March-April 2016

March/April 2016

Volume 113, Number 2

Health plan mega-mergers on the line Award-winning publication of the Colorado Medical Society

contents March/Apr 2016, Volume 113, Number 2

Features. . .

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AMA urges DOJ to block mergers–In a Q&A with AMA antitrust lawyer Henry Allen, Colorado Medicine explores why the AMA is leading the charge to block the proposed health insurance mergers.

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Legal battle for transparency– CMS outside legal counsel John Conklin reviews CMS efforts to bring transparency to the health plan merger analysis process.

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Division of Insurance role– DOI Commissioner Marguerite Salazar explains DOI’s role in approving the mergers and why the two proposed mergers differ in their requirements for public review.

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Aetna perspective–Aetna Regional Medical Director Gina Confitti, MD, provides her view on how the Aetna-Humana merger can meet the needs of consumers and physicians.

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Anthem perspective–Anthem Blue Cross and Blue Shield

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Physician burnout related to payer issues–Learn more

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AMA National Advocacy Conference–Physician leaders from around the state stormed Capitol Hill in Washington D.C. to educate lawmakers on medicine’s top concerns.

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Zika virus testing–A CDC lab in Fort Collins is leading the world in diagnostic testing for Zika virus and training public health facilities everywhere to detect the virus.

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Zika virus prevention– CMS board members Christine Nevin-Woods, DO, MPH, and Mark Johnson, MD, MPH, present guidance to physician members on the Zika virus.

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Final Word–Using data from a fall market analysis, AMA CEO James Madara, MD, explains why the AMA has and will continue to speak out about anticompetitive consolidation in the health insurance industry.

Cover story Up from the depths:

huge health plans look to swallow more of the market (again), raising alarm across the physician community. Read more about member perspectives, CMS board decisions and state and national action starting with the Executive Office Update on page 5 and continuing with the cover story starting on page 6.

Inside CMS 5 30 32

Executive office update COPIC Comment Reflections

Departments 34 40

Medical News Classified Advertising

Colorado Medicine for March/April 2016

of Colorado President Mike Ramseier gives his thoughts on how the Anthem-Cigna merger could close the gap between consumer expectations and health care outcomes. about the link between administrative burden and physician wellness, and how the mergers could worsen burnout.

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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

2015/2016 Officers Michael Volz, MD

President

Katie Lozano, MD President-elect J.T. Boyd, 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 Tamaan Osbourne-Roberts, MD

Immediate Past President

Board of Directors Charles Breaux Jr., MD Laird Cagan, MD Cory Carroll, MD Sami Diab, MD Joel Dickerman, DO Greg Fliney, MSS Jan Gillespie, MD Kendra Grundman, MSS Curtis Hagedorn, MD Mark B. Johnson, MD Richard Lamb, MD Tamara Lhungay, MSS Lucy Loomis, MD David Markenson, MD Gina Martin, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD David Richman, MD Scott Replogle, MD Floyd Russak, MD Charlie Tharp, MD Andrea Vincent, MSS

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

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

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

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

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

Mike Campo, Staff Support, Mike_Campo@cms.org

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

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

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

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

Printed by Spectro Printing, Denver, Colorado

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Monopoly, oligopoly, monopsony – the new board game for doctors Hopefully you caught the subtle imagery on the cover and have browsed the range of commentaries, including from Aetna and Anthem, on the proposed consolidation of four of the five largest commercial insurance companies in America. You will find the cover story’s analysis of a recent all-member CMS survey and a sample of the verbatim physician responses included with the charts both compelling and alarming. Among the health care policy priorities on our agenda, the patient-centered clinical and economic concerns of physicians will remain a singular priority of CMS along with the liability and professional review enviornment. We will continue to pursue policy shifts that assure competition over the value of care, not market-share or cost irrespective of that value.

Pursuing these policy shifts will be a grind.

There will be no “a-ha” moments and no battlefield epiphanies. The business motives of these companies are structurally in conflict with the clinical motives of physicians. Current and potential imbalances given the proposed mergers in the economic relationships between these companies and physicians are not only unfair, they can be dangerous. The transactions directly involve human lives and their health.

There is no definitive endgame when attempting to set policy guidelines on the size, operations and business relationships between physicians and these proposed leviathans. The process is inherently political. Developing and enacting legislative and regulatory language is complex and urgently needed to reset boundaries.

Despite the urgency, this is a long game with recurring adjustments as all the parties involved adapt and evolve to new Colorado Medicine for March/April 2016

policy and business model changes over multiple iterations and time.

Our mediation with Colorado Association of Health Plans (CAHP) ended without resolution on out of network (OON) or the many network issues we surfaced.

Complex problems demand collaboration, and we intend to continue a constructive dialogue with CAHP and any individual company that is interested. In the short term, the conversation over the next 60 days moves without much, if any, dialogue into the legislative branch and a network adequacy stakeholder process hosted by the Division of Insurance. We are reasonably certain that some, though not all, of the companies will use their considerable influence to make certain nothing substantive comes from this agency endeavor or out of the legislative branch this year.

We had a conversation with the commissioner of insurance and the executive director of the Department of Regula-

tory Agencies (DORA) in late February.

The meeting was of course civil (this is Colorado, not Texas) and the net of our message was straightforward, demonstrating our strongly held resolve and commitment. The network adequacy laws have not been meaningfully updated in almost 20 years while the marketplace has changed dramatically. The two agency heads spoke encouragingly of a strong partnership with physicians.

There are numerous ongoing reasons to engage the companies as well as legislators and regulators over the next year. In addition to the DOI stakeholder process on network adequacy, DOI hearings on the proposed Anthem-Cigna merger and upcoming legislation in 2017, DORA will be conducting a “sunset review” of DOI, which should attract considerable stakeholder attention to the agency’s role as overseer and referee in these complex relationships. This is indeed a target-rich environment. n

CMS Board of Directors votes to strongly oppose Aetna/Humana and Anthem/Cigna mergers At its March 11, 2016 meeting, the Colorado Medical Society board voted to strongly oppose the proposed health plan mergers due to the following: • Overwhelming opposition to the mergers expressed by physician members through the statewide survey on the subject; • Lack of transparency by the Division of Insurance surrounding the process and information used to evaluate the mergers, and the demonstrated unwillingness to receive input from principal stakeholders including physicians and patients; • AMA analysis of Colorado metropolitan statistical areas (MSAs) that demonstrates a current, significant anticompetitive health insurance marketplace in many MSAs that these mergers will only augment; • Ongoing and aggressive development by health plans of narrow provider networks that limit access to care and physician choice with little to no transparency about the standards used to create and maintain these networks.

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Health plan mega-mergers on the line

Cover Story

Insurance company mergers must be rejected by regulators Proposals will jeopardize office-based physician practices Benjamin Kupersmit, president, Kupersmit Research

STORY HIGHLIGHTS • CMS surveyed members in December and January and found that all member demographics – from new physicians to retired physicians – view the proposed health insurance industry mergers of Aetna with Humana and Anthem with Cigna with concern and skepticism.

• Especially in the free response sections of the survey, physicians revealed alarming practices by insurance companies that they believe will worsen if these mergers are approved, putting the survival of office-based, physicianowned practices in jeopardy.

• Physicians are clear: Approving these mergers will harm care for Coloradans, and regulators should say no.

Eight years of survey research have pointed to intense concern among CMS members about the practices of commercial payers, from contracting to service authorization to claim reimbursement.

Physicians also increasingly shoulder the costs of helping patients understand and navigate their health insurance, including both the financial costs of wasted staff or physician time, as well as the immeasurable costs of degraded patient-physician relationships in exam rooms across our state.

It comes as no surprise that physicians – especially those who continue to survive in small, office-based practices – view the potential consolidation of Aetna-Humana and Anthem-Cigna with tremendous skepticism and concern.

Colorado Medicine for March/April 2016

Our recent survey concerning these mergers shows the following: CMS members resoundingly reject mergers • By a 68%-5% margin, CMS members oppose allowing the mergers to proceed (including 48% who “strongly” oppose), with 28% saying “neither” or “not sure.” o Among physicians in active practice, 73% are opposed (54% “strongly”). o Among decision-makers (physicians who participate directly in contract negotiations with commercial insurers), opposition stands at 79% (63% “strongly”).

• Nearly all decision-makers (who make up one-third of CMS members, and are largely concentrated among office-based, smaller specialty care practices) believe contract negotiations will be less favorable to physicians if the mergers are approved, with 85% saying as much.

Physicians expect higher premiums, less patient access if mergers are approved • Specific impacts that CMS physicians expect to “definitely” or “probably” happen if the mergers are approved include higher premiums for subscribers (75%), reduced patient access to needed care (72%), lower reimbursements for providers (72%), more physicians pushed to an employee role (67%), reduced collaboration in patient care from payers (66%), more small practices out of business (66%), physicians forced to spend less time with patients (62%) and reduced investments in practice infrastructure (58%).

• If the mergers proceed, and they do not have a contract with the new merged entity, 44% of decision-makers say they will be forced to reduce

staff or staff salaries, 35% say they will be forced to cut investments to practice infrastructure, 32% say they will need to reduce the time they

Call to action: What Colorado physicians can do

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Communicate your views on the mergers immediately by writing the state insurance commissioner, Marguerite Salazar. Send a copy of your letter to Colorado Gov. John Hickenlooper and Colorado Attorney General Cynthia Coffman.

Commissioner Marguerite Salazar Division of Insurance, Colorado Department of Regulatory Agencies 1560 Broadway, Ste 850 Denver, CO 80202 Governor John Hickenlooper 200 E Colfax, Room 136 Denver, CO 80203 Attorney General Cynthia Coffman Colorado Department of Law Ralph L. Carr Judicial Building 1300 Broadway, 10th Floor Denver, CO 80203

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The Colorado Division of Insurance will soon hold hearings on the proposed Anthem-Cigna merger.

Email president@cms.org if you are interested in attending and possibly testifying on behalf of your practice.

CMS will provide you with assistance. spend with patients, 24% say they will need to close their practice and become an employee of a large group or hospital, 15% report they will

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Cover story (cont.) move to another locale with competitive reimbursement and 13% say they will retire from active practice.

Insurers currently exert significant market power over physicians • A majority (59%) of CMS members, and 80% of decision-makers, say they must contract with Anthem “to have a financially viable practice,” with majorities saying the same regarding the other commercial insurers we listed.

• Just 5% agree they can “turn away from an insurer and compensate for that lost revenue by treating more Medicare/Medicaid patients,” with 79% disagreeing (63% “strongly”). o Among decision-makers, 93% disagree (75% “strongly”).

• Nearly one-half of decision-makers (47%) have seen “take it or leave it” offers from insurers, and a similar percentage (44%) say they have seen “all products clauses” in contracts.

