March-April 2018 Colorado Medicine

March/April 2018

Volume 115, Number 2

A PHYSICIAN’S VIEW FROM THE CAPITOL Top 10 rules for effective advocacy from a political novice

Award-winning publication of the Colorado Medical Society

contents March/April 2018, Volume 115, Number 2

Cover story Physician-turned-

government-relations-professional Jandel Allen-Davis, MD, of Kaiser Permanente Colorado, presents her top 10 rules for effective advocacy, drawing parallels from each rule of advocacy to medical practice. Her list gives context and meaning to a process that may seem out of reach to anyone short of political professionals. Above all, effective advocacy means respecting others, even when it’s difficult, and conducting oneself with the highest standards. Read more starting on page 6.

Inside CMS

5 President’s Letter 35 COPIC Comment 36 Reflections 37 Annual Meeting Save the Date 38 Introspections

Departments 41 43

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Medical News CMS Corporate Supporters and Member Benefit Partners Classified Advertising

Colorado Medicine for March/April 2018

Features. . .

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Physician advocacy–The Public Policy Leadership Forum armed physician attendees with real-world tips and tricks for successfully advocating for their patients and practices.

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Public policy in practice–A panel of legislators and

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Forming relationships– A panel comprising two members of Congress and two physicians described the importance of developing symbiotic relationships with elected officials for effective political gains.

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Legislative update–The Colorado General Assembly is nearly halfway through the 2018 legislative session. Our staff expert outlines bills of interest.

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“Dreamland in Denver”– CMS physician leaders joined many other stakeholders in dialogue about the opioid epidemic at a January event with author Sam Quinones.

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AMA advocacy conference– Colorado physicians traveled to Washington, D.C. to hear from political insiders about top issues on the Hill and meet with congressional representatives.

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Learning from the past–A traveling exhibit from the U.S. Holocaust Memorial Museum will make a stop at the Anschutz Medical Campus this spring.

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Health care costs– CIVHC explains their latest report that reveals how Colorado could save millions in the health care system.

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State Innovation Model–Patient testimonials reveal satisfaction with integrated behavioral and physical health care as supported through SIM.

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Transforming clinical practice–Colorado TCPi practices are gaining national recognition for their work to reduce costs and improve quality in health care.

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Final Word– COMPAC Chair Chris Unrein, DO, presents four concrete ways physicians can engage in advocacy right now.

physicians explained the rise of the opioid epidemic in Colorado, and how physicians and legislators are responding.

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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 STAFF

2017-2018 Officers M. Robert Yakely, MD

President Debra J. Parsons, MD, FACP

President-elect David Markenson, MD

Treasurer Alfred D. Gilchrist

Chief Executive Officer

Board of Directors Cory Carroll, MD Sofiya Diurba, MS Curtis Hagedorn, MD Mark B. Johnson, MD Richard Lamb, MD Gina Martin, MD Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Brad Roberts, MD Charlie Tharp, MD Kim Warner, MD C. Rocky White, MD

Katie Lozano, MD, FACR

Immediate Past President

AMA Delegates A. “Lee” Morgan, MD David Downs, MD Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD AMA Alternate Delegates Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Brigitta J. Robinson, MD Michael Volz, MD AMA Past President Jeremy Lazarus, MD

COLORADO MEDICAL SOCIETY STAFF Executive Office Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Fetter, Director, Professional Services, Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org Division of Communications and Member Benefits Kate Alfano, Coordinator, Communications, Kate_Alfano@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org Division of Health Care Policy Chet Seward, Senior Director, Chet_Seward@cms.org Gene Richer, Director, Continuing Medical Education, Gene_Richer@cms.org

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 Krystle Medford, Director, Membership, Krystle_Medford@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Emily Bishop, Program Manager, Emily_Bishop@cms.org Colorado Medical Society Foundation Colorado Medical Society Education Foundation Mike Campo, Staff Support, Mike_Campo@cms.org

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

Subscriptions are available for $36 per year, paid in advance.

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

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

Printed by Hampden Press, Aurora, Colo.

Inside CMS

president’s letter M. Robert Yakely, MD President, Colorado Medical Society

The liability climate is at risk and we need your help The governor recently appointed a justice to the Colorado State Supreme Court who COPIC, CMS and the state’s lawsuit reform communities are concerned may indicate, based on previous published commentary, a move of the court to erode significant components of tort law and doctrines that in turn could undermine Colorado’s longtime stable medical liability climate.

Notwithstanding those concerns, the jury, so to speak, is still out on the question of whether advocates who become jurists set aside their professional and personal opinions when they put on the robe. No doubt, trial cases will be pursued all the way to our highest court with the underlying purpose of expanding defendant liability. Of course medicine and our many allies will diligently surveil and advocate as test cases emerge over time.

Meanwhile, we face another concern with the convening of this year’s Colorado General Assembly. We expect another effort to raise Colorado’s medical liability caps, and the laws governing medical licensure and peer review will be reviewed in advance of the 2019 sunset process when they can be potentially revised. Trial attorneys who sue doctors, hospitals and other health care professionals for malpractice will invest heavily in challenging legislators who have sided with medicine, especially regarding their perennial efforts to raise or repeal Colorado’s malpractice damage limits and breach the confidentiality of peer review records.

Now is the time for physicians to step up and support the many state legislators of both parties who have championed Colorado Medicine for March/April 2018

our issues as well as opposed the trial attorneys’ annual push to raise or repeal damage limitations. We are asking you to support our efforts to combat this by contributing to the CMS Small Donor Committee (SDC) and the Medical Society Liability Expense fund (MSLE).

The SDC works to elect candidates who support medicine’s efforts to preserve Colorado stable tort environment.

These contributions only benefit candidates who will protect Colorado’s medical malpractice caps and help us enact comprehensive liability reform. The maximum annual contribution is $50.

The MSLE solicits donations from physicians and other interested supporters to be spent exclusively on legal expenses associated with preserving Colorado’s stable tort environment and peer re-

view confidentiality. Since these funds are spent on legal expenses combating trial lawyers’ attempts to raise liability caps or weaken peer review confidentiality and are not used to contribute to political candidates for office, they are not reported to the Secretary of State or subject to donation limitations.

Your donation to either fund goes only to support Colorado’s medical liability climate. Donate securely online at www. cms.org/contribute.

We face a strong, well-financed adversary and your medical society is constantly fighting these expensive battles on your behalf. Thank you for your continued support of our profession and the community of organized medicine.

Please contact me at president@cms.org if you have any questions or concerns. n

New member benefit: Know Your Rights database Physician practices have rights under Colorado law that can be exercised to mitigate health plan barriers to care. These rights are being summarized and incorporated into a members-only online database for easy access. The tool will be searchable, and help physicians and practice managers understand what those rights are.

Legal rights for physicians advocated for by CMS over more than a decade include but are not limited to: physician profiling, prior authorization and referrals, telehealth, anti-retaliation, narrow networks, timely payment, contracting, and appeals. Watch for more information coming soon. The online database is scheduled for rollout by the end of March 2018.

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A PHYSICIAN’S VIEW FROM THE CAPITOL

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Colorado Medicine for March/April 2018

Cover Story Physician’s view: Just as in medicine, wherein we create differential diagnoses, hopefully based on a constellation of signs, symptoms and evidence, every policy issue has multiple sides, perspectives and evidence, both seen and unseen.

Number 9: Be on watch Bills and issues can take on a zombie-like quality. That is, they tend to come back, sometimes exactly in their former body, but more often are either shaped by the last fight or hidden in other issues.

Jandel Allen-Davis, MD, vice president of Government, External Relations and Research, Kaiser Permanente Colorado Public policy and advocacy are viewed by some as the third rail: done well, great aims can be achieved; done poorly, fairly narrow interests are served that require more work and are loaded with hidden costs.

I have seen awesomely good political advocacy. I have come to know a cadre of men and women who do this work as a profession, aided by content experts, whose role it is to educate, sometimes persuade, and help shape the best proposed legislation that works in the interests of most people.

I have seen some pretty bad political advocacy as well, the kind that has given the profession of government relations a bad name. I have seen my colleagues rail against people whose self-interests are laid bare, whose tactics and strategies require that you shower before, during and after work!

And I – a policy and political novice who spent most of her career caring for patients – have seen everything in between. Here are my top 10 lessons and observations for effective advocacy, having worked alongside some of the best since 2006.

Number 10: Compromise You aren’t going to get all you want. Life is lived in the grey. Don’t be so married to your perspective that your side wins a battle and loses the war. The art of compromise will almost always be required.

Colorado Medicine for March/April 2018

Physician’s view: The clinical equivalent of this lesson is found in chronic disease or multiple co-morbidities. The good clinician, like the good political strategist, is on the lookout for how, when, why and where those new manifestations of chronic illnesses or complications are likely to present themselves and must be prepared for “Round Next.”

Which leads me to my next lesson or observation.

Number 8: Pay attention The most skilled government relations specialists have big ears, an ability to appreciate all sides of an issue and can quickly prioritize the most important elements of any position, while discarding the less important ones.

Physician’s view: As clinicians, we spend our lives listening to spoken and unspoken words, signs and symptoms, and then triaging, prioritizing and discerning. The outcomes of this essential skill include cure, risk mitigation and optimization of the incurable, not to mention excellent patient engagement when done well.

Number 7: Know the nuance The reasons why any given legislator, lobbyist or advocate takes a given position is not always apparent, logical, reasonable or even moral/ethical. This work requires an innate ability to read people.

You have to know what matters to those involved in an issue and what competing and conflicting priorities may be at play.

You have to know who is with you and who isn’t and, most importantly, why they are positioned the way they are.

Physician’s view: Back to the exam room.

Patients walk into our spaces wearing an invisible backpack. The skilled clinicians are good archaeologists. They are able to intuit what may be in that backpack and/or are skilled at creating the space for patients to unpack it themselves and share its contents. It is through this practice that we diagnose correctly, avert harm, improve the likelihood of adherence to treatment and create the kinds of rich relationships with our patients that build trust.

Number 6: Look for the big picture Government relations is mostly a game of influence and good political strategists are translators. They have an innate

“In politics, nothing happens by accident. If it happens you can bet it was planned that way.”

- Franklin D. Roosevelt ability to take a pretty disparate set of participants, observations, concerns, issues and emotions, and distill them into a comprehensive, cohesive set of actions that work to either kill or pass a bill.

Physician’s view: By the same token, we have known and are slowly coming around to the reality that medicine is a team sport. We know that some of the most complicated and complex conditions are also the most deadly. We have to be able to step back and see the big picture and rely on the facts, the nuance and others to get the best outcomes.

Number 5: Pursue policy with caution If we started from the perspective that a need to promulgate laws and regulations should be viewed as a failure of communities to solve their problems, perhaps we would use this particular club in our political golf bag MOST sparingly.

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Cover story (cont.)

Left: CPMG physicians meet the distinguished opioid panel at the Public Policy Leadership Forum on Feb. 3. Top row, from left: Chris Fellenz, MD; Dave Downs, MD; Sen. Jack Tate; Don Stader, MD; Rob Valuck, PhD, RPh, FNAP; Kim Warner, MD; Nora Reznickova, MD; Oscar Sanchez, MD; and Ellie Jensen, DO. Bottom row, from left: Shannon Jantz, MD; Christina Ring, MD; Diane Winter, MD; Rep. Brittany Pettersen; Lane Fairbairn, DO; and Beth Lewkowski, MD. Right: Jandel Allen-Davis, MD, gives her perspective on advocacy as a physician-turned-government-relations-professional.

