medicare and Medicaid Services and other payers not to withhold claim payments based on 22

coding errors, mistakes or malfunctions in the system for two years directly following implementation, which would allow for a smoother transition so physicians can continue providing quality care to their patients. This has already led to an agreement with the federal CMS (see boxed announcement at the bottom of the next page). M. Ray Painter Jr., MD, the senior delegate of the CMS delegation, formulated the concept and the CMS AMA Delegation took it to the AMA two years ago. Although the resolution passed and has been AMA policy since that time, it did not receive much attention because of the AMA’s hard-line stance on achieving a delay of ICD-10 implementation, which they secured in 2014. Though the AMA is still firm on seeking a delay, this is not likely to happen again as vendors, health plans and practices have invested large amounts of time and funds on preparations for the code set. The federal CMS has acknowledged that the transition to ICD-10 will have an impact on physician payment processes, estimating that “in the early stages of implementation, denial rates will rise by 100-200 percent,” according to a 2013 report from the Healthcare Financial Management Association. A 2014 AMA study on the cost of implementing ICD-10 estimated that a small practice could see payment disruptions ranging from $23,000 to $100,000 during the first year of ICD-10 implementation and estimates that a small practice could incur a 5 percent drop in revenue because of productivity loss during and after the change.

The policy also directs the AMA to seek data on how ICD-10 implementation has affected patients and changed physician practice patterns, such as physician retirement or moving to allcash practices. Painter’s concept was re-introduced and showcased by the most vocal opponent to ICD-10, Jeff Terry, MD, of Alabama. “It speaks to Dr. Painter’s ability to continue working with a wide constituency effectively and with grace,” said fellow CMS Delegate Lynn Parry, MD. Colorado contributed to the passage of another important policy at the meeting regarding childhood immunizations. The 2014 AMA HOD asked the CMS Committee on Ethics and Judicial Affairs and the AMA Council on Science and Public Health to collaborate on a joint report, “Non-medical Exemptions to Immunization.” The reference committee heard a great deal of testimony on the report, including sharp criticism on its supposed ambiguity. It was referred back without adoption. However, Colorado and others in the Western Mountain States Coalition supported an amended resolution from the American Association of Public Health Physicians, “Vaccination Requirements to Protect All Children.” That resolution was adopted and creates AMA policy that is unequivocal about eliminating all exemptions other than medical exemptions from childhood vaccination requirements. “Given the extensive publicity of the Disneyland measles outbreak and the persistent resistance of some parents Colorado Medicine for July/August 2015

Features to immunizing their children, it was important for the AMA to have clear scientific social policy on childhood immunization,” said CMS Alternate Delegate Katie Lozano, MD. “An important win for public health!” AMA delegates also passed the CMS report on Integration of Physical and Behavioral Healthcare, which was prompted by a CMS resolution from the 2014 Annual Meeting, and they passed policies on the maintenance of certification process, prescription drug abuse and diversion, public health initiatives restricting youth access to energy drinks and electronic cigarettes, graduate medical education funding, and more. Member groups and sections also met during the meeting, including the Young Physicians Section, Resident and Fellow Section, and the Medical Student Section. Ethan Lazarus, MD, and Carolynn Francavilla, MD, both of Colorado and representing the American Society of Bariatric Physicians,

hosted the first ever Obesity Caucus at the AMA Annual Meeting. The caucus was an open forum to discuss resolutions related to obesity, allow delegates from different states and societies to talk about what their groups are doing for obesity, and brainstorm ways the AMA can help tackle the obesity epidemic. A highlight was discussing the obesity education resolution, co-authored by Colorado. In fact, most of the caucus involved discussing improving obesity education at various levels. Around 20 people attended the first Obesity Caucus, and all agreed that this should take place at each AMA meeting. Steven Stack, MD, an emergency physician from Lexington, Ky., was inaugurated as the 170th president of the American Medical Association and physicians from around the country vied for open seats on the AMA Board of Trustees and six AMA councils. Donald Eckhoff, MD, MS, FACS, of Colorado, who sits on the governing council of the AMA Section of Medical Schools and serves as their delegate

to the AMA House of Delegates, ran for a seat on the AMA Council on Medical education but was unsuccessful in his bid. Roughly 2,000 doctors and physiciansin-training gathered for the meeting in Chicago, with delegations from all 50 states, the District of Columbia, Guam, Puerto Rico and the Virgin Islands. Colorado’s delegation included CMS’s four delegates – M. Ray Painter Jr., MD; Lee Morgan, MD; Lynn Parry, MD; and Brigitta Robinson, MD – and four alternate delegates – David Downs, MD; Jan Kief, MD; Katie Lozano, MD; and Tamaan Osbourne-Roberts, MD – as well as CMS President-elect Michael Volz, MD, staff and representatives from the medical specialty societies and AMA sections. The 2015 AMA Interim Meeting is scheduled for Nov. 13-17 at the Atlanta Marriott Marquis in Atlanta, Ga. The 2016 AMA Annual Meeting will be held June 11-15 at the Hyatt Regency in Chicago. n

AMA and Centers for Medicare and Medicaid Services reach agreement on important elements of “grace period” for Oct. 1 implementation penalties Acting immediately upon a Colorado Medical Society-sponsored proposal reaffirmed and passed again at the AMA annual meeting in June, the AMA and Centers for Medicare and Medicaid Services jointly announced on July 6 that agreement has been reached on important elements of a “grace period” for the Oct. 1, 2015, implementation of the ICD-10 diagnosis code set. In guidance that was transmitted that same day, federal CMS announced that: · For a one-year period starting Oct. 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors. · To avoid potential problems with mid-year coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed. · CMS will establish an ICD-10 ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition. · CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation. The AMA will monitor and keep CMS apprised of any implementation issues that persist in 2016, and will urge the agency to make any needed adjustments to the grace period policy and timeline based on new information that surfaces during the implementation process. Physicians are encouraged to report to the Colorado Medical Society any problems their practice may be experiencing during the transition, to better inform our advocacy efforts on their behalf. It is important to note that the implementation deadline for ICD-10 is still Oct. 1, 2015 and time is running out for physician practices to complete their preparation. Read more on page 32 of this magazine or find ICD-10 resources online on the AMA’s website at www.ama-assn.org/go/icd-10 or on the Colorado ICD-10 Coalition website at www.cms.org/icd-10. This announcement pertains to Medicare specifically and it is hoped that commercial plans will follow their lead. Colorado Medicine for July/August 2015



Health care costs

Kate Alfano, CMS Communications Coordinator

Jeffrey Cain, MD

Q&A with Jeffrey Cain, MD, CMS representative to the Colorado Commission on Affordable Health Care Jeffrey J. Cain, MD, FAAFP, is a family physician in Denver and past president of the American Academy of Family Physicians. He is representing the Colorado Medical Society on the Commission on Affordable Health Care, which has been directed by the Colorado General Assembly to work over the next three years to identify systemic and other underlying causes of excessive and unnecessary health care costs and to propose specific legislative, regulatory and market-based strategies to reduce costs and improve quality. Colorado Medicine staff spoke with Cain for an update on the commis-


sion’s activities. For more information and to view minutes and other materials from their meetings, go to www.colorado.gov/pacific/cdphe/CCAHC. Colorado Medicine (CM): What is the Colorado Commission on Affordable Health Care charged to do? Jeffrey Cain, MD (JC): Colorado’s health care costs have been escalating, just like the rest of the nation. Right now one-sixth of our country’s GDP is spent on health care and is continuing to expand in a way that’s crowding

our ability to invest in other services in Colorado and around the country. It affects families, it affects businesses and it affects the fiscal health of our state and country. Lawmakers created the commission to study the fundamental drivers of health care costs and to make recommendations so everyone in Colorado can have access to affordable, highquality health care. Our recommendations will go to the governor’s office, the legislature and to Colorado’s health care business infrastructure. That’s what our charge is, to look at health care expenses to understand the drivers of health care