It is worth recalling data from our recent network adequacy survey, conducted in September 2015: • One-half of CMS members (47%) have encountered payers who reject

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claims “without clear explanation,” 40% have seen unnecessary delays of “time sensitive referrals,” and 36% have experienced “phone messages not returned in a timely fashion.”

• One-third (33%) have hired new staff, one-quarter (28%) have increased hours for current staff, 19% have increased use of an “outside billing company,” and 16% have increased use of “collections agencies” in response to the narrowing of provider networks.

Just say no Years of CMS member surveys and reams of studies of physician burnout point to a profession in crisis. Physicians prescribe medication or treatments and hope insurance companies will approve them. Then they fight to get paid for their work and face roadblocks and hassles at every turn, if they’re lucky enough not be rejected from a network or offered rates that force them out of business.

If approved, these mergers will only accelerate these trends, and put the survival of office-based, physician-owned practices in jeopardy. A decline in the number of independent voices standing up for the practice of medicine and for the rights of patients – including the humanity of medicine beyond dollars

and red tape – will continue to degrade the trust between Colorado’s physicians and their patients, a trust that is imperative each time a new patient enters a doctor's office for an initial examination.

Physicians are clear in their message today: Approving these mergers will harm care for Coloradoans, and regulators should say no. n Methodology This survey was conducted online by the Colorado Medical Society. It includes 597 fully completed surveys, including 153 interviews with decision-makers (those who are directly involved in contract negotiations). An additional 138 members partially completed a survey; these results are included in the tabulated results as well.

The margin of error for the entire sample of 597 is ±4.01%, and for the sample of decision-makers it is ±8.3% at the 95% confidence level. Surveys were gathered from Dec. 29, 2015 to Jan. 21, 2016.

Questions were asked regarding both the Aetna-Humana merger and the AnthemCigna merger. Attitudes on these questions did not vary significantly between the two mergers; the data is presented for the Anthem-Cigna results.

Colorado Medicine for March/April 2016

Cover Story

In their words...

Colorado physicians are concerned about the impact that proposed mega-mergers between Anthem and Cigna and Aetna and Humana may have on their patients and their practice. The following open-ended responses to the CMS physician poll on mergers underscores the depth of that concern.

“In short, the industry already uses every tiny advantage to sabotage clean claim payments to physicians and limit patient access to promised benefits. Limiting the competition between insurers with giant mergers will only worsen this crisis.”

“[I] have the unfortunate meetings with insurers suggesting changing my quality of care to substandard.”

“All [of] the market concentration has made it impossible to negotiate with insurance companies. The end result was that I went unpaid for two years while our practice failed...”

“Denials of care for our recommendations is the most pressing problem that we have as a practice. Patients are denied their rightful care and are left without options.”

“Commercial payers have been really aggressive in their negotiations especially if we want to be part of narrow network plans. They are using outdated and unrelated data to unfairly exclude some practitioners.”

“How do you work with an 800-pound gorilla that doesn’t care?”

“The insurance industry holds all the negotiating cards – only a handful of companies are negotiating with hundreds of thousands of physician practices...

Reducing the number of companies only compounds this.”

“Any merger in the health care field reduces competition and further reduces care that physicians can provide due to lower revenue per patient forcing more patients to be seen due to lack of competition.”

Join Now! Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or e-mail susan_koontz@cms.org Colorado Medicine for March/April 2016

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Cover Story

Cover Story

Features

AMA urges DOJ to block mergers CMS staff report

AMA Antitrust Attorney Henry Allen explains dangers to physicians and patients of allowing health plan mergers

Henry Allen (HA): Commercial health insurance markets in Colorado and across the nation are already highly concentrated; only a few health insurers with large market-shares compete with one another. The situation isn’t any better with respect to Medicare Advantage. The proposed mergers would reduce competition even further, to the great detriment of both patients and physicians.

HA: I don’t. There simply is no economic evidence that the formation of even bigger health insurers to counter hospital or health system monopolies benefits consumers. Negotiations between dominant health insurers and hospital systems have been likened to a battle between proverbial sumo wrestlers, where the match often ends in a handshake and consumers get crushed.

The better answer to hospital consolidation is to recognize that integrated care does not necessarily require hospital-led consolidation and that by encouraging entry into hospital markets, such as by physician led-organizations, hospital markets can be made competitive.

CM: Some supporters of the mergers claim that the mergers would create economies of scale and other efficiencies, which the insurers could then pass on to consumers in the form of lower premiums. Do you think that’s true?

CM: The AMA’s letter to the DOJ indicates that the mergers would enable the health insurers to exercise “monopsony” power. What is monopsony power and what effect does a health insurer’s exercise of monopsony power have on physicians and patients?

HA: No. Insurers have a dismal track record of passing any savings from an acquisition on to consumers. A growing body of research suggests that greater health insurer consolidation leads to higher insurance premiums. Also, studies show that where there are more insurers in the marketplace, insurance premiums are lower.

HA: A health insurer has monopsony power when it can force physicians to accept payments that are below competitive levels. This hurts patients and physicians in a number of ways. First, physicians are not able to invest in new equipment, technology and other practice infrastructure that could improve the access to and quality of patient care. Second, physicians may retire early, leave Colorado in favor of markets with higher reimbursement levels, or be forced to spend less time with patients to meet practice expenses. Third, the mergers may also cause even tighter provider networks, reducing patient access to physicians and effectively curtailing

has urged the U.S. Department of Justice (DOJ) and numerous state regulators to block the mergers between Aetna and Humana, and Anthem and Cigna. Why is this?

Henry Allen Jr., JD Colorado Medicine sat down with Henry Allen Jr., an attorney within the Advocacy Group of the American Medical Association, to talk about the proposed health insurance industry mergers.

With the AMA he specifically works on antitrust issues in health care and medical insurance markets and has testified before the United States Senate Judiciary Committee.

Allen is an adjunct professor at Northwestern University School of Law where he teaches antitrust and health care. He has also been an adjunct professor at the Kellogg School of Management of Northwestern University and at Cornell University, where for two decades he taught health law in the Sloan Institute of Health Services Administration.

Colorado Medicine (CM): The AMA 12

CM: Some merger advocates argue that the mergers are needed because the insurers need more bargaining power to respond to hospital consolidation by forcing hospital prices down to the benefit of consumers. Do you think that argument has any legitimacy?

Colorado Medicine for March/April 2016

Features the quantity and quality of their services.

CM: Are these potential harms to the physician marketplace now under investigation?

HA: The U.S. Department of Justice and many state attorneys general and departments of insurance are investigating the potential competitive effects of the proposed megamergers. A central focus of the DOJ investigation appears to be whether the mergers will create harm to the physician marketplace.

that the mergers would result in monopsony injury to physician practices and ultimately to their patients.

CM: What kinds of monopsony injury did the survey show?

HA: The survey confirmed that physicians expect that the merged health insurers would likely lower reimbursements for providers to the extent that physicians will have to:

• reduce investments in practice infrastructure; • spend less time with patients in order to meet practice expenses; • reduce staff or staff salaries; or • move to another locale with competitive reimbursement; or retire from active practice.

We believe that this information should assist the DOJ in reaching a decision to block the mergers. n

CM: What is the likelihood that the DOJ will challenge these mergers on monopsony grounds?

HA: In the past, the DOJ has successfully challenged several health insurer mergers (half of all cases it has brought against health insurer mergers) based on DOJ claims that the mergers would enhance health insurer buyer or monopsony power in the purchase of physician services. In addition, at least one state health insurance department has also effectively blocked a health insurer merger based in part on monopsony concerns in physician markets.

CM: The Colorado Medical Society recently commissioned a member survey concerning the mergers. What do you see as the benefit of this survey?

HA: The DOJ has asked both the CMS and the AMA for information. So the survey was designed to determine the effects of the mergers on the physician marketplace. We also wanted to identify any health insurer contracting practices that are ultimately harmful to patients – for instance, all products clauses.

CM: As an antitrust attorney, what do you think about the survey responses in Colorado?

HA: I was extremely impressed with the survey’s comprehensiveness and with the results. The response rate was fantastic! And the survey confirmed not only that physicians believe that the mergers will raise premiums, but also Colorado Medicine for March/April 2016

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Features

Legal battle for transparency John Conklin, Esq., Martin Conklin, PC

The fight for transparent review of insurance mergers The proposed health insurer mergers shine a spotlight on the laws that require the Colorado Division of Insurance (DOI) to review such mergers.

The merger between Anthem and Cigna is governed by a law that applies to domestic insurers. The public has received notice of Anthem’s initial filing with DOI of preliminary materials and DOI will hold a public hearing and prepare and release several analytical reports on the merger. However, Aetna and Humana are both foreign insurers under Colorado law. Although Aetna provided DOI with notice of the proposed acquisition of Humana last summer, current law did not require DOI to provide notice to the public or stakeholders that it was reviewing the proposed deal. DOI disregarded requests for notice. After 30 days passed without action by DOI, the merger was considered approved under Colorado law, again without notice to or input from physicians, hospitals or consumers.

The Colorado Medical Society is taking action to determine why DOI approved the Aetna-Humana merger without public notice or input. Using Colorado’s Open Records Act (CORA), CMS demanded from DOI a copy of the preacquisition notice Form E that was filed with DOI by Aetna. Aetna’s Form E contains Colorado market-share information Aetna submitted regarding the proposed merger. In response to CMS’ CORA request, DOI filed a lawsuit in Denver district court asking a judge to determine whether Aetna’s Form E is confidential under Colorado law. Aetna has joined in that lawsuit and the court will issue a decision this spring. While 14

CMS strongly believes the Form E is not confidential under the current law, if a judge disagrees and finds that Aetna’s Form E is confidential, then DOI’s approval of the merger will have occurred without public awareness that the merger was even under DOI review and without public access to the data Aetna submitted to DOI to gain approval for the merger.

The significance of the Form E data has been made clear through a second, broader Open Records Act request from CMS to DOI, which elicited documents that show DOI concluded – based on the data Aetna submitted – that the proposed Aetna-Humana merger violates the statewide competitive standard in two lines of health insurance: Medicare and other health insurance. Once a violation is found, DOI must then determine whether an exclusion applies, which would allow DOI to approve the merger.

For the Aetna-Humana merger, DOI concluded that an exclusion applies because the merger will not create a statewide monopoly or substantially lessen statewide competition among health insurers in those insurance lines. The data and analysis for that conclusion is contained in the Aetna Form E that CMS is seeking in court from DOI. Data from other sources supports a conclusion that the merger will impact competition in certain Colorado markets.

If successful in obtaining the document, CMS will be able to have it reviewed under the competitive standard by an expert, and also share it with the Department of Justice, which is conducting

an investigation of the proposed AetnaHumana merger under federal law.

