July-August 2014

July/August 2014

Volume 111, Number 4

Think globally, practice locally: How population health will improve health, reduce costs

Award-winning publication of the Colorado Medical Society

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Colorado Medicine for July/August 2014

contents Jul/Aug 2014, Volume 111, Number 4

Features. . .

Cover story

Larry Wolk, MD, MSPH, Executive Director of the Colorado Department of Public Health and Environment, urges physicians to "think globally and practice locally" by integrating the concept of population health into their practices to improve health and control costs. Coverage starts on page 8.

Inside CMS 5 7 40 41 44 46 48 50 52

President's Letter Executive Office Update Board of Directors Report Annual Meeting Registration ICD–10 Update AMA Annual Meeting Report Reflections Member Benefit Spotlight COPIC Comment

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Making a difference in Southern Colorado–Kaiser Permanente teams up with contracted physicians to deliver positive results with its population health program.

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Health insurance costs–The Division of Insurance recommends changing Colorado's geographic rating areas for 2015 to reduce variances in health care costs.

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Legislative update–CMS celebrates a successful legislative session borne out of hard work and collaboration with allies, stakeholders and legislators.

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Positive Colorado Supreme Court decisions–Two June rulings have provided defendant physicians and patient safety advocates with significant legal victories.

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Affordable Care Act implementation–CMS leads call for Division of Insurance to clarify provider notification rules during the 90-day grace period for newly insureds.

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Spring Conference programming–Starting on page 26 and continuing through page 39, this suite of seven articles offers complete coverage of the programs presented at this year's conference.

Find your grounding............................................ 26

What's your story?................................................. 28

Prescription drug abuse...................................... . 30

Practice the rare..................................................... . 32

Physician leadership............................................. 34

Physician satisfaction........................................... 36

Health care trends affecting physicians........ 38 58

Final Word–CMS Past President Gary VanderArk, MD, exhorts the provider community to address its biggest failure in health care – lack of communication.

Departments 54 56

Medical News Classified Advertising

Colorado Medicine for July/August 2014

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

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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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2013/2014 Officers John L. Bender, MD, FAAFP

President Tamaan Osbourne-Roberts, MD President-elect Kay D. Lozano, MD Treasurer M. Robert Yakely, MD

Speaker of the House Brigitta J. Robinson, MD

Vice-speaker of the House Alfred D. Gilchrist

Chief Executive Officer Jan M. Kief, MD

Immediate Past President

Board of Directors Charles Breaux Jr., MD Laird Cagan, MD Leslie Capin, MD Cory Carroll, MD Joel Dickerman, DO Naomi Fieman, MD Carolynn Francavilla, MD Jan Gillespie, MD Johnny Johnson, MD Richard Lamb, MD 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 Ranee Shenoi, MD Stephen Sherick, MD Joshua Tartakoff, MS Theodore Timothy, MS Michael Welch, DO Jennifer Wiler, MD

Allison Wood, MS Harold “Hap” Young, MD Lena Young, MS 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 Mark Laitos, MD Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD CMS Historian W. Gerald Rainer, MD CMS Connection Mary Rice, President

COLORADO MEDICAL SOCIETY STAFF Executive Office

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

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

Brad Pierson, Art Director/ Manager, Communications, Brad_Pierson@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 Shelley Rabern, Executive Legal Assistant, shelley_rabern@cms.org

Mike Campo, Staff Support, Mike_Campo@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902.

Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colorado, and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance.

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

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Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Brad Pierson, Art Director, Assistant Editor; Chet Assistant Editor.

Colorado Medicine forSeward, July/August 2014 Printed by Spectro Printing, Denver, Colorado

Inside CMS

president's letter John Lumir Bender, MD, FAAFP President, Colorado Medical Society

Colorado’s Medicaid expansion: Is the honeymoon over?

Dear Physician, In June I had the privilege, along with several other Colorado Medical Society physicians, to represent our state in Chicago at the annual meeting of the American Medical Association’s House of Delegates. Dozens of resolutions were vetted, many were passed, and one in particular caught my eye, the unanimous adoption of AMA Resolution 103, titled “Continuation of Federal Augmentation of Primary Care Medicaid Payments.” The national delegates to the AMA “big house” agreed on the need to advocate strongly for Congress to continue the federal augmentation of primary care Medicaid payments to Medicare rates in perpetuity.

Nevertheless, this understanding is in sharp contrast to the messages I received from our elected officials and legislative aids in Washington, D.C., when I visited Capitol Hill in Washington, DC back in April. At that time, it was clear that no such legislation was going to pass in the current Congress. With the midterm elections coming this fall, the Republicans are predicted by most political pundits to take control of the Senate as well as the House, implying almost certainly that no such appropriation will be made to fund this part of Obamacare at the federal level in 2015 or 2016.

On the brighter side, back here at home, Health Care Policy and Finance Director Sue Birch, strongly supported by specialty and CMS advocates, fought hard and won state level funding from the Joint Budget Committee (JBC) in April to ensure that the Medicaid “bump” is still fully funded, but with state tax dollars, for primary care physicians in 2015 Colorado Medicine for July/August 2014

if the feds do not pass the appropriation.

Furthermore, Ms. Birch also was given an additional 2 percent budget line item increase by the bipartisan JBC to distribute among specialty care physicians willing to see Medicaid beneficiaries in 2015. All good news for Colorado. However, here is where we start to see the end of the “honeymoon phase” of the Colorado Medicaid expansion.

For private sector primary care physicians daring to take on new Medicaid, the risk now is that the bottom may fall out in 2016 or beyond as it is likely the bump will be financed only on a yearto-year basis moving forward. Recall that Colorado has a billion dollar tax surplus in 2014, so funding the bump this time was perhaps more realistic this year than some future years for the legislature. But there is also ongoing need for payment reform at HCPF in how the bump is actually paid. Currently that extra payment comes to physicians in quarterly lump sums. But as the percentage of Medicaid in a private sector practice expands, having a larger and larger proportion of the accounts payable tied up in a bump payment which is made

only quarterly stresses the operational budget for any size organization. HCPF needs a new strategy to pay the entire claim, bump and all, much more timely if it wants a value chain of physician suppliers capable of meeting expansion demands.

The punch line is that here in Colorado physicians are still left with a fee-forservice program, with or without the bump. And fee for service is dead.

The only way to “reignite the romance” for the Medicaid expansion is for Colorado to move past fee for service and into physician-led accountable care organization (ACO) payment models that offer true shared savings or gain sharing.

We may have married over that little “bump” but it will take the real commitment of an ACO payment model to keep the marriage of HCPF and private sector physicians moving forward together.

Sincerely, John L. Bender, MD, FAAFP n

Please help support CMSF In March 1997, Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization. The 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. The Board of Trustees of CMSF is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. The spirit of Colorado is alive in the many ways that we help our neighbors.

Call 720-858-6310 for more information and to donate.

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Colorado Medicine for July/August 2014

Inside CMS

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

Supreme Court ruling keeps professional review confidential Last month the Colorado Supreme Court gave patient safety advocates a gift of immense legal value: the preservation of professional review confidentiality. At a time when some other legal jurisdictions are weakening peer review protections, Colorado’s Supreme Court upheld the privilege in a June 23 decision.

The Colorado Medical Board (CMB), an executive agency under the leadership of Gov. John Hickenlooper, challenged an administrative law judge decision that would have weakened professional review protections by allowing professional review records to be subpoenaed and discoverable, and admitted in a civil suit.

The court not only drew an exception for the Colorado Medical Board’s “letters of concern” which were at issue in the case, but also ruled that the professional review statute protects the records of a professional review committee from all forms of subpoena or discovery stating that current law “protects the records of a professional review committee from all forms of subpoena or discover." The Court went on to say, “the statute further protects the records from admissibility in civil suits. We also hold that ‘civil suit’ includes administrative proceedings of an adjudicatory nature.”

During the 2012 General Assembly CMS, the House of Medicine and COPIC had successfully led a coalition to update Colorado’s professional review laws consistent with the current patient safety movement, thus making the recent Supreme Court ruling all the more satisfying.

In our support of the CMB's appeal of Colorado Medicine for July/August 2014

an adverse lower court ruling, CMS argued that breaching confidentiality would discourage if not erase physician candor in professional review proceedings and inevitably compromise patient safety. Our lawyers cited findings from Colorado Courts that have historically acknowledged the public health and safety purpose served by this vital doctrine. We also noted the lower court's contradiction of clear legislative intent – that these records must not be breached. As always, COPIC was a steadfast ally, along with the Colorado Defense Lawyer’s Association.

The State Supreme Court's ruling reaffirms a legal doctrine that is routinely challenged by trial attorneys across multiple venues. Over the course of the last decade we have responded to multiple legal challenges, while at the same time rebuffed a range of legislative proposals intended to expand the price tag on a malpractice suit by raising the damage cap and/or shifting the balance of this complex process to the plaintiff attorney’s advantage.

Personal injury lawyers are tough advocates for their point of view. With COPIC at our side, we have been countering their efforts to chip away at one of the most enduring, stable liability systems in the country. This time-honored conflict will persist long after I have retired and opened a bait shop. It is the nature of an adversarial process. We are not expecting any change of heart from the trial bar in the near future, so until we can get out of this groundhog day litigation cycle, we are stuck on a repeat, which requires sustained vigilance and unrelenting advocacy. The Supreme Court has taken the vital aspect of professional review confidentiality out of

judicial play, which can only mean the challenges to the privilege will be revisited at the General Assembly. Battles in that venue are largely won and lost in the election cycle. This is why I urge you to support the candidate of your choice during the 2014 election cycle

The court not only drew an exception for the Colorado Medical Board’s “letters of concern” which were at issue in the case, but also ruled that the professional review statute protects the records of a professional review committee from all forms of subpoena or discovery. and contribute to our political action committee COMPAC as well as to our small donor committee that donates exclusively to candidates 100% committed to maintaining Colorado’s stable tort environment. You can donate on-line at www.CMS.org.

As a former state representative and friend Mike McKinney, MD, told his Texas colleagues, “if you’ve got a license to practice medicine, you’re involved in politics whether you like it or not.” n

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Cover Story

Think globally, practice locally: How population health will improve health, reduce costs Larry Wolk, MD , MSPH, Executive Director, Colorado Department of Public Health and Environment

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Colorado Medicine for July/August 2014

Cover Story As physicians, we spend much time with our patients treating diabetes, cardiovascular disease and mental health.

But to really move the needle on such conditions, we need to invest at least as much time – if not more time – on the population-based practice of medicine, rather than merely treating individuals.

That’s why the concept of “population health” has gained support from the medical community in recent years.

While population health has been given many definitions over the past two decades, I define it as any effort intended to impact the health of larger groups of people rather than one individual at a time. (Which, not coincidentally, is how I also define public health).

Advocates of population health include Tom Frieden, MD, MPH, director of the Centers for Disease Control and Prevention since 2009. Four years ago, Frieden introduced a five-tiered pyramid to provide a framework to improve health on a population level (Table 1). At the base of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socioeconomic determinants of health – the circumstances in which people are born,

Increasing Population Impact

grow up, live, work, and age, as well as the systems put in place to deal with illness.

It’s hard to get your head wrapped around the idea of the social determinants of health unless you’ve practiced in a Third World country or an impoverished area that lacks the things that we take for granted – such as clean water, sanitation systems, clean air and safe food: the basic tenants for keeping a population healthy. By and large in Colorado, we take those things for granted unless somebody is worried about oil and gas operations polluting our air or drinking water.

Population health addresses these and other environmental and social determinants by thinking outside the box to engage broader segments of the population to improve their health or influence public policy. (See sidebar: Population health in Colorado and Table 2). It is the natural progression of improving health and controlling costs that begins with the doctor-patient relationship, then advances to a specialized practice or medical home, then to a medical neighborhood, and ultimately to the general population.

Increasing Individual Effort Needed Counseling and Education Clinical Interventions

Long-Lasting Protective Interventions Changing the Context to Make Individuals’ Default Decisions Healthy Socioeconomic Factors

The Health Impact Pyramid

While we have an important role in individual patient care, I would argue that many physicians don’t even think about or participate in population healthbased activities. But doing so would make a significant and measurable difference to Coloradans, Americans and citizens worldwide.

Challenges and opportunities Some physicians might say they lack the time and resources to engage in population health, but I would argue that the Affordable Care Act removes some of the financial barriers associated with the concept – creating new incentives and opportunities for getting on board.

Meanwhile, advancements in health information technology (HIT) are making population health practice more possible than ever before. In many cases, doctors are already putting the tenants of population health into practice without necessarily knowing they are doing so.

Prior to the ACA and environmental health issues aside, the role of public health was viewed narrowly as immunizations, promotion of family planning and chronic-disease prevention.

Funding of public health initiatives was largely dependent on government entitlements and grants because there was no tangible return on investment.

Now, with the implementation of the ACA, that model is changing, with mandated health insurance, mandated preventive health benefits and substantially more people with coverage. Theoretically, if everybody is eligible for insurance, we shouldn’t need entitlements or grants for population-based health care services, including immunizations, family planning and/or cancer screenings.

I believe that such traditional public and population-health interventions should be shifted to the primary care settings or medical home settings. So, if population health is embraced by the entire medical sector, what is the role

Table 1 Colorado Medicine for July/August 2014

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Cover story (cont.) of public health? At the risk of sounding provocative, the role significantly changes, causing me to evaluate if and how public health departments should exist – regardless, from the patient and population perspective, even if the

transfer of some of these interventions from public health to the health care delivery system were to occur, isn’t that a victory for everyone?.

ment of Public Health as well our local public health authorities to shift the paradigm they operate under to the ACA and practice public health in the context of the evolving model of health I’ve challenged our own State Depart- care reform. I challenge the practicing community, physicians and hospitals to do the same by asking, “Can I address my population’s needs, given the new model of health care reform? In the extreme or ideal, primary care physicians may go so far as to say: “You know what? We don’t need public health to provide Population health may be a relatively new concept, but numerous programs and committed immunizations to our individuals are already at work in Colorado. Here are some things health professionals are doing community. We are prothroughout the state to make a difference on the health of large groups of people: viding family planning services to our commu9HealthFair – Since 1987, this nonprofit program has promoted preventative health maintenance nity. We are compenthrough free and low-cost awareness and educational screenings throughout metro Denver. With sated and incentivized the support of 16,000 statewide volunteers and the promotional strength of NBC affiliate KUSA, the to provide populationprogram has impacted more than 1.7 million individuals – earning endorsements from the Colorado based services.”

Medical Society, the Colorado Nurses Association and the Colorado Hospital Association. With nearly 100,000 people taking advantage of the 9HealthFair every year, Colorado health professionals The reason public should be sure to support this program. health departments offered immunizations Colorado Diabetes Prevention Program – One of out three Coloradans are at risk of contracting was so that people withdiabetes. With support from the American Diabetes Association, Colorado’s Diabetes Prevention out insurance could get Program conducts tests to determine who is among that group with blood tests, counseling and their vaccines and avoid education. Participants aim to lose 5-to-7 percent of their body weight by reducing fat and calories, catching or spreading and by being physically active for 150 minutes a week. This program deserves special accolades preventable diseases. for taking what is normally done on an individual patient-to-doctor basis and applying it in a For individual practices, population-health context. immunizations could be an opportunity to get 5th Gear for Kids – Led by James O. Hill, Ph.D., from CU’s Anschutz Health and Wellness Center, more people enrolled.