Colorado Medicine for July/August 2015

Features costs and quality, explore possible solutions, and make recommendations to help Colorado confront the rising costs. CM: What progress has the commission made so far? JC: The work of the commission will occur over three years. We are spending the first year focusing on examining the drivers of costs in Colorado. The commission has created a process to look at statewide cost data and to evaluate research on health care costs. This summer we will be meeting in all nine congressional districts to get local stakeholder input. Our goal this year is to prepare a report to the legislature by November 2015 on what we find are the major drivers of health care costs in Colorado. CM: Why is the work of the commission important to physicians? JC: No. 1, because it affects everything that we do in our office! No. 2, they say the most expensive tool in all of health care is the physician’s pad. In this day and age, I’d say the most expensive tool in all of health care is the electronic health record. No. 3, physicians have a trusted voice; we’re the ones actually sitting down with our patients and taking care of them. Our voice is respected because of that patient-focused perspective that we bring to the discussion. CM: Are these discussions opening up opportunities for organized medicine? Vulnerabilities? JC: I think the opportunities are being able to step up and talk about what’s important to our practices and to our patients. Our voice is sought after, so it’s common for the commission to turn and ask about the physicians’ perspective. The biggest vulnerability is to have decisions made without the voice of physicians. How can you have a conversation about health care and come up with solutions to the challenges without understanding what really happens in the doctor’s office? CM: What should organized medicine be working on during the course of the commission’s work and after? Colorado Medicine for July/August 2015

JC: CMS has formed the Task Force on Health Care Costs and Quality that is looking at the very issues that will help inform the process of the cost commission. As your representative, I am actively engaged in that group and encouraging Colorado physicians to engage with the task force to help CMS and the commission better understand the cost drivers for them and the small hassles that happen in physicians’ offices that get in the way of efficiencies. CMS must be proactive in helping the commission better understand cost and quality from a physician’s perspective to provide solutions that work for physicians and for patients. The commission will receive input from other stakeholders – from insurance companies, from hospitals, from employers – and the cost commission needs to be able to hear


David Mayer, MD

Vice President of Quality and Safety, MedStar Health

how the solutions will impact our ability to care for patients. CM: Are you hopeful for the work of the commission? Do you see potential for change? JC: I am an optimist. We have solutions in Colorado that show that more effective, more coordinated care can actually produce health care that is higher quality, lower cost and a better experience for patients. That’s the triple aim. And I believe it’s possible to find a solution that also makes practicing medicine more engaging and rewarding for physicians. That’s the quadruple aim. Physicians need to be engaged, both in this process and the legislature, because we can help improve our health care system for better outcomes for our patients and for our practices. n

Presents the 2015


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Achieving and sustaining a strong patient safety culture is not a single discrete event, but a journey.



Physician heroes: Going global Kate Alfano, CMS Communications Coordinator

Retired Fort Collins OB-GYN shares medical knowledge abroad Larry Kieft, MD, MPH, a retired obstetrician-gynecologist in Fort Collins, has always been interested in access to health care; his philosophy was that all women should have access to care. His former private practice was one of the few in the community at the time that accepted women with no health insurance, with very few resources or with Medicaid coverage. He helped start the Poudre Valley Prenatal Program – which provided prenatal care, delivery and postpartum services for approximately 300 underserved women annually – and he served as the clinical director for 21 years. “It’s always been part of my heart and desire that women have access to good preventative care as well as safe pregnancies and deliveries, and have a good start for their children,” Kieft said.

So when he heard a report about mother-to-child transmission of HIV in Africa, he embraced a call to service that would lead him around the world to provide OB-GYN care to women and teach indigenous health care providers methods to help prevent maternal mortality. First lessons His first trip abroad was to Bangladesh in south Asia to visit medical projects in rural areas and in the slums of Dhaka, the nation’s capitol. “This was important for me to do because I had in my mind that medical care and delivery systems in the developing world were probably like the 1950s [in the developed world]. It was really like the 1850s,” Kieft said. The maternal mortality rate in the United States is roughly seven women

Larry Kieft, MD, MPH

per 100,000; in the developing world it can be up to 600 women per 100,000. In rural areas in the developing world, there is no ambulance service, there’s no local hospital, and patients may have to walk for a day to reach a center where help is available. Women and babies are dying of what he considered to be preventable causes. “That was a real wake-up call,” he said. “I realized that health care delivery systems were very complicated in the developing world. Most women who were delivered in rural areas had no prenatal care. Traditional birth attendants did their deliveries but they just learned these skills from other women. They didn’t have access to supplies or equipment so women were dying from results of hemorrhage, infection following a delivery or a miscarriage, or complications of high blood pressure.” Because of the cultural challenges of a man caring for women in a Muslim country, he refocused on Africa and has since traveled to the countries of Mali, Nigeria, Kenya, Rwanda, Malawi and Zambia, working for a month at a time and searching for the “perfect fit” for his interests and skills. He sought a place where English was one of the primary languages and where he could teach indigenous physicians, which he felt could have more impact than just providing direct care.

Kieft teaches surgical techniques to young physicians in Mali. 26

Finding a place His five most recent trips have been to Tenwek Hospital in Kenya, a 300-bed hospital in a rural setting north and west of Nairobi. Providers there deliver 3,000 babies a year; “these are the complicated ones because the normal ones Colorado Medicine for July/August 2015

Features Kieft demonstrates principles of differential diagnosis and prioritization of patients, which are cornerstones of American medical education but not necessarily taught in African medical training. “These young physicians are very bright,” he said. “It’s not a lack of intelligence; it’s a different style of learning. Our medical education is very hands-on. Theirs is in big lecture halls. As far as treating patients, often what they learn is from other medical students or just by doing. I spend a lot of time with them, do rounds with them, go to clinic with them, discuss how they want to treat a condition, what they want to do. It’s modeling that kind of behavior. I’m very relational in my style of teaching so it goes over very well with these young physicians.” Kieft celebrates a successful delivery with a patient and her newborn baby boy. deliver at home,” he said. The hospital has an internship program both for medical interns and physician assistant interns, a nursing school, general surgery residency, orthopedic residency and a permanent medical staff comprised of expats and Kenyans. “Every time I’ve gone back to the same place, I’m trusted more, people know I’m taking them seriously, and I listen,” Kieft said. “I try to listen to what’s happening and to their goals, not impose my goals for their health or their community. It’s very important that when you deliver medical care in this kind of context that you understand their culture. We cannot just transport our technology to another place and assume it has the same meaning or use.” Kieft teaches young physicians surgical skills, basic prenatal care so that problems can be recognized before they become catastrophes, and how to manage a woman with a complication during pregnancy. He also focuses on early detection of cervical cancer through a method that uses vinegar and a flashlight: visual inspection of the cervix after acidic acid application, or VIA. Combined with cryotherapy, this approach has been proven successful in the developing world in detecting and treating pre-cancerous lesions in one visit. Colorado Medicine for July/August 2015

“In the developed world, the mortality rate from cervical cancer is about 20 percent once it’s diagnosed. In the developing world it’s 80 percent. The problem is that it’s not detected early, there aren’t any facilities for extended treatment, and all of the technology we would use isn’t available. This type of program, VIA, has shown that if a woman has only two such visits in her life, you reduce her risk of dying from cervical cancer by 40 percent.”

Another behavior he imparts is the value of women. He shared two quotes of great importance to him: • “The obstacles that stand in the way of better health for women are not primarily technical or medical in nature but rather social and political.” - Margaret Chen, head of the World Health Organization.

Kieft poses with a group of traditional midwives in Nigeria after teaching a course on postpartum hemorrhage. 27

Physician heroes (cont.) A way to love medicine again The work can be emotionally challenging but extremely rewarding. Kieft told a story of the parents of a young woman who died in the operating room. “They started by thanking me,” he said, with traces of tears in his eyes. “They said, ‘we know you tried everything. She was very sick when she got here.’”

Though Kieft travels to areas not known for tourism, he has experienced some sightseeing during his time in Africa. • “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” - Mahmoud Fathalla. “The status of women is not good in the developing world and their health care is even worse,” Kieft said. “Often they are in a position where they can’t make decisions about their own health care; they need money from their husband, father or brother, and permission to be treated. Economically, the value of a woman isn’t thought of very highly even though there’s all kinds of data showing that women who work enhance the economic wellbeing of the family. So the other thing I try to do is model the value of women and teach that to the interns and residents.”


“You have to open yourself to that possibility and be able to accept the fact that we can change many things but there are some things beyond our power to change. On the other side, there is great joy: A woman presents with a very complicated pregnancy and you get to deliver a healthy baby. We have that joy here but in the developing world we know it can go another way just as well. That gift of joy is really something. I get so much out of this. It’s good for my spirit.” Kieft’s passion for his work in the developing world is palpable and he is eager to share information with any CMS member interested in embarking upon a similar journey, particularly retired physicians who are interested in service in the developing world (email him at larrydkieft@gmail.com). “It’s been a great way for me to use my medical skills,” he said. “I really didn’t want to deal with the business of medicine anymore. I loved my patients; I loved practicing. This has allowed me to continue loving

medicine, interacting with patients and experiencing things that I’ve always loved, and putting to use the gifts that I have in an area of great need.” He advises interested physicians to just start talking to others: “let people know you’re considering international medical service. Once you put your name out there, people start feeding you information,” he said. “People are dying, literally dying, for the skills we have. Physicians have good hearts and I think this is a great opportunity to use their passions and skills in an exciting way.” n Editor’s note: The Colorado Medical Society recognizes the prevalence of burnout among physicians. To help our members reflect on the difference they’re making in the lives of their patients and community, and to recognize extraordinary actions, Colorado Medicine presents the Physician Heroes series. We will profile as many different members as we can who have gone above and beyond in the profession to help their colleagues or community. We hope you’ll see your own values reflected in these stories and be reminded of the joy of medicine. Nominate yourself or a member colleague by contacting Dean Holzkamp at dean_holzkamp@cms.org or Kate Alfano at kate_alfano@cms.org.