Some of the worst enacted laws and regulations are a reflection of the clash between politics and policy.

The politics side: bare, bald self-interest at all costs, whatever those interests may be. The policy side: a carefully considered understanding of all sides of an issue coupled with good judgment and a keen sense of whether an issue requires a legislative fix. This requires slowing down long enough to do the work and to sit in conversation with folks to determine if legislation is in fact the best way to approach a problem.

Physician’s view: My best clinical analogy for this is the work ahead of us in dealing with end-of-life issues; our opioid overuse, misuse and abuse; and overtreatment that is informed by all sorts of considerations that are irrelevant (e.g., the ability to pay, a given patient’s stature in the community or concerns about malpractice).

Number 4: Follow the chosen path There are few monoliths or absolutes in this world. The medical community or the health care sector is hardly one sector, including the physician commu 8

nity. This requires the ability to come to a decision/position and support it (or be quiet) until or unless changes of such grave or great significance happen that a different direction is required.

Physician’s view: How many times have you uttered, “Some patients don’t read the textbook?” After all the distillation of facts, figures and evidence, we have to choose a path and follow it, paying close attention to know when modification of a treatment plan is required.

Number 3: Know your role Check your title at the door (or as one political strategist commented about doctors, which was admittedly hard to hear, “I don’t care that you save lives with those hands!”). Know your role and play it well. Over a lifetime of clinical practice, doctors can come to believe that we are the smartest people in the room. Actually, we are the smartest doctors in the room! This is a critically important tenet to remember. Lobbying is not a game; it is a profession and we have to defer to the experts, play our role and be willing to learn – or be prepared to be humbled in the process! Our biggest contribution to helping pass good legislation is to be the voice of patients and

communities first, and to focus on our profession second.

Physician’s view: I don’t know to whom the following quote is ascribed, but someone said, “There are some patients we can’t help. There are no patients we can’t harm.” Keeping patients and families at the center in all that we do helps.

We have to know and understand our limits as well as medicine’s limits and work within them. The same is absolutely true of our role in this business.

Number 2: Foster good will At the end of the day, we have to be able to go out and have a beer with our opponents. They are not adversaries, they simply have a different view of the world on a given issue and a different set of beliefs. And on the next issue, those same folks may be your friends.

About beliefs, singer-songwriter John Mayer cynically asks, “Is there anyone who ever remembers changing their mind because of paint on a sign?”

Physician’s view: At the heart of all human commerce, relationships matter.

We know this is the most sacred part of the work we do as physicians. RelationColorado Medicine for March/April 2018

Cover Story ships must be tended gently, constantly and consistently. The best outcomes, even when they end in death or disability, have good relationships at their heart.

Number 1: Be respectful and respectable Political capital is earned, spent and lost based on the manner in which you conduct yourself. Under that dome, all you have is your reputation. Lose it and it is gone forever. Think in terms of the long game as well as the short game.

Never ever celebrate in the building. Resist cynicism. Keep your promises. Take meetings with almost anybody. Collaborate (never go it alone). Compromise.

Keep your fights quiet and appropriate.

Always be kind, honest and respectful. You win today – you lose tomorrow – based on how you hold yourself.

Build trust. And we know who you are whether you recklessly or carefully spend capital, as memories are long.

Physician’s view: The parallels of this tenet to our hallowed profession are too many to describe and are as obvious as the day is long. The best doctors are professionals, healers, great diagnosticians and good people. We are perfectly positioned to serve in the role of advisor and advocate and perhaps over time, government relations professionals. n

Owned and operated by the Colorado Medical Society and backed by a 50-year history of physician ownership, MTC is uniquely focused on the needs of its clients.

Serving medical professionals is all we do.

MTC's management team has over 50 years of experience in medical answering services. Our operators are professional, friendly and expertly trained to handle any client situation. We offer a full range of customizable services to ensure your patients enjoy personal, timely communication while you stay on top of your busy schedule.

MTC proudly received the prestigious 2009 Award of Excellence for the fourth year from ATSI (Association of TeleServices, Intl.), a service-quality award based on test calls placed over a six-month period. MTC is a member of the Denver/Boulder Bettter Business Bureau, ATSI and Telescan Users Network (TUNe).

MTC particpates in the Colorado Medical Society's Disaster Preparedness Program by contacting volunteer providers in the event of a large scale disaster. In addition we collaborate with CMS every six month in testing the response time of the volunteer providers.

Jandel Allen-Davis, MD, is vice president of Government, External Relations and Research for Kaiser Permanente Colorado. She leads the organization’s government relations and regulatory affairs, community relations and community benefit investment, clinical research activities, stakeholder engagement, communications, and advertising and marketing functions.

Allen-Davis is board certified in obstetrics and gynecology, and after 25 years of serving patients, transitioned from a physician leader to Kaiser Permanente’s Health Plan Leadership team.

Dr. Allen-Davis gave this presentation as part of the CMS CPMG Section/CMS Medical Student Component Society Public Policy Leadership Forum on Feb. 3.

Read more about the forum on pages 10-15 of this magazine.

Colorado Medicine for March/April 2018

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Features

Physician advocacy Kate Alfano, CMS Communications Coordinator

CMS CPMG Section, Medical Student Component and COPIC sponsor successful public policy training on Feb. 3 The CMS Colorado Permanente Medical Group (CPMG) Section and CMS Medical Student Component joined COPIC to sponsor the 2018 Public Policy Leadership Forum, which brought together an all-star lineup of speakers – including two members of Congress, two state legislators and many physicians and students– to give attendees real-world tips and tricks for successfully advocating for patients and physicians within the public policy and regulatory spaces.

“This concept for this session has been more than a year in the making,” said CPMG Section Chair Kim Warner, MD, in her opening address to the audience.

“What are we ultimately talking about in terms of health care advocacy? Quality improvement, and improving safety and availability for our patients. At the end of the day I want you to believe that you can make a difference in health care public policy on behalf of our profession and our patients, that there are a number of ways for you to step forward, be involved and have your voice heard, and to lead others in this endeavor. Right now you already have the skills available, if you’re willing to invest your time and follow your passions; we’re going to be even stronger for our patients and the physicians we serve.”

Sofiya Diurba, a medical student and student representative on the CMS Board of Directors, addressed her peers. “To the students in the room: public policy will affect us as doctors. It will affect our patients and we’ll be expected to step up in the future for our patients beyond the exam room. I hope what you’ll learn today will give you a greater understanding of how your white coat can bring greater value to society through public policy.”

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“What you should emerge from this session with is how to put the pieces together between public policy and how you practice,” said Ted Clarke, MD, COPIC chairman and CEO. “They are intimately connected and you have to be able to connect those dots.”

A bill’s journey Joe Hanel, associate director of strategic communications of the Colorado Health Institute, explained the journey of a bill in theory and practice before and during a state legislative session and why lobbyists exist. Fortunately, he said, Colorado has several “good-government laws” to make the legislative process more accessible to the public and less subject to political gaming. The GAVEL amendment ensures that each bill that is introduced gets at least one vote, most often in committee. This prohibits committee chairs from killing a bill by not scheduling a vote on it. The Single Subject Rule ensures that amendments to a bill fit under the title of the bill to avoid it being hijacked to pass policy on a completely different issue. Sunshine Laws ensure that meetings of two or more legislators are publicized 24 hours in advance and open to the public. The Colorado Open Records Act (CORA) requires most public documents to be produced within three days to anyone who asks.

Lobbyists are hired by organizations to represent them throughout the 120-day legislative session. They provide expert information on bills that legislators don’t have, particularly on the state level where it is common to have little or no staff support to research each issue. “Lobbyists build relationships and have reputations,” Hanel said. “The best way to burn your-

Moderator Joe Gagen, JD, explains how to be effective when meeting faceto-face with an elected official. self as a lobbyist is to lie and get caught.”

His final point was about what happens if and when a bill makes it through committee, passes both chambers and is signed by the governor into law. Once a bill passes, one of hundreds of citizen boards will be directed to do rulemaking.

All notices of rulemaking are published in the Colorado Register, available online on the secretary of state’s website.

These hearings are also open to the public and public testimony is solicited. “This is where expert advice really helps: In the real world, how will this work? How will agencies enforce this? Check the register to see where rulemaking hearings will be held and when. This is a crucial part of lawmaking that is overlooked by the media and most citizens in general,” he said.

Tell a story Moderator Joe Gagen, JD, focused on how to be an effective advocate on the Colorado Medicine for March/April 2018

Features

Medical student Sara Graves, right, practices her new advocacy skills in a mock legislative visit with Shannon Jantz, MD, left. federal level. His first message was that an individual meeting with his or her member of Congress can make a difference. This conclusion is reinforced by a survey of senior congressional staff of which 60 percent reported that of all the advocacy strategies directed at the Washington office, in-person visits had the most influence on a legislator who hadn’t arrived at a final decision on an issue. “That one-on-one conversation with your legislator, talking with them about your issue, is more likely to influence that legislator than letters, lobbyists or phone calls. Telling your story makes a big difference,” he said.

“The key to being effective is understanding your legislative audience,” he added. “Just like sales, when you talk with a legislator, you’re selling your issue, and you have to understand what’s important to the buyer. The better you understand the buyer, the more effective you will be at that sale.”

With the audience’s help, he listed various factors that influence legislative decision-making, which included: their constituents, the facts, personal experiences, philosophical beliefs on the role of government, proximity to an election and party leadership, among others.

Colorado Medicine for March/April 2018

Gagen explained that lack of time and expertise to fully research each issue necessitates a cadre of trusted experts on which the legislator can call for perspective. “If you don’t remember anything else from today, remember this: The key to being successful is establishing relationships, because relationships yield trust and the legislator lacks time to determine what is true. They look to people they trust to keep from making mistakes and the ones they trust are those with whom they have relationships.”

Finally, he gave his advice for effective legislative visits: Introduce those involved in the visit, directly state the reason for the visit, tell a story to illustrate the position, explain the legislation briefly if in support of the legislation, leave a one-page handout for more information, end on time and thank the legislator or staff member for the meeting, and take a photo of the group with the legislator or staff member to share on social media or the local newspaper to remind the legislator of the visit and reinforce the advocacy relationship.

Attendees then practiced their new skills in mock legislative visits. Read further in this issue for more coverage of the Public Policy Leadership Forum. n 11

Features

Public policy in practice Kate Alfano, CMS Communications Coordinator

Panel on opioid legislation outlines evolution of policy response to epidemic The Public Policy Leadership Forum gave attendees the opportunity to hear directly from physician leaders and legislators on the mechanics of passing legislation. The first panel of the day, “Making a Difference: The Anatomy of 2018 Public Health Legislation Resulting from the Opioid Crisis,” took the audience through the evolution of public health legislation resulting from the opioid crisis.

State Representative Brittany Pettersen (D-Denver) shared her personal testimony for getting involved in the effort to find viable policy solutions to aid groups in addressing the opioid epidemic: She saw her mother struggle with addition to prescription painkillers, then heroin, then be unable to find treatment when she wanted out of the vicious cycle of addition. “My story is ultimately why I started to lead on this issue because I saw a problem in our system,” Pettersen said. “I watched tens of thousands of dollars being spent just to keep my mom alive and then the doctors saying ‘I’m very sorry, there’s nowhere for us to send her,’ knowing that she would come back, sometimes that day or week but definitely that month.”