5th Gear for Kids is a collaborative effort between the Aurora Public Schools and Cherry Creek School District. The program includes activities, events and incentives to encourage fifth graders to Case in point: Every participate in healthy lifestyles. Participation is rewarded with prizes, free fitness classes, discounts physician has eligibilon food, admission to local recreation centers, youth sports at the YMCA and more. ity and billing systems that could be converted Walk with a Doc – Organized by Andrew M. Freeman, MD, FACC, FACP, a cardiologist at National into enrollment systems Jewish Health, this program promotes physical activity while giving people a chance to walk or with a little tweaktalk with a doc at a park at a regularly scheduled time. Participants range from people with serious ing. Instead of turning health problems to those who live a sedentary lifestyle who want to start an exercise regimen. somebody away who If more doctors throughout the state committed to taking routine walks with members of their doesn’t have insurance, communities, the entire population would benefit. why not host a kiosk in your office where people Public service – More physicians are seeking elected office because they see an opportunity to can enroll and nobody do something on a population level that they couldn’t do on a patient level. Sen. Irene Aquilar, MD, is turned away due to D-Denver, is a great example of someone who takes health-related issues and tries to do something lack of coverage? In eson a population level that individual practices could never achieve on their own. Medical directors sence, that’s population for health insurance companies also are in a position to impact population health in a big way since health. In fact, enrollthey could develop population-based programs for hundreds of thousands of people at once. ing someone in a health

Population health in Colorado

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Cover Story Health outcomes and distribution in a population (dependent variables)

Table 2

Patterns of health determinants over the life course (independent variables)

Policies and interventions at the individual and social levels

insurance plan may do more to improve a patient’s health than an annual physical evaluation.

If that sounds daunting or even crazy, the good news is that many physicians are already participating in population health, providing preventive services, disease control and family planning.

Addressing the social determinants, like insurance coverage, transportation, poverty and education may seem foreign but should be no less important and not that much more difficult to address, considering there are evolving models of payment reform that incorporate such activities.

Potential for the future As CORHIO (Colorado Regional Health Information Organization) and QHN (Quality Health Network) make gains toward connecting all of Colorado to health information exchange (HIE), the potential for incorporating the principles of population health to the mainstream of health care grows by leaps and bounds. With CORHIO and QHN, physicians in the not-too-distant future can take a population-based approach to help an individual’s health – effectively addressing the needs of many while applying it in an individual fashion.

As a physician, this means when a patient comes to see me, much of what I need to know is right there in their electronic health record – a much better way to prevent duplication and focus more broadly on my patient’s health.

Currently, CORHIO and QHN are

Colorado Medicine for July/August 2014

expanding and working on a direct exchange protocol – like a secure e-mail – that will enable doctors to access the kind of robust health information that helps Kaiser’s doctors use populationbased clinical data to inform patients about best practices in treating conditions like diabetes or heart disease.

As these exchanges or repositories of individual patient information become more robust, the individual practicing physician will have more tools and reports available to better treat his or her population of patients. So as it relates to health information technology. In the spirit of population health, every physician should move to an electronic health record system, get connected to an HIE and plan to eventually analyze your own data to improve the health of your population. Meeting that challenge is easier and less expensive nowadays in large part because of the ACA. Lastly, who can talk about population health and Colorado in the same breath without alluding to marijuana? With recreational cannabis now legal in the state, Colorado physicians may be uncomfortable talking about the pros and cons of consumption when the medical data hasn’t caught up. But population health leaves open the possibility that analytics can give physicians access to more information in the not-too-distant future. And whether it’s marijuana, or diabetes prevention or even the health effects of fracking – all issues that affect or are of interest to large populations – shouldn’t we as physicians make it a part of our roles to provide evidence-based

information, whether in the office, our schools or other community settings?

I had an idea at one point in my career that every pediatrician should link to the school-based health centers in their communities. If that were to happen, pediatricians would be sought for education on health, participate in assemblies, teach classes and build that sense of community. As a health care professional, that demonstrates that I’ll see you when you’re sick, but I am also investing my time in keeping you healthy.

Up until now, there hasn’t been a financial incentive for physicians to participate in such activities, but with the ACA, you’re starting to see funding mechanisms emerge that will let physicians invest their time and be paid for that time. That will lead to better outcomes. And part of payment reform is not paying for each individual patient you see, but for the health of the patients and outcomes of patients you’re seeing.

It’s going to take us a while to get there, but for those of us who really “get it,” we’re not going to move the needle by exclusively providing individual patient visits – we’re going to do it by getting out there and improving the economic and social surroundings that our patients are living in as well as spending the time to invest in the communities where we work.

If physicians in Colorado and nationwide make population health a priority, actuarial knowledge will over time show that we are making good health sustainable and affordable for generations to come.

As a physician and director of the Colorado Department of Public Health and Environment, I call on all of my peers to take steps to meet this challenge of bringing population health and community practice together – think globally! n

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Features

Making a difference in Southern Colorado C. Rocky White, MD, Market Medical Director, Kaiser Permanente Southern Colorado and Richard Spurlock, MD, Medical Director of Network Relations and Development, Kaiser Permanente Southern Colorado

Population health program demonstrates results Kaiser Permanente has long incorporated the concept of population health within an integrated delivery system.

But until recently, there has been little data to show how population health and managing chronic conditions can improve outcomes in a health care model where physicians operate independently in a community setting.

Fortunately, providers of Kaiser Permanente’s Southern Colorado region are already seeing some positive empirical evidence that population health works in a Collaborative Care Model we implemented in 2012. Results include the following:

their physicians and care teams through that electronic medical record, enabling increased care coordination. However, in Southern Colorado, approximately 90 percent of our 60,000 members visit contracted physicians through a Preferred Provider Organization (PPO) outside of our integrated system.

Due in large part to this fragmentation of the system, the metrics revealed a significant disparity between Southern and rural Colorado and our more integrated markets. Considering that Southern Colorado is in a sense a “test kitchen” for Kaiser’s PPO, a different kind of vision was needed.

Even though Kaiser has a very robust health information technology (HIT) program inside our integrated system, we are unable to exchange electronic medical records with individual practices – the interoperability is not yet there.

We developed a pay-for-value program where we engaged adult primary care offices, pediatric practices, cardiologists and OB/GYNs around quality programs.

• We have observed an increase in hypertension control of 7 percent.

• The control rate in our diabetic population increased by 12.5 percent.

• We developed a scorecard and worked with our OB/GYN practices in the region to reduce the number of elective deliveries before 39 weeks. When deliveries are induced electively prior to 39 weeks gestation, babies have a higher incidence of neonatal complications and may not be mature enough to thrive on their own (requiring intensive intervention).

Though we have demonstrated that giving groups the tools they need to do population management leads to measurable positive results, we have faced the same set of challenges as most of Colorado’s commercial health care sector.

Members who see Kaiser physicians in our medical offices are connected to Colorado Medicine for July/August 2014

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Population health (cont.)

We started with some of the larger groups by initiating a few quality metrics that physicians could agree upon. We began with five metrics for diabetes, one for high blood pressure, and three additional prevention measures, including breast cancer, cervical cancer screening and colon-rectal cancer screening.

Then, we provided financial incentives to hit certain targets and improve those quality metrics. Initially, there was some pushback to the program because providers are resistant to an insurance company coming in and telling them what to do. But we took the approach that physicians are highly motivated to

make a difference in individual patients’ lives, and a Kaiser Permanente physician, along with Kaiser Permanente nurses and support staff worked with them to help them do so.

We helped one reluctant physician set up a separate registry for his 30 diabetic patients. Within a year, he saw an improvement in the metrics of those patients and installed an electronic medical record (EMR) system when his practice saw the clear benefits of population health.

In another case, Kaiser gave a provider a list of patients who had not had breast

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Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org

cancer or colon-rectal cancer screenings. The practice succeeded in bringing in many of those on the list for screenings. The tests for two of those patients revealed early detectable cancers that were treated in the early stages – potentially saving both patients’ lives and avoiding more costly treatment later on.

For many practices, population health is the right thing to do but difficult to implement. But when you break down the barriers and provide a stipend for improving patient care, a nursing staff to provide outreach support, as well as educational resources about population medicine, the practices enthusiastically deploy new procedures.

Sometimes, implementing population health simply means helping an engaged staff understand the concept, gather office charts, and develop a spreadsheet around targeted patients. You don’t necessarily need a fancy EMR to do this (though it’s easier and more accurate).

From our observations, the tenants of population health really resonate with health care professionals when they see the difference it makes in individual patients’ lives. At the end of the day, that’s what Kaiser is about, and that’s why these professionals are in their field. n

Are you interested in teaching medical students and residents from the University of Colorado?

Join the clinical faculty of the CU School of Medicine! By becoming a preceptor, you can teach, guide and mentor young physicians and share the joy of the practice of medicine.

For an application, or for more information about opportunities, responsibilities and benefits as a Clinical Faculty Member, please see www.medschool.ucdenver.edu/ocbme or contact Nicole Bost or Dennis Boyle at 303-724-0044 or Nicole.Bost@ucdenver.edu.

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Colorado Medicine for July/August 2014

Colorado Medicine for July/August 2014

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Features

Health insurance costs Kate Alfano, CMS contributing writer

DOI recommends new geographic rating areas for 2015 The Department of Regulatory Agencies Division of Insurance is moving forward on a new structure for dividing the state to influence the cost of health insurance. Geographic rating areas are units made up of metropolitan statistical areas (MSAs), counties or three-digit zip codes, which are used by insurance carriers to price premiums. An MSA is a geographical region with a relatively high population center and close economic ties throughout the area.

Under the Affordable Care Act, states have the option to default the rating areas to their MSAs plus one non-MSA region or to expand upon those areas if the regions are actuarially justified, not discriminatory, lead to stability in rates over time, and apply uniformly, among other requirements.

For 2014, Colorado chose to implement a structure of seven MSAs and four non-MSAs. The seven MSAs are Grand Junction (Mesa County), Fort Collins (Larimer County), Greeley (Weld County), Boulder (Boulder County), Denver (metro Denver and the surrounding areas), Colorado Springs (Teller and El Paso counties), and Pueblo (Pueblo County). The non-MSAs are West, Southeast and Northeast, which comprise mostly rural counties in those areas of the state, and the Colorado Mountain Resort region, which comprises the counties of Garfield, Eagle, Summit and Pitkin.

A Kaiser Family Foundation report revealed that the Resort region had the Colorado Medicine for July/August 2014

highest health insurance premiums in the country at $483, which sparked an outcry from citizens and the threat of a lawsuit from Garfield County as county commissioners contested being grouped with the resorts.

“Variations in health insurance premiums across regions arise due to variations in the cost of health care across regions,” said Insurance Commissioner Marguerite Salazar in a news release.

“These variations are not new, but the transparency brought by the Affordable Care Act is new.”

At the beginning of the year, Gov. John Hickenlooper asked Salazar to convene a Healthcare Cost Study Group to learn more about the cost of health care and health insurance across the state. The group brought together representatives of hospitals, health care providers, consumer groups, insurance carriers and residents of the mountain communities.

The group engaged Miller and Newberg Consulting Actuaries to broadly review health cost trends in Colorado and evaluate geographic rating area options for 2015. The actuaries analyzed five options for the rating areas, including the current structure, and identified three that they said would minimize uncertainty and promote stability in the cost of health insurance premiums. Each option was scored based on four factors: credible membership, stability in utilization patterns, standard deviation of total cost, and cost per unit.

Challenges in the analysis CIVHC provided Miller and Newberg with claims data from the All-Payer Claims Database (APCD). Physicians understand all too well the inherent challenges with claims data due to the lag time between when services are rendered and when claims are paid. Some claims are paid one to three months after services are rendered, but some are paid four to 24 months after. To determine insurance premiums, the actuaries adjusted the claims driving the premiums for lag payments, which is referred to as “actuarial completion.”

The APCD data included paid dates through March 2013; this allowed for sufficient data for the year 2012 but not for 2013.

For a region or county to establish credibility to stand on its own, the actuaries determined that it must have a large membership base. Credibility is a qualitative score that assisted in the comparison of regions. In health care it is often defined through member months; that is, the total cost in that region or county must remain stable over the threeyear period to have high credibility.

Twenty-eight counties were determined to have low credibility and 15 were determined to have low-medium credibility. The vast majority of these counties were located in the non-MSAs: the northeast, southeast and west areas, with two in the Resort region. Of the five options evaluated by the actuar-

17

Geographic ratings (cont.) ies, only the current structure of seven MSAs and four non-MSAs had medium credibility. All others were determined to have high credibility overall.

The actuaries reported that credibility for future studies would improve as CIVHC works to enhance the number of complete carriers and adds small group data.

Another challenge arises from utilization and migration patterns, which drive stability in rates. Provider contracts have the potential to be very different in various regions due to the natural occurrence of different providers in the region.

For this reason, the actuaries concluded that grouping regions that cover large geographic areas could lead to instability in current costs and/or future costs as contracts change in those regions.

Utilization patterns have the potential to be very different as well because patients in various regions typically utilize health care services within their current region. The actuaries found that the non-MSA regions have varied utilization patterns and any combination of non-MSA regions lessens the stability in utilization.

The decision The DOI recommended pursuing the option that would create seven MSAs plus two non-MSAs. The MSA regions will remain the same. One non-MSA will now comprise the West region and the four counties of the Resort region (still excluding Mesa County), and the other non-MSA will comprise counties in the southeast and northeast.

They received 306 comments during the comment period, of which 138 addressed the rating area options; 117 comments were supportive of the new structure.

Salazar said in a release that the new non-MSA combinations will spread the cost risks more broadly. “We believe this option will lead to the fairest distribution of costs across these regions.”

The U.S. Department of Health and Human Services approved the structure on May 15 and it will take effect in January 2015.

slightly in Garfield, Eagle, Pitkin and Summit counties, but will slightly increase in other areas of western Colorado. Plymell said it’s certainly the hope that variations will be equalized but reductions in cost cannot be guaranteed.

The DOI doesn’t set health insurance rates; they review and approve submitted rates from insurers as long as they are actuarially justified.

Overall, Plymell said the whole process has been a positive learning experience.

They gained sound data on health care costs that the commissioner will share with the new Colorado Commission on Affordable Health Care Costs to aid in their discussions. “Anytime you can get people talking about their health care and their health insurance and engaged in that and asking reasonable questions, that will only be a good thing.

Sometimes you deal with questions that are tough to answer but it’s worthwhile to get to the bottom of them.” n

Some have speculated that premiums on the individual market will go down

When considering variability of total cost within a region, the actuaries measured standard deviation between the highest-cost county and the lowest-cost county. Regions with lower standard deviation scores have less variability and less potential for discrimination.

According to Miller and Newberg, the highest standard deviation scores for total cost are found in the West, Northeast, Southeast, Denver and Resort regions, in that order.

Vincent Plymell, DOI communications manager, said, “We were very pleased with their work, being able to tease out information and delineate it by services and by geography to look at things and then given that data to analyze options that were under consideration for the geographic rating areas.”

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Colorado Medicine for July/August 2014

Colorado Medicine for July/August 2014

19

Features

Legislative update Susan Koontz, JD, CMS General Counsel

CMS celebrates successful legislative session The Colorado Medical Society advocates for Colorado physicians and their patients in a challenging legislative environment. Despite strongly held beliefs among the elected officials, partisan control of both chambers is thinly held resulting in a raft of bipartisan legislation from the state budget to policy. In this environment, unique among most state legislatures, legislators addressed scope of practice issues, provider reimbursement rates, the rising costs of health care, clean claims, the growing problem of prescription drug abuse, children’s health issues, and many others.