Colorado Medicine for July/August 2015


Legal update John L. Conklin, Esq, Martin Conklin, P.C.

State Supreme Court is changing discovery rules STORY HIGHLIGHTS • The Colorado Supreme Court is making changes to its rules to streamline the pretrial exchange of information in lawsuits (discovery) to minimize disputes among parties and more quickly resolve disputes that do arise. • Proportionality will be a key factor in determining the extent of pretrial discovery permitted in a given case, with judges attempting to correlate the discovery costs to the relative value of the case.

mining the extent of pretrial discovery permitted in a given case, with judges attempting to correlate the discovery costs to the relative value of the case. Defense lawyers hope that application of this concept will prevent plaintiff lawyers from engaging in broad-based “fishing expeditions” during discovery, which often target policies, procedures and guidelines unrelated to the care at issue in the case. To apply proportionality, the attorneys must jointly submit a proposed Case Management Order, or discovery plan, proportional to the value of the case to become an order of the court.

The Colorado Supreme Court is making changes to the Colorado Rules of Civil Procedure, which apply to all civil cases including medical malpractice cases filed on or after July 1, 2015. The changes are not intended to favor either side, and have been established to streamline the pretrial exchange of information in lawsuits, also known as discovery, to minimize discovery disputes among parties, and more quickly resolve disputes that do arise.

Another change consistent with proportionality is that the submitted discovery plan must list the subjects of expert testimony with a presumptive limit of one expert per side per subject. Many judges have already been limiting the number of experts in civil cases either as part of pretrial case management or at trial as an evidentiary limitation on trial testimony. Medical malpractice cases may have multiple defendant providers who treated the patient at different times, raising the possibility of inconsistent positions. In those situations, sharing the same expert on standard of care or causation may not be feasible. The new rules require the judge to take into account any differing positions or interests among the parties on one side of the case, as well as proportionality, in formulating limits on the number of expert witnesses. The new requirement for early disclosure of categories of expert witness testimony should help prevent surprises.

The overarching theme of the rules changes is proportionality. Proportionality will be a key factor in deter-

The widespread use of electronic medical records has led to increasing requests for production of electronic records, logs

• Among other changes, the submitted discovery plan must list the subjects of expert testimony with a presumptive limit of one expert per side per subject, and the discovery plan must include a provision for any anticipated electronic discovery.

Colorado Medicine for July/August 2015

and files in medical malpractice cases. The new rules require the discovery plan to include a provision for any anticipated electronic discovery. If the plaintiff lawyer intends to seek extensive electronic discovery, the issue can now be addressed with the judge earlier in the case. Another change to the rules designed to streamline discovery and focus the parties on the issues in dispute is that the scope of information sought will be limited to matters relevant to the specific claims and defenses raised by the parties in the case, rather than the old standard, which permitted discovery on the broader “subject matter” of the case. For physicians who engage in medicallegal work as retained experts, the new rules require that expert opinions be contained within an expert report signed by the expert, rather than as a summary of opinions prepared by the lawyer. Opinions of treating physicians testifying about their own care of the patient may still be disclosed in a summary prepared by the attorney. Expert depositions will be limited to six hours, unless permission for a longer time is obtained from the judge or agreed to by the attorneys and expert. Finally, drafts and correspondence between attorneys and retained experts will not be discoverable by the opposing side unless the expert relies on facts contained in those materials. Additional rule changes require the court to take into account proportionality when awarding litigation costs to either side and raise the standard for striking claims or defenses of a party as punishment for a rules violation. n 29


Workers’ comp Ryan Grange Senior Communications Specialist, Pinnacol Assurance

Phil Kalin broadens Pinnacol’s mission When Phil Kalin took the job as President and CEO at Pinnacol Assurance, he came with more than just the requisite executive experience. He came with a plan to expand Pinnacol’s focus on health and wellness in workers’ compensation. “Throughout my career I’ve observed arbitrary lines between the health care of individuals and their safety on the job,” Kalin said. “There needed to be more of an integrated push to align efforts between medical providers and insurers.” Kalin may have seemed a surprising choice for Pinnacol, Colorado’s leading provider of workers’ comp insurance. With decades of experience in hospitals, health care

technology and nonprofits, he didn’t fit the mold of a workers’ comp CEO. But a focus on total employee health and wellbeing was exactly what Pinnacol was looking for. And after 18 months on the job, his efforts are starting to bear fruit. Progress began when Pinnacol recognized that the risk management efforts and injury prevention programs that have been a core part of Pinnacol’s mission for decades made a solid foundation for health and wellness efforts. From the beginning, Kalin has promoted the idea that workers’ comp and commercial health care are intrinsically

Phil Kalin linked. When the workers’ comp system is inefficient, health care providers are impacted and injured workers don’t receive the best possible care. Colorado employers are becoming increasingly aware of the connection between the overall health and well-being of their employees. They are recognizing that their employees’ health and safety goes beyond the workplace. “In many ways, an employer’s success depends on how well it protects its human capital,” said Kalin. “That requires them to address total employee health and wellbeing.” A 2015 study by the Colorado School of Public Health that examined Pinnacol’s worksite wellness program found that for every $1 invested by employers in a worksite wellness program, $2.03 in medical and productivity savings resulted. The same study confirms that employee health factors and behaviors – like obesity, high blood pressure and smoking – can contribute to the occurrence of a workplace injury, as well as severity and frequency of an injury. Despite the overlap, the existing silos between workers’ comp and traditional health care prevent the best overall treatment and outcomes for injured workers. Because of Pinnacol’s role as Colorado’s workers’ comp insurer of last resort – and as the insurer of choice for nearly 60 percent of the state’s employers – Kalin believes Pinnacol is in prime position to bridge the gap. Under Kalin, Pinnacol is seeking to integrate its efforts with health and wellness by creating partnerships with provid-


Colorado Medicine for July/August 2015

Features ers, health insurers, and organizations that support healthy behaviors. Recent partnerships with Colorado Quitline and HealthLinks will open up valuable health resources to the more than 900,000 employees of Pinnacol’s policyholders in Colorado. As a former hospital executive, Kalin understands that for Pinnacol to be truly successful at addressing total employee health, the company’s working relationship with medical providers must be effective. One way to improve insurer-provider interactions is by taking advantage of the large amounts of data Pinnacol collects. Analysis of this data will help in several ways. • Developing best practices in treatment. • Proactively identifying and managing conditions and behaviors that contribute to workplace injuries. • Ensuring Pinnacol delivers the right information, in the right place, at the right time to support providers and generate better patient outcomes. Technology can also play a significant role in making the insurer-provider partnership effective. For example, upgrading systems can make the transfer of data less cumbersome. “In the Digital Age, it’s easy to get paralyzed by information overload,” Kalin said. “The same goes for the insurer-provider relationship. Insurers must be more intentional about which medical information is shared, focusing on data that will be useful to an injured worker’s provider.” The administrative side of treating injured workers can be onerous, and Kalin is looking at ways to improve those processes. He believes that providers who get the best outcomes and the best value should be rewarded accordingly. And payment mechanisms need to be enhanced, potentially via bundled payments and telemedicine. By taking a holistic view of worker health and wellness – and engaging more effectively with providers – Kalin anticipates long-term benefits to Colorado employees, employers and medical providers. n Colorado Medicine for July/August 2015


Inside CMS

ICD-10 deadline Oct. 1 Marilyn Rissmiller, Senior Director, Division of Health Care Financing

Use the summer to prepare for ICD-10 implementation With just three months left to transition to the ICD-10 code set, it’s crunch time. Several organizations have resources to get your practice ready for the Oct. 1 deadline. The American Medical Association has made available a handy month-by-month primer for ICD-10. Below are their recommendations for the summer whether your practice is already on the road to implementation or you need a little more guidance.

scribing module, disease management registry or other systems.

are different types of testing and each type serves a different purpose.