Pettersen was finally able to get her mom into treatment by overcoming difficult barriers to care. “My mom has been sober for more than six months.

I never thought I’d have her back,” she said. “It’s an example of what’s possible when we wrap these services around people who are struggling and desperate for help.”

State Senator Jack Tate (R-Centennial) gave an overview of two bills he’s 12

CMS Past President David Downs, MD, center, asks a question of the opioid panel. sponsoring in the 2018 legislature on the topic. “How do you gently have the state intervene in the clinician-patient relationship? The state can have a pretty heavy hand, and telling doctors what to do when it comes to patient care is something we should take with a certain amount of patience and prudence,” Tate said.

Tate spoke of one of his bills that would place prescription limits on opioids and set rules for how prescriptions are initiated and refilled while also putting regimens in place to check for drug-seeking behavior from patients.

“It’s a complicated bill, and I’d say there’s still not consensus. It takes a lot of work and time to get people to understand what the agenda is, what the problems have been, and it’s important to let people have a role in the process and be heard to create agreement with the initiative.”

Jan Kief, MD, detailed the history of her awareness of the prescription drug abuse issue during her term as CMS president, the governor’s commitment to reduce the problem in Colorado, and the recommendation and subsequent passage of CMS policy by the CMS Board of Directors that set this issue as a high priority and committed CMS to coordinate and work proactively with the governor on effective strategies to reduce prescription drug abuse.

“CMS is a lean, mean machine – we have limited resources, but we respond when members identify something that needs to be raised to priority,” she said. ‘“Leaders listen’ was the key, and the board did the right thing.”

Robert Valuck, PhD, RPh, FNAP, chair of the governor’s Consortium for Prescription Drug Abuse Prevention, discussed the evolution of the consortium, now a collaboration of more than 400 Colorado Medicine for March/April 2018

Features stakeholders from state and federal agencies and task forces, nonprofit organizations, physician and patient advocacy groups, public health organizations, and other groups who volunteer their time on 10 working groups focused on the major levers of the issue.

As for the future of the consortium, the State of Colorado approved the creation of a center dedicated to substance abuse research and prevention at the University of Colorado Anschutz Medical Campus in May 2017. The new center received $1 million from the state and will be part of the CU Skaggs School of Pharmacy and Pharmaceutical Sciences. The center will provide additional resources to the consortium as it works along with its partners to coordinate and support Colorado’s response to the opioid epidemic.

CMS has been involved since the beginning of the consortium. “We accept that physicians are part of the problem,” Kief said. “We are going to own some of this, learn as much as we can and do our part to educate. The public trusts us and we need to clean out any outliers in our house. The CMS workers’ comp committee had already seen the problems with opioid abuse for years. They are a very capable committee of dedicated people. It was not a hard sell at all.”

Don Stader, MD, CMS liaison to the Opioid and Other Substance Use Disorders Interim Study Committee, got involved in this issue years ago through his work as an emergency room physician. “The ER is where bad policy shows its face. We’re the ones who see the opioid epidemic through overdose, complications of using these and other drugs, or deaths. I have spoken with countless families who told me they knew [their loved one’s death] would happen. It gives you a new perspective.

For medical students who will have rich careers, whenever you see injustices, it’s imperative that physicians stand up and try to fix that injustice,” he said.

“Physicians have been reluctant to participate in politics to the detriment of Colorado Medicine for March/April 2018

Top: Panelists discuss the rise of the opioid epidemic in Colorado, CMS’s response to reduce prescription drug abuse and misuse, and how policy to address the issue was formed and is progressing through the 2018 Colorado General Assembly. From left: CMS Past President Jan Kief, MD; Donald Stader, MD, CMS liaison, Opioid and Other Substance Use Disorders Interim Study Committee; Robert Valuck, PhD, RPh, FNAP, chair, governor’s Consortium for Prescription Drug Abuse Prevention; Rep. Brittany Pettersen; and Sen. Jack Tate. Bottom: Sen. Jack Tate talks with CMS President M. Robert Yakely, MD, following the panel discussion. our society and patients,” Stader added.

“We have to be much more involved; we have to realize the power in getting involved and forming relationships with great legislators so if we need something we can get it. That’s a tremendously important part of your practice. You as physicians have such a powerful voice because you see truth on a daily basis and you can articulate exactly what your patients are going through.” n

Where are the opioid bills now?

Read the legislative update on page 17 for more information on the progress of legislation developed by the Opioid and Other Substance Use Disorders Interim Study Committee.

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Features

Forming relationships Kate Alfano, CMS Communications Coordinator

Panel of congressmen and physicians discuss the importance of knowing your elected officials An afternoon panel discussion at the Public Policy Leadership Forum, “Making Friends Before You Need Them,” featured Congressman Mike Coffman (R-Aurora, 6th Congressional District) and Congressman Ed Perlmutter (DJefferson County, 7th Congressional District). They both stressed the importance of developing and fostering a relationship with elected officials, and sharing expertise with them.

“There is a lot of trust between physicians and the community, so when you come to visit with [elected officials] we clearly understand that,” Coffman said.

“What’s great in the medical profession, with CMS and other groups representing primary care practices or specialty groups, is you come and see us, not a lobbyist representing you. I think that’s somewhat unique to your profession and it’s extremely positive. It helps in that trust relationship [between doctors and elected officials].”

“The medical profession touches every person, every family, every individual,” Perlmutter said. “There’s the business component to it; there’s the professional piece – the knowledge of the doctor and the ability to work with your patient;

An afternoon panel explains how and why to know your elected officials. From left: Congressman Mike Coffman; Congressman Ed Perlmutter; orthopedic surgeon Mitch Seeman, MD; and CMS Past President Lynn Parry, MD. and there’s the research and technology piece. Your profession is changing every day. For those of us who aren’t in the medical profession, you have to give us your perspective on what’s really happening, how this change in the law or this change in technology has affected your practice and your ability to care for your patients. We need your input.”

Perlmutter gave two examples of how

Join Now! Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext. 6327, or email susan_koontz@cms.org

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he has fostered relationships with the two physicians on the panel: Mitch Seemann, MD, of Panorama Orthopedics, and Lynn Parry, MD, CMS past president and neurologist.

“Mitch’s practice has probably worked on every Perlmutter in the area,” he said.

“The first order of business is to be a good doctor and to do right by your patients, partners and practice. Then that by itself is the foundation of trust that makes a difference when maybe there’s an issue that comes up that affects your practice or affects how you conduct your affairs as a doctor.”

“Lynn has been a friend of mine for more than 20 years, starting as an advocate on behalf of the medical society when I was first elected to the state senate,” Perlmutter continued. “The friendship has grown. There’s a relationship of trust Colorado Medicine for March/April 2018

Features

Top: Medical student attendees of the Public Policy Leadership Forum pose with U.S. Rep. Perlmutter, center left, and U.S. Rep. Coffman, center right.

Middle: U.S. Rep. Perlmutter talks with CMS President M. Robert Yakely, MD, after the panel discussion. Bottom: U.S. Rep. Coffman answers a question of a PPLF attendee. and honesty. Relationships really do matter, in our business as well as yours.”

Seeman agreed, advising the audience to get to know elected officials “when they need you more than you need them” through campaign events, town hall meetings and in-person meetings over many years. He gave an example of when he had to call on Perlmutter when proposed policy was affecting his practice. He and his practice partners were working on a project to deliver orthopedic care in a better way by giving physicians greater input and focusing on higher quality and lower cost care for a favorable value equation.

Unfortunately, a provision of the Affordable Care Act (ACA) created a roadblock. “Ed was very helpful for us,” Seeman said. “The way we look at things is you do grassroots at the local level, getting to know your local elected officials, then you do the high-grass things to get to the higher-level people on the national level.” n Colorado Medicine for March/April 2018

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Features

Legislative update Susan Koontz, JD, General Counsel, Senior Director of Government Relations

2018 General Assembly focuses on substance use, other health care issues As we approach the halfway point of the Colorado General Assembly’s 2018 Regular Session, the Colorado Medical Society is tracking more than 20 bills related to the interests of Colorado physicians and their patients. The lobby team expects many more bills to be introduced before the end of session – including legislation relating to out-ofnetwork providers, physical therapists, acupuncturists and medical marijuana.

With staff support, the CMS Council on Legislation (COL) reviews each relevant bill to understand its intent, possible outcomes, and the political landscape to collectively determine how and at what level CMS should engage.

Below are a handful of bills of particular interest to CMS members and supporters as we look toward the second half of the session. Six bills currently under consideration come from the work of the bipartisan Opioid and Other Substance Use Disorders Interim Study Committee, which conducted business during summer 2017.

Supported by COL SB18-022 Clinical Practice for Opioid Prescribing This bill would limit an initial prescription to seven days for patients who have not had an opioid in 12 months, with the option to allow for one seven-day refill. This limit would apply to the prescribing practices of physicians, physician assistants, podiatrists, dentists, advance practice nurses, optometrists and veterinarians.

The bill allows for certain exceptions Colorado Medicine for March/April 2018

to the seven-day prescription, to be determined at the prescriber’s discretion.

Those include chronic pain that: • Lasts longer than 90 days or past the time of normal healing, or to a patient following transfer of care from another provider who prescribed an opioid; • Is the result of underlying conditions or diseases; • Is the result of cancer; • Is a part of palliative or hospice care and is focused on improving quality of life; • Is the result of surgery where, due to the nature of the procedure, postsurgical pain is expected to last more than 14 days.

The bill also makes exceptions for patients undergoing medication-assisted treatment and those who are prescribed an abuse deterrent drug.

Senators Irene Aguilar and Jack Tate have been diligent sponsors for this bill and COL supports their hard work. The bill passed unanimously through the Senate Health and Human Services Committee after testimony by CMS physicians and is assigned to the House Health, Insurance and Environment committee.

SB18-024 Expand Access Behavioral Health Care Providers Another piece of legislation to come out of the interim study committee, this bill creates two programs for substance use providers, specifically licensed addiction counselors (LAC) and certified

addiction counselors (CAC).

The first program is a scholarship for the continued education of already-practicing CACs. The second is a new category of loan repayment for behavioral health providers with addiction-specific education and training who commit two years of service to an area labeled as having a behavioral health care provider shortage. An amended version of the bill was referred to the Committee on Appropriations.

SB18-040 Substance Use Disorder Harm Reduction This bill aims to address and manage overdose and the spread of disease related to substance use as an intermediate step in the opioid crisis as treatment and demand concerns are in the process of being addressed. Specifically, it would pave the way for establishing clean needle exchanges and overdose prevention sites. CMS physicians testified on behalf of the bill; however, it died in committee on Feb. 14.

HB18-1003 Opioid Misuse Prevention CMS is closely following the progress of this bill aimed at maintaining the momentum created by the interim study committee. The committee would evaluate current data, statistics, policy, education and other relevant information to determine the most effective response to Colorado’s opioid crisis.

The bill is assigned to the House committee on Public Health Care and Hu-

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Legislative update (cont.) man Services and is scheduled for hearing March 13.