CMS lobbied for or against more than 40 bills to ensure legislation benefited physicians professionally and helps improve the health and wellness of Colorado patients. The CMS Council on Legislation (COL), along with their policy and public affairs professionals, reviewed each bill to understand its intent, its possible outcomes and the political landscape to collectively determine how and at what level CMS should engage. Demonstrating that organized medicine in Colorado is not an oxymoron, CMS, component medical societies, and state specialty societies united on numerous bills to enhance impact and assure positive outcomes.

The accomplishments of the session can be divided into six categories: Liability CMS participated vigorously in the 2012 election cycle by making pres 20

ervation of Colorado’s stable liability climate a priority. Despite Democratic control of both chambers and the governorship, which had the potential to favor traction by the trial lawyers, the legislature preserved the liability climate and there was no erosion to professional review – the two highest priorities based on CMS member polling.

Maintaining these priorities is a direct result of physician member contributions to the Colorado Medical Political Action Committee (COMPAC) and the Small Donor Committee. The interview and endorsement process enabled by your contributions builds strong legislative relationships and drives commitments from legislators on these top issues.

Physician payment For the second year in a row, legislators approved an across-the-board increase in Medicaid payment, with 1.5 percent last year and 2 percent this year and an additional 0.5 percent increase to conduct pilot projects on specialty access.

This pattern demonstrates a commitment by Gov. John Hickenlooper and his administration to ensure good access to health care for this population.

Additionally, the legislature maintained Medicaid pay parity with Medicare for primary care through 2015 at a time when the federal government discontinued this increase. The Hickenlooper Administration, backed strongly by primary care and CMS advocates, is directly responsible for extending the

payment increase and preserving primary care access.

CMS advanced the process for standardization of claims edits. We strongly supported SB14-159: Extending the Clean Claims Taskforce, which allows for an extension of the work of the Colorado Clean Claims Task Force so the group can work to implement reforms nationally. The development of uniform edits for commercial payers has the potential to save $80 to $100 million per year in Colorado alone. The bill was signed into law on May 29.

Prescription drug abuse This is an emotionally charged issue and could have potentially sparked a backlash against physicians, but CMS worked to support two bills to reduce opioid misuse and abuse while not adding substantial burden to physician practices. The new CMS Committee on Prescription Drug Abuse reviewed all bills in detail and provided CMS decision-makers with subject matter expert advice.

HB14-1283: Modify Prescription Drug Monitoring Program, signed into law on May 21, makes modifications to the electronic prescription drug monitoring program (PDMP), including the ability for physicians to designate up to three people to access the PDMP on their behalf. The bill mandates registration of physicians to the system but it does not mandate use or education. CMS registered strong support for this bill throughout the legislative process while Colorado Medicine for July/August 2014

Features also being involved with the Colorado State Board of Pharmacy to update the PDMP to make it more user-friendly.

HB14-1207: Household Medication Take-back Program, also signed into law on May 21, creates a permanent infrastructure that allows individuals to dispose of unused medications at approved collection sites, and for carriers to transport unused medications from approved collection sites to disposal locations.

Health care cost SB14-187: Colorado Commission Affordable Health Care, signed into law on May 29, creates a 12-member commission to undertake a comprehensive, evidence-based analysis of the principal cost drivers in health care in Colorado and the effectiveness of strategies for controlling health care expenditures.

The commission will include representatives from across the state, appointed on a bipartisan basis by the governor and legislative leadership. CMS recommended five physician nominees for service on the commission. CMS member Jeff Cain, MD, was appointed. The commission is required to make recommendations to the legislature for each of the following three years.

The Colorado Center on Law and Policy incubated this legislation. Virtually every stakeholder was lined up to testify in support of the bill, including the business community, health plans and providers. Our support positions CMS well as the commission is established to bring ideas to the table about quality, cost containment and access.

Bad ideas killed at our urging CMS was instrumental in killing HB14-1068: Physician Report Driving Condition, which would have required a physician to report a patient to the state for any condition that could compromise his or her ability to drive a vehicle – “loss, interruption or lapse of consciousness or motor function” – imposing both criminal and civil penalties for failure to report. It also would have removed physician immunity for reporting to the DMV thereby exposColorado Medicine for July/August 2014

ing physicians to additional liability by third parties.

CMS president-elect Tamaan Osbourne-Roberts, MD, and COMPAC Chair Dave Ross, DO, testified against the bill, explaining the potential consequence that patients would avoid medical treatment and evaluations and physicians would face criminal harassment or prosecution if a patient, regardless of ability, were involved in a traffic accident.

CMS also opposed SB14-32: Alternative Health Care Providers Treat Children, which would have repealed the restrictions on alternative health care providers to treat children of any age. After a tough fight, CMS and its specialty allies prevailed and the bill was killed in the House Health, Insurance and Environment Committee.

CMS opposed SB14-128: Modify Naturopathic Doctor Act, which would have allowed a naturopathic doctor (ND) who does not satisfy the education and examination requirements determined last year by HB13-1111 but who holds an active certification in good standing from the American Naturopathic Medical Certification Board to obtain a state-issued ND registration. The bill was killed in the Senate Health and Human Services Committee.

(CDHPE) to issue a community clinic license to a community clinic that provides emergency care if it is located more than 25 miles from a hospital in the state. Two years after the effective date of the bill, all other freestanding emergency rooms would have been required to be owned and operated by a licensed or certified hospital. CMS supported the bill but it was viewed as anticompetitive by conservatives on both sides of the aisle and did not pass.

As originally drafted, HB14-1288: Student Immunizations Prior to School Attendance would have put into place modest educational requirements for parents who were considering use of the “personal belief exemption” for opting out of immunizing their children.

Unfortunately, the bill was amended to remove the educational requirements to only require schools to report vaccination rates. The governor signed the bill into law on May 21. The CMS lobbying team anticipates that the fight for stricter educational requirements around an increasing vaccine opt-out rate will continue into next session and beyond.

CMS was instrumental in killing HB141364: Treatment of PTSD with Medical Marijuana, which would have added post-traumatic stress disorder to the list of conditions that could be treated with medical marijuana.

HB14-1108: Copayments for Physical Rehabilitation Services would have prohibited a carrier from charging a covered person a copayment for physical rehabilitation services that is more than the copayment charged for a visit to a primary care physician. The bill required a carrier to clearly state the availability, including limitations, conditions, and exclusions, of physical rehabilitation services under its plan.

This bill could not be killed in the statehouse and the governor vetoed it.

A bill that would have decreased the hours for prescriptive authority of advanced practice nurses was proposed but not introduced. In the interim we have pledged to work with other health care providers on prescriptive authority, anesthesia and telehealth.

SB14-155: Medical Marijuana Health Effects Grants Program will create a sub account in the CDPHE medical marijuana cash fund that will provide funding for medical marijuana health research. The governor signed it on May 21.

Other significant legislation SB14-016: CDPHE Regulate Freestanding Emergency Centers would have permitted the Colorado Department of Public Health and Environment

We want to thank the members of the Council on Legislation for their hard work and congratulate all CMS members for an exceptional session. n

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The Jane Nugent Cochems Trust

eed n n i s Financial h n a i c elp for physi

Application deadline: October 15, 2014 The Colorado Medical Society administers grants from the Jane Nugent Cochem's Charitable Trust to offer short-term financial help to physicians in need. The average grant to approved applicants ranges from $5,000 to $10,000 although larger amounts can be approved.

The application process is simple and the review process is completely confidential.

For more information or to obtain an application form, please contact Tom Wilson at the Colorado Medical Society at 720-858-6316 or by e-mail at tom_wilson@cms.org.

Visit http://www.cms.org/about/cochems-trust/ to download an application form.

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Colorado Medicine for July/August 2014

Features

Colorado Supreme Court Susan Koontz, JD, CMS General Counsel

June rulings good news for physicians and patient safety The Colorado Supreme Court has provided defendant physicians and patient safety advocates court rulings of immense legal value in two decisions handed down this month: the preservation of a vital rule of evidence and professional review confidentiality.

Working together, Colorado Medical Society and COPIC spend considerable resources to protect Colorado’s relatively stable liability climate and collaborate with partner organizations to promote patient safety. These two decisions represent important victories in that battle.

Defendant Physician v.

Haralampopoulos: Colorado Supreme Court ruling June 16, 2014 The Colorado Supreme Court issued an important case decision that will help support physicians in the defense of malpractice cases by permitting the introduction of hearsay evidence in support of alternative causes to negligence for plaintiff injuries. In this case, the Court properly recognized that an ex-girlfriend’s statements about a patient’s cocaine abuse were admissible for purposes of diagnosing the past medical event even though they would not affect future treatment. The Court agreed, as advocated by COPIC, CMS and others, that diagnosis of a patient’s condition does not end at some defined point, but frequently continues and is refined as more information is received.

COPIC vigorously defended the practice of good medicine throughout this case that involved two appeals. CMS supported that effort by submitting an Amicus, or friend of the court, brief on behalf of the defendant physicians in the case to help Colorado Medicine for July/August 2014

persuade the Colorado Supreme Court to rule in their favor and clarify Colorado hearsay rules in favor of physicians defending malpractice cases. In addition, CMS recognized the importance of the issue to all physicians and recruited additional organizations to join in the Brief on behalf of the defendant physicians, including the American Medical Association (who contributed financially to the case), the Colorado Chapter of the America College of Emergency Physicians, the Colorado Radiological Society, the Colorado Society of Anesthesiologists and the Regents of the University of Colorado.

This decision will assist physicians in defending malpractice claims by permitting the introduction of hearsay evidence in support of alternative causes to negligence for the plaintiff’s injuries. In malpractice cases, plaintiff’s must prove that the alleged negligence caused the injury and many times a primary defense of the physicians is that there was a different cause.

Sometimes, as in this case, the evidence of that alternative cause may only be obtained from family members or others who know the patient’s habits and activities.

Colorado Medical Board v. Office of Administrative Courts: Colorado Supreme Court ruling June 23, 2014 The significance of this decision is that the Colorado Supreme Court has reaffirmed professional review in Colorado at a time when courts in other jurisdictions have issued opinions that have had the effect of weakening professional review. The Colorado Medical Board (CMB), an executive agency under the leadership of Governor Hickenlooper, challenged an administrative law judge decision that would have

weakened professional review protections by allowing professional review records to be (1) subpoenaed and discoverable, and (2) admitted in an administrative action.

In this case, CMB petitioned the Colorado Supreme Court for review of a district court’s ruling. The Colorado Medical Society, COPIC and the Colorado Defense Lawyers Association joined forces and each submitted an Amicus, or friend of the court, brief in support of CMB’s position.

The Colorado Supreme Court ruled that the professional review statute protects the records of a professional review committee from all forms of subpoena or discovery.

The statute further protects the records from admissibility in civil suits, and the Supreme Court also ruled that the term “civil suit” includes administrative proceedings of an adjudicatory nature.

Accordingly, the CMB’s records are protected from subpoena or discovery and are not admissible in the administrative hearing regarding the denial of a physician’s medical license, and the CMB need not furnish the records at issue in this petition.

“This ruling is significant,” said Mark Fogg, COPIC’s General Counsel. “It strongly affirms the principles of the new professional review statute that CMS, COPIC and others worked diligently on to be enacted.”

Learn more Read complete summaries of both cases by clicking the news link located in the upper right corner of the CMS website home page at www.CMS.org. n 23

Features

Affordable Care Act implementation Kate Alfano, CMS contributing writer

CMS to DOI: Clarify notification during the 90-day grace period With the large number of Coloradans newly insured through the Affordable Care Act (ACA) comes a risk for payment issues to physician practices due to a provision in the law known as the 90-day grace period. CMS Immediate Past President Jan Kief, MD, testified at a hearing of the Colorado Division of Insurance on May 1, 2014, about a proposed state rule that would clarify the insurers’ responsibility for notifying patients and physicians when enrollees enter this grace period, and CMS President John L. Bender, MD, provided comments through a letter to DOI Commissioner Marguerite Salazar.

Per federal rule, patients who receive federal advance payment tax credits to purchase plans through the state health insurance exchange have a 90-day grace period for non-payment of premiums.

During the first 30 days the health benefit plan must pay for claims as if the patient were eligible, but in the last 60 days the plan can suspend claims. If the patient’s coverage is cancelled after 90 days because of non-payment of premiums, the insurer may deny all suspended claims for services furnished during the 31-90 day time period.

Physician practices could therefore be in a position of providing services for up to 60 days, only to be stuck with the prospect of either having to absorb the costs as bad debt or attempting to collect arrears from patients who may not have the means to pay these bills given that they couldn’t pay for their premiums. “If the carrier denies the claim(s) for ser 24

vices rendered in the second or third months of the grace period, this will create a financial burden on physicians and other health care providers, as well as be a disincentive for participating in the health care exchange in our state,” Bender wrote in the letter.

The ACA requires insurers to notify the enrollee’s physician and other health care providers when a patient enters into the second and third month of the grace period, but the notification requirement is vague, stating “Issuers should notify all potentially affected providers as soon as practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.”

The proposed regulation – 4-2-48 – would require carriers to provide notice to policyholders advising of the premium payment delinquency, of their intent to terminate coverage due to non-payment of the premium, and that they may be required to pay all amounts owed for services incurred after the first month of the grace period. The regulation would require carriers to notify providers with pended claims incurred in the second and/or third month of the policyholder’s grace period that the claims may be denied if no further premium payments are received from the policyholder.

Kief testified that the proposed regulation should include language that will ensure providers receive eligibility information in a timely manner, and in a manner detailed enough so that they can anticipate any potential problems.

“Unless physicians and other providers are notified as soon as possible that an enrollee has entered into the second or third month of the grace period, physicians and health care providers cannot anticipate or mitigate the effect of claims denials and otherwise the financial aspects of their practices,” Bender wrote in his comments.

Kief said, “The division has the unique opportunity to not only address the consumer and health plan issues related to grace periods but also the concerns of those actually delivering the care to the policyholder. These proactive measures will give our health care professionals the assurance they need to continue providing access to care for the Coloradans receiving advance tax payments through the purchase of exchange products.”

The Colorado Association of Health Plans surveyed six of its member plans and all reported that they offer immediate eligibility verification by phone that is updated either daily or in real-time; five can immediately report by phone the patient’s effective date and whether the patient is in the grace period. Five offer verification by electronic transaction and four offer verification by secure web portal.

One plan reported that it will have a field in its core system labeled “paidthrough date” that indicates the end of the month that a patient’s premium is paid through. If on the date of eligibility check that date is more than one month Colorado Medicine for July/August 2014

Features past, then the patient is in the threemonth grace period. That information, along with an explanation, would be provided by phone, electronic transaction or secure web portal.

Kief testified on behalf of the Colorado Medical Society, the Colorado Hospital Association, the Colorado Medical Group Management Association, the Colorado Academy of Family Physicians, the Denver Medical Society, University Physicians, the Colorado Society of Anesthesiologists, the Colorado Orthopaedic Society, the Colorado Chapter of the American College of Physicians, and Pikes Peak Professional Association of Health Care Office Management.

Bender submitted comments on behalf of the Colorado Medical Society, the Denver Medical Society, the Colorado Academy of Family Physicians, University Physicians, the Colorado Medical Group Management Association, Pikes Peak Professional Association of Health Care Office Management, the Colorado Orthopaedic Society, and the Colorado Chapter of the American College of Physicians.

The final regulation will take effect on July 1, 2014. n

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Features

Find your grounding

work

life

Kate Alfano, CMS contributing writer Kate Alfano, CMS contributing writer

CMS president-elect chooses future by reflecting on past high school, and went off to college wondering what to choose as a career.