This also is the time to communicate with your payers and related vendors, such as billing offices, and other physician practices and agencies from which your practice may seek advice, assistance or materials. Be sure to ask the insurers you contract with about payment changes, processes for “unspecified” codes and other information.

Just getting started? Spend the summer identifying the changes you need to make in your practice for ICD-10. For example, you’ll need to update your systems, forms and workflow processes. Pull together all staff members involved in coding, billing, claims processing, revenue management and clinical documentation, then figure out each task necessary to bring your practice in line with the new code set. Ask the group members how and where they use ICD-9, and go from there.

Already on your way? ICD-10 requires new levels of documentation requirements, so now’s the time for practices already preparing for ICD-10 to assess their current documentation practices and how they will support the new code set.

• Content-based testing assesses your practice’s documentation and ability to code in ICD-10. It involves being given documentation and coding a clinical scenario in the new code set. The Healthcare Information and Management Systems Society offers resources for your practice on their website, www.himss.org. • Internal testing evaluates your practice’s ability to create and use ICD-10 codes throughout the patient workflow where you currently use ICD-9 codes. This type of testing requires system upgrades to be installed already and helps you follow the flow of a patient through a visit to see where codes are used. Use this testing to identify any gaps in your ICD-10 updates. • External testing tests your practice’s ability to send and receive transactions that use ICD-10 codes with your external trading partners, including your billing service, clearinghouse or payers. Check with these groups about their testing plans.

Once you have a plan, you can more easily estimate and secure funds to update your practice management system, purchase new coding guides and send your staff to training. Use a transition checklist like one found on the Colorado ICD-10 Coalition website, www.cms.org/icd-10, to get started. Then, contact vendors about upcoming changes. Most practices will need vendors to complete system updates to support the new code set. The two largest systems impacted will be your practice management system and your electronic health record system. You also may need to update your e-pre 32

The more detailed documentation for ICD-10 coding may not be that different than what you’re already recording in your clinical notes. Also, keep in mind the changes in codes and increased level of detail are specific to specialties. Orthopedics has the highest increase in codes because many are simply separate codes for “right” versus “left.” This information would already be in your documentation. Decide whether you want to perform the documentation assessment yourself or you would like to get outside expertise. There are organizations that will provide feedback on your current situation and whether it will be sufficient for ICD-10, or you can conduct your own assessment.

One type of external test is acknowledgement testing with Medicare, which simply acknowledges that a claim has been received. Physicians can do acknowledgement testing with their Medicare Administrative Contractors and the Common Electronic Data Interchange contractor any time up to the Oct. 1 implementation date.

Next on your summer to-do list is to test your practice’s ICD-10 readiness and identify potential problems. There

Three bills related to ICD-10 are currently under consideration in the United States Congress. Two contain Colorado Medicine for July/August 2015

Inside CMS a delay or repeal of ICD-10 and are unlikely to gain much traction, but one – H.R. 2652, “Protecting Patients and Physicians Against Coding Act of 2015” – has received more attention. It would create a two-year grace period where health care providers’ ICD-10based claims submitted to Medicare and Medicaid would not be denied due to coding errors. H.R. 2652 had 32 co-sponsors as of June 8, and has been referred to the House Committee on Energy and Commerce as well as the Committee on Ways and Means. This policy concept was passed by the American Medical Association House of Delegates in early June, with full support by the Colorado delegation to the AMA. Find ICD-10 resources online on the AMA’s website at www.ama-assn.org/ go/icd-10 or on the Colorado ICD-10 Coalition website at www.cms.org/icd10. n

Robert Marinaro, MHS Mary Beth Marinaro, CT (ASCP) 720-440-9095 rmb@legacygroupestates.com www.legacygroupestates.com/physicians

“Your specialty is medicine and serving patients. Our specialty is real estate and serving you.” Each RE/MAX® Office is Independently Owned and Operated. Equal Housing Opportunity.

Colorado Medicine for July/August 2015


Inside CMS

Educating physicians JoAnne Wojak, Director, Continuing Medical Education

CMS-sponsored workshop helps organizations design better CME programs Professionals from accredited continuing medical education organizations attended a workshop in Denver in May sponsored by the Colorado Medical Society about how CME should be used as a tool to improve quality, and how to improve the effectiveness of their CME activities by adding innovative formats to traditional lectures. Jay Want, MD, medical director of the Center for Improving Value in Health Care (CIVHC), began the program with an introduction of how quality metrics and measurement techniques will change in the era of “big data” – predisposing participants to consider how to address quality gaps of the future that will include cost of care, patient

experience and total population health. Beryl Vallejo, PhD, an expert in quality and patient safety systems, then led a discussion about ways that quality improvement and CME professionals can work together – “integrating CME and QI” to improve measures. Vallejo pointed out that community-based physicians are unlikely to attend CME explicitly focused on Q and that QI components should be embedded in CME that is focused on clinical content. An example would be a diabetic CME program about new drugs/therapies that include strategies designed to reduce CV risk factors and manage HbA1C. This method does not teach QI skills, but focuses on a well-documented quality gap.

Professionals from accredited CME organizations participate in an interactive session titled, “Let’s get that box so we can think outside of it!” led by Marcia Jackson, PhD, president of CME by Design. 34

Marcia Jackson, PhD, led a discussion about innovative formats for activities designed for adult learners. Breakout groups then had an opportunity to apply principles of “purposeful planning” and innovative features to traditional learning activities. These features include case example quizzes, problem-based learning, pro-con debate, and jeopardy games. The whole group critiqued the activities using specified criteria and voted for the bestdesigned CME activity. A prize was presented to the winning team. One of the goals of this activity was to encourage CME-accredited organizations to begin thinking about “QI Education,” i.e. incorporating education tools and techniques into QI improvement activities. This linking of QI and CME requires these two distinct functions at institutions to work together to close quality gaps. The second goal of the workshop was to help CME providers improve the effectiveness of traditional CME formats. Imparting medical knowledge to physicians is typically offered as a traditional lecture format, such as a one-hour PowerPoint presentation during breakfast or lunch. These often result in low retention and little-to-no practice change. CME research shows that when adult learners are actively engaged in their own learning (e.g. innovative and interactive formats), this helps to improve retention and behavior change. The survey results of this workshop showed very positive ratings. Participants noted new strategies that they will apply to CME planning. n Colorado Medicine for July/August 2015

Inside CMS

Foundation focus Michael J. Campo, PhD, support staff, Colorado Medical Society Foundation

EBD program to help more Coloradans make better decisions, receive more effective care With support from a $1.2 million grant from the Colorado Health Foundation, the Colorado Medical Society Foundation entered into a contract with Engaged Public, a Denver-based public policy firm, in November 2013 to extend its Engaged Benefit Design program statewide with the goal of making Coloradans the best and wisest health consumers in the nation. Engaged Public develops approaches to promote improved value and better-informed patients with insurance coverage that eliminates co-pays for high-quality, proven treatments. The program is based on the increasingly popular value-based insurance design philosophy. The CMS Foundation’s mission is to administer and financially manage programs that seek to improve access to health care and health services, with the potential to improve the health of Coloradans. “Engaged Benefit Design represents a bold and innovative step toward the future of health and health care,” said Gary VanderArk, MD, CMS-F president. “We are proud to support this important work.” Engaged Benefit Design: • Removes financial barriers to evidence-based chronic disease care for specific services, • Covers patient decision aids that help patients understand their treatment choices, and • Provides objective information to patients to better understand the Colorado Medicine for July/August 2015

risks and limited benefits of services that in many cases are of questionable value. “The funding enables us to build on a widely supported approach to improve decision-making for preference- and supply-sensitive health care,” said Dave Downs, MD, CMS past president and medical director at Engaged Public. “Prospects are excellent for statewide strategies to extend the concept and realize an increase in evidence-based care and cost containment.” Engaged Benefit Design was initially piloted at San Luis Valley Health in Alamosa, Colo., from 2012-2014, testing the impact of patient decision aids and economic incentives on the health care decision-making processes of the medical center’s 725 covered employees and dependents. The results of the pilot study demonstrated that patients felt an increased sense of ownership in their own care as a result of the program and that the overall approach was highly acceptable to consumers, providers and the employer. “Ten months into the study, the providers there, as well as other health care administrators and insurance providers, were asking how they could expand or implement the approach with all their patients,” Downs said. Hilltop Community Resources, based in Grand Junction, Colo., is the latest employer to implement the Engaged Benefit Design health insurance program for its 800 employees. Hilltop

provides a continuum of community-based services meeting the needs of youth, adults and seniors in and around Grand Junction. While the goal of Engaged Benefit Design is to inform patients so they get the care they need and want, the program could have a great effect on costs over the long term. Several studies have shown that patients who are fully informed when making treatment decisions often choose less-invasive treatments, which in many cases translates into less-expensive options and cost savings. “As shared decision-making is studied further, it is becoming apparent that it may also address the third domain of the triple aim – per capita cost reduction,” Downs said. “The Institute of Medicine has estimated that broad implementation of shared decisionmaking could save the country as much as $9 billion. This is a new approach to health care that relies on better-informed patients and incentivizes people to make better, smarter health care decisions. We believe that programs like this are the way of the future.” Engaged Public will work to demonstrate how the model can be scaled and automated to meet the needs of consumers across Colorado and nationwide. Visit EngagedBenefitDesign. org to learn more about this program and CMS.org to learn more about the CMS Foundation. n