A serious flaw revealed by the AetnaHumana merger is that the competitive standard used to initially determine whether a merger or acquisition is potentially harmful to the Colorado health insurance market only looks at the statewide impact. But physicians, hospitals and patients all operate in local geographic markets. The AetnaHumana merger approved by DOI will almost certainly have substantial competitive market impact on patients, physicians and hospitals in some local geographic markets. Unfortunately, nothing in the current law specifically requires DOI to look at the proposed merger’s impact on local geographic health insurance markets.

A solution to this flawed standard is to change Colorado law to require DOI to conduct an investigation and hold a public hearing whenever a merger or acquisition involving a foreign insurer shows violation of the competitive standard for any insurance line, so that further input and analysis on a statewide and local level may then occur. The process would gain both transparency and input from affected parties. DOI could also make a more informed decision, and better fulfill its obligation to maintain a healthy, competitive health insurance marketplace for consumers, physicians, hospitals and others. n

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

Colorado Medicine for March/April 2016

Features

Division of Insurance

Marguerite Salazar

Marguerite Salazar, Colorado Insurance Commissioner, Head of the Division of Insurance

Mergers in health insurance: the DOI's role The two mergers announced last year – Aetna-Humana and Anthem-Cigna – have generated much national coverage. That’s not surprising, as the U.S. Department of Justice’s Antitrust Division and the Federal Trade Commission review these large mergers for their impact on competition in all states.

While the national angle is important, the states are also looking at these transactions. It is critical that Coloradans understand how the Colorado Division of Insurance (DOI) reviews the mergers, as each is treated differently under state law.

Aetna-Humana As neither company is domiciled in Colorado, the entities only had to file a Form E notification with the Division.

The Form E is a pre-merger notification, which includes information on the statewide competitive impact, as well as the effect on competition in all lines of insurance. The DOI initially had 30 days to review.

For Aetna-Humana, the Form E was filed on Oct. 8, 2015. After considering the statewide impact to all lines of insurance and evaluating the minor product overlap among the two entities, the Division determined that the transaction did not violate competitive standards.

In the states where these companies are domiciled (Connecticut for Aetna; Kentucky for Humana), those states’ departments of insurance take a larger role in the review. The companies must file a Form E and a Form A, which provides detailed information on the acquiring Colorado Medicine for March/April 2016

party’s financial condition and its postmerger intentions. Each state of domicile reviews the merger using standard procedures to ensure policyholders are protected from a financially weak acquiring party.

The domiciliary states’ departments of insurance have the authority to review the transaction and its impact to the companies’ financial health, including their ability to meet reserve requirements and to maintain obligations to policyholders. Essentially, the departments of insurance where these companies are domiciled have greater authority to conduct a more detailed review of the merger.

Ultimately, any newly merged company will still have to meet all Colorado licensing requirements, rate filing requirements and network adequacy requirements, as well as all notice requirements, should the company want to stop offering some plans and begin offering new products. And, the newly merged entity still has to meet current obligations to its members.

Anthem-Cigna The key distinction with the AnthemCigna merger is that both companies are domiciled in Colorado, meaning the DOI will take a larger role, including a review of the Form A filing. We have received the Form A filing for this transaction and it is available on the DOI notices webpage at https://www. colorado.gov/pacific/dora/node/112251.

For several reasons, including the fact that this merger is pending with the federal entities, the Division has not yet received the Form E for this merger. We expect the federal government’s review

of the Anthem-Cigna merger to take at least until this summer.

There is also a special provision in Colorado law that is particular to our state when it comes to such mergers.

CRS 10-3-803(6)(b) stipulates that part of the independent investigation of the proposed merger’s impact must include “an analysis of the probable effects of the merger on consumers and on suppliers of services.” Investigation into the impact on consumers is common among states, but investigating the impact on suppliers of services is not. This will be another factor that goes into the DOI’s evaluation of this merger.

The Division will hold a public hearing to review this merger and its impact on the Colorado market. At this time, we do not have a date set for the hearing, as we are waiting for the Form E to be filed.

However, we have created an email notification list for people who want to receive notice of the filings related to the Anthem-Cigna merger. You can sign up for this list on our “Division of Insurance Alerts” webpage – www.colorado. gov/pacific/dora/node/91826 – enter your email address under “Merger Information Notifications” and click “subscribe.”

What’s best for Colorado consumers?

I am confident that a competitive marketplace will continue in Colorado. To that end, the Division will work to ensure that Colorado consumers will be able to continue choosing from a marketplace with sufficient competition to keep quality health care affordable and available. n

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Features

Health plan perspective

Gina Conflitti, MD Regional Medical Director, Aetna

Aetna and Humana: Working together to accelerate health care transformation Kate Alfano, CMS contributing writer The model for providing health insurance is undergoing a fundamental shift in the United States. The health care industry is rapidly transforming amid a highly competitive environment where new companies are continually entering the market, providing consumers with more flexibility and choice than ever before. After the Aetna-Humana transaction closes, Medicare beneficiaries will continue to have access to a broad choice of products and high quality, affordable health plan options. It is estimated that only 8 percent of seniors receive their health benefits from Aetna or Humana, meaning that 92

percent of all beneficiaries receive their health benefits from traditional Medicare or other Medicare Advantage plans.

At Aetna, we envision a world where health care is focused on the consumer. A world where our ability to analyze data to see what health issues are most prevalent in a community can be coupled with Humana’s ability to put more nurses and clinicians in people’s homes. One where Humana’s commitment to long-term health is bolstered by Aetna’s deep partnerships with community organizations across the country. Our combination will bring this

vision to life, pairing two complementary companies that will be better equipped to serve the dynamic needs of patients, families and providers.

Consumers seek a simplified experience that engages them in their health and offers greater transparency and convenience. A recent survey found that eight in 10 Americans believe a consumer-oriented approach to health care is good for the nation, and 60 percent say they prefer to take a lead role in decisions about their health care. We look forward to creating a shopping experience that will enable consumers to easily compare plan prices and benefits and understand upfront how much they would pay. The insights of Aetna’s existing services like ActiveHealth and Denver-based iTriage – which provide individuals with advice on how to manage their health – could be combined with the capabilities of programs like Humana Vitality, which reward individuals for taking steps to become healthier.

We are also focused on building a firstclass health services business, where we work with providers to create value-based payment arrangements that improve care and lower costs. Aetna’s goal is to have 75 percent of medical spending in valuebased payment arrangements by 2020.

Provider partnerships with Centura and Physician Health Partners are already showing real results in Colorado.

Combining these companies will enable Aetna to offer consumers more accessible, affordable, comprehensible coverage options. Ultimately, we believe this transaction will allow us to increase the number of healthy days our members enjoy each year. n

Colorado Medicine for March/April 2016

17

Features

Health plan perspective

Mike Ramseier, President, Anthem Blue Cross and Blue Shield in Colorado

Anthem, Cigna committed to working with providers to improve patient outcomes The Anthem-Cigna merger makes sense for many reasons. From a broader policy perspective, the merger aligns with and gives greater effect to the goal of improving patient outcomes, reducing waste and containing costs. As a result of the merger, Anthem will be able to provide a better, more integrated product that enables a more cost-effective continuity of care for individual consumers and employers than either company can do today.

Neither payers nor providers alone can bring about the change necessary to close the gap between consumer expectations and the outcomes that the health care system has historically delivered. Anthem has taken this need for change head-on by focusing on three strategic areas, which are the pillars of our proposed acquisition of Cigna: 1) a better consumer experience; 2) cost containment to improve affordability; and 3) strong collaboration with providers.

Anthem and Cigna each have a record of pursuing productive consumer and provider collaborations toward these objectives, but together we can do better.

Alone, we will continue to improve, just not at the pace demanded by consumers, employers, providers and policymakers. A pertinent example of this demand is the Feb. 5 announcement of the creation of a Healthcare Transformation Alliance by 20 of America’s largest companies; the number one focus is to accelerate efforts to better utilize health care data.

No longer is it enough for health insurers to serve as financial stewards of health care delivery and pay out claims. As an industry, we need to do more to leverage the data we have from paying claims to increase transparency for consumers and 18

assist consumers as they interact with the health care system.

Anthem’s Imaging Cost and Quality program, for instance, enables consumers to identify significant variations in price for the same imaging procedure. With Cigna, Anthem can expand the impact of this proven approach to quality and cost improvement. Similarly, Cigna has developed a mobile app technology platform called “myCigna” that provides consumers direct access to cost and quality information that is often difficult to find.

Cigna’s consumer platform is a unique, award-winning tool that consumers value because it helps them make better informed health care decisions.

One of these partnerships is with Mountain View Family Medicine (MVF), a three-doctor practice in Fort Collins.

MVF is part of Anthem’s Enhanced Personal Health Care program. Anthem care coordinators met with the practice every month as they created new systems to better analyze patient data. We worked with MVF to identify trends to better serve high-risk patients. And the practice has thrived. As one doctor writes, “the tools [Anthem’s] program has provided us…has enabled us to increase the quality of care provided to our patients. Anthem’s approach…has allowed us to provide more relevant care to our patients.”

Our industry must also accelerate efforts to partner with providers by offering human and financial resource support, actionable data analytics, and tools that further their efforts to focus on the health of their patients, while shifting from volume- to value-based payments. The commitment to provider collaboration is a foundational pillar of the Cigna transaction.

Cigna’s Collaborative Care (CCC) program takes a different path to value-based provider care. It uses incentives to engage health care professionals and help drive improved health, affordability and patient experience. Eighty-two percent of doctors and hospitals with two or more years of experience with CCC have had success in achieving their total medical cost targets and 72 percent had success in achieving their quality targets.

To that end, Anthem and Cigna have invested in complementary initiatives to become personal health care coordinators for consumers. For example, Anthem’s Enhanced Personal Health Care (EPHC) program augments the physician-patient relationship by assisting its covered members with improved quality of and access to health care services. EPHC has led to measurable progress where it has been implemented, averaging a net savings of $6.62 per member per month with fewer hospital admissions and shorter hospital stays. Importantly, providers are a part of this solution, with $36 million in shared savings paid out to participating providers.

This merger is about using health care data to improve continuity of care while containing rising health care costs. It is well understood in other industries that more data leads to better analysis, improved predictability and more efficient delivery of services. The scale of the data available to a combined Anthem/Cigna will make possible data-driven, evidencebased medical protocols that enable providers to improve patient care and deliver services more efficiently. This is something we can only do more effectively and deliver more quickly for Colorado’s consumers if Anthem and Cigna do it together. n Colorado Medicine for March/April 2016

Only one physician opportunity per geographic region.