Spring Conference

Tamaan Osbourne-Roberts, MD Tamaan Osbourne-Roberts, MD, CMS president-elect, chose his future by reflecting on his past. But even after years of hard work placed him in the seemingly perfect position, the young physician discovered that he had to find balance to ensure a long and happy professional and personal life. “Find your grounding” was his message as he opened the 2014 Spring Conference in Vail in May.

Osbourne-Roberts looked to his parents’ example – a teacher and a soldier – and he knew he would have a service-oriented career. He also knew he loved bioscience and he was interested in serving people. “The obvious answer was medicine,” he said. “I veered off into education for a couple years, figuring I’d follow in my mother’s footsteps, but eventually I followed my mother’s dream to become a doctor.”

He met his wife during medical school, completed his family medicine residency, had two children, bought a house, entered practice where he wanted to work and seeing the patients he wanted to see. “As you can see, all of this looks like it’s going according to plan. It looks fairly ideal,” he said.

He set the scene by telling the story of his childhood and the cumulative experiences that would lead him to medicine. His parents, immigrants from Trinidad, met in Brooklyn. His mother wanted to become a doctor but instead became a teacher when she was told international students couldn’t pursue medicine. His father joined the U.S. Air Force and the couple moved to Guam where Osbourne-Roberts and his brother were born.

But starting practice is where things got difficult. He – like many other physicians – felt alone as he struggled with the issues of the times. For him in 2010 it was the economic meltdown, a boom of patients who desperately needed care but couldn’t pay, and the Affordable Care Act that brought a lot of instability and concern among physicians and patients. All of this weighed on him, he said. He also struggled to be present, wanting to give both his family and his patients 100 percent. “That just doesn’t work,” he said.

Moving to various locations around the world fueled his interests in nature, science and people. He eventually ended up in Colorado for middle school and

“You’ve all been in this place. It’s a hard spot to be in. It’s isolating, it’s cold, it’s difficult, it’s hard. So now that I’ve depressed you, let’s talk about answers.

26

How do we get out of here?”

For him, many of the solutions were related to his practice. They restructured how they saw patients, how many they saw and how they handled their electronic medical record. “But the thing that brought me back to a much happier place where I find myself today is something a mentor of mine referred to as ‘grounding,’” he said. “A tree cannot stand if it has no roots.”

He encouraged the audience of physicians and physicians in training to reflect on their grounding, and remember why they decided to dedicate their lives to service through medicine. It’s difficult because of “all the challenges we have on a daily basis; the things that wear us down, make us question why we’re doing this, burn us out, keep us awake at night worrying about the people under our care, keep us away from our families, make us forget why we’re doing what we’re doing. These take away from that grounding.”

Osbourne-Roberts found grounding for his professional life in the Hippocratic oath, and one line in particular: “I will apply for the benefit of the sick all measures that are required.”

“All measures,” he repeated. “For me that one sentence was the grounding I needed to bring me back from this (dark) place in my professional life.

We’re all very tied to what we do in our profession, but the reality is we have other things we need to keep in mind.”

One part of this, he said, is summarized in the phrase, “physician, heal thyself,” Colorado Medicine for July/August 2014

Features

“Your compassion is incomplete if it does not include yourself, if you’re not working to heal yourself as a physician and to make sure you can be there in a full way for the people who need you.

You work is going to be compromised, your home is going to be compromised and you won’t be able to do what you want to do to be happy in life.”

He found his grounding in hiking the Colorado 14ers, cooking for his family and exploring beautiful places with his family. “This is what keeps me able to do all of the other things I do. It’s not

easy to find time to be a full-time physician, father, husband, son, brother, and still find time to get out and exercise. It’s not easy to find time to cook healthy meals or take vacations.”

“It’s hard to find the balance but I strive toward it,” Osbourne-Roberts said.

“Why? The things that keep me able to do what I do are the things that keep me grounded. It’s about holding onto what’s important in your professional life – for me my oath – and in your personal life – for me my family. Whatever those things are for you, hold onto those things because those are the things that are going to keep you able to do what you do.

They’re going to keep you grounded.” n

LOOKING?

Encourage a colleague to join the Colorado Medical Society and your local medical society today!

Visit www.cms.org to learn more about the benefits of becoming a member For more information and an application to join, call Tim Yanetta at

720-858-6306 or e-mail tim_yanetta@cms.org

Spring Conference

asserting that physicians apply for others all measures that are required but don’t pay themselves the same service.

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To place your ad call (720) 858-6310

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27

Features

What’s your story?

Kate Alfano, CMS contributing writer Kate Alfano, CMS contributing writer

Developing stories that engage and move

Spring Conference

Effective physician leaders – from those in formal positions of authority to those simply leading patient change – understand the power of stories. Leaders must inspire a vision to move a group of disparate people in the same direction. This is most effectively accomplished with a narrative, said Aaron Templer, an independent consultant who creates brand strategies and marketing and communications plans. “They connect us; they bring us together. We know that this is something that bonds us as human beings. We come together over narratives to create bonds and to understand the human condition.”

The reason stories move people to action better than facts and data is because they engage the brain in more regions than simple data processing. “When you receive data, you interpret it, you make meaning of it in one part of the brain, but when you listen to stories it engages multiple parts of the brain,” he said.

“Your brain is an active participant when you listen to stories. It’s not just a passive interpreter of information.”

Listeners pay attention to stories because they become part of the action. “If I’ve got a goal or a vision that I want you all to follow it’s much better if you all have some sort of buy-in,” Templer said. “Better yet, if I can tell a story and make your brain feel that it is your goal or your vision, it is all the more effective.”

Admittedly some physicians find it difficult to use stories to convey information as they were trained to rely on scientific data and ignore anecdotes. But having data to support the story makes it that 28

much more powerful, particularly as physicians deal with objective criteria in the face of irrational behavior. “This is your world: People who don’t eat right, who don’t use condoms, who share needles when they know they shouldn’t and you’re blue in face trying to get them to stop. Stories are the way around this.”

That’s why, Templer said, the skill of storytelling should be honed and developed – just like any other leadership skill.

Powerful stories require thought and are created with intention.

Structure Templer presented a simple structure for stories that will meet most storytellers’ needs. The first piece of a good story is the context, which develops the important parts of the story: Where and when the story takes place, economic conditions, and the identities of the villain and the main character. “We need to know what the main character wants.

Without that we don’t have anything to root for.”

After the context is established comes action. Storytellers typically make the mistake of jumping directly to the action but taking time to set up the context around action creates a more logical path for the listener. Finally comes the result, which provides the listener with something from which to learn and change.

“This is a basic and simple way to structure a story and if you can have those elements you’re onto something pretty powerful,” Templer said.

The four truths The four truths of the storyteller, de-

veloped by film executive Peter Guber, present a strategy to move and captivate people with stories. Guber asserted in the Harvard Business Review that the most effective stories are true to the teller, the audience, the moment and the mission.

To be true to the teller, the teller must bring his or her authentic self to the story; listeners can tell when the teller isn’t truly passionate. And one of the most effective ways to impart authenticity is by showing vulnerability. To be true to the audience, the teller must stop talking about why he or she is great and start talking about the great things he or she will do for the listener. An important part of this truth is finding ways in the story to turn “I” into “we” to pull the audience into the story.

Truth to the moment requires reacting to the audience, being prepared to pivot to adjust the story to their needs. “Being able to pivot is very important, but do prepare,” Templer said. “We need to know that you care enough about your storytelling to give it some thought.”

And finally, to be true to the mission means finding and connecting the story to “something larger and bigger than we are.”

Story types There are five basic story types that leaders use to convey a point. The first is the “Stranger in a Strange Land.” A person has been dropped into a new place, has to learn the norms, language and rules.

Some unfriendly locals provide severe challenges until she or he finds a balance between their values and his or her own.

These stories are effective in leadership Colorado Medicine for July/August 2014

Features

“Rags to Riches” presents an everyday person who beats the odds and takes on a well-established institution with some new technology or good old-fashioned elbow grease to find success. This story type is popular to convey doing less with more, such as in a low budget situation or a resource-constrained environment.

The “Love Story” typically involves two people where one is out of the other’s league, class, group, accepted norms, etc.

They pursue their love anyway and are forced apart, but there is forgiveness or reconciliation in the end. “Love stories are very powerful to use when inspiring people to come together, such as through mergers and acquisitions, or to bring together different groups to collaborate that normally don’t work together. The common goal, the common vision or set of values will always prevail.”

The “Tale of Revenge” is less effective in the physicians’ setting but still has applications. In this story type, a morallycentered person works hard and does the right thing but bad things happen and he or she is awakened to the reality that good isn’t always returned. The person finds peace through payback. One application for physicians would be to use a revenge tale in regards to processes and systems, inspiring a group to do the work and overcome the system in the end.

the status quo. When you start to recognize that in the people you’re trying to engage, that’s the first step to inspiring people to get on board. Stories get them started in that process and start to undo the cognitive biases.” In the end, anyone can use the power of stories to create

compelling visions and inspire change behavior. And one doesn’t have to be on top of an organization to do it. “You can step up in whatever your small niche is and start telling stories and start leading people toward a better tomorrow,” Templer concluded. n

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The “Hero’s Journey” is the most common story type: In this tale a person is reluctantly called to action through a transformational event, meets a mentor, faces severe obstacles, almost turns back, but emerges from the other side better and wiser for the journey. Leaders use it when they want to inspire change – not just lead through change.

“Based on the research I’ve read, most leaders who are leading change fail because they fail to recognize that everyone resists change,” Templer said. “We have cognitive biases that keep us rooted in

Colorado Medicine for July/August 2014

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Features

Prescription drug abuse Kate Alfano, CMS contributing writer

State effort focuses on safe use, storage and disposal

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Aaron started using prescription opioids when he was in high school. From an upper-middle-class family, his parents described him as a typical teenager; light-hearted and full of energy, he was athletic and loved to wrestle. He went to a so-called “pharming” party where students raid their home medicine cabinets, bring any prescription drugs they can find, mix them up in a bowl, pick one or two, and chase them with a beer.

“That’s considered fun, a reasonable thing to do and reasonably safe because the kids think, ‘they’re just prescription medications. How dangerous can pills be?’” said Rob Valuck, PhD, president of the Colorado Prescription Drug Abuse Task Force and coordinating center director of the Colorado Consortium for Prescription Drug Abuse Prevention.

Without major incident from that first experience, Aaron continued his nonmedical use: trying one or two of his parents’ Vicodin, then one or two more; getting more from friends; and gradually falling into a downward spiral. Tolerance led to increased use, then to dependence, and ultimately addiction.

As his addiction became stronger, Aaron started to scam doctors for opioid medications. In an interview with authorities, he estimated that he visited between 40 and 50 doctors over an 18-month period and went to about an equal number of pharmacies to stay beneath the radar. He said most doctors would give him at least an initial prescription for Vicodin. When he developed a tolerance he progressed to OxyContin.

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Aaron eventually started using OxyContin at very high doses, often mixed it with Xanax and alcohol, and overdosed at age 21. He had a difficult stay in the ICU: two myocardial infarctions, seizures, a staph infection and pneumonia, on top of extreme withdrawal symptoms. Doctors prepared Aaron’s parents for his death, which appeared imminent and very likely. Surprisingly, he regained consciousness and eventually recovered well enough to be discharged home. But the overdose left him paralyzed and unable to speak.

“The worst consequence is death,” his mother said in a video about this real patient case for the Medicine Abuse Project. “Other consequences are, like Aaron, trapped in your own body alive but unable to communicate in the way that you would hope that you could. You also lose all of your hopes and dreams and everything you wanted to accomplish in your life.”

in poor and rural areas. “That said, this cuts across all strata demographically – age group, gender, race, ethnicity, diagnoses; it’s a problem all over the place,” Valuck said.

And while the public typically hears statistics on overdose deaths, Aaron’s story demonstrates that death isn’t the only outcome. In 2011, for every opioid overdose death, there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who met the medical criteria for abuse or dependence, and 825 selfadmitted nonmedical users.

“What’s gotten our attention in Colorado is that we’re high in the ranking in self-reported nonmedical use of prescription pain relievers among anyone age 12 or older,” Valuck said. “It’s nonmedical use that puts people at very high risk for becoming addicted and having those problems. That’s led us to do something about it.”

The growing epidemic Prescription drug abuse and misuse is serious problem in Colorado and around the United States. In 2010, more than 38,000 people died from a drug overdose in the United States – one every 14 minutes, Valuck said. Nearly 60 percent of those deaths involved prescription drugs and, of those, 75 percent were opioid painkillers. In Colorado, the number of drug overdose deaths range from 250-500 per year; in 2010 it was just over 300.

Taking action A small percentage of providers prescribe the majority of controlled substances. In Oregon, 8.1 percent prescribed 79 percent of these drugs, which Valuck said is typical, especially considering some specialties’ scope of work.

“Many doctors prescribe few; some doctors don’t prescribe them ever. It’s really variable and we know that this isn’t an indictment on doctors or one type of doctor.”

The rates of misuse and overdose death are highest among men, persons ages 20-64, non-Hispanic whites, and those

However, providers who do prescribe these medications frequently inherently see more higher risk patients and Colorado Medicine for July/August 2014

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One of the answers is to try to develop a coordinated response among the many stakeholders. “We could attack this problem at any place in the distribution chain, from manufacturers to the medical system to pharmacies to insurers and payers to patients and the public. Everyone needs education about this,” Valuck said.

As for physicians, he has six recommendations for what an individual can do to help mitigate the prescription drug abuse epidemic.

1. Take continuing education courses and seek out additional training.

Colorado Medicine for July/August 2014

2. Find and follow guidelines for safe opioid prescribing, whichever they are.

3. Be willing to prescribe less, whether that’s smaller quantities or other alternatives, and see patients more often.

4. Check the prescription drug monitoring program (PDMP) more often.

5. Educate patients on the importance of safe storage and disposal of unused medications.

6. Talk with colleagues, family, friends and neighbors about the issue and tell them stories about affected patients.

In regard to the PDMP, a bill was signed into law in late May that requires physicians to register for a PDMP account (but not mandate they use it) so they have access when they need it, allows for delegated access of up to three delegates per provider, provides unsolicited reports of potential doctor or pharmacy shoppers, gives the Colorado Department of Public Health and Environ-

ment access to the system for public health surveillance, and creates an advisory board to guide implementation and future directions.

Outside of the bill is action by the Colorado Board of Pharmacy to enhance the PDMP system: allow for daily reporting of dispensing data by pharmacies, interface enhancements, batch querying and reporting, and fewer clicks and attestations.

“Over the next six to nine months, we (through the Colorado Consortium for Prescription Drug Abuse Prevention) will be doing a significant amount of public awareness and provider education on safe use, safe storage and safe disposal as a starting point, and we’ll try to work upstream over the next several years about alternatives and doing a lot of things better.” n

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are more likely to have patients who are doctor shopping for opioids. “It’s not necessarily your fault; it’s just the territory,” Valuck said. “You’re working with highly addictive stuff and people who become addicted. That’s where 63 percent of the overdose deaths come, among the 20 percent of prescribers who prescribe the most.”

Features

Practice the rare Kate Alfano, CMS contributing writer

Preparing forwriter the once-in-a-career emergency Kate Alfano, CMS contributing

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How can a medical team prepare for emergencies? The answer, said Gerald Zarlengo, MD, and Jennifer Roller, MD, is to practice and to learn from that practice. Zarlengo is a board-certified OB/GYN at Midtown Obstetrics and Gynecology and serves as the medical director of Women’s and Children’s Services at St. Joseph Hospital. Roller is a family physician in Grand Junction and on the faculty of the family medicine residency program at St. Mary’s Hospital and Regional Medical Center.