Inside CMS

CMS 2015 Annual Meeting

Sept. 18-20 • Beaver Run Resort • Breckenridge Good friends, good food and good fun:

Register online at www.cms.org to attend this year's annual meeting in Breckenridge

CMS thanks the following sponsors and exhibitors for their support of this year’s annual meeting

Presenting Level Sponsor COPIC Gold Level Sponsors CIGNA HealthCare Colorado Drug Card UnitedHealthcare U.S. Army Healthcare Recruiting Exhibitors • CardioDX, Inc. • Center for Dependency, Addiction and Rehabilitation • Center for Personalized Education for Physicians • Colorado Physician Health Program

• Donor Alliance • First Healthcare Compliance • Medical Telecommunications • Sharkey, Howes & Javer • TransFirst • U.S. Navy Recruiting District Denver

Colorado Medical Society call for nominations

Colorado Medical Society is issuing a call for nominations for the following elected offices at its annual meeting September 18-20 at the Beaver Run Resort in Breckenridge. Visit www.cms.org to view qualification and application requirements. To date, the following physicians have announced their candidacy. President-elect (one-year term) Katie Lozano, MD CMS Historian (one-year term) W. Gerald Rainer, MD, incumbent


AMA Delegate (elect three) (One, two-year term beginning Jan. 1, 2016, ending Dec. 31, 2017) Brigitta Robinson, MD, incumbent Ray Painter, MD, incumbent Lynn Parry, MD, incumbent

AMA Alternate Delegate (elect three) (One, two-year term beginning Jan. 1, 2016, ending Dec. 31, 2017) David Downs, MD Jan Kief, MD Tamaan Osbourne-Roberts, MD Colorado Medicine for July/August 2015

Inside CMS

2015 CMS Annual Meeting Sept. 18-20 Beaver Run Resort, Breckenridge, Colo. www.cms.org/events/annual-meeting

Colorado Sen. Michael Bennet keynotes CMS Annual Meeting Colorado U.S. Senator Michael Bennet will be the featured speaker as part of the 144th Colorado Medical Society Annual Meeting and convening of the CMS House of Delegates (HOD) scheduled for Sept. 18-20 at the Beaver Run Resort. Saturday’s AMA-COMPAC luncheon will feature Sen. Bennet who will participate in an interactive discussion on health care, the state-federal working relationship, and other issues important to physicians (Colorado U.S. Senator Cory Gardner was also invited but unable to attend). In addition to Sen. Bennet and an important business agenda for the HOD, the weekend event will feature fall revelry, with fun, friends and interactive programming on issues important to physicians and patients under the theme “Next Gen CMS.” The House of Delegates will conduct business integral to the continuing success of CMS, electing a new slate of officers and establishing CMS policies. Once again, the main events of the annual meeting will span two days instead of three to make the most of busy delegates’ time. All proposed resolutions for the HOD must be submitted by Aug. 10, which will allow the reference committee to hold two meetings and submit their report to be posted online prior to Colorado Medicine for July/August 2015

the annual meeting. The report will be distributed to delegates upon arrival Friday evening or Saturday morning. Check-in for the annual meeting opens Friday at 3 p.m. All annual meeting registrants and their families are encouraged to attend the Oktoberfest-themed exhibitor welcome reception Friday evening to support our sponsors and to socialize and enjoy beer tasting and light appetizers. The HOD convenes Saturday at 8:30 a.m. District 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. The AMA-COMPAC lunch featuring Sen. Bennet will follow before CMS HOD delegates begin Saturday afternoon’s interactive programming as part of their continued management of the business of CMS. That evening, attendees have the opportunity to meet the candidates for CMS President-elect and the AMA Delegation at a reception before heading to the presidential gala to celebrate the installation of 2015-2016 CMS President Michael Volz, MD. The HOD reconvenes Sunday morning to elect officers and finish the business of the HOD. Attendees can also participate in additional programming, including COPIC educational sessions and lectures.

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 2015 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. Fall is coming; make plans to join your colleagues in Breckenridge. n Register: www.cms.org/register Hotel accommodations: Online at tinyurl.com/2015-CMS-AM-hotel or by phone at 800-525-2253, Group Code 50H9WH House of Delegates: Resolutions must be submitted 40 days prior to the meeting of the House of Delegates, Aug. 10. Each component society will nominate one member to serve on the reference committee. The committee will hold two meetings prior to the annual meeting. Their report will be posted on the CMS website and distributed to delegates upon arrival at the annual meeting. CMS will open the HOD Saturday morning, Sept. 19. More info: www.cms.org/events/ annual-meeting 37

Inside CMS

Annual Meeting Registration Now Open

Colorado Medical Society Annual Meeting • Beaver Run Resort • Sept. 18-20, 2015 Visit www.cms.org to register online. It's quick, simple and secure. Name (please print) Component Society Name of Spouse/Guest(s) CMS Connection Member q Yes q No Registration deadline is Sept. 11, 2015. 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, Sept. 18

member spouse/guest

6:00 pm


Exhibitor Reception


Saturday, Sept. 19 (Complimentary for member and one guest only) 6:45 am 12:15 pm 5:30 pm 6:00 pm

Breakfast Buffet AMA/COMPAC Lunch Candidate Reception Inaugural Gala Meat dinner Vegetarian dinner Vegan dinner Gluten-free dinner

Sunday, Sept. 20 6:45 am

Breakfast Buffet


q q q

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

q q q q

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

member spouse/guest



TOTAL amount enclosed for non-members and additional guests.

#_______ @ $35/each_________


Please make check payable to: Colorado Medical Society, or charge ❑ Visa ❑ MasterCard ❑ Discover ❑ Am. Express

#exp. date

Signature Register online at www.cms.org or e-mail this form to dianna_mellott-yost@cms.org; mail it to PO Box 17550, Denver, CO 80217-0550; or fax it to 720-859-7509.

Hotel Reservations Reservations must be received by Tuesday, Aug. 18, 2015, to be eligible for the group rate. Visit www.cms.org/events/annual-meeting, or call 800-525-2253 to reserve your room today. Remember to use Group Code 50H9WH to secure the conference group rate. ROOM TYPE RATE Hotel $145 Studio $160 Colorado Suite $175 One-Bedroom Suite $180 Two-Bedroom Suite $242 Check-in is 4 pm and check-out is noon. Self-parking is $10 per car per day. Beaver Run Resort is a nonsmoking and cannabis smoke-free property, with all non-smoking units.


Colorado Medicine for July/August 2015

Colorado Medicine for July/August 2015


Inside CMS

Reflections Reflective writing is an important component 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 School of Medicine faculty members Steven Lowenstein, MD, MPH, and Henry Claman, MD.

He’s sleeping most of the time now. I think it’s time to take him off dialysis and focus on pain control.

Kelsey Luoma University of Colorado School of Medicine

Kelsey Luoma is a fourth-year medical student at University of Colorado School of Medicine. She grew up in San Jose, Calif., and spent her undergraduate years at Point Loma Nazarene University in San Diego. She is planning to apply for a residency position in internal medicine and pursue a career in hospital medicine or critical care.

Death, You are a patient customer. Stopping to check out the place, Strolling across the grounds before deciding to stay. His renal function is worsening at an alarming pace. We can’t seem to get his blood pressure back up. You begin to negotiate, Back and forth, debating your price. You linger a little longer these days. The delirium comes and goes. He doesn’t know where he is anymore. I think it’s time to talk about goals of care. One room at a time you establish yourself. Slowly unpacked belongings, Consume things once beloved. 40

Methodically, you crowd out what once was. Memory walks away; emotion peels off the wall in flakes. Pain is the last to go, slinking under the floorboards. Mr. O and his wife have decided on home hospice. He always wanted to die peacefully, with family nearby. You’ve settled in, made your space. The gleam of Medicine finds limit. Eyes drift shut, and we pass our patient gently off to you. n

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

Consider giving a tax-deductible donation of $25, $50, or more to help CMSF continue its mission. Questions? Call 720-858-6310.