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Colorado Medicine for March/April 2016

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Features

Physician wellness

Physician burnout and its tie to payer issues A Q&A with Doris Gundersen, MD The latest statistics on physician burnout from the Mayo Clinic show this troubling trend is on the rise: 45.5 percent of physicians admitted to at least one symptom of burnout in 2011 while 54.4 percent admitted to burnout in 2014. A November 2013 study conducted by the American Medical Association and the RAND Corporation found that being able to provide high-quality care to their patients is the primary reason for job satisfaction among physicians, while obstacles to doing so are a key source of stress.

Given the results of the managed care survey featured in this issue’s cover story, Colorado Medicine asked Doris C. Gundersen, MD, medical director for the Colorado Physician Health Program, to talk about how physician wellness may be linked to administrative burden on physicians, particularly interactions with payers.

power differential, for physicians as well as patients. Faced with the ongoing responsibility of providing excellent patient care with less autonomy, fewer resources and little power to advocate for needed change, physicians will experience significant stress and burnout.

CM: What is the danger of physician burnout, specifically as it relates to a physician’s ability to care for patients?

DG: Burnout is not just a matter of feeling dissatisfied or unhappy. Burnout is a very serious syndrome characterized by emotional exhaustion, personal detachment and a lost

Doris C. Gundersen, MD

sense of efficacy. Burnout has the potential to interfere with the delivery of quality medical care through inefficiencies and errors.

CM: What happens to a physician suffering from burnout – emotionally, physically, in his/her career or personal life?

DG: A physician experiencing burnout is a physician in a lot of pain. He or she feels completely depleted, hopeless and ineffective. The joy usually experienced helping patients is lost. Tragically, if burnout is not recognized and treated, a physician may decide to leave the profession altogether. n

Colorado Medicine (CM): How is physician satisfaction affected by interactions with payers and administrative requirements?

Doris Gundersen (DG): Physicians are happiest when they can devote their skill and expertise to providing high-quality medical care to their patients. Mounting administrative burdens, whether time spent appealing treatment denials or attempting to negotiate fair contracts with major insurance carriers, takes away from their devotion to patients and leads to overall dissatisfaction.

...because

CM: Do you believe the proposed insurance mergers would negatively affect physician satisfaction? Why or why not?

DG: Insurance mergers reduce competition and choice and create an unequal Colorado Medicine for March/April 2016

21

Features

National Advocacy Conference Kate Alfano, CMS Communications Coordinator

CMS leaders storm the Hill to educate congressional legislators Physician leaders from CMS and the component societies of ADEMS, Denver, Mesa, Northern Colorado and Aurora-Adams were on Capitol Hill in Washington, D.C., Feb. 23-24, to advocate for physicians and patients. They focused on educating the Colorado congressional delegation on four main issues: • Support for H.R. 4499, the Promoting Responsible Opioid Prescribing Act of 2016, and the Colorado coalition's efforts to reduce prescription drug abuse; • Concerns with the proposed health insurance industry mergers; • Support for the enactment of meaningful electronic health record (EHR) reforms; and • Support for S. 2484/H.R. 4442, the Connect for Health Act telemedicine legislation.

“The mantra in our state is ‘simplify, standardize and make clinically relevant laws and regulations to make more time for patients, less red tape and less physician burnout,’” said CMS Presidentelect Katie Lozano, MD. “The AMA has been really supportive.”

The Hill visits were part of the American Medical Association’s National Advocacy Conference (NAC), which brought together more than 30 state medical associations to hear the latest on national health policy and the politics of the 2016 election cycle. This was the first trip in well over a decade that physicians did not have to lobby for a fix to Medicare’s sustainable growth rate (SGR).

The Colorado NAC delegation met 22

Physician leaders from CMS and four component societies were on Capitol Hill in Washington, DC, Feb. 23-24, to advocate for physicians and patients. They met with both Colorado senators and many representatives or their aides. From left to right: Donna Sullivan, MD; Brandi Ring, MD; Patrick Peveto, MD; Sen. Michael Bennet; CMS President Michael Volz, MD; CMS President-elect Katie Lozano, MD; and Usha Varma, MD. with several representatives and senators from Colorado. “Though we’re bringing our own issues to the Hill,” Lozano said, “we want to thank them for the work they’ve done so far – for repealing the SGR – and to ask them what they need from us. We offer to serve as a resource because this is a partnership for the people in our state.”

Regarding the specific issues, the opioid abuse and misuse crisis has reached a national public policy level and both the administration and the federal legislative branch are now involved in developing solutions. From a political perspective,

physicians could easily be put in the crosshairs of finding a solution. The Colorado NAC delegation discussed what Colorado physicians are already doing to address the issue. For example, the CMS board of directors voted to make the abuse and misuse crisis a priority in 2012, and continues to actively participate in the Colorado Consortium to Prevent Prescription Drug Abuse. CMS is also partnering with multiple organizations to provide educational modules for physicians.

The AMA recommends and CMS supports reauthorizing funding to enable the Colorado Medicine for March/April 2016

Features modernization of prescription drug monitoring programs (PDMPs), and encourages physicians and other prescribers to register for and use these programs. Colorado already has mandatory registration in place. The AMA also recommends increasing coverage for and access to comprehensive treatment for opioid use disorder, increasing access to overdose prevention tools such as naloxone, and de-linking survey questions on pain from reimbursement determinations under the Hospital Value-Based Purchasing program.

The second big issue is the proposed mergers of Aetna-Humana and Anthem-Cigna. They are controversial; both chambers of Congress held hearings last year. State insurance commissioners and the U.S. Department of Justice are largely the decision-makers on whether the mergers are approved, denied or modified and the insurance companies have invested tremendous resources into pushing the mergers through. CMS is taking these mergers and their potential impact on physicians and patients very seriously, and discussed concerns with elected officials.

For the third major issue, physicians presented recommendations for reforms to the Meaningful Use program: to focus on the interoperability of electronic health records and resolve technology limitations; assess all measures based on their relevance, ability to meet the needs of patients and cost benefit; and align new measures with other payment and delivery system reform incentive programs.

Finally, telehealth. Colorado has made great gains in expanding access to telehealth to allow patients and physicians across the state to benefit from remote visits. The CONNECT for Health Act advances telemedicine on the national level and accelerates the adoption of health care delivery models that promote coordinated and patient-centered care. The bill establishes a bridge to help physicians meet the goals of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-based Incentive Payment System (MIPS), among other provisions. The AMA supports the bill. n Colorado Medicine for March/April 2016

23

Features

Zika virus testing Kate Alfano, CMS Communications Coordinator

Fort Collins lab leads Zika testing effort The World Health Organization rang a global alarm over the Zika virus on Feb. 1 when they declared the outbreak a “public health emergency of international concern.” The disease is spreading exponentially in the Americas and the organization predicts as many as four million people could be infected by the end of the year. Since the spring of 2014, more than 30 countries have reported locally acquired cases of Zika. Global health authorities face the delicate task of alerting the world to the dangers of Zika without provoking panic – particularly as affected areas experience increased reports of birth defects and Guillain-Barré syndrome – while at the same time coordinating the four-pronged public health response of diagnosis, treatment, prevention and research.

Health officials at the Centers for Disease Control and Prevention (CDC) have taken the lead in the United States in issuing guidance to patients and physicians on the prevention and evaluation of Zika, with Colorado’s own CDC Division of Vector-Borne Diseases in Fort Collins leading in testing and research.

Robert Lanciotti, PhD, is chief of the diagnostic and reference laboratory within the Arbovirus Diseases Branch in Fort Collins. His lab has been receiving up to 300 samples per day to test from nearly every U.S. state and many countries. He became one of the world’s leading authorities on Zika in 2007 when he and a team traveled to the tiny island of Yap in Micronesia to study the first

recorded epidemic. He was lead author of a paper following the trip that analyzed the epidemic and described three diagnostic tests.

As he puts it, Zika was obscure and uninteresting until a little more than a year ago. It was first discovered in 1947 by a researcher working with sentinel monkeys in Uganda and, over the next 60 years, would only be reported in fewer than 10 people in Africa and Southeast Asia. There are roughly 500 vectorborne diseases – viruses transmitted by fleas, ticks and mosquitos – and around 100 can cause human illness. Zika was known to cause human illness but the symptoms were minor: fever, rash, joint pain and conjunctivitis.

Concern for Zika heightened when it crossed hemispheres – an alarming sign in the virus world – and heightened further with the suspected connection to microcephaly. Brazilian health authorities contacted the CDC and Lanciotti was part of a team invited to travel to the country in January to conduct a weeklong training of public health personnel from Central and South America.

“There is a critical need to diagnose in Brazil,” he said. “That’s the first thing you need to figure out with an epidemic like this: who’s infected. Then you focus on treatment, prevention and then research. They’re hard workers and they’re getting the job done in Brazil, but slowly. They’re behind and there’s still work to be done. It’s not slowing down.”

That’s what struck him about the trip,

Public health workers practice the diagnostic tests for Zika virus.

Colorado Medicine for March/April 2016

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Zika virus (cont.) the sense of panic. “Eighty percent of the people in Yap were infected with Zika and 75 percent didn’t know they were infected,” Lanciotti said. “They think the number in Brazil may be about the same. There are still some questions about whether Zika virus is causing microcephaly but if it is, it will end up being one of the most devastating viruses in history.”

From an epidemiological standpoint, he sees a strong link between the virus and microcephaly. Two public health workers who attended the training came from Pernambuco, the state of Brazil located in the northeast region of the country where the majority of microcephaly cases have been diagnosed, and the scientists brought photos of the babies, brain scans and laboratory data. Of the babies diagnosed with microcephaly who didn’t survive, they saw clear evidence of virus in their brains, and in the cases where the babies survived, the placenta was loaded with virus, he said.

“What we’ll learn in the next few months is critical to establishing the link be-

26

Robert Lanciotti, PhD, of the Arbovirus Diseases Branch in Fort Collins, guides learners through his research on Zika. tween Zika and microcephaly,” Lanciotti said. “The first case in Brazil was detected spring of 2014; nine months later that’s where microcephaly is occurring.

Of those countries in South and Central Americas who diagnosed cases of Zika since that time, will we see microcephaly in nine months? That will be one of the proofs of the link between the virus and the birth defects.”

While the work isn’t slowing in Brazil and it isn’t slowing yet in Lanciotti’s lab,

it is expected to slow in the U.S. in six to seven months as more state public health labs are trained in running patient samples and as more U.S. patients heed the CDC’s travel advisories to the affected countries. In another month or two, once the initial crisis has passed, the CDC will be able to address the next level – research – working with the National Institutes of Health and other publically and privately funded companies to answer critical questions and start the long road to developing vaccines. n

Colorado Medicine for March/April 2016

Features

Zika virus prevention Christine Nevin-Woods, DO, MPH Mark Johnson, MD, MPH

Colorado Medical Society guidance to physician members on Zika virus prevention and diagnosis The Colorado Medical Society will be assisting physicians with information and guidance as the Zika virus situation progresses both here in the U.S. and internationally.