Zarlengo spoke about his experience at St. Joseph with amniotic embolism – a rare pregnancy complication that occurs in between 1 and 12 patients per 100,000 deliveries. Before the hospital implemented Critical Events Team Training, they experienced one maternal death from the condition. Since then they have had four occasions of amniotic embolism with four survivals.

In Critical Events Team Training, every member of the obstetric medical team – physicians, residents, nurses, scrub techs and unit secretaries – goes through a halfday training covering two of a dozen potential scenarios, not knowing in advance what they will be. “You want to practice the rare but, more important, you want to practice the common to constantly improve,” Zarlengo said.

The concept of the training is to level the playing field and create a safe environment.

“The take-home message from our process is to get nurses, physicians, everyone to realize that when we’re in the middle of a situation, we’re a team,” he said. “I’m not better than the nurse because I have an ‘MD’ after my name. The most important person on the obstetric unit when all three ORs are dirty and we need to do an emer 32

gency C-section is housekeeping. Realize that having everyone on your team is how you’ll have a safe outcome.”

Two other best practices he’s learned from the program are the importance of daily and real-time debriefs. For the daily debrief every member of the medical team jams into a labor-and-delivery room to hear about the day’s patients. “You might have 12 people on the board and you might not be taking care of those people but later in the day when a disaster happens, you’ve already put together what you might do to care for them.”

More important are the real-time debriefs, Zarlengo said. It’s easy to forget the details during a root-cause analysis – where the medical team and the risk management staff go over the details of an adverse event two to three weeks after it occurs. With a real-time debrief, the providers involved gather the day of the event to talk and record the details. “We started a process where anyone in labor and delivery can call for a real-time debrief at the end of the shift. It doesn’t have to be a seminal event.”

Roller helps coordinate the pediatrics curriculum at St. Mary’s residency program, and as she got more involved she realized they had an issue. St. Mary’s is not a critical care children’s hospital but critically ill children are often referred to them for care, particularly when poor weather prevents transport to Denver. Roller and the other program faculty identified their many resources for caring for these young patients: They have pediatric anesthesiology, a pediatric surgeon, and many pediatricians and family physicians trained in neonatal resuscitation and pediatric life support.

But even with these resources, the team

identified areas where they could improve pediatric resuscitation. The biggest factor was to help providers overcome the fear of treating critically ill children. They also wanted to reduce response time, establish a leader in emergency situations and delegate tasks, create protocols for equipment location and use, remember or access PALS protocols, and avoid drug dosing errors.

By studying how people learn most effectively, the faculty knew the best way to improve care would be through hands-on learning in St. Mary’s simulation lab. “One of the barriers we had was that a lot of the doctors said, ‘I don’t need this. This is for medical students or residents but this isn’t for me who has been in practice for 15 or 30 years,’” she said. “The interesting thing was that when we finally did the sims, the experienced faculty didn’t do so well. We all thought we could do these simulations and that we knew how to resuscitate a child and we really didn’t. That was eyeopening.”

Their team practices numerous scenarios – from respiratory events to cardiac emergencies to trauma – and afterward conducts a post-simulation debrief, which Roller said is more important than the actual simulation. Participants give each other feedback, ask questions about a person’s thought and decision processes, and then go back to the simulator to practice again.

The lesson, Roller said, is that it’s possible to have success stories, even in rare situations, if you practice and actively strive to improve care. “There’s nothing special with what either of us has done in our systems, it’s just about looking at your own system, identifying the problems and finding solutions.” n Colorado Medicine for July/August 2014

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Features

Physician leadership Kate Alfano, CMS contributing writer

What it means as a discipline and a principle

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Physicians are constantly challenged to stand up and lead their patients and communities to better health or through myriad health policy changes, but with increasing rates of practice consolidation many may not know where or how to start. A panel of experts spoke at the 2014 CMS Spring Conference in Vail, defining leadership as a discipline and principle and giving practical advice on how to make a difference no matter where you fall on the organizational chart.

First, the definition of leadership came from Kathy Kennedy, DrPH, MA, an associate clinical professor of preventive medicine and director of the Regional Institute for Health and Environmental Leadership, an advanced leadership training program: “Leadership is influencing others in the attainment of a common goal.” To get others to follow you to this mutual goal, leaders typically display five types of behavior, she said.

• Leaders are role models.

• They inspire others toward a shared vision that represents a better future.

• They challenge the status quo because they have a vision of how things could be better.

• They empower others to act.

• And they encourage people; leaders are a positive force.

The most obvious leaders have what’s called “positional authority.” They sit at the top of the organizational chart and their job titles have the word “chief” or “director” in them. Positional authority is given to a leader by agreement; people agree to an arrangement whereby the leader has certain rights and responsi 34

bilities: to hire and fire, make decisions on behalf of the organization, and to set and execute goals.

But reflecting on the five behaviors, she asserts that physicians do not need positional authority to lead. “In fact I think the whole reason we’re talking about this is because it’s important for physicians to think, believe and understand that they can lead without being chief of something.” Kennedy said she has often heard physicians express feelings of helplessness, that there’s nothing they as individuals can do to change things.

“Nothing could be further from the truth,” she said.

Tamaan Osbourne-Roberts, MD, CMS president-elect, has struggled to think of himself as a leader but said that the nature of a physician – to serve others – reflects a genuine desire to make the world a better place. “When people see that, they want to follow us. People trust us because we all are – all of us, in some fashion – committed to service.”

The idea of followers leads directly into the concept of power, Kennedy said.

While authority is influencing others as a verb, power is influencing others as a noun. “Power is the currency of influence. You earn power; people give it to you when they agree to be led by you.

This is what followership is; it’s giving power to someone else. Power is a function of leadership, not a function of positional authority.”

Case study in leadership and affecting change Jay Crosson, MD, the American Medi-

cal Association’s Group Vice President – Physician Satisfaction: Care Delivery and Payment, described his path to leadership over the course of his professional life. He and his wife, also a physician, took jobs at Kaiser Permanente in California 37 years ago with no family or friends in the area and a new sixmonth old baby. He said those first few years were tough balancing work and family, but they had jobs.

After those first difficult years he found that he genuinely liked the organization, felt that Kaiser’s culture and values agreed with his, and knew he and his wife would stay long-term. It was then that he started thinking about himself not as just a physician with a job but one with a career. “This transition from job to career created another set of values in me,” he said. “If there were problems in the institution, I knew I would try to fix them because now I have an investment.”

Later he experienced another transition from career to mission, what he calls the “fundamental element,” which came once he understood himself, who he was and what mattered to him. He knew he had skills he’d learned in his job that would benefit other physicians. “So all through the later part of my work there, that was the thing that drove me: Try to understand what was important, what had to change, what benefitted physicians but also patients, and follow that.”

It was this confidence become an ling a very

mission that gave him the to retire from Kaiser and AMA vice president tackambiguous topic: physician

Colorado Medicine for July/August 2014

Features satisfaction and how to make practice more fulfilling at a time of great change.

“I accepted because I had gone from a person with a job to a person with a career to a person who was dragged into a sense of mission. And I think for many of us, particularly those who have gone through this transition, that then forms the platform from which you can lead.”

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However, through all of his accomplishments, Crosson said the most important part of leadership is creating other leaders. “Some of the things I’m most proud of are not what I’ve done but the fact that as I’ve gone along I’ve been able to spot younger people who had some spark inside of them, and tried to influence and support them in their career, put them in positions of authority gradually where they could succeed, then experience the unique joy of watching an individual who has those capabilities flower and become a true leader in his or her own right,” he said. “There are few things in life that I think we can do that provide as exquisite a joy as that.” n

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Features

Practice sustainability and physician satisfaction Kate Alfano, CMS contributing writer

Why many physicians are unhappy and what we can do about it

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With 37 years as a physician and executive at Kaiser Permanente under his belt, Jay Crosson, MD, was on the verge of retiring to play golf and travel with his wife when James Madara, MD, the CEO of the American Medical Association, approached him about the AMA’s new strategic agenda. They wanted to do three things, he recalled: Get physicians more involved in quality improvement, change the nature of medical education, and deal with the question of why so many physicians seem to be unhappy and uncertain about what to do about it.

Professional satisfaction Crosson and his team reviewed the literature on physician satisfaction but found it to be outdated. So they employed the RAND Corporation to design a field survey to take to 55 physician practices of various sizes and specialties in six states to determine what’s going on in these practices, what the problems are and how the AMA might address them.

The resulting study – “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” – was released in October 2013.

He agreed to take on the mammoth task and became the AMA’s Group Vice President of Physician Satisfaction: Care Delivery and Payment. Admittedly he had no idea where to start so he formed an advisory group of experts knowledgeable about practice in the United States.

The authors identified a number of factors or elements in and outside of practice that tended to statistically relate to satisfaction or lack thereof:

Medicine has experienced a tremendous amount of change over the past few decades with the Affordable Care Act, changing patient demographics and the evolution of the science of medicine. All of this has created a situation that has left many physicians with a vague sense of anger and anxiety, Crosson said.

More than “physician happiness,” they had to “try to help physicians deal with what’s going on at the moment and try to improve that situation, and also try to help physicians prepare for what’s coming down the line in a way that’s socially responsible and ends up improving the quality and cost of care for the population.”

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• The physician’s sense to be able to provide high-quality care, • Electronic health records (EHRs), • Issues of autonomy and work control, • The nature of leadership, • The issue of collegiality, • Work quantity and the pace, • The ability to work with your staff, • Issues of income and practice sustainability, • Concerns with regulatory and professional liability concerns, and • The unsettling effect of health care reform, at least in the minds of a number of physicians.

“To the extent that physicians felt they weren’t able to deliver the kind of care to patients that they felt they should be delivering as a professional overwhelmed every other issue and led to dissatisfaction,” Crosson said. “And to

the extent that they didn’t feel this way, that they felt good at the end of the day about the care they were able to deliver, highly correlated with satisfaction.”

Additionally, the authors were shocked about the scope and scale of impact of EHRs on day-to-day practice. “There’s a general understanding among most physicians that the emergence of EHRs all in all is a good thing.” They understand the benefits but – “and the but is very significant” – almost every individual physician reported issues with data entry being too time-consuming, the user interface interfering with workflow, the interface interfering with patient interaction, the lack of information exchange with other providers, the expense of the system, and the fact that some of the solutions to the problems with EHRs have created more problems.

Since the release of the study, Crosson and his team have developed a work plan to address the discovered issues.

The first element of the plan focuses on reversing the flow of the physician’s workday from administrative work back to patient care; recent data show that some physicians spend up to 50 percent of their workday performing administrative tasks.

They have also identified opportunities to make small but meaningful changes, like pre-visit planning, pre-visit laboratory tests, various forms of expanding the use of office staff, a systematic approach to refilling prescriptions for chronic medicines, changes to the EHR interface, lean techniques, and the use of scribes in certain types of practices.

Colorado Medicine for July/August 2014

Features “Not one of these things is going to turn your practice into nirvana overnight if you’re having problems but virtually every practice I’ve found can employ a set of these and make a profound difference.”

Crosson recognizes that change is difficult. There have been many attempts over the years to change physician practices for the better but they don’t always take hold and grow.

“We also recognize that no matter how good we get at changing our practices, how efficient we get and patient-centered we get, there are still externalities that impact our practice or will impact our practice in the next decade and we have to do something about that.”

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Next steps The AMA plans to implement three projects to address these externalities. The first is a study that aims to understand the evolution of physician payment from the perspective of physicians so they’ll be able to help physicians understand what’s happening, project ahead and recommend a course of action. The second is a study on the consolidation of physician practices with hospitals. The AMA has teamed up with the American Hospital Association to discuss the enactment of a representative process for physicians to influence the direction of the larger organization. And the third relates to EHR usability and pressing the large EHR vendors to respond to physician needs. “As a profession and as organized medicine, we have the capability to do that and that’s what we’re coming to do,” Crosson said.

“There’s a lot that has been accomplished and much more that needs to be accomplished,” he said. “The goal here is to identify, support and grow the models of care delivery and payment that promote the long-term sustainability of and satisfaction with medical practice for our physicians, and lead to improvement in the cost and quality of American health care.” n

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Features

Health care shifts Kate Alfano, CMS contributing writer

Five trends affecting the work of physicians in Colorado

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Health care has been rapidly evolving for the past decade; as such it’s often difficult to predict the next iteration.

Michele Lueck, president and CEO of the Colorado Health Institute, (CHI), does this, though, using her organization’s extensive research to present five trends that will affect the work of Colorado physicians over the next two years.

These trends relate to affordability, physician workforce, the pressure to control costs, innovation and integration, and the rise of consumer-available health care data.

Affordability depends on where you live.

Health policy experts understand that the cost of health insurance varies widely based on a patient’s location but with the Affordable Care Act, (ACA), and the rise of its state health care exchanges, consumers can now easily compare their insurance costs to those of their peers in other cities and regions. It was revealed that the Colorado mountain resort region has the highest health costs in the country.

“Here’s the fundamental problem,” Lueck said, pointing to a matrix of costs.

“If a single 38-year-old nonsmoker lived in Denver or Weld counties, he could buy a plan for around $227. In Pitkin County where Aspen is, it would cost somewhere between $471 and $650 for the exact same plan with the exact same benefits. We see this huge variation of health insurance premiums within the state. That’s a fundamental policy issue that the governor and his team are working hard to figure out.”

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Additionally, CHI surveys Coloradans every other year on their perception of health care. The current average monthly price paid for single insurance premiums through Connect for Health Colorado is $376. In their most recent survey CHI asked Coloradans how much they were willing to pay for health insurance. Nearly 30 percent said “zero,” that they weren’t willing to pay anything; 8.5 percent said between $1 and $25, nearly 25 percent said between $26 and $75, and nearly 20 percent said $76 to $150. Only a fraction – a little less than 20 percent – said they would pay more than $150.

What this means for physicians, she said, is that patients who come into a physician’s office or clinic and who have paid for health insurance already think they’ve paid a lot to see you and they may be confused about additional copays and deductibles.

There are plenty of providers for the commercially insured.

There are fewer for the most vulnerable.

The influx of nearly one million newly insured individuals through the ACA in addition to existing patient population raises questions about workforce adequacy. CHI conducted a study to project into which programs or markets the 900,000 who were uninsured before Jan. 1, 2014 would go. They projected that 130,000 would go into Medicaid or CHP+; 220,000 would purchase individual coverage; 160,000 would be picked up by employer-sponsored plans; and 360,000 would opt to remain uninsured.

A separate CHI study revealed that the state needs 120 more clinicians to take care of the newly insured – already a difficult task. But the bigger issue is in the distribution of physicians around the state. Lueck showed areas of low demand and high demand, as well as primary care “hot spots” where there aren’t enough physicians to take care of either the general or Medicaid population.

While ideas for optimizing workforce abound, she admitted that they don’t know exactly how they’re going to take care of all of the Coloradans who are newly insured and the current patient population. “I would suggest to you that we really need your leadership and insight about how we’re going to accommodate the new populations coming into the ACA.” Cost control means you (and others).

Lueck was quick to point out that this statement is not a judgment; it’s an acknowledgment that physicians are seeing pressure on the systems to control costs that will carry down to the practice level. The most recent example is the establishment of the Colorado Commission on Affordable Health Care Costs, which will study the drivers of health care costs over the next few years and propose solutions to control them.

Physicians are familiar with the line graph depicting health care costs: Workers’ earnings and inflation are rising slightly at the bottom of the graph while health insurance premiums are increasing at a much more rapid rate.

Colorado Medicine for July/August 2014

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The good news is the rate of increase in health insurance premiums has slowed slightly – only growing by 3.9 percent between 2009 and 2011 – but inflation grew at 2.9 percent over the same period, and Lueck suggested more needs to be done to address this.