Colorado Medicine for July/August 2015

Colorado Medicine for July/August 2015


Inside CMS

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

Work that begins when the legislative session ends

COPIC’s year-round advocacy efforts reinforce the practice of good medicine Sometimes it is a good thing when the harder you work, the less people notice. An example of this is the legislative advocacy that COPIC undertakes in collaboration with partners such as the Colorado Medical Society and the Colorado Hospital Association. When health care professionals can focus on delivering the best patient care – instead of dealing with policies that impede this – then we know our efforts are paying off. Between now and the start of the next legislative session, COPIC is busy with work that supports a stable health care environment. So what exactly does this entail? While tort reform is always on the top of people’s minds when they think about COPIC’s advocacy efforts, there are several other initiatives that we engage in: • Following the implementation of bills – What will be the intended (and unintended) consequences of new legislation? That is the question that COPIC cares about as bills are put into action. We are steadfast in monitoring their actual impact on health care and what this means for providers and patients. For example, in 2014, COPIC participated in conversations around House Bill 1283, which created a mandate for all DEA-licensed providers to register and maintain an account with Colorado’s Prescription Drug Monitoring Program (PDMP). As the bill was implemented, we sought to gain assurances from the Department of Regulatory Agencies (DORA) that it would provide practitioners with educational materials and reminders to register. COPIC suggested language for the PDMP notice letters to providers as well as for the pharmacy board regulations implementing the statute to improve provider’s understanding of the appropriate use of the PDMP. • Building relationships with legislators and informing them on issues – This summer and fall, COPIC will be meeting with more than 50 incumbent legislators to inform them of the challenges in health care and strengthen our relationships. By interacting with this audience as well as candidates, we not only reinforce the perspectives of health care professionals, but we also 42

demonstrate how COPIC can help legislators better understand the issues and make informed decisions. • Teaming up with partner organizations – One of the reasons we are effective in our advocacy efforts is because we stay connected with partner organizations. Each organization has its own expertise, and collaboration that taps into this is essential. At events such as the Colorado Health Symposium, we are engaged with our partners to gather insight and develop ideas that support a positive future in health care. • Serving as a resource for regulatory agencies – COPIC has a long-standing relationship working directly with DORA, and both organizations understand the importance of improving medical outcomes. That is why we work together to address challenges and review existing regulations. For example, COPIC met with DORA this summer for initial discussions about regulations for surgical assistants and technologists, which are scheduled to “sunset” in 2016. • Keeping an eye on tomorrow’s issues – Through decades of experience, we recognize the value of being a stakeholder that helps influence the future of health care. In 2014 and 2015, COPIC worked with partners in the medical community and DORA on appropriate language in medical board policies in light of advances in telemedicine. As the medical board considers the policy changes, there will certainly be new questions and COPIC is ready to provide the necessary guidance. What will the key issues during the next five years be? Nobody knows, but we are certain that COPIC will be involved. There is a strong sense of pride in being able to represent the medical community. It is a role that we continue to invest in and a responsibility that requires dedication. Advocacy is one of the ways that COPIC is more than just a medical liability insurance provider – we are a partner that the health care community can depend on. n

Colorado Medicine for July/August 2015

Inside CMS

CMS and COPIC staff report

Supporting the future of medicine through education and fellowship Medical students and residents are entering a health care landscape that continues to transform. As this presents different opportunities and challenges, CMS and COPIC recognize how the knowledge within our organizations is vital in helping these future physicians succeed. Since 1999, COPIC has offered a weeklong rotation for medical residents to help them understand medical liability issues and how to adequately prepare for these. The training focuses on the following: • An inside look at medical incidents and claims, and the world of medical-legal practice. • Patient safety initiatives and opportunities for enhancing practices and systems, as well as addressing barriers to implementation. • An understanding of the difference in epidemiology by medical specialty. • The value of communication, early reporting and patient relationships in improving outcomes. In 2014, COPIC hosted more than 150 participants from over 12 different medical facilities and organizations. We know the program is making a difference when we hear comments from participants such as “[What I liked most was] having direct access to real cases to learn from as well as open, knowledgeable experts in this field,” and “This is an amazing experience for residents. No discussion, lecture or presentation given during residency can replicate going over real Colorado Medicine for July/August 2015

cases with real [claims] adjusters and real lawyers.” COPIC’s Practice Essentials program is a one-day seminar that is designed to provide residents with a glimpse into the world ahead. It is supported by the Colorado Association of Family Medicine Residencies and the Colorado Commission on Family Medicine, and offers insight on topics including: • Assessing and evaluating practice opportunities in the areas of practice type, setting and location. • Financing life after residency with investment principles that help achieve long-term financial goals. • Reviewing key physician contract provisions when contemplating employment and managed care contracts. • Understanding basic business accounting practices and what to look for when assessing the bottom line. • Discovering the opportunities, unique rewards and challenges in rural practices. In addition, the COPIC Medical Foundation provides scholarships to students in health-related areas of concentration. We currently have scholarship programs through the University of Colorado School of Medicine, Rocky Vista University and Regis University. The Colorado Medical Society supports residents by offering them complimentary memberships and the associated benefits of membership, and

ensures their voices are heard through the continued support of the resident section, which grants them a seat on the CMS Board of Directors. CMS provides funds for medical student memberships, which in turn fund the medical student component. This is unique among other state medical societies in that the medical student component uses the dues from CMS to provide their members with travel funds to attend CMS meetings and develop educational programs, among other activities. They also receive seats on the CMS Board of Directors and the Council on Legislation, and they represent the largest delegation in the CMS House of Delegates. CMS also pays for Colorado medical students to be members of the American Medical Association. This connects them to the Journal of the American Medical Association (JAMA) and its 10 specialty journals, a database through which they can research residency programs, resources on choosing their career path and specialty, grants for school events and activities, test review guides, and discounts on student loans and AMA books. Medical education and training can be a busy, stressful time. CMS and COPIC help support medical students and residents with educational programming, networking events, advocacy and resources so they can achieve their full potential in medicine. n



medical news CMS Treasurer Katie Lozano, MD, announces candidacy for CMS President-elect CMS board member since 2008, I understand what it has taken and what it will take to advocate for our profession in what we all understand is a complex set of dynamics reordering our medical universe.

Katie Lozano, MD I have announced my candidacy for CMS President-elect and respectfully ask for your support. I am proud to be part of a state medical society that enjoys a well-earned reputation as one of the most respected and effective in the country. Our reputation is a consequence of thoughtful leadership, grassroots engagement, and focusing our resources where our ideas and actions have optimal influence. As your Treasurer and chair of the Finance Committee for five years and having served as a

We've broken barriers with a series of national firsts for physicians’ rights in payment systems, peer review protections, contracting, profiling and physician ratings, prior authorization, and prompt payment. We have built coalitions around patient advocacy and fair markets instead of defaulting to destructive professional and political rivalries, and we will need to continue this pragmatic approach to anticipate and fix the problems of the future. There are incentives to be realigned, barriers to care to be removed, fragments to be stitched together into meaningful collaborations, and bridges to be built across the usual political divide. We must manage economic and political pressure not only from outside our organization but also from within our own house. Given the powerful forces working both for and against the value of our services, as a society of physicians we have a moral responsibility to use our influence to ensure

that physicians and patients have choices, and ensure that our care is delivered at the right time, place, and value. We are all fortunate to be a part of a society that knows how to represent physicians, and I am doubly fortunate that my partners support my active involvement because they understand that patient advocacy and practice viability extend well beyond our own individual practice settings. We as a society have the collective talent, organization, and leadership to navigate these troubled waters successfully. I would be honored to be chosen to serve as president-elect of a proactive medical society that has established itself as a bridge-builder, convener, and problem-solver, bringing together the best and brightest to help doctors help patients, and to ensure that physicians and patients thrive in our state. Please contact me at treasurer@cms.org if I can answer any questions about my candidacy or to share with me how CMS can better serve your needs. Thank you for your consideration. n