Currently, the CDC recommends reassuring patients that the vast majority of those who are exposed to the virus either never have symptoms or have very mild symptoms. The risk of a homegrown outbreak is low, largely because of more effective mosquito control and the type of mosquito that transmits the virus. The average American who is not traveling to the affected area is at very low risk. The greatest danger is risk of infection in pregnant women, especially in the first trimester. However, now that we know the infection can be transmitted sexually the issue has become more complex.

Below are specific guidelines and facts for physicians.

General information • Zika virus is a mosquito-borne flavivirus transmitted primarily by the Aedes aegypti mosquitoes, which are the same vectors that transmit dengue and chikungunya virus and are found throughout much of the Americas, including parts of the U.S. • These mosquitoes are very aggressive daytime biters and feed both indoors and outdoors. They can also bite at night.

• It is estimated that 80 percent of people infected with Zika virus are asymptomatic. Symptomatic disease is generally mild and characterized Colorado Medicine for March/April 2016

by acute onset of fever, maculopapular rash, arthralgia and nonpurulent conjunctivitis. These symptoms last from several days to one week. Severe disease requiring hospitalization is uncommon, and fatalities are rare.

• Once a person has been infected, he or she is likely to be protected from future infections.

• Guillain-Barré syndrome has been reported in patients with suspected infection.

• Affected areas currently include Cape Verde, the Caribbean, Central America, Mexico, some Pacific Islands (America Samoa, Marshall Islands, Samoa and Tonga), and South America.

General international travel guidance • All travelers going to affected areas should receive general information about the virus to make informed decisions.

• This is very important when families are traveling together and at-risk members are included. This includes infants and children, at-risk fertile women, pregnant women, and those who have immunosuppressive conditions.

• Vector control education and guidance should be included, including avoidance of outdoor activities during high-risk times, air conditioning or window and door screens when indoors, long sleeve and pant use, bed nets, permethrin-treated clothing and gear, and insect repellent (DEET and oil of lemon eucalyptus) use in affected areas.

• Most EPA-registered insect repellents can be used to protect children aged 2 months or older against mosquito bites. Products containing oil of lemon eucalyptus should not be used on children under the age of three years. Mosquito netting can be used to cover infants in carriers, strollers or cribs to protect them against mosquito bites.

International travel guidance for pregnant women • Pregnant women should avoid all travel to affected areas and delay travel plans. Airlines and cruise lines are working with pregnant women to cancel, delay or reschedule travel until a later time.

Guidance for women who are of reproductive age during travel • Women who are fertile are a very high-risk group, including adolescents and adult women who are sexually active.

• Detailed reproductive histories, pregnancy tests and contraceptive guidance, including education regarding abstinence and contraceptive prescriptions, are critical prior to travel.

• Hormonal forms of birth control (long-acting reversible contraceptives are most effective) are recommended, along with condoms. An option to consider for women who are not currently using a reliable form of contraception is a Depo Provera (progesterone) injection prior to

27

Zika virus (cont.) travel, which lasts for three months.

If a woman is currently using birth control pills, careful counselling is important in terms of maintaining effectiveness. The pills should be taken as directed and at the same time each day without missing a day.

Emergency Contraception to be taken up to five days after unprotected sex is available as Plan B One Step progesterone pill.

Guidance for the prevention of sexual transmission of Zika virus • Sexual transmission of Zika virus is possible and is of particular concern during pregnancy.

• The duration of persistence of Zika virus in semen remains unknown and might persist in semen when it is no longer detectable in blood.

• Men who have had Zika infection or have current symptoms should avoid sexual activity until medically evaluated and should inform all female partners of the infection potential.

• Men who reside in or who have trav-

28

eled to an area of active Zika virus transmission and have a pregnant partner should abstain from sexual activity or consistently and correctly use condoms during any type of sex.

Diagnostic testing Who can be tested for Zika virus?

should be collected between two to 12 weeks after returning from travel. The appropriate test for asymptomatic pregnant women is IgM. At this time, asymptomatic people who are not pregnant are not being tested.

Where can patients go to get tested?

Patients (men and women) who have had two or more symptoms (acute onset of mild fever, maculopapular rash, arthralgia, headache, malaise and/or conjunctivitis) during or within two weeks of travel to an area with local Zika virus transmission can be tested. Patients should have specimens collected within seven days (sooner is better) of symptom onset. The appropriate test for individuals who have been ill for fewer than seven days is RT-PCR (reverse transcription polymerase chain reaction). If the individual became ill more than four days before sample collection, IgM testing is also appropriate. Asymptomatic pregnant women with a history of travel to an area with local Zika virus transmission may also be tested. Specimens

Patients should request testing from their health care provider. The Colorado Department of Public Health and Environment (CDPHE) is unable to collect specimens directly from patients.

Health care providers should submit patients’ specimens for testing to the CDPHE laboratory. Providers must indicate clearly the testing type they are requesting on the form (IgM and/or RT-PCR for Zika virus).

What specimens can be tested for Zika virus?

Serum is the only acceptable sample for RT-PCR testing. Serum, CSF and amniotic fluid can be used for IgM and

Colorado Medicine for March/April 2016

Features plaque-reduction neutralization tests (PRNT) – if IgM serology results are positive.

How should samples be collected?

Serum samples can be collected using red top, tiger top or serum separator tubes.

How much serum, CSF or amniotic fluid needs to be collected for testing?

One red top, tiger top or serum separator tube is recommended for serum. CDC requires a minimum of 0.25 mL of serum or CSF for testing, and CDPHE requires 0.25 mL for RT-PCR testing. If you are requesting both RT-PCR and IgM testing, please send at least 0.5 mL of serum.

For amniotic fluid, 1 mL is preferred, but 0.5 mL is acceptable for testing.

Where do I send specimens for testing?

All specimens need to be sent directly to CDPHE’s lab (address below). CDPHE will conduct RT-PCR testing for symptomatic patients with samples collected within seven days of symptom onset.

For asymptomatic pregnant women or symptomatic patients with samples collected after seven days of symptom onset, CDPHE’s lab will send the samples to CDC for IgM serology and PRNT testing, as applicable.

Besides the specimen, what else needs to be submitted to the CDPHE lab for testing?

• All submitters MUST submit the CDPHE Request for Analytical Services form.

• If IgM testing is being requested, submitters should complete both the CDPHE request form and the CDC Specimen Submission form.

• The CDPHE form, #270/271, can be requested by calling the CDPHE Serology Laboratory at 303-692-3485 or CDPHE at 303-692-2700.

The CDC 50-34 form can be found online (www.cdc.gov/laboratory/specimensubmission/pdf/form-50-34.pdf), on the CDC website through the Zika virus page, or CDPHE can fax or email the form to you. In order to get the 50-34 form from CDPHE, call 303-692-2700.

The CDC 50-34 form must be filled out in its entirety (including any symptoms, date of onset, travel and vaccination history, and pregnancy status), or the specimen will not be tested, or testing will be delayed.

• On the top left corner on side one of the form, the submitter can simply put “Zika.” Since IgM serology for Zika virus can cross-react with immune responses of other flaviviruses, it is imperative to note if the patient has had a Yellow Fever vaccine.

How do I get the specimen from my clinic to the CDPHE lab?

How do I know which test (RT-PCR vs. IgM) to order?

Specimens can be dropped off for CDPHE routine courier pick up at your hospital laboratory, local public health department or be sent to the CDPHE Laboratory Services Division by the courier of your choice or via FedEx. The specimens should be sent to:

• RT-PCR testing can be performed only for symptomatic patients with samples collected within seven days of symptom onset. If your patient meets these criteria, order the RTPCR test on the CDPHE 270/271 requisition form.

• For asymptomatic pregnant women or symptomatic patients with samples collected after seven days of symptom onset, RT-PCR testing cannot be performed, and the submitter will need to order IgM testing to be conducted by CDC. • If providers would like IgM serology when RT-PCR testing is negative, they will need to indicate both RTPCR and IgM testing on the test

CDPHE Laboratory Services Division 8100 Lowry Blvd Denver, CO 80230 For a current list of pickup times and locations for the CDPHE lab routine courier, please go to www.colorado.gov/ pacific/sites/default/files/Kangaroo%20 Update.7.29.14-SK.pdf for more information.

Colorado Medicine for March/April 2016

requisition form (CDPHE #270/271 form) and fill out the CDC 50-34 form to include with the sample. The CDPHE lab will not automatically send samples for additional CDC testing unless this is indicated on the form. The lab will also not make the determination for which test to perform. n For more information • Centers for Disease Control and Prevention Guidance for Health Care Providers – www.cdc.gov/zika/hcproviders/index.html • Zika Virus Resource Center from the American Medical Association – www. ama-assn.org/go/zika • Colorado Department of Public Health and Environment Zika information webpage – www.colorado.gov/cdphe/zika • HAN Advisory: Recognizing, managing and reporting Zika virus infections in travelers returning from Central America, South America, the Caribbean and Mexico. January 15, 2016. http:// emergency.cdc.gov/han/han00385.asp • Possible Association Between Zika Virus Infection and Microcephaly – Brazil, 2015. www.cdc.gov/mmwr/volumes/65/ wr/mm6503e2.htm?s • Update: Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure – United States, 2016. www.cdc.gov/ mmwr/volumes/65/wr/mm6505e2.htm • Interim Guidelines for Prevention of Sexual Transmission of Zika Virus – United States, 2016. www.cdc.gov/ mmwr/volumes/65/wr/mm6505e1.htm • Oduyebo T, Petersen EE, Rasmussen SA, et al. Update: Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure – United States, 2016.

MMWR Morb Mortal Wkly Rep 2016;65:122–127. DOI: http://dx.doi. org/10.15585/mmwr.mm6505e2.

• Fleming-Dutra KE, Nelson JM, Fischer M, et al. Update: Interim Guidelines for Health Care Providers Caring for Infants and Children with Possible Zika Virus Infection – United States, February 2016. MMWR Morb Mortal Wkly Rep 2016;65:182–187. DOI: http://dx.doi. org/10.15585/mmwr.mm6507e1. n 29

Inside CMS

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

Sharing what we have learned The process behind developing COPIC’s education activities Education is a significant aspect of health care. From the first day of medical school to the final days of practice, we understand that our roles require a dedication to lifelong learning. To support this, COPIC combines the experiences of our staff and insureds with the extensive data we review in order to develop professional education opportunities.