HB18-1012 Vision Care Plans Carriers Eye Care Providers This bill prohibits a carrier or entity that offers a vision care plan from requiring an eye care provider with whom the carrier contracts to provide services or materials to a covered individual at a fee set by the carrier. The only exceptions to this are if the services or materials are fully covered by the carrier or entity and if they then reimburse the eye care provider a reasonable amount. The bill also prohibits requiring an eye care provider to participate in any of the carrier’s other vision plans as a condition of participating in one vision plan.

The bill passed its third reading in the House on Feb. 15 and is assigned to the Senate committee on Health and Human Services.

HB18-1006 Infant Newborn Screening This bill would update the current timeline for newborn hearing screenings and require the results be included in electronic medical records. It also requires proper follow-up services be provided for at-risk infants or those that were not screened. The program would be paid for partially by a fee increase and partially by the establishment of the newborn hearing screening cash fund.

The bill passed out of committee with amendments and is awaiting a hearing with the Committee on Appropriations.

HB18-1211 Controlling Medicaid Fraud Created with input from CMS and its lobbyists, this piece of legislation would establish the Medicaid fraud control unit to investigate and prosecute Medicaid fraud and waste, as well as patient abuse, neglect and exploitation. The bill also creates offenses related to Medicaid fraud. The bill has a March 15 hearing with the Judiciary Committee.

HB18-1207 Hospital Financial Transparency Pending a hearing with the Health, Insurance and Environment Committee, 18

this bill aims to monitor hospital expenditure and uncompensated costs. It requires general hospitals in the state to provide the Department of Health Care Policy and Financing with information regarding costs submitted for Medicaid and Medicare services, annual audits, staffing, and centralized data of hospital utilization and finance.

This report would be public information, accessible by the governor, committees of the general assembly, and on the department’s website. This bill will be heard March 8 by the House Health, Insurance and Environment Committee.

HB18-1094 Children and Youth Mental Health Treatment Under current law, the Child Mental Health Treatment Act provides children and youth access to mental health services. This bill aims to indefinitely extend and streamline the program.

The House committee on Public Health Care and Human Services referred an amended bill to Appropriations.

HB18-1182 Statewide System for Advance Directives This bill would create a statewide electronic system for uploading and accessing advance directives. The system will be paid for by grants, donations, and gifts. The hearing for this bill is scheduled for March 15 with the House Health, Insurance, and Environment Committee.

SB-146 FSED Required Consumer Notices This bill requires an FSED to provide multiple written and verbal disclosures to individuals regarding the facility’s affiliations, insurance partners, average costs for common services and the individual’s rights.

Pending the adoption of an amendment regarding the requirement to provide a post-emergency screening disclosure that may lead to complications with insurance providers, COL originally voted to oppose this bill. However, upon the adoption of the desired amendment, COL reconsidered and now supports it.

Opposed by COL HB18-1068 Eliminate Registered in Naturopathic Doctor Title Under current law, a naturopathic doctor (ND) may use “registered” in their title, or the initials R.N.D. This bill would remove that distinction under pretext of eliminating public confusion surrounding the title and its distinction from other professions.

CMS opposes the licensing of NDs and supports enforcing the Medical Practice Act, which, among other things, prohibits the use of the term physician by any person other than an MD or DO. This bill died on Feb. 26.

SB18-115 Apply Stark Laws to Medical Referrals Outside Medicaid Current law prohibits medical providers who receive Medicaid reimbursement to refer patients to entities owned by that provider or an immediate family member. This bill would extend that prohibition to all health care providers.

CMS strongly opposes any legislation that would make it more difficult to provide quality patient care and limit the abilities of health care providers. The potential negative outcomes of this bill far outweigh the positives. This bill died after its hearing with the Senate State, Veterans, and Military Affairs Committee on Feb. 14.

HB18-1112 Pharmacist Health Services Coverage This bill would allow carriers to compensate pharmacists for health care services they preform in health professional shortage areas. The compensation would be comparable to that received by a physician. The bill passed the House on its final reading and is awaiting assignment in the Senate.

Other bills of interest HB18-1007 Substance Use Disorder Payment and Coverage Another bill to come out of the interim study committee, this would prohibit plans from penalizing physicians for having bad pain scores and prohibit the requirement that a covered person or Medicaid recipient undergo step therapy.

Colorado Medicine for March/April 2018

Features It would require commercial health plans and Medicaid to cover certain medicines, standardize requirements for medication assisted treatment, and would authorize pharmacists to inject naltrexone. A hearing with the Public Health Care and Human Services Committee is scheduled for March 13.

CMS is monitoring the bill.

SB18-050 Freestanding Emergency Department as Safe Haven (monitor) The purpose of this bill is to expand Colorado’s Safe Haven laws by including, in addition to firefighters and hospital staff, all staff of free-standing emergency department (FSED) facilities, allowing them to take physical custody of infants younger that 72 hours old if voluntarily surrendered by the parents. The bill is awaiting the governor’s signature after passing both the Senate and House.

SB18-065 Add HMOs Life and Health Insurance Protection Assistance (monitor) This bill amends the Life and Health Insurance Protection Association Act by including HMOs in these associations and requiring HMOs contribute to the fund for the purpose of defraying the costs of a health insurer insolvency.

CMS took a monitor position on the bill but it died in committee Feb. 5.

HB18-1097 Patient Choice of Pharmacy (Neutral) CMS has taken a neutral position on this bill that would prohibit insurance carriers that cover pharmaceutical services from limiting or restricting an individual’s ability to select a pharmacy or pharmacist of their choice. Similar legislation was also introduced last year but failed. CMS was neutral on that as well. This year’s bill passed the House on third reading.

HB18-1118 Create Health Care Legislative Review Committee The committee that this bill looks to create would be responsible for studying health care issues affecting Colorado residents. It would consist of members from the House and Senate committees on health and human services and Colorado Medicine for March/April 2018

would be able to recommend up to five bills a year.

An amended version of the bill was referred to Appropriations by the House Health, Insurance and Environment Committee. CMS is monitoring the bill.

HB18-1136 Substance Use Disorder Treatment The most recent bill to come out of the Interim Study Committee on Opioid and other Substance Abuse Disorders, this bill would add substance use disorder services to the Colorado medical assistance program. If this goes into effect and Colorado receives the necessary federal approval, money would be allocated from the marijuana tax cash fund to assist individuals not otherwise covered by insurance.

CMS has taken a monitor position on this bill. The hearing with the Public Health Care and Human Services Committee is scheduled for March 13.

HB18-1114 Require Genetic Counsel License This bill would require genetic counselors to be licensed by the director of the division of professions and occupations in the department of regulatory agencies.

CMS supported a similar bill in 2015.

Pending an amendment clarifying the language in the bill, COL has taken a position of conditional support pending that amendment. The hearing for the bill is March 8.

HB18-1212 FSED Licensure This bill would create a new license for health facilities that offer emergency care. The license breaks facilities into two categories: those that are hospital affiliated and those that are independent. Health facilities with FSEDs are subject to facility fees.

The hearing for the bill is scheduled for March 15 with the House Health, Insurance and Environment Committee.

CMS is currently monitoring the bill.

HB18-1155 Sunset Continue Physical Therapy Board Functions

This bill would extend current licensure until 2027 and allow PTs to make physical-therapy-related diagnoses, extend scope of practice to include supervising unlicensed PTs, allow PT assistants to preform wound debridement, and add a PT assistant to the physical therapy board.

Physical therapists are also trying to add a provision to allow them to perform dry needling. The hearing is scheduled for March 5 with the House Finance Committee. CMS is monitoring.

HB18-1179 Prohibit Price Gouging on Prescription Drugs This bill would prohibit price gouging on sales of essential generic and offpatent drugs and make that practice a deceptive trade act under the Colorado Consumer Protections Act. Any price gouging would need to be reported to the attorney general, who is authorized to seek subpoenas and file lawsuits.

A hearing with the House Committee on Health, Insurance and Environment is pending. CMS has taken a monitor position on this bill.

CMS continually demonstrates influence at the Capitol thanks to strong lobbying efforts and through the engagement and involvement of dedicated physicians on COL. Active involvement in advocacy is crucial to Colorado physicians and patients, and CMS encourages anyone interested to get involved.

Go to www.cms.org/advocacy for more information. n

Join Now! Colorado Medical Political Action Committee Call 720-858-6327, 800-654-5653, ext.

6327, or email susan_koontz@cms.org

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Features

“Dreamland in Denver” Kate Alfano, CMS Communications Coordinator

Stakeholders gather for evening of powerful talks on opioid epidemic Correcting myths and challenging preconceptions about the use and abuse of opioid pain relievers were two outcomes of an event held at the University of Colorado Anschutz Medical Campus in January. “Dreamland in Denver,” organized by the Colorado Consortium for Prescription Drug Abuse Prevention and the Emergency Medical Minute, featured a series of TED talk-style presentations to illustrate the escalation of the opioid epidemic and the necessity for a multifaceted response. Nearly 600 stakeholders from across the spectrum of the epidemic were in attendance, including many leaders from the Colorado Medical Society, and CMS joined the list of sponsors in supporting the event.

The first speakers were Admiral (Ret.) James Winnefeld, former vice chairman of the Joint Chiefs of Staff, and his wife Mary, who shared a powerful cautionary tale about how opioid addiction can affect any family. They lost their youngest son, Jonathan, in September 2017 from an overdose of heroin laced with fentanyl following a years-long battle of drug addiction. He died just three days after his parents helped him move into the dorms at the University of Denver to start his freshman year of college.

Losing a child to the opioid epidemic is “a club none of you ever want to be a part of,” Mary Winnefeld said. “Unfortunately, membership in this club is growing every day.”

In 2017, an estimated 66,000 Americans died of an overdose. The couple has founded Stop the Addiction Fatality Epidemic, or SAFE, to raise aware 20

CMS leaders attended “Dreamland in Denver” on Jan. 24, joining nearly 600 other stakeholders to discuss the opioid epidemic in Colorado. From left: Donald Stader, MD, CMS liaison to the Opioid and Other Substance Use Disorders Interim Study Committee; CMS President-elect Debra Parsons, MD, FACP; keynote speaker Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic;” and CMS President M. Robert Yakely, MD. ness of the opioid addiction and use effective, evidence-based action to prevent overdoses and to mitigate the opioid epidemic.

are important, medication-assisted treatment is important, treatment is so important. These are the only ways out of this epidemic.”

Albert “Alby” Zweight, JD, current presiding drug court magistrate for the 2nd Judicial District in Denver, shared his story of heroin addiction in his 20s, which he says uniquely qualifies him to run a “therapeutic court” focused on second chances. “Opioids are a problem, but we have an addiction epidemic,” he said. “We must understand addiction in a different way. No one wants to be an addict. Addiction blinds people. Addicts use drugs because they are suffering and they are doing things to keep from feeling awful. Drug courts

Robert Valuck, PhD, RPh, FNAP, chair of the governor’s Consortium for Prescription Drug Abuse Prevention, presented his list of 10 fallacies that fueled the opioid epidemic. “Pain is physiologically important. The thought that we can get a patient to zero pain [on the pain scale] is a myth,” he said. “We have to quit using the word ‘painkiller’ because we can’t ‘kill’ pain. We need to figure out how to manage and treat pain.”

He also “busted” myths about opioids’ effectiveness and safety compared with Colorado Medicine for March/April 2018

Features other medications and treatments. “It’s almost an urban legend that opioids are ‘the good stuff,’ the best pain relievers there are,” Valuck said. “That’s wrong.”