Nominations sought for Michael J. Skolnik Award for Patient Safety Citizens for Patient Safety (CPS) and the Colorado Hospital Association (CHA) are currently soliciting nominations for the Michael J. Skolnik Award for Patient Safety. The award recognizes an individual or group that advances the quality and safety of health care for patients across Colorado. Michael, the namesake of the award, died in 2004 at age 22 following complications related to medical errors. The nominee must be a person, team or 44

organization that is actively involved with patient safety initiatives in Colorado. Nominees will be judged based on impact or benefit of the work performed, innovation or creativity of the work, and sustainability and replicability of the work. Nominees can include direct caregivers, health care executives or leaders, health care organizations, individuals from inside or outside health care who have actively promoted improvement in patient

safety, or students who have shown notable leadership. The awardee will receive $3,000 and be honored at the CHA Patient Safety Leadership Congress on Oct. 20, 2015. Anyone can submit a nomination and self-nominations are accepted. Submit a completed nomination form with an attached narrative by e-mail to safety. award@cha.com. The deadline is July 31, 2015. n Colorado Medicine for July/August 2015


medical news Colorado health insurers commit to SIM reforms Plus, CMS member appointed to SIM advisory board Six Colorado health insurers have committed to adopt reforms that set the stage for broader integration of behavioral and physical health care in Colorado: Anthem Blue Cross Blue Shield, Cigna, Colorado Access, Colorado Choice Health Plans, Rocky Mountain Health Plans and UnitedHealthcare. The state’s Medicaid program has also committed to reforms. Voluntarily crafted by each of the health care payers, the insurance plans vary in detail and are shaped to meet the different customer bases and business platforms of each payer while supporting Colorado’s State Innovation Model (SIM), an ambitious effort to integrate medical and behavioral health care and ensure the payment structures are in place to make that happen. In December the state received a $65 million federal grant and engaged in a cooperative agreement to implement this initiative. “This commitment from health insurers and the state Medicaid program is another chapter in that book and a huge step in making Colorado the healthiest state,” said Gov. John Hickenlooper in a news release. “We applaud these health care leaders for taking this step.” Additionally, CMS member Glenn Madrid, MD, a family physician with Primary Care Partners/Western Colorado Physicians Group in Grand Junction, has been selected as one of four appointed members of the SIM Advisory Board. The other appointees include the following: • Lilly Marks, vice president for health affairs, University of Colorado, and executive vice chancellor of the Anschutz Medical Campus. • Jeannie Ritter, mental health ambassador and former first lady of Colorado Colorado Medicine for July/August 2015

• Patrick Gordon, associate vice-president, Rocky Mountain Health Plans. They will join these other five board members appointed through their positions in the administration: • Reggie Bicha, executive director of the Colorado Department of Human Services. • Sue Birch, executive director of the Colorado Department of Health Care Policy and Financing. • Marguerite Salazar, Colorado insurance commissioner. • Larry Wolk, MD, executive director

and chief medical officer for the Colorado Department of Public Health and Environment. • Vatsala Pathy, SIM director. Colorado was awarded the SIM grant by the U.S. Department of Health and Human Services to create a coordinated, accountable system of care that gives Coloradans access to integrated primary care and behavioral health. The state will use the funding over the next four years to further develop and implement a blueprint to achieve this aim. Learn more at www.coloradosim.org. n

Colorado Supreme Court rules on surgery supervision The Colorado Supreme Court gave physicians a partial victory on June 1 when the justices ruled on a lawsuit challenging a 2010 decision by then-Gov. Bill Ritter that exempted Colorado’s rural hospitals from the federal regulation requiring a physician to supervise a nurse anesthetist delivering anesthesia care during surgery. CMS thanks the AMA Litigation Center for their support in this effort. The Colorado Medical Society and the Colorado Society of Anesthesiologists brought suit against the governor in 2010 arguing the exemption was contrary to Colorado state law. A Colorado District Court ruled against CMS and CSA in 2011 and the Colorado Court of Appeals upheld the lower court decision in 2012. The Supreme Court decision negates the major portion of the earlier rulings and reinforces the standing of CMS and CSA to challenge the Ritter decision in order to protect patient safety in anesthesia care.

CMS President Tamaan Osbourne-Roberts, MD, made a statement in response to the ruling. “Colorado law continues to classify delivery of anesthesia by a CRNA as a delegated medical function subject to physician supervision,” he said. “Such supervision is consistent with patient expectations and Colorado’s application of the Captain of the Ship doctrine, which designates legal responsibility for care of patients under anesthesia.” “Colorado Medical Society recognizes CRNAs as valuable members of the surgical care team. There is no dispute that nurse anesthetists are highly trained professionals; however, their training is shorter in duration, narrower in scope, and less comprehensive than the medical training of physicians. The Colorado Supreme Court’s decision clarifies that the governor’s decision is not a legal interpretation of either Colorado’s Medical or Nursing Practice Acts. n



Colorado Medicine for July/August 2015


medical news Colorado Medicaid and CHP+ provider revalidation begins Sept. 15 New federal regulations established by the Centers for Medicare and Medicaid Services require enhanced screening and revalidation of all Medicare, Medicaid and CHP+ providers.

clude a criminal background check, fingerprinting and unannounced site visits – including pre-enrollment site visits for some providers. Providers who fail to revalidate and enroll by March 31, 2016 may have their claims suspended or denied.

Beginning Sept. 15, 2015, all Colorado providers who want to continue, or begin, providing services to Medicaid and CHP+ members after March 31, 2016 will be required to enroll and revalidate their licensure and business information under new federal enrollment screening criteria. The Department of Health Care Policy and Financing (HCPF) has posted more information on the provider screening rule on their website. Go to www.colorado.gov/ pacific/hcpf and click on “Federal Provider Screening Regulations.”

Timeline Existing Colorado Medicaid and CHP+ providers will begin revalidation/enrollment on Sept. 15, 2015. To help all existing providers meet the March 31, 2016 deadline, HCPF will group counties together and initiate a series of revalidation/ enrollment “waves” by county. A map showing the county waves/groups and a schedule of when each wave can begin their revalidation/enrollment will be released in July 2015.

Based on the federal CMS’s provider type and risk designation, this process may in-

Providers are strongly encouraged to start preparing now by gathering documenta-

tion that will be needed to begin the revalidation/enrollment process: • Obtain your National Provider Identifier. o If you do not have an NPI, you may request one through the National Plan and Provider Enumeration System (NPPES) website, https://nppes.cms.hhs.gov/NPPES/ welcome.do. • Make electronic copies of certifications and licensures. HCPF has created a general “Provider Enrollment Checklist” that lists information you will need to have ready. The checklist and a number of helpful FAQs can be found on the Provider Resources webpage of HCPF’s website, www.colorado.gov/ pacific/hcpf/our-providers. Providers are encouraged to visit the website often as this information is updated frequently. n

Effort will help Colorado Medicaid patients, save taxpayer dollars Starting this year, diabetes education will benefit Coloradans on Medicaid, enhancing the quality of life for thousands of residents while potentially saving taxpayers nearly $30 million a year in health care costs. Thanks to a collaborative effort between state departments of Public Health and Environment and Health Care Policy and Finance, the Colorado Legislature recently approved funding to provide diabetes self-management education as a Medicaid benefit. The agencies estimate 11 percent of those in the health care programs that cover most Medicaid patients have diabetes, and at least 30 percent have prediabetes. Accredited, evidence-based education programs can help them learn how to eat healthier, stay active, monitor their medications and solve health issues. “This will eliminate needless suffering for thousands of Coloradans and save taxpayers Colorado Medicine for July/August 2015

millions of dollars in preventable acute care,” said Gabriel Kaplan, who manages the state health department’s Chronic Disease Prevention and Health Promotion Branch. Diabetes self-management education programs have been shown to improve health and reduce complications such as heart and kidney disease, nerve damage, amputations and hospitalization. According to a 2009 study in diabetes education, every dollar invested in such education programs saves an estimated $2.29 in health care costs. If all of Colorado’s Medicaid patients with diabetes received the education, the state could save nearly $30 million per year in health care costs related to diabetes. Kelly McCracken leads health department efforts to expand access to diabetes prevention and self-management. She and others have been working for several years to add Colorado to the 30 states that offer diabetes education programs as a Medicaid benefit.