Each year, we present nearly 400 in-person seminars that feature more than 20 speakers, and we currently have a library of over 25 on-demand courses available. Most of the seminars and courses qualify for CME credit. And each year we go through a rigorous process to identify topics for these activities. The following are key resources that COPIC draws from to develop its education opportunities.

1. Insight from claim reviews – The detailed data we gather through our claims review process helps us pinpoint areas of concern and better understand the causes of adverse outcomes. Once we identify an issue that requires attention, we are able to respond in a timely manner and develop education that offers insight and guidance for the health care community.

• “Diagnostic Errors – Thinking Like Sherlock” is a seminar that we developed to address the crucial issue of diagnostic errors found in medical liability claims. Participants discuss the importance of addressing diagnostic errors and identify types of these errors they are likely to encounter.

Using diagnostic timeouts and awareness of how we reason, an approach similar to Sherlock Holmes’ in solving cases, the seminar also focuses on building a skillset to decrease and prevent diagnostic errors from occurring.

2. Current medical literature and trends in health care – Every week, new research appears and has the potential to influence how we practice medicine. From prominent medical publications to information released by government agencies, we follow this closely and examine how it may change approaches to patient care.

• In response to a significant rise in prescription drug overdoses, COPIC developed “Opioids: It’s Still a Problem.”

This seminar is designed to help distinguish specific liability risks in the medical treatment of pain, with a focus on areas such as misdiagnosis, overprescribing and diver 30

sion. It also covers tools to help in managing patients with chronic pain, including opioid agreements, pain specialist consultation and documentation guidelines.

• “Maximizing Safe and Effective Practice with Physicians, PAs and APNs” has become a particularly relevant seminar as the Affordable Care Act has changed how health care systems and medical practices utilize allied health professionals and the ways they interact with patients.

3. Input from our staff – The day-to-day interactions we have with medical professionals also provide us with important insight. Whether it is direct inquiries from insureds or issues identified as part of on-site reviews, these experiences keep us connected to current challenges in health care.

• “Tales from the Hotline” is a seminar we offered last year and brought back in 2016 due to its popularity. Using deidentified case studies based on real calls we received on our risk management hotline, we profile complex medicallegal situations that may arise and discuss how to manage these effectively.

4. Feedback from insureds – Every time an insured completes a COPIC course or seminar, he or she is able to provide feedback on what he or she liked and where we can make improvements. This information is invaluable for adjusting the focus of current activities and helping us identify emerging topics.

• As the role of technology continues to expand in health care, new questions about practice standards also emerge.

“Communicating Electronically with Colleagues and Patients” was specifically developed to address the use of email, texting, web portals and telemedicine. This seminar helps participants understand the privacy and security risks with electronic communications, and reviews best practices and guidelines to consider.

Sharing knowledge with others is essential to improving medical outcomes. That is why COPIC remains committed to investing the time and resources to develop education that supports medical professionals and their efforts to stay informed. Visit www. callcopic.com/education to learn more about the education courses and seminars that COPIC offers. n Colorado Medicine for March/April 2016

The New CMS

7 7 Reasons Reasons CMS CMS Endorses Endorses COPIC COPIC

Born Born of of aa crisis crisis and and recognized recognized today today as as aa national national leader leader in in patient patient safety safety and and risk risk management, management, COPIC COPIC isis one one of of Colorado’s Colorado’s proudest proudest health health care care achievements.

The physician-governed organization was founded in 1981 by CMS to address the upward spiral on the cost of medical liability achievements. The physician-governed organization was founded in 1981 by CMS to address the upward spiral on the cost of medical liability insurinsurance ance that that was was adversely adversely affecting affecting access access to to care. care. For For over over 30 30 years, years, CMS CMS and and COPIC COPIC have have united united on on legislation, legislation, education education and and advocacy. advocacy. At At the the same same time, time, COPIC’s COPIC’s connection connection to to CMS CMS has has helped helped the the company company develop develop patient patient safety safety programs programs that that address address on-the-ground on-the-ground realities realities for for physicians. physicians. CMS CMS endorses endorses COPIC COPIC as as its its number number one one strategic strategic partner partner and and the the preferred preferred medical medical professional professional liability liability company company for for all all Colorado Colorado physicians. physicians.

1

Patient Patient safety safety and and risk risk management management resources resources that that support support better better medicine. medicine.

2

Direct Direct access access to to medical medical and and legal legal experts. experts.

3

3Rs 3Rs (Recognize, (Recognize, Respond, Respond, and and Resolve) Resolve) Program.

Program.

4

Unparalleled Unparalleled defense. defense.

5

Strong Strong partner partner in in legislative legislative advocacy. advocacy.

6

COPIC COPIC Financial Financial Service Service Group Group (FSG).

(FSG).

7

Commitment Commitment to to improving improving health health care care in in Colorado.

Colorado.

Education Education courses courses and and seminars, seminars, on-site on-site Practice Practice Quality Quality Reviews Reviews and and Safety Safety Risk Risk Assessments, Assessments, and and downloadable downloadable medical medical tools tools are are just just some some of the resources included in COPIC coverage.

These benefits provide preventative and proactive ways for medical professionals to integrate of the resources included in COPIC coverage. These benefits provide preventative and proactive ways for medical professionals to integrate best best practices, practices, improve improve internal internal systems, systems, and and reduce reduce risk. risk.

Navigating Navigating the the complexities complexities of of health health care care often often requires requires insight insight from from those those who who understand understand the the medical, medical, legal, legal, and and regulatory regulatory environments. environments.

COPIC’s physician risk managers and legal team work together to answer questions from insureds and provide trusted support.

COPIC COPIC’s physician risk managers and legal team work together to answer questions from insureds and provide trusted support. COPIC also also offers offers aa 24/7 risk management hotline as an added level of support in urgent situations.

24/7 risk management hotline as an added level of support in urgent situations.

COPIC’s COPIC’s innovative innovative program program helps helps physicians physicians maintain maintain communication communication with with patients patients and and work work toward toward aa resolution resolution when when unexpected unexpected outcomes outcomes occur.

Recognized by The New England Journal of Medicine and Health Affairs, the 3Rs Program focuses on preserving the physician-patient occur. Recognized by The New England Journal of Medicine and Health Affairs, the 3Rs Program focuses on preserving the physician-patient relarelationship tionship while while reimbursing reimbursing the the patient patient for for medical-related medical-related expenses. expenses.

COPIC’s COPIC’s defense defense team team vigorously vigorously defends defends insureds insureds when when medicine medicine meets meets the the standard standard of of care care and and works works closely closely with with them them to to ensure ensure they they have have aa clear clear understanding understanding of of the the options options available available as as well well as as the the recommended recommended course course of of action. action. In In addition, addition, coverage coverage applies applies to to the the defense defense costs costs of of issues such as disciplinary proceedings and governmental investigations. issues such as disciplinary proceedings and governmental investigations.

Along Along with with CMS CMS and and the the Colorado Colorado Hospital Hospital Association, Association, COPIC COPIC works works tirelessly tirelessly to to ensure ensure Colorado Colorado remains remains aa great great state state to to practice practice medicine. medicine. This This includes includes monitoring monitoring and and reviewing reviewing proposed proposed legislation, legislation, fostering fostering relationships relationships with with legislators legislators while while educating educating them them on on important important issues, issues, and and keeping keeping insureds insureds aware aware of of policy policy changes changes and and their their potential potential impact impact on on health health care. care.

COPIC’s COPIC’s independent independent brokerage brokerage firm firm offers offers financial financial services services and and products products for for the the personal personal and and professional professional needs needs of of health health care care professionals. professionals.

FSG’s team provides experience and expertise in areas such as property and casualty insurance, employee benefit plans, life and FSG’s team provides experience and expertise in areas such as property and casualty insurance, employee benefit plans, life and disability disability insurinsurance, ance, cyber cyber liability, liability, and and financial financial planning. planning.

From From medical medical resident resident training training programs programs and and medical medical student student scholarships scholarships to to no-cost no-cost volunteer volunteer physician physician coverage coverage and and grant grant funding, funding, COPIC’s COPIC’s dedication touches many aspects of health care in ways that truly make a difference. dedication touches many aspects of health care in ways that truly make a difference.

FOR FOR MORE MORE INFORMATION: INFORMATION:

For For more more information information about about COPIC, COPIC, visit visit www.callcopic.com. www.callcopic.com.

Stay Stay tuned tuned to to CMS CMS communications communications to to learn learn more more about about important important issues issues to to follow follow our our progress progress and and learn learn how how you you can can get get involved. involved.

We We want want to to hear hear from from you you and and are are available available to to answer answer your your questions. questions. Please Please contact contact CMS CMS President President Michael Michael Volz, Volz, MD, MD, at at president@cms.org. president@cms.org.

Colorado Colorado Medical Medical Society Society || 7351 7351 E. E. Lowry Lowry Boulevard, Boulevard, Suite Suite 110, 110, Denver, Denver, CO CO 80230-6083 80230-6083 || (800) (800) 654-5653 654-5653

www.cms.org www.cms.org

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.

Robin Christian University of Colorado School of Medicine

Robin Christian is a third-year medical student at University of Colorado. He is a native of Aurora who took the long road to medical school. He discovered his love of people working in amusement parks and arcades across the country, then found his love of medicine as an EMT in the Denver metro area. He plans to pursue a career in OB/GYN within a safety net system, providing care and compassion to people who need it most.

Turning point The first week of my first clerkship, I had an experience that set the tone for the year. It probably set the tone for my entire career. This experience made me commit to learning the art of helping people who push others away.

A patient, I’ll call him Bobby, came in to the hospital with a fever and headaches. He was in his late 30s, unemployed, lived in his mom’s basement and used a lot of drugs. I asked to follow him because all of my other patients had pneumonia and I wanted to see something different. Once I actually met Bobby, I regretted my decision. Culturally, we were fairly similar. We were close in age and grew up in similar situations with few resources. He reminded me of people I knew 40 32

growing up, and of everything I didn’t like about myself. On top of that, he was whiny and obnoxious. He blamed us for his being sick, but he used drugs every day, had a horrible diet, didn’t brush his teeth and let his diabetes rage out of control. He had actually thrown away his glucometer. He was also racist, homophobic and misogynistic. He thought the world owed him something, just for existing. The intern and resident were ecstatic that they didn’t have to deal with him very often. Unfortunately, I did.

I began to think of Bobby as a person with two different layers. There was the superficial layer that I didn’t like – the angry, unmotivated and nasty person who was so difficult to deal with. But I saw a deeper layer before rounds one day.

Bobby was squirming in bed with his hand over his eyes and moaning uncomfortably. He was a human being who was suffering. He was sick and scared. Pain and fear were emotions I recognized. This is the layer I tried to connect with.