He also emphasized the importance of understanding drug interactions; a substantial number of accidental overdose deaths occur when opioids are mixed with benzodiazepines.

Donald Stader, MD, section chair and associate medical director of the Department of Emergency Medicine at Swedish Medical Center in Englewood and CMS liaison to the Opioid and Other Substance Use Disorders Interim Study Committee, addressed medicine’s role in creating the opioid crisis. While acknowledging pharmaceutical companies aggressively marketed the drugs and the government created penalties for doctors who didn’t control pain, Stader said doctors ultimately drove this epidemic through the prescription pad. “Our calling is to be healers, not harmers, and to fulfill the sacred calling that we will do no harm,” he said. “We can do better.”

Finally, keynote speaker Sam Quinones, investigative reporter and author of “Dreamland: The True Tale of America’s Opiate Epidemic,” gave his unique perspective of how drug dealers, pharmaceutical companies, doctors and economic decline combined to create the epidemic. In his view, the loss of community institutions, jobs and the fraying of America’s social fabric are major contributors to the opioid epidemic. The connections that hold communities together have withered, contributing to isolation which feeds addiction.

Colorado hospitals achieve 36 percent reduction in opioid administration through CHA pilot Colorado currently has the nation’s 12th highest rate for misuse and abuse of prescription opioids. Beginning in June 2017, the Colorado Hospital Association (CHA) and its member hospitals conducted a sixmonth pilot in eight Colorado hospital emergency departments (EDs) and two freestanding emergency departments (FSEDs) with the goal of reducing the administration of opioids by ED clinicians. This initiative, one of the largest opioid research efforts in the United States, used treatment guidelines developed by the Colorado Chapter of the American College of Emergency Physicians (Colorado ACEP) that recommend the use of alternatives to opioids (ALTOs) as a first-line treatment for pain rather than opioids.

All participating members successfully implemented the pilot, which returned remarkable results. The EDs achieved a 36 percent reduction in opioid administrations when compared to the same time period in 2016, far surpassing the original pilot goal of a 15 percent reduction. This amounted to a projection of 35,000 fewer individual opioid administrations between the 2017 pilot and the 2016 baseline period.

The changes in ED pain management behaviors were dramatic, and

“There’s an opportunity to turn away from the isolation that made us ill,” Quinones said. “We’re seeing in county after county that taskforces are bringing together different voices to leverage their talents. There is no one solution; there is a mosaic of solutions.”

we saw in this country with a few scandalous outliers. It has to be the mainstream that adopts this idea. I believe if you take out all the pill mills and all the docs who have been prosecuted, you still wouldn’t come up with the enormity of the supply that was unleashed on the country year after year after year, increasing through the late 1990s into the 2000s and into this decade.”

In an interview with Colorado Medicine before the event, Quinones said he does not place blame for this epidemic on doctors. “You can’t effect a change like

“I think doctors were pushed, pressured, cajoled into doing this, and a lot of that came from us – American health consumers. We wanted easy [solutions], we

Colorado Medicine for March/April 2018

the usage of ALTOs increased to the point that they became more commonly administered than opioids for some diagnoses in the treatment of pain. The pilot facilities treated a combined total of 130,631 unique patients during the six-month pilot period.

Pleased with the results of the pilot, CHA President and CEO Steven Summer said, “These results suggest that the opioid crisis in Colorado could be significantly reduced by a widespread implementation of the ALTO treatment guidelines and that is something we know our member hospitals and health systems are very interested in pursuing.”

“The potential that opioid prescriptions carry for addiction and abuse made the need for these guidelines clear,” said Donald Stader, MD, Colorado ACEP secretary, ED assistant medical director Swedish Medical Center. “My colleagues and I are very excited by the pilot results. It appears that we are one step closer to solving the opioid crisis in Colorado.”

For more information and additional details about the results, visit www.cha.com/opioid.

wanted to be fixed, we didn’t want to be accountable for our own core health decisions.”

Quinones sees a role for insurance companies to once again pay for new and a wider variety of non-opioid pain strategies. But ultimately, he said, it comes down to talking to patients: Establish realistic expectations of pain, what medications can and can’t do, and nonmedication strategies. Have patients reclaim their wellness, getting back to what he calls “American self-reliance.” n

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Features

AMA advocacy conference Kate Alfano, CMS Communications Coordinator

Colorado physicians travel to Washington, D.C. to meet with legislators, get updates on national health care issues The American Medical Association (AMA) National Advocacy Conference was held Feb. 12-14, 2018, in Washington, D.C., and brought together physicians from around the country, industry experts, political insiders and members of Congress to discuss the latest health care issues. Colorado had a strong showing, with most areas of the state represented by their respective physicians, and these physician delegates had the opportunity to meet with all members of the Colorado congressional delegation or their key health policy staff.

During the group-session portion of the conference, AMA President David O. Barbe, MD, MHA, and senior advocacy staff unveiled the 2018 advocacy agenda: • Protect and expand access to coverage to help patients live longer and with a higher quality of life.

• Reform Medicare physician payment

Physician leaders meet with U.S. Sen. Cory Gardner (R-Colorado), center. systems to provide better support for coordinated, high-value care.

• Modernize state laws regarding the adoption of telemedicine and ensure physicians are paid for this kind of care delivery.

Colorado physician leaders meet with U.S. Sen. Michael Bennett (D-Colorado), center.

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• Encourage transparency in pharmaceutical pricing through our TruthinRx campaign.

• Address short-sighted insurer policies that undercut physicians’ ability to practice medicine and create waste in the system.

• End the opioid epidemic by eliminating prior authorization for medication-assisted treatment, working with payers to remove barriers to multidisciplinary pain care, and more.

• Target the inefficient, opaque priorauthorization policies that cost physician practices time and money, delay treatments and may harm patient outcomes.

• Eliminate and streamline the many federal regulations that contribute to doctors spending two hours on administrative tasks for every hour they spend with patients.

• Protect patient well-being that is threatened when health care practitioners are allowed to practice beyond their education, training or experience.

Colorado Medicine for March/April 2018

Features The AMA is the voice of medicine: Become a member and make a difference in federal advocacy Lynn Parry, MSc, MD, Colorado Delegate to the AMA

From left: CMS President-elect Debra Parsons, MD, FACP; Brandi Ring, MD; and Frank Dumont, MD; stroll Capitol Hill between visits with legislators.

Keynote speakers included Erik Wahl, an internationally recognized artist, TED speaker and No. 1 bestselling author, and Chris Wallace, an award-winning journalist and host of Fox News Sunday.

Attendees also heard from Rep. Josh Gottheimer (D-N.J.) and Rep. Tom Reed (R-N.Y.) – cofounders of the Problem Solvers Caucus, a bipartisan group in Congress that includes approximately 40 members from both parties who are committed to forging bipartisan solutions.

Kate Goodrich, MD, MHS, Centers for Medicare and Medicaid Services director and chief medical officer of the Center for Clinical Standards and Quality, provided an overview of Merit-based Incentive Payment System (MIPS) Year 2 and Advanced Alternative Payment Models (APMs). The federal CMS is working on developing more advanced APMs. The agency has also made efforts to simplify the data submission portal for MIPS by giving immediate feedback to users and allowing multiple opportunities to submit data.

Interested in federal advocacy? Save the date for the 2019 AMA National Advocacy Conference, Feb. 11-13, 2019, and contact your component society staff or CMS’s Dianna Fetter at dianna_fetter@ cms.org for opportunities to attend on behalf of your region. n Colorado Medicine for March/April 2018

Each year, in the midst of late winter/early spring, the AMA gathers delegates from across the country to learn the latest insights and federal legislation and to meet with their Congressional representatives.

This year at the 2018 National Advocacy Conference, a number of Colorado physicians and staff from CMS, component societies and specialty societies descended on Washington, D.C. to hear Rich Deem, AMA senior vice president for advocacy, and others explain how critical physicians contacting their representatives was to securing important items in the Budget Bill.

These included CHIP reauthorization, permanent repeal of the IPAB and important fixes to MACRA. More than ever, physician awareness and involvement in advocating for their patients and their profession is critical. Because the voice of medicine is active, physicians already have made gains, particularly in the Quality Payment Program (QPP) final rule, by aligning other quality programs and reducing the burden of electronic health records.

The 10 legislative goals for the AMA rolled out by AMA President David O. Barbe, MD, MHA, and listed in the report on the opposite page cannot be achieved without the help of physicians with boots on the ground. And legislative advocacy is a completely different skillset and a different way of looking at the universe than we physicians

are comfortable with. Our own state Sen. Irene Aguilar, MD, a 2015 recipient of the AMA’s Nathan Davis Award for Outstanding Government Service, shared her “culture change” with AMA News: “In medicine, especially internal medicine, I want to tell you everything I know because it may trigger a thought that helps with the diagnosis,” she said. “But in politics, you’re playing poker and you hold things back. It does take learning a new paradigm.”

It can be difficult to shift from an “evidence-based” narrative to personal stories, but advocating for the voice of medicine and the betterment of our patients is rewarding. The AMA has multiple tools, courses and support for physicians – whether they want to just put a finger in to test the temperature or dive fully clothed into the deep end of “The Swamp” – available on their website, www.ama-assn.org.

One of these tools is the AMA’s “Congressional Check-Up,” a guide to help physicians, residents and medical students navigate and cultivate relationships on Capitol Hill. It contains information about how and where to reach members of Congress, how to effectively communicate with members of Congress and what resources the AMA has available to support your efforts. n

Plug in to your reinvented medical society! www.cms.org/central-line 23

Features

Learning from the past Meleah Himber, M.Ed, Community Outreach Coordinator, Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus

U.S. Holocaust Memorial Museum exhibit “Deadly Medicine: Creating the Master Race” opens in Aurora March 22 The United States Holocaust Memorial Museum’s traveling exhibition “Deadly Medicine: Creating the Master Race” will make a stop in Aurora this spring. The exhibition examines how the Nazi leadership, in collaboration with individuals in professions traditionally charged with healing and the public good, used science to help legitimize persecution, murder, and ultimately genocide. It opens at CU Anschutz on March 22, 2018 and will be on display through May 22, 2018.

note speaker Patricia Heberer-Rice, PhD, senior historian at the U.S. Holocaust Memorial Museum and an expert on the Deadly Medicine exhibit.

“Deadly Medicine explores the Holocaust’s roots in then-contemporary scientific and pseudo-scientific thought,” explained exhibition curator Susan Bachrach. “At the same time, it touches on complex ethical issues we face today, such as how societies acquire and use scientific knowledge and how they balance the rights of the individual with the needs of the larger community.”

The annual HGCB program was first developed a decade ago by William S. Silvers, MD, a Denver-based allergist/ immunologist whose parents were Holocaust survivors. Silvers, with other physicians and community stakeholders, created the original program to educate health professionals on the legacy of medical involvement in the Holocaust and its impact on contemporary bioethics.

Matthew Wynia, MD, MPH, director of the University of Colorado Center for Bioethics and Humanities, welcomes the Deadly Medicine exhibit as an expansion of the annual Holocaust Genocide and Contemporary Bioethics (HGCB) program of the CU Center for Bioethics and Humanities. The theme of the 2018 HGCB program is Echoes of the Holocaust: Cultivating Compassion in 21st Century Healers, and it will include programming across all four CU Campuses during the Week of Remembrance, April 9-13. The program will feature key-

“As the program expands, we want to relate the content to contemporary ethical challenges faced by health professionals working in areas of the world experiencing genocide, violence and political conflict. Physicians must always practice with compassion, respect and justice – especially in difficult, conflicted times,” said Silvers, who is not surprised by how much the program has grown, despite its difficult subject matter.