They were well positioned to take advantage of a window opened by health care reform. Across the nation, the Affordable Care Act is driving the integration of health care and public health, bringing together the shared goals of expanding access, controlling costs and improving population health. In Colorado, the Department of Health Care Policy and Financing is exploring new health care delivery models and sustainable cost structures for improving the quality of care for its clients. Meanwhile, the Department of Public Health and Environment is focused on how health care reform can be used to improve population health. Agency leaders meet monthly to align efforts, set statewide initiatives and plan how to better connect public health with Medicaid. They have identified diabetes prevention and management, tobacco cessation, and training for nontraditional health care workers as priorities for collaboration. n 47


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

➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES EMERGENCY MEDICINE PHYSICIAN OPPORTUNITIES. NOVEMBER 2015 START DATE DENVER, COLORADO. SEEKING EM PHYSICIANS FOR FREE STANDING EMERGENCY DEPARTMENTS Premier Emergency Services, PC, is an entity associated with APEX Emergency Group, PC, is seeking Emergency Medicine Physicians to staff free standing emergency departments affiliated with Centura Health as they expand services throughout northwest metro Denver. • BE/BC in Emergency Medicine or

FP’s with Emergency Medicine board certification. • Premier Emergency Services, PC is 100% physician owned and democratically owned • Opening two facilities in Golden/ NW Denver area starting November 1st, 2015, with additional sites opening in 2016 • Experienced physicians or graduating residents are welcome to apply • Competitive base compensation with differential pay for holidays, 1099 independent contractor model • Malpractice paid

Westmed Family Healthcare is seeking a Full Time Family Physician Westmed Family Healthcare is a well-established Family Practice. We are currently seeking a Full time Family Physician to join our busy practice in a much sought-after location in Westminster Colorado to do strictly outpatient care with no OB. Westmed Family Healthcare offers a competitive salary, excellent benefits including a one-in-ten call schedule. Your work/life balance will be enhanced by a flexible work and call schedule. Please submit your resume to: lori@westmedfamilyhealthcare.com Lori Anderson Practice Manager Westmed Family Healthcare 48

• Full-time positions in recently developed free standing emergency departments within NW Metro Denver • Twelve hour shifts with approximately 10-12 shifts per month, as volume increases moving to eight hour shifts • New state of the art facilities • Denver offers the metropolitan amenities of world-class restaurants, museums, the performing arts and national sporting venues • Top rated public and private educational institutions • Easy access to renowned Colorado Rocky Mountain for summer and winter fun. Outdoor recreational activities abound with snow skiing, boarding, mountain biking and hiking, rafting and fishing readily available. • www.denver.org • www.colorado.com For additional information, please contact: Nicole Pajer: atdresourceshr@gmail.com

Serving the CME needs of Colorado physicians Your bridge to quality improvement in health care Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720.858.6309

Colorado Medicine for July/August 2015


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

➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES SUCCESSFUL PHYSICIANOWNED PRACTICE SEEKING BOARD ELIGIBLE/CERTIFIED FAMILY PRACTICE AND INTERNAL MEDICINE PHYSICIANS. Successful, physician-owned multispecialty medical group with fifteen medical offices throughout the Colorado Springs area is currently seeking Board Eligible/Certified Family Practice and Internal Medicine physicians who show our commitment to quality healthcare and compassionate service. The selected candidates will enjoy the benefits of practicing with a comprehensive team of professionals in an outpatient setting, with an established patient base. Colorado Springs is located one hour south of Denver and offers a majestic view of the Rocky Mountains. Situated near the base of Pikes Peak, “America’s Mountain”, it’s locale provides easy access to many outdoor activities including skiing, snowboarding, hiking and bicycling. Area public schools have an excellent reputation, and housing is reasonable with a relatively low cost of living. Relocation support available. Visit our website at www.mvmg.com. Contact Lori Spahn: E-mail: lspahn@mtviewmedgroup.com Phone: (719) 590-1177 or by Fax: (719) 590-1360 LOCAL ALLERGY/ASTHMA PRACTICE IS LOOKING TO RELOCATE IN CASTLE ROCK. We are seeking a medical practice to share space for 2 days per week. Practice will need around 4-6 exam rooms and a waiting area with 10-15 chairs. If you would like to office share space, please contact Dakota Reed, at 720858-7449. Colorado Medicine for July/August 2015

CONSULTATIVE EXAMINATION (CE) PROVIDERS NEEDED. Colorado Disability Determination Services is seeking qualified CE providers throughout Southwestern Colorado. The CE Provider performs one-time examinations on claimants applying for Social Security disability. Our most pressing need at this time is for licensed physicians to perform internal medicine, orthopedic, or neurological focused examinations in Southwestern Colorado. For more information, contact the Professional Relations Unit at 303-368-4100 or by email at KC.DE.

CO.S07.PR.Unit@ssa.gov. For general information about the DDS or Social Security CE guidelines, please visit these sites: http://www.colorado.gov/cs/Satellite/ CDHS-VetDis/CBON/1251580725146 or http://www.ssa.gov/disability/professionals/greenbook/ce-guidelines.htm

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

SEEKING PRIMARY CARE PHYSICIANS OR CLINICS IN THE DENVER METRO AREA If you are considering: • A new practice opportunity, • Integrating your current practice into a progressive group, • The sale of your practice, or • A change of employment. We offer a unique opportunity: • To be part of a progressive primary care group that has been a Level 3, Patient Centered Medical Home since 2009, • With a competitive compensation package, • Achieve a work/life balance, and • Care for patients without administrative headaches. If interested, contact us at (303) 493-5276. All inquiries will be kept in strict confidence and will receive a prompt response. 49


the final word Leo Tokar Senior Vice President in the Health Care Practice Lockton Companies

Conflicts in providing vs. financing care In today’s insurance environment, in order to answer the question “how do I care for my patients?” in a way that honors a doctor’s Hippocratic Oath, a physician is often forced to forgo an answer to the business question of “how do I get paid?” The answers to these questions are frequently not aligned. The only certainty is that changes in the insurance markets are forcing physicians to make changes in choosing a business model and with whom the physician will align. Those who don’t choose will inherently be disadvantaged as the pace of change quickens. Those who take a leadership role will adapt more quickly and find ways to be successful. From HIPAA compliance to meaningful use, there is no shortage of pressure on a practice. However, the greatest pressure is occurring on the health care financing side. A partial list of current insurance trends include the following: • Narrow and tiered networks. • ACOs, including financial coordination and sharing of risk. • Evolving forms of reimbursement. • Price and quality transparency. • Cost-based provider steerage. • Products with increased patient costsharing. In a prior “Final Word,” Jay Want, MD, wrote that health care has benefited from “lack of adult supervision of our spending patterns.” The dizzying myriad of initiatives being thrown at various aspects of health care, particularly the financing side, are meant to compensate for that lack of supervision by engaging all involved parties more meaningfully. Each one of them is somehow flawed, yet each one is a response to the need to better manage the escalating cost of health care. 50

Nowhere is this more true than in the employer insurance market. Employment-based insurance covers almost 150 million individuals in this country. Arguably, there is no natural connection between employment and health care. Nonetheless, employers are very much a driver of health care financing. Even though national health expenditures have flattened relative to GDP, midsize to large employers are experiencing 8 percent health benefit cost increases on average (after years of double digit increases), with those numbers expected to pick up in 2016. Premium trends continue to outpace most measures of inflation, wage growth and business revenue growth. Since that type of premium escalation cannot be absorbed year over year, that leaves employers in the difficult position of making changes to their health benefit plans that affect employees and their families. Insurers and thirdparty administrators become the vehicles through which those changes are implemented. Employers constantly scan the market, mine their data and push insurers for approaches that can be used to manage costs and provide alternatives to simply reducing benefits or increasing their employees’ benefit costs. In some cases, government programs like Medicare join in driving the market. Many of those approaches come down to making difficult choices for all parties – insurers, physicians, consumers (patients) and employers: • Insurers are choosing to align with providers, and push alternate reimbursement models. • Physicians are choosing to align with health systems and with increasingly narrow networks, and to provide

greater price and quality transparency. • Consumers are making trade-offs between premiums and benefit plan richness, breadth of network, cost of procedures and providers. • Employers, as mentioned, are choosing between subsidizing premiums and shifting costs to employees, offering broad choice or tighter networks, and, among many other trade-offs, between managing costs and simply getting out of providing benefits. The cost trends will not go away by maintaining the status quo. Those in the provider community who will be most successful will figure out how to manage within this evolving environment while also influencing its direction so that care quality is improved. Some opportunities for CMS and physicians include: • Taking the lead in defining how quality should be measured in ways meaningful to consumers. • Aligning with other physicians to present medical neighborhoods that can be used as the basis for narrow networks. • Choosing business models that allow greater risk-sharing. • Evaluating insurers based on criteria important to physicians. • Identifying where practices drive the greatest value, proving it, and promoting themselves. Health care delivery is driven largely by the physician community. Physicians have significant untapped opportunity to drive the financing side of the industry in a way that preserves their interests while also helping address the pressing cost management needs of the employer and consumer markets. n

Colorado Medicine for July/August 2015

Colorado Medicine for July/August 2015



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