Expect to be asked to innovate and integrate.

Practices are already seeing multiple initiatives coming down from the federal and state government around innovation and integration, for better or for worse. The state is currently pursuing federal funds to integrate behavioral health and primary care in recognition that half of behavioral health disorders are treated in primary care and that nearly half of appointments for psychotropics are with primary care providers.

Lueck recommended that CMS stay engaged in the State Innovation Model. “I encourage that for a few reasons. One of them is that when you start thinking about integration, it gets fuzzy about the outcomes you should measure and it would be important for you to weigh in on that in a meaningful way. It’s also important to think about how this model might be aligned for all payers.

By definition this innovation grant has to be multi-payer but it’s important to think about how much administrative burden that’s going to put on your practice.” It’s also important to consider how to invest in practices so the effort isn’t pushed out as an unfunded mandate, she said.

how those practices are evolving.”

Your patients are becoming savvy shoppers.

Finally, Lueck shared the idea that patients are becoming more savvy shoppers as more are moving from receiving a defined benefit for health insurance – where an employer chooses a health insurance product for employees – to a defined contribution – where an employer gives an employee a stipend to buy a plan and the employee must cover any cost above that stipend. “When that happens, people become more invested, more aware of what they’re buying. That’s factor number one.”

The second factor is the rising number

of patients with high-deductible health plans, which also require more patient buy-in. And the third factor is heightened transparency of information for consumers at both the federal and state levels. This includes the recent data release that revealed what Medicare paid individual physicians in 2012.

“I think all of this information is very dangerous to consumers,” Lueck said.

“It doesn’t mean that they won’t use it; they’ll use it a lot.” But consumers won’t know how to process the data. “Right now there’s a whole host of information out there that’s just information and data and there’s going to be a lot of need and a lot of demand to help figure that out.” n

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“When they talk about bending the cost curve, this is what they’re talking about,” she said.

Colorado Medical Political Action Committee Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org

“On a micro level, I would suggest to you that innovation and integration is expected or at least there are a lot of policy pressures being put on your practices in order to change and adapt to these new ideas and new situations. I also think that’s happening on a macro level if we go up to the hospital level.

I wanted to suggest that that’s another facet of the work we’re thinking about at CHI that really impacts how you might think about your practices and

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Inside CMS

CMS Board report Kate Alfano, CMS contributing writer

CMS Board moves forward on multiple policy fronts The Colorado Medical Society Board of Directors met on Friday, May 16, to conduct business integral to the success of the society and its members and take action on a host of issues, including maintenance of licensure, proposed clarification of the Affordable Care Act’s 90-day grace period provision, a potential strategic partnership to help with the transition to value-based care and opioid prescribing and dispensing.

Maintenance of licensure Brent Keeler, MD, chair of the CMS Committee on Maintenance of Licensure (MOL), addressed the board. The House of Delegates created the MOL committee in 2011 and charged its members to develop a Colorado-specific MOL framework.

The committee recommends that licensees who are current with MOC requirements of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) should be considered to have satisfied CME requirements. All other physicians with an active license under this proposal will be required to fulfill 50 credits/hours of accredited or certified category 1 CME that is relevant to his or her practice during each two-year renewal cycle. The board approved these specifications and will send the proposal to the House of Delegates for consideration at the annual meeting in September.

90-day grace period CMS Immediate Past President Jan Kief, MD, presented information on a rule proposed by the Colorado Department of Insurance to clarify the reporting stipulation in the 90-day grace period that was not addressed in the federal Affordable 40

Care Act. Patients who receive federal subsidies to purchase health insurance plans through the state health insurance exchange have a 90-day grace period for non-payment of premiums. During the first 30 days the health insurer must pay for claims as if the patient were eligible, but in the last 60 days they can suspend claims. If the patient’s coverage is cancelled after 90 days because of non-payment of premiums, the insurer may deny all suspended claims for services furnished during the 31-90 day time period. That could leave physicians on the hook for collecting payment for services and imperil access to care.

The ACA requires that the carrier notify the patient’s physician and other health care providers when a patient enters into the second and third month of the grace period, but the notification requirement does not indicate when such notification must be made. Kief testified before the DOI on May 1 that the proposed regulation should include language that will ensure providers receive eligibility information from health insurers in a timely manner, and in a manner detailed enough so that providers can anticipate any potential problems. Read more about this issue on page 24.

ACO/network opportunities and physician support The board agreed to move forward to explore a potential collaborative relationship with a company that would offer practice tools, resources and solutions to enable CMS members to succeed in accountable care and other payment initiatives. Such a relationship could also involve an ACO or other network arrangement with CMS. The board referred the issue to the CMS

Committee on Physician Practice Evolution.

Opioid policy The board heard a presentation by Lynn Parry, MD, on opioid prescribing and dispensing. The four provider licensing boards – regulating dentists, physicians, nurses and pharmacists – proposed a joint policy on this issue and requested comments from stakeholders. With previous approval by the executive committee, CMS provided comments and revisions that were well received by the four boards.

CMS strongly recommended that the policy not be interpreted or published as a “rule” to maintain flexibility; a rule has the force and effect of law. Rather, it should be written as a “policy,” which acts as guidance. CMS supports a policy that is helpful to prescribers and dispensers without establishing legal or disciplinary grounds for action followed by increased prescriber education. CMS also expressed concern that the proposed policy does not differentiate between chronic, non-malignant pain; cancer-related pain or palliative/hospice care; or short-term acute care situations. CMS recommended that the policy be limited to chronic non-malignant pain or clearly delineate between guidelines for the three types of pain.

Learn more The Board also took important positions concerning workers’ compensation, the gainful employment requirement, the CMS policy manual, scope of practice, and the CMS strategic plan refresh.

Visit http://www.cms.org/uploads/CMS_ Board_report-May_16.pdf to read a complete summary of the meeting. n

Colorado Medicine for July/August 2014

Inside CMS

Annual Meeting Colorado Medical Society

2014

September 19–21, 2014 • Vail Cascade Resort

Good friends, good food and good music:

CMS is bringing the best of Carnival to the mountains

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

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 Purdue Pharma L.P. UnitedHealthcare Wells Fargo Exhibitors

athenahealth BIOSPACE Bluestein Law Firm, PC Center for Dependency, Addiction and Rehabilitation Center for Personalized Education for Physicians Colorado Physician Health Program CORHIO Colorado Medicine for July/August 2014

Donor Alliance GL Advisor Harmony Foundation Life Care Centers of America Medical TeleCommunications Sharkey, Howes & Javer TransFirst 41

Inside CMS

Annual Meeting Registration Now Open

Colorado Medical Society Annual Meeting • Vail Cascade Resort • Sept. 19-21, 2014 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 September 5, 2014. Registrations accepted on a first-come, first-served basis (may be limited for some

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

Friday, September 19 member spouse/guest 6:00 pm

Exhibitor Reception

q

q

Saturday, September 20 (Complimentary for member & one guest only) 6:45 am 12:15 pm 5:30 pm 6:00 pm

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

CHARGES FOR ADDITIONAL GUESTS

q q q

q #_______ @ $35/each_________ #_______ @ $35/each_________ q q q #_______ @ $105/each_________ q #_______ @ $105/each_________ q #_______ @ $105/each_________ #_______ @ $105/each_________ q

q

q q q q

6:45 pm

Breakfast Buffett

q

Sunday, September 21 member spouse/guest

TOTAL amount enclosed for non-members & 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 Thursday, August 21, 2014, to be eligible for the group rate.

Visit www.cms.org, www.vailcascade.com, or call 800-420-2424 to reserve your room today.

Remember to use Group Code 40R5XG to secure the conference group rate.

ROOM TYPE RATE Lodge $149 Preferred $169 Summit $189 Cascade Courtyard Suite $239 Mountain View Suite $269 The above rates do not include a $15.00 resort fee and 9.8% sales tax. Check-in is 4 p.m. and check-out is noon. Pets are allowed, please contact the hotel for details. This is a non-smoking facility.

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Colorado Medicine for July/August 2014

Colorado Medicine for July/August 2014

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Inside CMS

ICD-10 update Denny Flint, Director of Business Development, Assistive Coding, LLC

ICD-10 is just the vessel. The real cargo? Data!

Stop focusing on ICD-10! The real elephant in the room is the rapid proliferation of diagnosis-based reimbursement. The role of ICD-10 (if and when it actually comes to pass) needs to be re-evaluated. ICD-10 will merely be the language by which your public face (coding profile) is expressed to the outside world. ICD-10 is a vehicle for capturing more specific, detailed data, nothing more and nothing less.

The nation is rendering itself asunder with an ICD-10 argument that completely misses the point. Forget ICD-10 for a moment and take a look around.

Think about all the new acronyms – ACO, HCC, RAF, PCMH and how they relate to chronic disease burden management. The old paradigm that says “the more you treat, the more you make” is changing. Insurance companies are aggressively pushing shared risk programs that stress quality of care at less cost. The only way to do that is to move away from the unsustainable model we have now. The paradigm shift to the new mantra “the less you treat, the more you make” needs to be embraced while upholding the sacred commitment to high quality of care.

We saw the shift start to occur with capitation in the ‘80s. The “per head” model frankly failed because we didn’t have the data to truly assess how sick our assigned patient population really was in order to analyze whether or not the amount of capitation was sufficient to carry the treatment burden for that population. Not having adequate data is also the reason many ACOs fail.

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With an anticipated 30 percent of the patient population moving to shared risk models within the next year, isn’t it time we took the new paradigm of “less is more” seriously? Patient Centered Medical Home with its tiered $1, $2, $3 per head compensation is yet another attempt to open the door to providers taking on more and more risk. We’ll get used to a capitation model in the same way PQRS started to get us comfortable with “value based” reimbursement.

As we go through the next phase of physician compensation shift, the value based model tells us that physicians will not get paid based on what they do, but rather for how well they can prove they do it. Is consumerism the next iteration? Perhaps. In the final drive to diagnosis-based reimbursement, physicians will not be paid based on what they do (CPT), but rather based upon what’s wrong with the patient (ICD-9 or 10). For the naysayers and for those of you old enough to remember, I merely remind everyone about what the prevailing hospital-view was when Yale released the original DRG system in the ‘70s. “Oh, it’ll never happen.”

It happened to hospitals and it’s happening once again to physicians. You see, insurance companies want to take the decision for care out of the provider’s hands. Their clarion calls were, “needless diagnostic tests, over-treatment, and unnecessary procedures.”

When insurance companies shift to paying physicians according to what’s wrong with the patients, the ability to overwork the system is removed. Before

everyone cries foul, please keep in mind our current system is unsustainable.

So how does a practice thrive in this drive to “less is more” ACOs and other related Dx-based reimbursement models? The key is data. Arm yourself with accurate acuity level data that indicates how sick your patients really are and what amount of care can be expected to be delivered. This is where an ACO decision-to-participate needs to begin.

Without this data you are flying blind.

Specificity, at least in as much as ICD9 currently affords, is key. When asked about the best way to begin an ICD-10 transition, I always say, “It starts with clinical documentation improvement that mandates physicians must provide the documentation elements to meet the specificity.” Specialty-specific physician documentation education, baseline chart reviews that reveal current documentation shortfall, and HCC analysis for your particular specialty are valuable tools.

By doing so, you will reap benefits not only for the future of ICD-10 success for your practice, but also for the current shift in the way physicians will be paid.

Denny Flint is a Senior Consultant and Director of Business Development for Assistive Coding, LLC, a member of The Pinnacle Group family of physician financial, education, strategic planning, and coding suite of services.

Denny can be reached at dflint@assistivecodingservices.com or at 970-390-8970. n

Colorado Medicine for July/August 2014

Colorado Medicine for July/August 2014

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Inside CMS

AMA Annual Meeting Kate Alfano, CMS contributing writer

Report from 2014 AMA House of Delegates meeting Delegates and leaders representing the Colorado Medical Society traveled to Chicago June 7-11, 2014, to attend the annual meeting of the American Medical Association House of Delegates.

Coloradans experienced great success in policymaking and continue to carry great influence in the AMA. Resolutions The four Colorado delegates to the AMA – A. Lee Morgan, MD, delegation chair; M. Ray Painter Jr., MD; Lynn Parry, MD; and Brigitta Robinson, MD; the four alternate delegates – David Downs, MD; Jan Kief, MD; Mark Laitos, MD; and Tamaan Osbourne-Roberts, MD along with CMS President John Bender, MD, who was also seated as an alternate delegate– worked hard to testify on and carry important resolutions to passage through the House of Delegates. As is CMS tradition, all delegates and alternate delegates rotated in casting votes on all items before the AMA House of Delegates.

Colorado presented and successfully passed one resolution, authored by AMA Past President Jeremy Lazarus, MD. The resolution directs the AMA to study and report back on the current state of knowledge regarding the integration of physical and behavioral health. This includes recommendations for further study, the implementation of models of physical and behavioral health integration, and other tools or policies that would benefit patients and the health care system by the integration of physical and behavioral health.

In other policy news, delegates voted 46

to ask President Barack Obama to provide timely access to care for eligible veterans through the health care sector outside of the U.S. Department of Veterans Affairs health care system and to urge Congress to enact long-term solutions so these veterans can always have timely access to entitled care. They also voted to continue investigating maintenance of certification (MOC), osteopathic continuous certification (OCC) and maintenance of licensure (MOL), including assessing the impact of MOC on physician practices. And they approved a set of principles for coverage of and payment for telemedicine services.

Elections Physicians from around the country vied for open seats on the AMA Board of Trustees and six AMA councils. CMS Immediate Past President Jan Kief, MD, ran for a seat on the Council on Constitution and Bylaws but was unsuccessful.

She received wide praise for running a difficult, upbeat race and she thanked all in Colorado and the Western Mountain States Conference (WMSC) for their support.

The future of medicine Members of the Young Physicians Section (YPS), the AMA Resident and Fellow Section (RFS), and the AMA Medical Student Section participated in a variety of engaging events during their annual meetings.

The young physicians discussed priority issues and worked on shaping AMA policy, adopting two resolutions for consideration by the AMA HOD. The first asked the AMA to study diversity

among AMA delegates and develop mechanisms to promote diversity within the HOD. The second asked the AMA to oppose special licensing pathways for physicians who are not currently enrolled in an Accreditation Council for Graduate Medical Education or American Osteopathic Association training program, or have not completed at least one year of accredited post-graduate U.S. medical education.

The residents and fellows attended a welcome reception that encouraged networking with peers, and participated in educational sessions and policy discussions. They proposed policies on medical school debt, evaluating transfers in and out of residency programs, improving the use of mobile medical technology, and developing a national prescription drug monitoring program.

They also offered guidance to medical students on their upcoming transition to residency.

The medical students considered 47 items of business during their assembly, and brought several successful resolutions to the House of Delegates, including an FDA nutrition label revision, modernization of HIV-specific criminal laws, and complete maternity care under the ACA. For the first time, the students utilized a fully virtual reference committee to consider testimony from students around the nation, regardless of whether they were able to attend the meeting. They also had the opportunity to participate in educational sessions on topics such as community service, health care policy, legislative advocacy, loan management and leadership.

Colorado Medicine for July/August 2014

Inside CMS Paul Pukurdpol of the University of Colorado School of Medicine was elected, for the second time, to serve on the AMA-MSS Governing Council as the section alternate delegate, where he will lead the entire medical student delegation. Paul is also the outgoing vice speaker and spearheaded many innovative measures to make the AMA-MSS the nation’s leading medical student organization.