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“The legacy of health professionals’ involvement in the Holocaust is critical to understanding virtually every aspect of modern medical ethics, from medical aid in dying to genetics, privacy and public health,” Wynia said. “What’s more, it casts a shadow on many current social and political events that cannot be ignored.”

“We started this to inspire all health professionals to remember the lessons

of the Holocaust, a time when those who should have been healers became killers in response to a tragic and powerful political ideology. The ultimate duty of a health professional is to protect the patient, not become a servant of the state or a dominant political ideology or culture,” Silvers said. “It is important to know that what happened during the Holocaust was not the result of the actions of a few outlier ‘crazy doctors.’”

By 1942, 38,000 doctors, approximately half of all German physicians, had become members of the Nazi party.

The Deadly Medicine exhibit traces the tragedy of the Holocaust to its roots in the theory of eugenics, which was influenced by early-20th-century beliefs asserting that Charles Darwin’s scientific theories of “survival of the fittest” could be applied to humans. Supporters, spanning the globe and political spectrum, believed that through careful controls on marriage and reproduction, a nation’s “genetic health” could be improved.

The Nazi regime was founded on the party’s conviction that some races were inherently inferior, including the so-called Jewish race, and that those individuals had to be eliminated from German society so that the fittest “Aryans” could thrive. The Nazi state fully committed itself to implementing a uniquely racist and anti-Semitic variation of eugenics to “scientifically” engineer what it considered to be a superior race. By the end of World War

Colorado Medicine for March/April 2018

Features II, six million Jews had been murdered. Millions of others also became victims of persecution and murder through Nazi “racial hygiene” programs designed to cleanse Germany of “biological threats” to the nation’s health, including “foreign-blooded” Roma and Sinti (Gypsies), LGBTQ individuals, and persons perceived as “hereditarily ill,” a category which included mental illness and those with physical or intellectual disabilities.

The Deadly Medicine Exhibit will be on display at the Fulginiti Pavilion on the University of Colorado Anschutz Medical Campus from March 22-May 22. The exhibit opening will be held 5-8 p.m. on Thursday, March 22. Exhibit hours are 9 a.m.-5 p.m., MondayFriday. The exhibit is free and open to the public. n

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

Colorado Medicine for March/April 2018

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Features

Health care costs Center for Improving Value in Health Care

New study shows Colorado’s health care costs are 17 percent higher than other states A recent multi-state study shows Colorado could save more than $48 million annually across 102 adult primary care practices if prices for health care services were closer to the average across Colorado’s participating practices. Results found that Colorado’s total costs across all health care services were 17 percent higher than other states, and substantially higher with respect to outpatient services (30 percent higher). Colorado’s overall high costs were driven by both higher use of health care services and higher prices for those services when compared to other states.

Figure 3: Colorado Total (Inpatient, Outpatient, Professional, Pharmacy) Median Risk-Adjusted Per Member Per Month (PMPM) Cost by CO Division of Insurance Region Fort Collins

Greeley

$559

$424

West

$439

$547

Boulder Denver

$403

Grand Junction

Colorado Springs

$539

$390

East

$591

Pueblo

$455

As health care costs continue to rise in Colorado and across the nation, it’s essential to better understand what’s driving those increases in order to make positive changes. There are a number of reasons why costs may vary both within one state and among several, including the health of the population, how often people see a health care provider or fill prescriptions (also known as utilization), and the prices of those services. The Total Cost of Care project, funded by the Robert Wood Johnson Foundation and led by the Network for Regional Healthcare Improvement, is the first of its kind to measure those factors in a standardized way across multiple states.

Center for Improving Value in Health Care (CIVHC) participated in the study on behalf of Colorado using claims data from the Colorado All Payer Claims Database (CO APCD). Colorado’s data included information from 14 commercial payers for patients attributed to 102 adult primary care practices, and 24 pe 26

Total Cost Statewide Median PMPM: $437

Table 3. Total (Inpatient, Outpatient, Professional, Pharmacy) Median Risk-Adjusted Per Member Per Month (PMPM) Cost by CO Division of Insurance Region East Greeley West Grand Junction Pueblo Boulder Fort Collins Denver Colorado Springs

COST PMPM

UTILIZATION Compared to the CO Statewide Median*

$591 $559 $547 $539 $455 $439 $424 $403 $390

8% 6% 2% 9% 5%

Statewide Median:

$437

8%

PRICE Compared to the CO Statewide Median*

21% 17% 33% 23%

7% 8% 4%

1%

7% 6%

8% Statewide Median

Statewide Median

*Statewide medians only reflect results for the 102 adult primary care practices included in the study

diatric practices. Across the participating states – Colorado, Oregon, Utah, Minnesota and Maryland – results of the national report show that the ways people access health care and the associated pricetag differ significantly, resulting in very different per-patient total costs from state to state.

In Colorado, across all categories of services analyzed (hospital inpatient, outpatient, professional and pharmacy), higher total costs were driven more by patients using health services more frequently than the price of those services

Colorado Medicine for March/April 2018

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Colorado Medicine for March/April 2018

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CIVHC (cont.) compared to other states, although both were a factor.

Figure 5: Colorado Provider Practice Utilization and Price Comparison Individual CO Adults Primary Care Practices

“Providers and other stakeholders are well aware that health care costs are high in our state, and that costs – especially premiums – can vary greatly depending on where you live,” explained Ana English, CIVHC president and CEO. “Until now, we haven’t had much insight into what’s driving that variation – people using a lot of services, high prices for care, or both. This analysis helps us begin to understand causes of local variation and enables providers to understand patient patterns outside their practice to help them make informed care decisions.”

Statewide Median

*CO All Payer Claims data represents 102 adult primary care practices included in the Total Cost of Care Project

Of the four service categories analyzed, Colorado’s costs were higher than any other state for three out of the four: outpatient (30 percent higher), inpatient (16 percent higher) and pharmacy (24 percent higher). Professional services was the only category where Colorado fared better than other states, although total costs were still higher than two participating states. Higher costs in outpatient and pharmacy services appear to be driven mostly by higher utilization whereas inpatient costs are driven almost solely by above average prices.

To address relatively high costs in Colorado, it is important to understand which areas of the state have the biggest opportunities for change. Within Colorado, total costs varied substantially by Colorado Division of Insurance (DOI) geographic rating area and ranged from $390-$591 per member per month (PMPM) across the 102 adult primary care practices analyzed.

Six regions in Colorado had higher PMPM total costs than the statewide average. The East and Greeley regions had the two highest risk-adjusted PMPM costs in the state, driven by both higher utilization and higher prices.

Grand Junction and the West regions had the third and fourth highest total costs respectively, primarily driven by higher prices, as utilization in those areas is either lower than or nearly equal to the statewide average.

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Colorado’s outpatient category total cost, which exceeded the five-state average by the largest amount at 30 percent above the multi-state benchmark, showed variation across Colorado DOI regions between $87-$208 PMPM. All regions except for Boulder, Denver and Colorado Springs were above the statewide median ($104 PMPM). Greeley, West, East and Grand Junction regions were top four for highest outpatient costs, driven by both higher than average utilization and higher than average prices in those areas.

As part of this project, CIVHC also provided detailed practice-level reports to the 102 adult primary care physician practices and 24 pediatric practices included in the Colorado analysis.

“Although primary care providers cannot always directly address what’s happening with patients beyond their walls and across all service categories, the information can help them understand patient care patterns and identify specific opportunities to reduce total costs,” said Jonathan Mathieu, vice president of research and compliance for CIVHC. “The data we provided specific to practices can help them be successful under new payment models that reward value over volume. This information allows practices to see how their cost and utilization performance compares to that of their peers, helps them make better

informed decisions regarding patient referrals, and assists in designing targeted patient education programs.”

According to the CIVHC analysis, only 32 percent of the adult primary care practices in the study fell into the low cost and low utilization category, leaving 68 percent of practices with opportunities for cost saving improvements in price, service use, or both.

In order for this information to be actionable to providers, it has to indicate both high-level and specific areas of opportunity to reduce total costs. For example, data provided to one practice showed that their total Professional costs were 23 percent higher than average, driven by 26 percent higher utilization. Total costs for outpatient services at this practice were 7 percent lower than average, despite 55 percent higher utilization because prices for those services were 40 percent below average.

The practice can also see that their patients are less healthy with a 35 percent higher “risk score” compared to the state average.

Further detail shows that patients receiving MRIs at this practice experienced 63 percent higher total costs than average, also driven by higher utilization and price. Equipped with this data, this practice could consider evaluating where patients are going for MRI serColorado Medicine for March/April 2018

Features vices to ensure that they are referring patients to the highest value (low price and high quality) providers possible.

In the coming year, CIVHC will add nationally endorsed quality measures to the practice-level reports, enabling a variety of stakeholders to evaluate performance on both total cost and quality of care, and will evaluate the potential to expand reporting to more practices.

CIVHC also plans to work with providers to make summary cost and utilization information contained in the practice-level reports available publicly at www.civhc.org.

An important first step toward practicelevel quality reporting is the quality measures interactive report on CIVHC’s website. Also available are interactive cost of care reports, utilization reports and chronic condition reports that show trends and opportunities across Colorado for the Medicaid, Medicare Advantage and Commercially-insured populations.

If you have questions or would like to provide input on the next phase of this project, please contact us at info@civhc. org. n

Serving the Continuing Medical Education needs of Colorado physicians Your bridge to quality improvement in health care

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For more information contact the Colorado Medical Society CME office at 720-858-6309 Colorado Medicine for March/April 2018

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Colorado Medicine for March/April 2018

Features

State Innovation Model Heather Grimshaw, Communications Manager, SIM

Finding their voices: Patients speak up Laura Carroll talks about the value of receiving integrated behavioral and physical health care in concrete terms with specific examples of how “wholeperson care” has helped her family.

band’s primary care provider to the hilt in the podcast. The one thing she laments: The provider did not ask about mental health or how his chronic pain had affected him.

“That behavioral health piece is so very important and something that we’ve really been missing as a ‘whole health’ model, so I’m excited that the state of Colorado is stepping up to do something about it,” Carroll said during a recent podcast with the Colorado State Innovation Model (SIM) team.

“She keeps track of his case like nothing I’ve ever seen in my life, but never once did she say, ‘Do you want to talk with somebody? Do you think there are some things that are going on that you should get out?’”

SIM, a federally funded, governor’s office initiative, is working with 246 primary care practice sites and four community mental health centers. It will reach 25 percent of the state’s primary care practice sites during its four-year time frame, which ends in July 2019.

Carroll, who participates on the Health First Colorado (Medicaid) Member Experience Advisory Council, values her ability to share her perspective and make positive changes.

“It gave people who felt like they needed their voice to be heard an opportunity to use that voice,” she said during a recent podcast. “[It’s been] helpful and valuable for me personally but more importantly we see that we’re effecting change in the state.

And that’s really exciting. We need more patient and family voices in the entire process of health care in the state.”