Eventually, he began to realize that I really did want to take away his suffering and that I really did want him to do well.

He began to open up about his drug use, diabetes and his family situation.

As we built a relationship, his condition deteriorated. His fever worsened and he became weaker and less talkative.

Despite this, he wanted to leave against medical advice “to take care of [his] mom.” I was tasked with persuading him to stay. I felt like I was in over my head, but it was worth a try.

I listened to him talk about why he wanted to leave. His reasons seemed petty, but I tried to hear the motivation behind them. He wanted control. He wanted someone to listen. He vented his frustration and agreed to stay.

Despite treatment, things got worse. A lumbar puncture indicated bacterial meningitis. Infectious disease was consulted and the outlook was not good. I was sent in to talk ColoradoMedicine Medicinefor forMarch/April July/August 2015 Colorado 2016

Inside CMS to Bobby about his test results. By the time I got to him, he had already heard. He was lying in bed with a blank stare. I asked what happened and he immediately went on a profanity-laden, racist tirade against the infectious disease doctor.

I didn’t know whether to tell him that I was sorry or turn around and walk out disgusted. So I waited. He finally asked, “Is it real?”

“Yeah, it’s real. There is an infection in your brain. We have a plan, but this is serious.”

He broke down crying. He asked why this was happening. I knew but it wasn’t the time to talk about his choices. I simply replied, “I don’t have an answer right now.” He told me about his mom and his best friend. I stayed and talked until he was calm. I told him about the medications we were trying and stressed that he needed to help us by going along with the plan. He said he understood and genuinely thanked me.

Over the next few days, he started improving. His personality came back. Once again, he was offensive, hard to deal with, and making bad decisions. This time he was refusing meals and eating from a big bag of Halloween candy. He offered me a piece. I told him that I couldn’t eat chocolate because I also have a health condition that gets worse when I eat certain things. In my case, it’s migraines. He said that was too bad for me, and he’s glad that he can eat whatever he wants. He added, “It just makes the doctors whine when I eat candy.” I asked if he knew that high blood sugar could affect his immune system. He waved me off with a “whatever.”

He shook my hand, gave me a hug and said he was glad I was there to get him through. I thanked him for hanging in there with us and said I knew this was one of the hardest things he’d ever been through. I told him that I want him to do well.

Bobby left, and I celebrated. I was happy that he had a plan and was as healthy as we could get him. I was equally happy that I didn’t need to listen to the neverending stream of offensiveness that came out of his mouth. Admitting both of those things to myself was a huge relief. I don’t know what Bobby’s long-term outcome looked like, but I know we worked with him to do the best we could. Realistically, that was enough.

After this, the residents dubbed me “The Jerk Whisperer.”

They always asked if I wanted the difficult patients who came in and I usually said yes. I also sought out patients who were going through scary, life-altering things. I realized that as challenging as it can be to connect with difficult people or with reasonable people in difficult situations, I really like doing it. Showing compassion to people who really need it, connecting to that deeper layer, feels like my purpose.

It seems easy now, but I’m also afraid of burning out. I am actively working on mindfulness and reflection, because I know it’s my responsibility to figure out how to keep making those hard connections while keeping my kindness and sanity intact. n

15th Anniversary

“Bobby. You’re an adult, I trust you to make your own decisions. But I want you to know that your immune system is so bad, it’s as if you have AIDS.” I said it deliberately. I knew that word would shock him. “Your sugars are so out of control that your immune system is destroyed. That’s why you got this kind of infection. And we can’t fix your immune system. Only you can.”

He stared at me. I waited. He said nothing. Eventually, I asked him if he wanted to order breakfast. He said he would. I told him that it would be a good start to get something high in protein and low in carbs. He changed the subject. I poked my head in the room later and saw him eating bacon and eggs, but the candy was still on the table.

Saturday, April 9th Hyatt Regency-Denver Tech Center 7800 East Tufts Avenue Denver, Colorado 80237 Visit www.RockyMountainGastro.com for more details & registration!

He was discharged the next day. He found me in the hall before he left.

Colorado Medicine for March/April 2016

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Departments

medical news 2015 EHR Meaningful Use hardship exemption deadline extended The deadline to apply for a Meaningful Use (MU) hardship exemption has been extended to July 1, 2016 from its original deadline of March 15. The AMA is encouraging ALL physicians who participated in the 2015 Medicare MU program to apply for the hardship.

The application and additional instructions are available on the federal CMS EHR Incentive Programs website, www.cms.gov/EHRIncentivePrograms. Submission of a hardship exception application does not prevent providers from attesting and receiving an incentive payment if meaningful use requirements are met. In essence, the hardship exemption will

act as a safety net. Therefore, physicians who believe that they met the MU requirements for the 2015 reporting period should still apply for the hardship protection.

Note that the program operates on a two-year look-back period, meaning that physicians who are granted an exception for the 2015 program will avoid a financial penalty for 2017.

The federal CMS has stated that it will broadly accept hardship exemptions. n

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

CMS president testifies on payment and delivery system reform CMS President Mike Volz, MD, testified before the Colorado Commission on Affordable Health Care on Feb. 8, providing thoughts on behalf of the society regarding payment and delivery system reform.

He commended commission members, thanking them for their service and leadership “in pursuit of finding ways for Coloradans individually and collectively to reduce the cost of health care while simultaneously improving the quality of that care.”

He made the following points, among others: • There is no one right way to structure payment reforms and experimentation should be encouraged.

• In addition to bundled payments, other models should be pursued like payment for high-value service, condition-based payments, warrantied payments and episode payments.

• He constantly hears the frustration from doctor colleagues that one plan requires that they do things one way, while another requires them to do it another way. When it comes to payment reform, the only way to harness the critical mass necessary for practices to change is through aligned all-payer approaches.

• It is important to support enhanced primary care reimbursement using value-based models; high performance primary care is the foundation upon which cost-effective, quality care rests.

Read his full testimony on CMS.org. n

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Colorado Medicine for March/April 2016

Departments

medical news Free support for Colorado providers to transform chronic pain care in the fight against prescription opioid abuse The Weitzman Institute, a center dedicated to primary care research and innovation, is working with the Colorado Department of Health Care Policy and Financing to offer free telehealth education and training sessions to health care providers on evidence-based strategies for better management of complex pain and medication-assisted treatment for opioid addiction.

Providers may participate in one or two HIPAA-compliant teleconferencing programs, which are available at no cost to their practices.

• Project ECHO Pain connects primary care providers with chronic pain specialists to learn more holistic, multidisciplinary approaches to treating

chronic pain and to reduce the need for prescribing opioids. The sessions are provided twice monthly for one year. Participants and staff members from participating sites also receive access to PainNET, an online resource where staff can access pain care tools, news and blogs, and collaborate with experts and peers.

• Project ECHO Buprenorphine links providers with specialists on buprenorphine treatment and counseling, providing them with the support and expert advice that they need to gain confidence in their management of opioid dependence with buprenorphine. The sessions are provided once a month for one year.

Last year, providers from 42 practices

across all regions of Colorado participated in the Project ECHO Pain program provided by the Weitzman Institute and the Colorado Department of Health Care Policy and Financing. Julie Brady, MD, from Colorado Springs Health Partners reports, “Project ECHO has helped me to have more honest, direct conversations with patients about the impact and risks of long-term narcotics. The case presentations have given me additional insight into alternative treatments for peripheral neuropathy and given my patients hope that we still have more options for treatment regimens.”

“ECHO sessions are designed to give health care providers real strategies and tools to help them manage complex pain cases and substance use disorders,” says Agi Erickson, director of Project ECHO. “Our participants report measurable improvement in their knowledge and ability to provide care in these areas.” For more information about Project ECHO Pain and Project ECHO Buprenorphine, contact Erickson at ericksa@chc1.com or call 860-347-6971 ext. 3741. 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, call Tim at 720-858-6306 or e-mail tim_yanetta@cms.org

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Colorado Medicine for March/April 2016

Departments

medical news CMS members urged to complete Continuing Medical Education needs assessment survey All Colorado Medical Society members are urged to complete the Continuing Medical Education needs assessment survey (see link at end of story). The electronic survey takes less than five minutes to complete and all responses will be kept confidential.

Colorado Medical Society’s CME program is committed to its primary goal of disseminating current and new information concerning public health concerns, practice management, health care systems transformation, patient communication and safety, and other needs as determined by health environmental changes. This survey aims to identify

professional development needs of physicians and their practice teams and will allow us to focus our efforts toward those areas that will be most beneficial to physicians, practices and patients.

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Colorado Medicine for March/April 2016

37

Departments

medical news Colorado SIM office announces first cohort of primary care practices selected to participate in practice transformation activities The Colorado State Innovation Model (SIM) Office announced the first cohort of primary care practices selected to participate in practice transformation activities through the SIM initiative. To view the practices participating in the first cohort, go to www.colorado.gov/ healthinnovation/sim-practice-transformation. The cohort reflects a variety of practices, including pediatric practices, residency programs, school-based health centers and independent practices, as well as those affiliated with various health systems, and represents a unique partnership between providers, foundations, academic institutions, public and private insurers, and government agencies.

These practices will play an integral role in achieving Colorado SIM’s goal of providing access to integrated physical and behavioral health care services in coordinated systems, with value-based payment structures, for 80 percent of Colorado residents by 2019.

By participating in SIM, practices will receive a comprehensive practice transformation support package and the opportunity to participate in alternative payment models, the goals of which are to improve patient outcomes while promoting greater return on investment.

Over the next two years, primary care practices in the first cohort will work toward adopting practice milestones that relate to the “Colorado Framework for Whole Person Care.” Each practice will work with a practice facilitator, provided through an approved practice transformation organization, to design and implement a practice improvement plan that outlines a pathway toward greater integration of care based on the practice’s strengths and needs.

Additionally, practices will report their progress toward a common set of clinical quality measures and will be providColorado Medicine for March/April 2016

ed with a clinical health information technology advisor to assist in building practice data capacity. The University of Colorado is providing oversight for practice transformation activities undertaken by the SIM practices and will offer provider education, convene biannual collaborative learning sessions and provide technical assistance to help support practice progress.

integrated care delivery models and ensure that the transformation activities begun under SIM are sustainable beyond the term of the award. Further, practices will be eligible to receive participation payments of up to $5,000 as well as competitive small grants disbursed through the SIM Practice Transformation Fund to help offset the initial costs of integrating care.

The state’s major health plans have agreed to provide selected SIM-participating primary care practices in their networks with enhanced, value-based payments. Each practice in the first cohort will be supported by at least one payer through alternative payment models that align with categories of the Health Care Payment and Learning Action Network (HCPLAN) Alternative Payment Model Framework.