Social time The meeting wasn’t all business. Saturday evening all Colorado leaders gathered for dinner to enjoy each other’s company. “As technology lures us away from face-to-face encounters on many fronts, we must always remember the value of collegiality and just taking the time away from business to enjoy being with one another,” Kief said.

A kickoff event on Friday night reminded attendees of the heart of medicine – the patient-physician relationship – at Inspirations in Medicine. The event at the Museum of Broadcasting featured three physicians and one patient telling their personal accounts of how the patient-physician relationship has inspired them. Kief said it was “just what the doctor ordered.”

“We heard stories about how a physician, despite being unable to save a patient’s life, gave him valuable time that he appreciated to say goodbye to his family. We heard stories of patient courage and partners in care with their physicians and how those struggles changed them both, and we saw our own president-elect Tamaan Osbourne-Roberts on the big screen being interviewed about the difference you can make in patients’ lives.”

Thank you to all of the leaders who attended the 2014 AMA Annual Meeting. n

Encourage a colleague to join the Colorado Medical Society and your local medical society today!

Visit www.cms.org to learn more about the benefits of becoming a member

For more information and an application to join, call Tim Yanneta 720-858-6306 or e-mail Tim_Yanetta@cms.org

Colorado Medicine for July/August 2014

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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.

Lindsay Heuser

Lindsay Heuser is a fourth-year medical student at the University of Colorado School of Medicine. She is originally from Colorado Springs, Colorado and earned a BA in chemistry from Bowdoin College. She intends on pursuing a residency in psychiatry.

During her time outside of the wards, she enjoys playing piano, skiing, hiking, writing, and reading.

Lemon sorbet “You know, he’s really upset with you for interrupting his sorbet earlier.”

I looked up from my computer and realized that the ICU nurse was addressing me.

“What? You mean, Mr. G?” “Yeah, he’s not happy about what you did this morning.”

I stared at her, somewhat dumbfounded.

Mr. G was the team “peach,” as my intern dubbed him.

A man with disdain running through his veins and a tongue sharper than a razor’s edge. He was a long-term alcoholic with 4+ bilateral pitting edema, a belly more distended than the tightest of drums, and a disposition like 48

an icicle. He made no attempts to hide his dislike of our team and for the hospital setting at large. He rolled his eyes, spoke in terse utterances. Complained, complained, complained. He was uncomfortable and angry. You did not have to be around Mr. G long to understand that this was a man with a lifetime of regrets, a man whose choices had led him to this point. This was a man at his very end.

Of course, Mr. G was my patient. A nice challenging patient for the medical student. I had earned it or something. For some strange reason, I thought that if I just tread lightly around Mr. G, all would be well. I have always been easy to get along with, after all. It was easy to envision. I would smile and be courteous in my interactions, and he would tolerate me, the annoying medical student who made him repeat exams when he didn’t feel like it. That sounded reasonable to me. Not too much to ask. And for the first couple of days after his admission, all seemed to be going well. He grumbled at me when I came in during the mornings but really did nothing more than that.

But now he was upset with me? Because of sorbet? Because I had requested that he stop eating his lemon sorbet for a minute while I listen to his heart and lungs? I pondered for a minute. I didn’t even think twice to make the request. I did my usual song and dance. Smiled and said “it’ll only be for a minute. I promise!” Did my exam and then left the room, thinking nothing of it. Was I being insensitive? Was he being ridiculous? What was this?

I had never upset a patient before. I don’t upset people.

My R2 came up to me, “So I heard about Mr. G and the sorbet. You really shouldn’t worry about it. He’s an old, cranky man. I promise it’s not you, it’s him. Forget about it.”

Colorado Medicine for July/August 2014

Inside CMS Later that afternoon, I started to read the note palliative care had dropped after visiting Mr. G a few hours earlier.

I was curious to know more about my patient’s final wishes. I halted when I saw the phrase “lemon sorbet” toward the end of the note. I moved in closer to the computer.

“The patient requests that he be allowed to eat his lemon sorbet without any interruptions from his health care team.”

I paused. Now the entire palliative care team knew about my lemon sorbet incident? And uninterrupted lemon sorbet was one of his final requests? I was embarrassed. I was angry. I was upset. Had I been pushy when requesting that he put down his sorbet? I imagine that I could have come back in a few minutes after he had finished eating, but I was in a rush to get done pre-rounding.

I had sacrificed his creature comforts on behalf of my stubborn determination to accomplish my morning tasks.

Efficiency, after all, is the name of the game in medicine.

Succumbing to the lemon sorbet demand and sacrificing morning efficiency is not part of the traditional list of competencies that earns you honors. And yet…

Yet there was something more to this. Mr. G was at the end of his life and simply wanted those around him to treat his final actions with respect. It all seemed so silly to me, this big fuss over sorbet. Of course, that’s easy to think when you’re 26 and death isn’t nipping at your heels. Lemon sorbet is a thing to be had next summer, some other summer. Mr. G had no more summers.

I dared to presume that I understood the value of lemon sorbet in a man’s life and equated it with my own. Who really knows what memories a lemon sorbet can hold? It could be an entire lifetime’s worth. All I had to do was ask and listen.

I stepped away from my computer. Humility is a big part of this physician business. Much bigger than I could have ever imagined. I strode over to Mr. G’s room. I paused.

Pride swallowed, I knocked on the door and walked in the room. I spotted the lemon sorbet carton out of the corner of my eye.

“Mr. G,” I began. “I’d like to apologize…” n

Colorado ICD-10 Coalition helping physicians prepare for coding switch The Colorado ICD-10 Coalition, a statewide organization of interested educators, consultants, physician and practice representatives, continues to help Colorado physicians prepare their offices for the scheduled implementation of the ICD-10 diagnosis codes in advance of the deadline that has recently been extended to at least Oct. 1, 2015.

"Despite the recent delay in the implementation of ICD-10, physicians and their staffs would be wise to continue their preparations so they don’t feel overwhelmed when it eventually goes into effect," said Marilyn Rissmiller, CMS senior director of the Colorado Medical Society Division of Health Care Financing.

The coalition’s resources include a series of webinars, educational events, worksheets, task lists and apps that are available on the group’s website, www.cms.org/icd-10. The two most recent webinars, Project Planning Phase 1 and 2, provide viewers with information on how to jumpstart this transition.

To learn more and to access resources to help you navigate the ICD-10 maze, go to www.cms. org/icd-10.

Colorado Medicine for July/August 2014

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Inside CMS

Member Benefits

John Collins and Jason DiLorenzo, GL Advisor

Obama’s 2015 budget proposal and its potential impact on medical graduates Every year the President publishes a budget proposal for the upcoming fiscal year.

President Obama has always worked to appeal to younger generations, recognizing their potential as a critical voting demographic and their plight as one that must be addressed. An example of this is his announcement in October 2011 of the Pay As You Earn (PAYE) program, leading to the program’s implementation in July 2012.

PAYE is an improvement of the previously existent income-based repayment (IBR) program, capping monthly payments at 10 percent instead of 15 percent of discretionary income and allowing for the forgiveness of the remaining federal student loan balance after 20 years of payments instead of 25. However, the PAYE program as it exists today is only available to those borrowers with no outstanding federal student loan balance on Oct. 1, 2007, AND a disbursement of federal student loan funds after Oct. 1, 2011, while all borrowers with a partial financial hardship (most medical graduates entering residency can demonstrate this) are eligible for IBR. Public service loan forgiveness (PSLF) is a separate program that works in concert with the two aforementioned repayment plans, relieving public or nonprofit sector workers of their remaining federal student loan balance after 10 years and 120 qualified payments while employed in the sector. For many young medical professionals, this program provides much needed relief, especially as the salaries of primary care physicians and internists, 50

often employed by non-profit entities, stagnate while demand for their expertise increases.

Under the 2015 budget proposal from the Obama administration, all borrowers would be able to limit their monthly payments to 10 percent of their discretionary income, as PAYE-eligible borrowers may do today. This by itself is welcome news, as even smaller initial payments allow medical residents to more easily manage their cash flow at the start of their careers.

However, the cap on payments (currently the 10-year standard payment amount) would be removed, suggesting that borrowers who eventually earn higher incomes may be required to pay significantly more than the standard 10-year payment would necessitate. For certain specialties, this could translate into an increase in payments made during residency to those required as an attending physician, such that these programs actually increase the cost of one’s debt over the life of the loan.

Of equal importance are the proposed changes to the forgiveness programs.

Framed as a requirement aimed to “protect against institutional practices that may further increase student indebtedness,” Obama proposes to limit the amount forgiven through the PSLF program to $57,500. This number, derived from the federal student loan borrowing limit for an independent undergraduate student, is well below the $160,000 $220,000 average federal education debt load of 2014 medical school graduates, not to mention future medical school

graduates. With inelastic demand for medical school education, this change would likely have no impact on tuition rates at university programs across the United States.

In addition to the changes to PSLF, all borrowers, regardless of their employment, would be eligible to have balances of up to $57,500 forgiven by the federal government after 20 years or qualified payments. Balances in excess of this figure would remain an obligation of the borrower until paid in full or 25 total years of repayment. While the $57,500 limit to the forgiveness value at 20 years is not necessarily advantageous to certain borrowers, the proposal also allows balances forgiven at years 20 and/or 25 to avoid tax consideration, whereas the existing legislation considers these forgiveness amounts taxable as income (PSLF is tax-free).

To examine how this may impact a 2014 medical school graduate, we’ve prepared a simple analysis. Let’s start with the average debt portfolio mix for a medical school graduate. With just under $200,000 at just under 7 percent, our graduate’s education debt is certainly a sizable concern that must be addressed strategically. Given the terms of Pay As You Earn and Public Service Loan Forgiveness, our borrower strides into residency confident that she will effectively manage her debt in an affordable, costeffective fashion.

Utilizing today’s programs, our newly minted MD or DO can do just that. If she Colorado Medicine for July/August 2014

Inside CMS does her residency, which we’ll assume is a four-year program, as well as her first six years as an attending in nonprofit, 501C3 hospitals while repaying her debt under the terms of PAYE, she’ll be eligible for forgiveness of her entire balance at the end of 10 years. During this 10-year period, her highest monthly payment is less than $1,400. The balance remaining at the time of forgiveness is just under $230,000, and she spends a total of about $97,000. We assumed this doctor practiced in one of the primary care specialties, with an average salary of about $167,000 over her first six years as an attending.

But if the proposal recently laid out by the administration was approved as is and forced upon the thousands of students and borrowers who’ve already developed a reliance on the current program details, the economics would look much different. Our doctor’s average monthly payment would increase by an average of $400 per month and she wouldn’t be done paying her debt for an additional 10

Colorado Medicine for July/August 2014

years, spending nearly $200,000 more to retire her debt.

For attendings, those of you actively participating in a residency or fellowship, or those on the precipice of graduating from medical school, you should be reassured by a few things. For one, the master promissory notes (MPNs) you signed in order to borrow each loan you took out for medical school included language about PSLF and your right to utilize the program. Thus, a legal contract between you and the federal government says you borrowed under the assumption you’d be able to utilize the PSLF program under the terms of the program at the time you took out the loan.

Second, if you’re actively working toward repaying your loans through the PSLF program and have made economic decisions based on the program’s details, you’ve demonstrated a detrimental reliance on the terms as they exist today. As such, the federal government is obligated to grandfather you and others in the

same situation through any changes to the laws, based on historical legal precedent. In summary, this means you’re very unlikely to be affected by the proposed changes.

However, if you’re an M1, M2, M3 or future medical student, you may take comfort in similar facts, including that your existing loans required you to sign MPNs that include the mention of PSLF. Additionally, the unintended impact the proposed changes to the PSLF program would have on the supply of health care would harm the success of the Affordable Care Act. Many students and young health professionals see PSLF as a means to make their career serving others possible, especially in light of the lack of growth in primary care physician wages.

Recognizing these facts, GL and many other institutions are advocating on behalf of graduate students and professionals in hopes that the detrimental changes to PSLF and the repayment programs are not passed into law. n

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Inside CMS

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

The value of legislative advocacy

Taking a proactive stance in shaping Colorado’s health care landscape Over the years, I have learned the importance of being at the table when a conversation begins so I don’t miss an opportunity to be part of it. This is especially true in discussions about legislative policies that influence health care. A wide range of issues, from the protection of patient records to tort reform, can surface at the state Capitol each year. Because of this, COPIC has an active presence to ensure that Colorado remains a great place to practice medicine.

COPIC formed its public affairs team to focus on state level policy, as well as public outreach and engagement.

Collaboration is key, and our advocacy efforts are done in coordination with partners such as the Colorado Medical Society (CMS) and Colorado Hospital Association (CHA).

Together, we are able to pay close attention to initiatives that may impact regulatory oversight, create burdens on health care delivery or change access to quality health care delivery.

Medical professionals continue to recognize how the dedicated resources of COPIC, CMS and CHA help them navigate the changes brought about through legislative policies. Our proactive work has established a “seat at the table” to engage with legislators and represent the perspectives of health care professionals.

COPIC’s legislative advocacy efforts are year-round and focus on the following areas: • Monitoring and reviewing proposed legislation – Every year there are countless bills brought forth that have the potential to impact health care. Our public affairs and legal teams review all drafted and introduced bills during a session, assessing each for possible unintended consequences impacting patient safety, quality of care and liability issues.

• Offering guidance to insureds on complex legislative issues – COPIC’s internal teams analyze legislative changes from every angle so we can explain the details and notify insureds of any steps to take. When there are important issues at stake, we also distribute information to the medical community to generate awareness and action.

• Educating legislators and building relationships – As issues emerge, legislators are inundated with information.

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Our goal is to educate them with facts and evidencebased data so they better understand the medical, legal and economic implications of their decisions. We also host annual forums for legislators, which reinforce our ability to be heard early in the policy-making process.

During the 2014 Colorado General Assembly, COPIC was actively involved in House Bill 1283, which aims to increase participation in the state Prescription Drug Monitoring Program (PDMP). COPIC, jointly with our partners, provided a perspective from the medical community to ensure that discussions were well-informed. This led to the bill not expanding liability for providers now mandated to register, and assurances that enforcement would be delayed until after the first renewal period so providers have adequate notice.

We were also involved with Senate Bill 162, which establishes the components of a quality management program for emergency medical services (EMS) organizations. The goal was to reinforce the importance of frank and honest quality reviews of pre-hospital care and how this supports improved patient safety and quality of care. The bill incorporated legal protections for the records of an EMS quality management program and immunity from civil actions for those participating in these activities when they act in good faith.

Perhaps the best example of where our legislative advocacy played a significant role was the Colorado Professional Review Act (CPRA). CPRA is a critical component of better care and patient safety as it supports open discussions designed to learn from past outcomes in order to improve future ones. In 2012, COPIC, CMS and CHA formed a coalition to draw attention to the importance of CPRA and why physicians are in the best position to review the medical care of other physicians. The coalition was successful in getting CPRA’s protections extended for another seven years.

All of these examples illustrate how legislative advocacy plays an important role in defining Colorado’s health care environment. For COPIC, it is a responsibility that we are committed to and our efforts support the ability of medical professionals to focus on what matters most – improved care for all patients. n

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Departments

medical news Michael Volz, MD, announces candidacy for president-elect ally rewarding. Each and every day brings a new lesson, challenge, or question to address; and, the most satisfying aspect is caring for our patients – their health and well-being. These are the benefits above all others that underpin my passion for our profession and daily strengthen my resolve to address our many concerns.

Michael Volz, MD I am announcing my candidacy for CMS President-elect and respectfully ask for your consideration and support. My decision to run and serve is based on the following three fundamentals.