As a caregiver, Carroll has a keen appreciation for receiving the right care at the right time from the right care team members and praises her husColorado Medicine for March/April 2018

It was only after her husband had a major car accident and saw a back specialist that he was asked, by the specialist, “Have you ever talked with someone about how you feel about being in pain all the time?” she explained. “And that was the first time ever since he’s been diagnosed with illness 20 years ago that anyone ever approached that question.”

What happened after he was put in touch with a mental health specialist changed his life.

“He’s still hurt, he’s still got challenges, he’s still not able to do what he wants to do but he doesn’t feel as if he’s the only person in the world who has felt this way,” she said.

Listen to the full podcast: bit.ly/ patient-podcast.

Care teams hear patient perspective on integrated care Patients are weighing in on integrated behavioral and physical health in primary care settings. And they appreciate the type of patient-centered, team-based care they are receiving

at practices that are participating in the Colorado State Innovation Model (SIM), according to patient testimonials in SIM podcasts.

“I have experienced the follow-up care, the calls, the team approach, and I feel very well taken care of and very safe” at this practice, said one patient, Mary Catherine Conger, who talked with care team members at the Roaring Fork Family Practice in Carbondale in December for a SIM podcast.

“That’s powerful,” noted Kris Hubbell, BS, RN, CHC, clinical quality coordinator at Roaring Fork Family Practice.

“That brings tears to my eyes… Hearing that has made all of our hard work worth it.”

Care team members from the practice talked about some of the work they’ve completed as a SIM cohort-1 practice.

And Conger, who listened carefully, said that she had benefitted from that investment of time and energy.

“The systems that you’ve put into place are effective and working,” she told the care team, which talked about the work they’ve done to ensure a patient-centered approach. “For the first time ever, I have been able to relax a little bit and feel like I’m not solely responsible” for my medical records and care.

Listen to the discussion between this patient and the Roaring Fork Family Practice care team: bit.ly/ roaringforkpatient. n

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Features

Transforming clinical practice Matt Keelin, TCPi program manager

Colorado TCPi practices recognized nationally Practices that participate in the Colorado Transforming Clinical Practice Initiative (TCPi), a federally funded, governor’s office initiative, are continuing to be recognized for their work to curtail costs while maintaining or improving quality.

One practice, Denver Health, was honored during the Centers for Medicare and Medicaid Services national quality conference held Feb. 12-14, 2018, in Baltimore, Md. Another practice, SurgOne, PC, a Denver-based comprehensive surgery group, was highlighted in a federal CMS newsletter for cost-savings achieved with coaching and guidance from TCPI. They saved approximately $1,000 per case.

Since the passage of the Affordable Care Act, the federal CMS has

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launched numerous programs and models to help health providers achieve large-scale transformation.

Programs and models – such as the Hospital Value-Based Purchasing Program, Accountable Care Organizations, and the Partnership for Patients initiative with Hospital Engagement Networks – are helping clinicians and hospitals move from volume-based practices towards value-based and patient-centered health care services.

To date, there have only been smallscale investments in a collaborative peer-based learning initiative. The federal CMS estimates that about 185,000 clinicians currently participate in existing programs, models, and initiatives that facilitate practice transformation. This represents only 16 percent of the nation’s one million Medicare and Medicaid providers.

While this is an increase over previous years, there is more work to be done.

TCPi supports efforts among medical group practices, regional health care systems, regional extension centers, and national medical professional association networks. These efforts help clinicians expand their quality improvement capacity, engage in greater peer-to-peer learning, and utilize health data to determine gaps and target intervention needs.

Learn more about TCPi cost savings to date on the opposite page. Find more information about TCPi in Colorado at www.co.gov/healthinnovation/tcpi. n

Colorado Medicine for March/April 2018

INDIVIDUAL PRACTICES MAKE A COLLECTIVE DIFFERENCE

$ 36

million saved

out of total commitment of $ 85.9 million

S AV I N GS AT T RIBUT E D T O

82 practices

11 practices

80 practices

68 practices

working on reducing emergency department visits through expanded access and patient engagement

working on reducing hospitalizations improved access, patient engagement

working on medication management, including generic prescribing

working on reducing tests and procedures, including high value referrals, use of HIE

AB OUT T HE CO LOR A DO PR A CT I CE TR AN S FO R MATIO N N E TW O R K

COLORADO

Statewide PTN

27 different specialty types

186 practices 1,929 clinicans 87% specialists

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Colorado Medicine for March/April 2018

Inside CMS

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

The road to physician wellness Physician burnout has always been a concern, but in recent years, research shows a more widespread impact that threatens personal well-being, professional satisfaction and patient care. Whether it’s anxiety from a medical liability lawsuit or the accumulation of everyday stressors, the factors behind burnout are being examined closely to better understand this issue. The 2018 Medscape National Physician Burnout and Depression Report surveyed physicians across the country and notes that: • 42 percent of respondents said they were “burned out.”

• The highest rate of burnout occurred in critical care and neurology (48 percent), family medicine (47 percent), and OB/GYN and internal medicine (46 percent).

• Factors cited in burnout: too many bureaucratic tasks (56 percent); too many hours at work (39 percent); lack of respect from administrators, employees, colleagues or staff (26 percent); and the increasing role of EHRs (24 percent).

The report also highlights the connection between burnout and depression, and how physicians are not reaching out for support – 66 percent of male physicians and 58 percent of female physicians have not sought professional help in dealing with these issues. The evidence we are seeing has expanded the conversation from addressing burnout from an individual perspective to exploring larger, systematic approaches that focus on prevention and reinforce wellness.

“There was this assumption that doctors could take on extra work seamlessly, but now it is crowding out our true work as healers. Physicians are at the sharp end of the stick for accountability, regulatory issues, and now even data acquisition and entry – it’s too much,” said Christine Sinsky, MD, vice president for professional satisfaction at the American Medical Association, in a recent New England Journal of Medicine (NEJM) article.1 Not surprising, the article cites “clerical burden” as one of the major factors for burnout. Studies have shown that for every hour physicians spend with patients, they spend one to two more hours on tasks such as documentation, Colorado Medicine for March/April 2018

ordering tests and responding to patient requests.2 Most of this work is not reimbursed and physicians trying to keep up often complete it on nights and weekends.

Of particular interest to COPIC is the finding that physicians with burnout symptoms are more likely to report having made a major medical error in the past three months, and receive lower patient-satisfaction scores.3 COPIC’s seminar “Healing the Healer – Creating a Wellness Toolkit,” goes beyond common recommendations such as sleep more, eat well and take a yoga class.

It focuses on understanding the stress and factors behind burnout to develop a toolkit based on practical solutions to improve wellness and increase satisfaction. In addition, the seminar helps attendees identify the early symptoms of burnout and how to deal with them in ways that support productivity without draining inner resources.

COPIC’s Care for the Caregiver program provides crucial support when physicians need it most – during a lawsuit. This program connects insureds with “peer” practitioners who have experienced the litigation process. These peers offer a shared perspective to address difficult feelings such as anger, guilt, fear and isolation – which can drive burnout and depression. Confidential discussions with a peer encourage open dialogue and focus on the emotional well-being of the individual, not analyzing the medical facts of a case. The ultimate goal is to build resilience so physicians can move forward on both a professional and personal level.

“We’re spending our days doing the wrong work. At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work,” Sinsky said in the NEJM article. We at COPIC couldn’t agree more and recognize our responsibility to ensure that those who take care of patients are also taking care of themselves. n References

1. N Engl J Med 2018; 378:309-311 2. Ann Intern Med 2016;165:753-760.

3. JAMA Intern Med 2017;177:195-205.

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Inside CMS

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

Vishnupriya Manavasi Krishnan University of Colorado School of Medicine

Vishnupriya Manavasi Krishnan, a second-year medical student, is passionate about the intersections between the humanities and medicine. She obtained a B.A. in Music (Violin Performance) and a B.S. in Physiology and Neurobiology from the University of Maryland, College Park in 2015. As a member of the TOTUS Spoken Word Collective in college, she discovered her interest in using artistic efforts for social change. She currently plays as a violinist with the Boulder Symphony and the Anschutz Symphony Orchestra; she also participates in poetry initiatives throughout the country. In her future career, she hopes to continue to explore how the arts and medicine illuminate health care disparities and lend insight into the patient-physician relationship.

Little earthquakes

The first time I see him, he is sitting upright, face pressed up against the bars of the crib with the peeling pink paint. His head bobs uncertainly on his neck, sending his bangs spinning like windmill blades. His eyes flit uncertainly around the room, settling briefly on a magenta bottle of hand sanitizer, a faded poster of dogs and cats playing, a nearby baby, but focusing on nothing in particular.

Beside the crib, beneath a broken plastic mobile whirring 36

lopsided overhead, his mother snores on the unforgiving tile floor, an infant ensconced in her arms.

I never see him smile, never hear him talk. During rounds, a flurry of white coats surround him – it must be like being in a life-sized snow globe, or a collapsing igloo, I think – and he scowls, head wobbling. A doctor listens to his lungs with his stethoscope, and he whimpers.

Each seizure is like a mini-earthquake, his body twisting and thrashing to escape its confines, tongue gnashing against his teeth. One morning, on the staircase to the terrace, as the ground rumbles beneath, I grasp the railing as my tea makes oceans of itself, and all I can do is wait for calm. Perhaps this is how it feels.

No amount of CT slices, held up to the light every which way, examined and marveled at like the stained glass windows of Sainte-Chapelle, can reveal the swirling undercurrents of his story: an older sister lost in the earthquake, no money to defray medical expenses beyond this hospital stay, the looming possibility of being deposited on the doorstep of an orphanage along the dusty road home, the certainty of growing up with an intellectual disability.

The last time I see him he is wearing what his mother tells me is his favorite outfit, a green T-shirt decorated with a big red dog that reminds me of Clifford. The hair on his head is matted; his mother, with the baby balanced in one arm, hands me the hairbrush. We smooth out the tangles, and long after his fever breaks and the doctor releases him home, he cries and cries.

Afterwards, his head lolls backward into a fitful sleep, a bewildered expression on his little face. I pray he has good dreams. n Colorado Medicine for March/April 2018

Inside CMS

Save the date: 2018 CMS Annual Meeting Sept. 14-16 Vail Marriott, Vail, Colo.

Make plans to join your colleagues from around the state at the premiere event for Colorado physicians. Find more information at www.cms.org/events/annual-meeting

Colorado Medicine for March/April 2018

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Departments Inside CMS

Critical reflective writing holds a prominent place in the Medical Humanities curriculum at Rocky Vista University, College of Osteopathic Medicine. Beginning in the first semester of Medical Ethics, students engage in critical reflection to explore their own assumptions and biases and how their values impact their practice. This submission is selected and edited by Christopher Unrein, DO, Professor of Internal Medicine; Nicole Michels, PhD, chair of the Department of Medical Humanities; and Alexis Horst, MA, Writing Center Instructor.

Alexandra Scoles Rocky Vista University College of Osteopathic Medicine

Alexandra Makenzie Scoles, OMS III, grew up in Sonora, Calif., and attended the University of California Irvine for a Bachelor of Science in Biology where she also played Division I soccer. She obtained a master’s degree in Biomedical Science at UNC in Greeley, Colo. Alexandra has a strong passion for patient-centered care and is interested in pursuing a specialty that will allow her to couple this focus with athletics and medicine.

Between third-year clinical rotations, she enjoys whitewater rafting, backpacking, snowboarding, and spending time with her family.