This shift away from fee-for-service to value-based payment models will support practices as they transition toward

The selection process for the first cohort practices was competitive, with 188 practices applying for 100 spots. Practices were selected by the SIM office based on the recommendations of a panel of 18 expert reviewers and characteristics that would ensure a diverse cohort. The SIM office encourages primary care practices that were not selected for the first cohort to apply for cohorts two or three of SIM, expected to begin in 2017 and 2018, respectively. n

39

Departments

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Support the Colorado Medical Society Foundation The Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization in 1997.

We strive to administer and financially manage programs that improve access to health care and health services to improve the health of Coloradans.

Consider giving a taxdeductible donation of $25, $50, or more to help CMSF continue its mission.

Questions?

Call 720-858-6310.

40

Colorado Medicine for March/April 2016

The New CMS

7 7 Strategies Strategies to to Achieve Achieve Safe Safe Opioid Opioid Prescribing Prescribing

CMS CMS strongly strongly supports supports Governor Governor John John Hickenlooper’s Hickenlooper’s efforts efforts to to reverse reverse the the escalating escalating trend trend of of opioid opioid abuse abuse and and misuse misuse and and its its often-tragic often-tragic consequences in Colorado.

The CMS platform on preventing prescription drug abuse guides our active participation in the Colorado consequences in Colorado. The CMS platform on preventing prescription drug abuse guides our active participation in the Colorado ConsorConsortium tium for for Prescription Prescription Drug Drug Abuse Abuse Prevention.

Prevention. Through Through collaboration collaboration with with the the Consortium, Consortium, CMS CMS isis working working to to ensure ensure access access to to compassioncompassionate, ate, evidence-based evidence-based care care for for patients patients who who suffer suffer from from acute acute and and chronic chronic pain, pain, while while reducing reducing the the potential potential for for medically medically inappropriate inappropriate use use and diversion of prescribed medications. and diversion of prescribed medications.

1

Advocate Advocate for for safe safe prescribing. prescribing.

2

Use Use the the Colorado Colorado Prescription Prescription Drug Drug Monitoring Monitoring Program.

Program.

3

Know Know DORA’s DORA’s opioid opioid prescribing prescribing guidelines. guidelines.

4

Become Become educated educated about about safe safe opioid opioid prescribing. prescribing.

5 6 7

Join Join the the CMS CMS Prescription Prescription Drug Drug Abuse Abuse Committee Committee and and become become an an advocate advocate for for safe safe prescribing. prescribing. ItIt isis the the mission mission of of the the CMS CMS Prescription Prescription Drug Abuse Committee to reduce the abuse and misuse of prescription drugs through improvements in education, public Drug Abuse Committee to reduce the abuse and misuse of prescription drugs through improvements in education, public outreach, outreach, reresearch, search, legislation, legislation, safe safe storage storage and and disposal, disposal, and and treatment. treatment.

Check Check the the Colorado Colorado Prescription Prescription Drug Drug Monitoring Monitoring Program Program (PDMP) (PDMP) when when you you prescribe prescribe controlled controlled substances. substances. Review Review the the Colorado Colorado Prescription Drug Monitoring Program website at https://www.colorado.gov/pacific/dora/PDMP to learn about opioid and Prescription Drug Monitoring Program website at https://www.colorado.gov/pacific/dora/PDMP to learn about opioid and other other controlled controlled substance substance prescriptions prescriptions that that your your patient patient maybe maybe receiving receiving from from other other providers. providers.

Be Be familiar familiar with with the the DORA DORA Opioid Opioid Prescribing Prescribing Guidelines.

Guidelines. Compare Compare your your own own practice practice with with the the recommendations recommendations in in the the guidelines guidelines and and determine determine what what you you can can do do to to enhance enhance your your prescribing prescribing practices. practices. Follow Follow recommended recommended guidelines guidelines to to ensure ensure that that your your opioid opioid patients patients aren’t aren’t at at high high risk risk for for overdose. overdose.

Colorado Colorado has has many many excellent excellent resources resources for for education education such such as as the the Colorado Colorado Department Department of of Health Health Care Care Policy Policy and and Financing’s Financing’s Pain Pain ManageManagement Course (Project ECHO); CPEP’s Prescribing Controlled Drugs: Critical Issues and Common Pitfalls; and the University of Colorado ment Course (Project ECHO); CPEP’s Prescribing Controlled Drugs: Critical Issues and Common Pitfalls; and the University of Colorado School School of of Public Public Health’s Health’s The The Opioid Opioid Crisis: Crisis: Guidelines Guidelines and and Tools Tools to to Improve Improve Chronic Chronic Pain Pain Management.

Management.

Discuss Discuss safe safe storage storage and and disposal disposal with with your your patients. patients.

Whether Whether at at home home or or during during travel, travel, you you can can help help your your patients patients understand understand that that medications medications should should never never be be shared shared or or kept kept where where others, others, including children, have access to them.

For additional information on safe storage and disposal, refer them to www.takemedsseriously.org. including children, have access to them. For additional information on safe storage and disposal, refer them to www.takemedsseriously.org.

Give Give patients patients access access to to Naloxone.

Naloxone.

Make Make certain certain that that all all of of your your opioid opioid patients patients who who might might be be at at risk risk for for overdose overdose have have access access to to Naloxone.

Naloxone. Naloxone, Naloxone, also also known known by by its its brand-name of Narcan, is a synthetic drug that reverses the effects of a prescription painkiller overdose.

If administered in time, naloxone brand-name of Narcan, is a synthetic drug that reverses the effects of a prescription painkiller overdose. If administered in time, naloxone can can save save the the life life of of an an individual individual who who has has overdosed. overdosed.

Learn Learn to to identify identify substance substance abuse. abuse.

Be Be comfortable comfortable identifying identifying substance substance abuse abuse and and be be ready ready to to help. help. Addiction Addiction isis aa chronic chronic disease disease that that needs needs treatment. treatment. Be Be ready ready to to help help patients in whom you identify potential addiction by knowing local treatment resources. patients in whom you identify potential addiction by knowing local treatment resources.

FOR FOR MORE MORE INFORMATION: INFORMATION:

Stay Stay tuned tuned to to CMS CMS communications communications to to learn learn more more about about these these important important issues, issues, follow follow our our progress progress and learn how you can get involved. and learn how you can get involved.

We We want want to to hear hear from from you you and and are are available available to to answer answer your your questions. questions. Please Please contact contact CMS CMS President President Michael Volz, MD, at president@cms.org.

Michael Volz, MD, at president@cms.org.

Colorado Colorado Medical Medical Society Society || 7351 7351 E. E. Lowry Lowry Boulevard, Boulevard, Suite Suite 110, 110, Denver, Denver, CO CO 80230-6083 80230-6083 || (800) (800) 654-5653 654-5653

www.cms.org www.cms.org

Features

the final word James L. Madara, MD, AMA CEO

Patients and physicians pay heaviest price if mergers go through We know from history that competition is essential in a thriving health care environment, promising consumers improved service and better quality care at lower costs.

Whenever competition is threatened, as it is now with the proposed mergers of four of our nation’s five largest health insurers, it is patients who stand to pay the heaviest price.

The American Medical Association (AMA) is leading the effort to stop the proposed mergers on behalf of physicians and consumers, a position consistent with our long history of speaking out against the lasting effects of anticompetitive consolidation in the health insurance industry. The AMA has argued before Congress, the Department of Justice (DOJ), state attorneys general and state insurance departments that the mergers would further impair access, affordability and innovation in markets for health insurance. Moreover, the mergers would deprive physicians of the ability to negotiate competitive health insurer contract terms, thereby reducing the quality or quantity of services that physicians offer patients.

Last fall, the AMA released its 14th annual “Competition in Health Insurance” study, which found that the proposed mergers are occurring in markets where there has already been a near total collapse of competition. Seventy percent of American markets were rated as “highly concentrated,” using the same metrics the DOJ and Federal Trade Commission (FTC) use to analyze market competition. In 147 metropolitan statistical area (MSA)-level markets and in 14 state-level markets, a single insurer held at least 50 percent of the commercial insurance market. In 46 states, just two insurers had a combined market share of at least 50 percent of the commercial market.

The AMA has also determined that under market measures utilized by the DOJ and 42

FTC, the proposed mergers are presumed to enhance market power in a vast number of markets. The consolidations are therefore presumptively anticompetitive, the effects of which are likely to be permanent. Barriers to entry, such as the need to have lowcost, high-quality provider networks, and the challenge of overcoming brand-name visibility of established insurers effectively block out new players from entering the market.

The conclusion of a growing body of peerreviewed literature is that greater health insurer consolidation leads to price increases, as opposed to greater efficiency or lower health care costs. For example, a study of the 1999 merger between Aetna and Prudential found that the increased market concentration was associated with higher premiums, results similar to those following the 2008 merger between UnitedHealth Group Inc. and Sierra Health Services.

Recent studies also suggest premiums for employer-sponsored fully insured plans are rising more quickly in areas where insurance market concentration is increasing.

In physician markets, health insurer monopsony (i.e. buyer) power acquired through the proposed mergers would, as the DOJ has found in earlier cases, likely degrade the quality and reduce the quantity of physician services. Consumers do best when there is a competitive market for purchasing physician services. When mergers result in monopsony power and physicians are reimbursed at below-competitive levels, consumers may be harmed in a variety of ways.

Physicians may be forced to spend less time with patients to meet practice expenses.

They also may be hindered in their ability to invest in new equipment, technology, training, staff and other infrastructure needed to deliver quality care and enable physicians to successfully transition into new value-based

payment and delivery models. In the long run, health insurer monopsony power may cause physicians to retire early or seek more rewarding opportunities outside of medicine. This would exacerbate an already significant shortage of primary care physicians in the United States.

These detrimental effects of health insurer buyer power would not likely be offset by health insurers passing along lower physician reimbursement to consumers in the form of lower insurance premiums. Facing little if any competition, health insurers lack the incentive to lower premiums. As Leemore Dafny, PhD, a noted professor of competition in the health care industry at Northwestern University, told a U.S. Senate Committee last fall: “If past is prologue, insurance consolidation will tend to lead to lower payments to health care providers, but those lower payments will not be passed on to consumers.”

Crucial physician roles include advocating for patients and navigating their care, tasks that rely on trust and time spent understanding the patient’s needs on the most basic human level. But if these mergers are allowed to proceed, insurers would undoubtedly become less responsive to patient needs.

We cannot allow insurance giants to become so powerful that they can coerce doctors’ decision-making on the course of care for patients.

They cannot become so dominant that they raise fees and premiums without fear of someone offering the same or better services for less.

Fortunately, competition is the simplest and best remedy. The proposed mergers must be blocked. n Colorado Medicine for March/April 2016

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