1. Passion: I care deeply about our profession and the professional and personal wellness of my colleagues; 2. Commitment: To serve our patients and our profession; and, 3. Qualified: Through many years of involvement with organized medicine and in private practice I have learned the importance of listening first and the wisdom of acting with a broad consensus.

The most fundamental reason is passion and concern – OUR passion and concern – for medicine. Like you, I entered medical school with great enthusiasm for the vision of being a physician. Today my fire still burns bright – even brighter than ever before – because this amazing profession continues to enrich my life with the privilege of helping patients in their time of need and through camaraderie with my colleagues. The joy of medicine is intellectually stimulating and person 54

I am committed to a unified profession.

Finding unity is often challenging given the complexities of the external environment. If elected president-elect, I will dedicate myself to that which unifies us all – our patients. Our core function is to address the well-being of the patient.

In today’s rapidly changing climate, our care and compassion to patients, and the relationship we enjoy with them, just may be needed more now than at any time in recent memory. I will vigorously advocate for remedies that remove the debilitating administrative barriers to quality care. CMS efforts to simplify and streamline administrative functions across payers must continue with even greater vigor. Eliminating administrative barriers will improve professional satisfaction and improved professional satisfaction means better care for patients and happier physicians. Indeed, medicine is one of the oldest and most noble professions. Listening to, hearing, being inquisitive, and caring for the patient always has been and remains the key to try to solve the needs for patients. We all know from studies, surveys, and our experience that the interaction with our patients gives the greatest opportunity to determine the problem and to do what is needed.

Please consider my 33 years of experience in organized medicine as qualifications for the office of president-elect and president. As a medical student, my col-

leagues selected me to serve as their representative for four years to the American Association of Medical Colleges. I was also honored to represent my fellow interns and residents during my threeyear residency at the University of Miami. I served as the president of the Colorado Allergy and Asthma Society, the medical director for the American Association of Colorado asthma camp, and more recently for eight years on the CMS Board of Directors. I also participated in many other ways at CMS and elsewhere because my desire to be involved and to contribute continues to grow over time.

What I have learned from these many experiences has improved my leadership skills and allowed me to develop personal relationships with many physicians from all specialties across Colorado.

Over time, we have seen many changes in medicine – some have been intended to improve patient safety, others have been intended to improve the accuracy of making a diagnosis, efficiency, treatment, and to control costs. Unfortunately, the success and impact of these elements are widely variable, with the overall effect of physicians spending less time with patients, efficiencies not being as expected or worse, fighting to perform/ order tests or provide treatment when clearly indicated, and other similar effects. We continue to see costs go up and the care for many to be increasingly difficult or fragmented. Surveys have shown the most important factor for physician satisfaction is the time and interactions with patients.

So, how do we as physicians try to reconcile this dichotomy? We do what we have always done – we step up. Much

Colorado Medicine for July/August 2014

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medical news Michael Volz, MD, (cont.)

Ana English joins CIVHC as CEO

of what is working well in health care is derived from the exam room perspective as opposed from the top down. We need more local innovation and more physician leadership. We need to work with our patients, our colleagues and other stakeholders. We need to do what we did in medical school and residency when the going got tough – look inward, recall that burning desire to be a physician and come together as colleagues and friends for support. CMS is a large diverse organization. It is physician-led and draws on the strengths and wisdom of our colleagues, working with many other stakeholders. With the vision recently confirmed by the CMS board of directors to make Colorado the best state in which to provide and receive safe, high quality, and cost-effective medical care, I am prepared and eager to serve you and our patients.

The challenge is to understand, address, and to reconcile the increasingly complex problems before us, CMS, and physician leaders and to do so with passion, experience, and courage. I believe my experience and acquired skills now put me in a position to fill this role and represent CMS, you, and our patients.

The board of directors of the Center for Improving Value in Health Care (CIVHC) has selected Ana English, MBA, to serve as CEO of the organization. English, a seasoned health care executive, brings extensive provider and payer experience, as well as keen familiarity with health care data, to the non-profit organization.

its acquisition of Electronic Network Systems, a healthcare electronic data services organization, in which English held the role of president and COO. With OptumInsight, English steered several key contract initiatives aimed at developing new provider and payer solutions to achieve high value health care.

Most recently, English served for four years as vice president for the American Medical Association (AMA) and operated as the general manager of one of its subsidiaries. English led efforts to develop and provide solutions for providers to thrive in pay for value markets and to support performance improvement through the use of health information technology. During her tenure, she developed critical strategic partnerships and launched a national portal assisting physicians with changing technology needs.

“Ana's national experience, business acumen and understanding of how to deploy health care data are key assets for CIVHC,” said Mike Huotari, board chair for CIVHC. “Her experience combined with her ability to engage key players will help advance CIVHC's mission to achieve the Triple Aim for Colorado: improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care.”

Prior to AMA, English was co-president and chief operating officer for Assist Group, a medical claims resolution company working with health plans and third party administrators. She also served as senior vice president of OptumInsight, a subsidiary of UnitedHealth Group, for eight years through

I ask for your support, promise to listen first and to use my passion and experience to advance our noble cause. n

English joins CIVHC on August 4, 2014. “Leading CIVHC's efforts to advance Colorado's health care system is an honor,” English said. “I look forward to building new relationships across the state and strengthening those I've already established to help CIVHC advance health care for all Coloradans.” n

Call for nominations

The Colorado Medical Society is issuing a call for nominations for the following elected offices at its upcoming annual meeting September 19-21 at the Vail Cascade Resort. Visit www.cms.org to view qualification and application requirements. To date, the following physicians have announced their candidacy.

President-elect (one-year term) Michael Volz, MD

Vice-Speaker of the House (two-year term) Brigitta Robinson, MD, incumbent

Speaker of the House (two-year term) Bob Yakely, MD, incumbent CMS Historian (one-year term) W. Gerald Rainer, MD, incumbent

AMA Delegate (elect one) (One, two-year term beginning Jan. 1, 2015, ending Dec. 31, 2016) A. “Lee” Morgan, MD, incumbent

Colorado Medicine for July/August 2014

AMA Alternate Delegate (elect one) (One, two-year term beginning Jan. 1, 2015, ending Dec. 31, 2016) Kay Lozano, MD Daniel Perlman, MD

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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 PEDIATRIC ASSOCIATES OF DURANGO – seeks an experienced BC pediatrician for an out-patient position. This is a private, well-established single physician practice in beautiful Durango, Colorado. We are passionate about setting a new standard for health that empowers children to reach their full potential. If interested please email pchau3@aol.com or call 970-259-7337. www.paofdurango.com LITTLETON PEDIATRIC MEDICAL CENTER – is seeking a part time or full time board certified pediatrician for its Highlands Ranch or Ken Caryl offices both in metropolitan Denver.

Please call Nita O’Brien, R.N. @ 303791-9999 or email address: nita-littlepeds@qwestoffice.net MD NEEDED FOR BUSY CHRONIC PAIN AND REHABILITATION CLINIC IN SOUTH DENVER – Full-time position will includes performing evaluations and medical case management of physically injured patients. (no procedures). No nights, no call.

Malpractice included. Salary $200K+ depending on experience. Applicant must have valid CO license and DEA license. Interested applicants please send resume to Heather@CherdackPMR. com.

LOOKING? Whether you’re looking for new opportunities or selling your product or service, CMS’ classified ad section is the place to be seen.

To place your ad call (720) 858-6310

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Colorado Medicine for July/August 2014

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classified advertising ➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES ➤ PROFESSIONAL OPPORTUNITIES PHYSICIAN (GENERAL MEDICINE) – FULL TIME AND INTERMITTENT – The Department of Veterans Affairs is seeking to fill full time and intermittent physician positions located in Golden, Colorado. The compensation and pension (C&P) physician performs history and physical examinations, orders and evaluates appropriate diagnostic studies, and acts within the guidelines and quality indicators set forth by the Disability Management Administration (DMA), the C&P Service, and the VA Eastern Colorado Health Care System (ECHCS). The C&P physician will be responsible for generating C&P exam reports utilizing CAPRI CPRS templates; dictation templates and/or other methods as approved by the Medical Director C&P service - for the official record of the veterans' C&P examination. The C&P physician will engage in DMA internal review procedures and other C&P administrative duties as outlined by the Medical Director C&P Service. The C&P physician must be able to demonstrate the knowledge and skills necessary to evaluate veterans served by the ECHCS VAMC C&P Service. The individual must demonstrate the knowledge of the changes associated with aging and possess the ability to evaluate veterans based upon physical, psycho/social, cultural, safety and other age related factors as noted in the competencies described in departmental and/or unit specific policies and procedures. C&P physicians will maintain productivity standards as set by the C&P Medical Director.

TOUR OF DUTY: Monday through Friday, 7:00 a.m. - 4:30 p.m. Candidate must be willing to work weekends, irregular work hours and extended hours.

The candidate must be willing to be placed, detailed or temporarily assigned to other related services and/or locations, if necessary. Please refer to https:// Colorado Medicine for July/August 2014

www.usajobs.gov/ vacancy identification number (VIN) 1129592 to apply for the full time positions. Please refer to https://www.usajobs.gov/ vacancy identification number (VIN) 1079946 to apply for the intermittent positions.

PHYSICIAN (PHYSICAL MEDICINE AND REHABILITATION) (NEUROLOGY) – FULL TIME – The Department of Veterans Affairs is seeking to fill a full time physician position located in Golden, Colorado.

The compensation and pension (C&P) physician performs history and physical examinations, orders and evaluates appropriate diagnostic studies, and acts within the guidelines and quality indicators set forth by the Disability Management Administration (DMA), the C&P Service, and the VA Eastern Colorado Health Care System (ECHCS).

The C&P physician will be responsible for generating C&P exam reports utilizing CAPRI CPRS templates; dictation templates and/or other methods as approved by the Medical Director C&P service - for the official record of the veterans' C&P examination. The C&P physician will engage in DMA internal review procedures and other C&P administrative duties as outlined by the Medical Director C&P Service. The C&P physician must be able to demonstrate the knowledge and skills necessary to evaluate veterans served by the ECHCS VAMC C&P Service. The individual must demonstrate the knowledge of the changes associated with aging and possess the ability to evaluate veterans based upon physical, psycho/ social, cultural, safety and other age related factors as noted in the competencies described in departmental and/ or unit specific policies and procedures.

C&P physicians will maintain productivity standards as set by the C&P Medical Director. TOUR OF DUTY:

Monday through Friday, 7:00 a.m. - 4:30 p.m. Candidate must be willing to work weekends, irregular work hours and extended hours. The candidate must be willing to be placed, detailed or temporarily assigned to other related services and/or locations, if necessary. Please refer to https://www.usajobs.gov/ vacancy identification number (VIN) 1117932 to apply for this position.

PSYCHOLOGIST (NEURO) – FULL TIME – The Department of Veterans Affairs is seeking to fill a full time neuropsychologist position located in Colorado Springs, Colorado. Clinical Responsibilities: The incumbent provides a full range of psycho-diagnostic services including neuropsychological assessment and using the most appropriate psychotherapeutic techniques in providing disability assessment. The incumbent performs neuropsychological evaluations for outpatient and medical inpatient veterans and active-duty military. Will also perform standard Compensation and Pension exams for diagnosis and reporting for rating. The incumbent consults with ECHCS and DOD staff as appropriate under HIPAA regulations on a wide variety of patient care issues. Participates in improvement of clinical skills. Is responsible for timely completion of all clinical charting and documentation. Maintains ongoing scholarly and continuing education activity in psychology and neuropsychology. Participates in psychology peer review as required. TOUR OF DUTY: 08:00 a.m. to 04:30 p.m., Monday - Friday, unless other hours requested by management. Please refer to https:// www.usajobs.gov/ vacancy identification number (VIN) 1120039 to apply for this position.

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the final word Our biggest failure in health care Our biggest failure in health care is a lack of communication. Lack of communication produces more than 100,000 deaths per year and 100,000 injuries to hospitalized Medicare patients each month. Lucian Leape, MD, a Harvard Health Policy Analyst, says, “Health care’s dirty little secret is that nobody is responsible for coordinating care.” Ineffective communication is responsible for 80 percent of all adverse incidents, 71 percent of all malpractice claims, and 70 percent of all Joint Commission “sentinel events.”

Coordination of care must involve communication, knowledge and good relationships. Coordination of care involves not only the health care system but social service and public health systems as well.

Then to be complete, we must include the patient in their home setting. There is a strong positive relationship between a provider’s communication skills and a patient’s capacity to follow through with medical recommendations.

To communicate care we must gain access to and integrate services and resources.

Then we must link services with the patient and family. We should avoid duplication and unnecessary cost and advocate for better outcomes. Shared decision-making becomes more complex each year as new discoveries are constantly being made.

The Affordable Care Act makes coordination of care and communication mandatory, or at least reduces reimbursement.

Patients will now judge how efficiently we communicate and hospital reimbursement for Medicare patients will consider patient satisfaction.

The federal government also encourages all providers to meet HITECH use requirements. The Health Information Technology for Economic and Clinical Health (HITECH) Act which amended HIPAA in 2013 was specifically designed 58

to provide the necessary assistance and technical support for providers so that every American can benefit from an EHR (Electronic Health Record) as part of a modernized, interconnected and vastly improved system of care delivery. The Act establishes incentive payments under the Medicare and Medicaid programs.

Is the EHR really going to improve communication? Fifty percent of all communication in health care is still face-to-face.

Will EHR change present data that suggests that half of all hospitalized patients do not know their diagnosis or the names of the medications they are taking?

There are so many barriers to communication! Gender, ethnicity, culture, language, jargon, personal values, commitments, schedules and many more factors hinder effective communication. Add those to attitudes, behaviors, morale, memory, stress, fatigue, distractions and interruptions and effective communication does not happen.

Communication is most likely to fail at times of transition. When we pass the ball, it gets dropped. Successful hand-offs are critical. Transitions of care are where we make mistakes. There has to be a system.

The aviation industry has a system called Crew Resource Management (CRM). Because of CRM we all fly safer. Each member of the crew understands exactly what their role is and how they are to respond to any situation. Many large medical groups, including Kaiser Permanente, are using SBAR to improve transitions. SBAR stands for Situation, Background, Assessment, and Recommendation. This means that each provider must respond to the following four questions in making a handoff: 1) What’s going on with the patient?; 2)What’s the patient’s history?; 3) What do I think the problem is?; 4) What would I do to correct it? Hand-off communication performance has been proven to decrease adverse events by more than half.

Gary D. VanderArk, MD CMS Past President The answer to improving communication in health care is to become a team – a group of individuals who work together to produce products or deliver services for which they are mutually accountable.

TEAM means Together Everyone Accomplishes More! Health care teams must have regular meetings to define objectives, clarify roles, apportion tasks, encourage participation and handle change.

The ten requirements of a health care team: 1. Demonstrate reliability 2. Communicate constructively 3. Listen actively 4 Participate actively 5 Share openly 6. Cooperate and pitch in 7. Be flexible 8. Show commitment 9. Work as problem solvers 10. Treat everybody with respect Bill Russell, Hall of Fame center for the Boston Celtics, said: “The most important measure of how good a game I played was how much better I’d made my teammates play.”

Health care is changing and we all must change too. There must be a new focus on quality and efficiency. We must agree on standardized functions. We can eliminate unnecessary steps and automate any work that can automated. We can delegate work to appropriately trained non-physicians.

We must progress to patient-centered care by activating and engaging the patient and their family. Jerry Garcia of the Grateful Dead said: ”Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”

The new world of health care must involve cooperation, communication and collaboration.

We can! We must! We will! n Colorado Medicine for July/August 2014

Colorado Medicine for July/August 2014

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