Humbled in primary care As I sit here typing between seeing patients, I am awed by how much the pace and course of my days have changed over the past year. Last year at this time I was sitting in a lecture hall learning about pathology I had never seen and memorizing diseases I had never treated. Less than a year later, I am in the clinic diagnosing not only pathology, but more important, people, and the humanity of medicine has been at the forefront of my learning during this rotation.

Third year of medical school has been everything I could have hoped for and a better learning experience than I ever could have imagined.

Family medicine was my first rotation starting third year.

It was a whirlwind of medications, patients and late clinic hours. Therefore, I was grateful to have been assigned my 38

eight-week surgery rotation between two blocks of family medicine rotations. This time has allowed me to successfully reflect on the unique qualities of primary care and to learn more about the importance of bridging the gaps in care between the hospital and subspecialties when managing chronic disease. I have seen countless encounters over the past two months in which my preceptors have provided care and critical medication changes for a patient who otherwise would have slipped through the cracks in the medical system. Yet, while I have been able to be a part of the positive impact of primary care every day, one patient experience humbled me.

This patient reaffirmed the knowledge that a person’s health, much like the ocean, is constantly changing, and just when you think you have it figured out, the tides will change and a wave will take you tumbling to the ocean floor. Such is the case with a patient whom I first encountered at the beginning of my first family medicine rotation. She was a pleasant 50-something-year-old woman who was accompanied by her husband and her grandson. She was presenting for a follow up of her labs and her annual physical exam, with her only complaint being intermittent headaches over the past six months that have become increasingly more persistent.

She stated that they often come on in the mornings and that they can usually be relieved with ibuprofen. They are located in the front-temporal region of her head and radiate behind her right eye. She had started to notice that her vision seems to be getting slightly blurrier, but she had not had her annual eye exam yet. Nothing makes them worse, and that they alternate from achy to stabbing in nature. The patient denied associated dizziness, nausea, lightheadedness SOB or chest pain.

This was an HPI for someone I believed to be a generally healthy patient with new onset tension headaches from watching her grandson. The patient was examined for her physical exam, and sent home with a clean bill of health. I went on with the rest of the rotation, learned many things, made mistakes, honed my skills, gained confidence, and left Colorado Medicine for March/April 2018

Inside CMS that month having thoroughly enjoyed my time in the clinic.

I went off to the world of surgery for eight weeks before returning to the same clinic to finish the second half of my family medicine rotation. I walked in on the first day smiling and greeting all of the familiar faces that I had left weeks before. I sat down and grabbed a free computer and logged in to the familiar EMR. The day passed without incident and I felt that I was picking up right where I had left off. The next week passed in the same fashion. Each patient was a unique challenge and provided new opportunities for me to learn not only about chronic disease but about insurance, Medicare, Medicaid and the health care system in general.

With a week left in my rotation, I walked into the clinic on a Wednesday morning, and opened my computer to the day’s schedule. I saw a familiar name in the middle of the list. It was the same 50-something patient I had seen months earlier; I vaguely remembered that she had headaches and hoped she was doing better. As the chaos of the morning began to unfold I pushed her out of my mind until the MA told me that she was ready to be seen in exam room A. I offhandedly asked how she was doing, and the MA replied that she was following up from her recent oncology appointment.

I almost did not register what I had just heard as I turned to leave my desk and walk into the patient’s room, but as the word oncology slowly seeped into my being, my heart sank.

That was the moment I learned that this patient, the one who complained of headaches just weeks earlier, had been diagnosed with a stage IV glioblastoma.

This is where the story of this patient stops and the reflection begins. For although we all know how this patient’s case will end up, the guilt, self-doubt and second-guessing I began to feel as soon as I heard her diagnosis weighed on me more than I ever thought possible. The idea of how to deal with loss. With not always getting it right, doing your best and still not knowing it all. Missing a diagnosis. This is something that can’t be taught in the classroom, and I do not believe that it gets easier when you are in residency and practice. After my preceptor and I went to see this patient we had a lengthy discussion regarding her prognosis, the treatment options for her, and ultimately whether or not she would make it through the holiday season with her family.

My preceptor and I discussed at length that although this person presented with headaches, 70 percent of our patient population admit to having occasional/frequent headaches.

She then explained that the line between practicing “safe/ defensive medicine” and running every test for every complaint, exposing the patient to excessive, potentially harmful and expensive testing, is a hard line to walk. If every middle-aged woman dealing with the stress of the holidays, kids, family and life who complained of headaches was sent for an MRI, yes, all the stage IV glioblastomas would be found, but at what cost? Evaluating risk versus reward is seemingly the true art of medicine and science just falls in line.

Colorado Medicine for March/April 2018

We all go to medical school thinking that we are going to get a blueprint on how to save lives. We are taught that we are the gatekeeper between health and disease. Life and death. But people slip through the holes in this gate and, try as you may, there is no way to catch everything. An article titled “Guilty, Afraid and Alone – Struggling with Medical Error,”1 published in the New England Journal of Medicine in 2007, focuses on the feelings that medical providers have after a poor outcome. It explores the idea that physicians who feel guilty after making a medical error will fear that their medical decision will adversely affect their clinical reputation, patient outcome and medical license.

The entities responsible for advising physicians on the legal side of medicine tell physicians to avoid using words that could implicate fault such as “error,” “adverse,” “negligence,” “problem” or “fault” when explaining an adverse outcome to a patient or family. The result is that this fear, shame and appearance of deflecting blame can cause an impersonal demeanor that may lead patients to view physicians as uncaring. To date, approximately 30 U.S. states have adopted “I'm sorry” laws, which, to varying degrees, render comments that physicians make to patients after an error inadmissible as evidence for proving liability.

Fault, guilt, fear and blame all parallel hope, helping and healing as the reasons that we each decided to join the medical field in the first place. I am quickly realizing that while each of us enters medicine to help people, help and harm are closer possibilities from a single medical decision than I previously thought. This experience helped to reaffirm that the world of practicing medicine is a realm fraught with responsibility that should be entered into humbly every day.

I am excited for what the next six months of rotations will bring. This patient, and the idea of balancing the reward of helping people with the risk of harming them, is something that I will think about frequently going forward. The challenges, the fear, the learning that I will experience are lessons that I will take with me throughout the rest of my medical career. n 1. New England Journal of Medicine. (2017). Guilty, Afraid and Alone- Struggling with Medical Error – NEJM. (online) Available at: http://www.nejm.org/doi/full/10.1056/ NEJMp078104#4t=article. [accessed 14 Nov. 2017].

Plug in to your reinvented medical society! www.cms.org/central-line 39

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Colorado Medicine for March/April 2018

Departments

medical news Anthem agrees to fully rescind modifier 25 cuts The Colorado Medical Society, American Medical Association, and other specialty and state medical societies successfully advocated against a plan

by Anthem Blue Cross Blue Shield to reduce payment for significant, separately identifiable evaluation and management (E/M) services that are provided on the same day a procedure is performed or a wellness exam is conducted.

Craig E. Samitt, MD, MBA, executive vice president and chief clinical officer of Anthem, Inc., notified Jack Resneck Jr., MD, chair-elect of the AMA Board of Trustees, of the reversal in a Feb. 23 letter and said the company formally notified its contracted providers a few days later.

concerns regarding Anthem’s policies on the retrospective denial of payment for emergency room visits, restrictions on advanced imaging in hospital outpatient facilities, and the denial of payment for monitored anesthesia care or general anesthesia for cataract surgery.

quality, access and affordability.”

In a Feb. 23 email from Resneck to state medical society executives, he expressed the AMA’s gratitude for the strong advocacy efforts carried out on the state level over the past few months. He said, “We believe that Anthem’s decision reflects the growing recognition of the need for a different type of dialogue and engagement between health plans and the physician community to improve health care

• Enhance consumer and patient health care literacy, • Develop/enhance and implement value-based payment models for primary and specialty care physicians, • Improve access to timely, actionable data to enhance patient care, and • Streamline and/or eliminate lowvalue prior authorization requirements. n

And on March 2, the AMA and Anthem jointly released a statement indicating they will pursue opportunities for collaboration in the following areas:

Anthem originally announced in December that it would implement a pay cut of 50 percent for E/M services provided on the same day by the same provider, effective Jan. 1, 2018. Later in December, following pressure from organized medicine, the company announced that it would reduce the size of its planned pay cut from 50 percent to 25 percent and push back the implementation date to March 1, 2018.

On the state level, CMS President M. Robert Yakely, MD, and Elizabeth Kraft, MD, medical director of Anthem BCBS in Colorado, exchanged several letters about the issue while the AMA and other states waged similar campaigns. All organizations continually expressed that the rationale for the pay cut cited by Anthem was incorrect and the reduction was inappropriate.

In the Feb. 23 letter, Samitt expressed Anthem’s commitment to continuing to work with the AMA, state medical associations, and national medical specialty societies to address physician concerns with other policies and guidelines. The AMA has already raised Colorado Medicine for March/April 2018

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Departments

medical news AMA launches “Share Your Story” campaign to document barriers to care in pain management The American Medical Association is launching a new digital toolkit as part of its ongoing efforts to improve access to high-quality treatment for patients seeking multidisciplinary pain care and for a substance use disorder. The tool kit will be used by the AMA and the na-

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tion’s state and local medical societies to urge physicians to upload stories about their patients who encounter obstacles when seeking care for pain and/or a substance use disorder.

part of the AMA’s work to end the opioid epidemic and is designed to highlight physician efforts as well as urge payers and policymakers to improve access to treatment.

The “Share Your Story” campaign is

“We know that prior authorization and other administrative practices used by health insurers can impede appropriate, necessary care – resulting in unnecessary harms and sometimes fatal consequences – for a patient with a substance use disorder,” said Patrice A. Harris, MD, chair of the AMA Opioid Task Force, in a news release. “These stories will enable us to identify the unique challenges faced by patients and physicians and share them with health insurers and policymakers in support of solutions to increase access to care. Without proper treatment and

Colorado Medicine for March/April 2018

Departments access to care, this epidemic will only get worse.”

A recent study of six large cities found that prior authorization for buprenorphine, used to treat opioid addiction, occurred 42 percent of the time, often delaying patients’ access to necessary medicine at a crucial point in their potential recovery. According to the Substance Abuse and Mental Health Services Administration, in 2016 alone, nearly 90 percent of people who need treatment for illicit drug use didn’t get it, largely due to practices such as these.

Physicians agree that these practices must be discontinued, and medicationassisted treatment (MAT), the gold standard in treatment for opioid use disorder, needs to be immediately available.

Physicians can share their story at www. end-opioid-epidemic.org/treatment/ treatment-contact-form. The AMA Opioid Task Force recommendations to end the nation’s opioid epidemic can be found at www.end-opioid-epidemic.org. n

CMS Education Foundation Founded in 1982, the Colorado Medical Society Education Foundation (CMS EF) is a nonprofit, tax-exempt charitable foundation established primarily to support educational and charitable programs in Colorado.

The Foundation has dedicated itself almost exclusively to the funding of scholarships to incoming students at the University of Colorado School of Medicine and Rocky Vista University.

Scholarships are awarded to students who come from underserved areas, have high academic credentials, demonstrate a financial need, and anticipate practicing in a rural or underserved area.

Help send a student through school. Call 720-858-6310 for information and to donate.

Colorado Medicine for March/April 2018

CMS Corporate Supporters and Member Benefit Partners

While CMS analyzes the quality and viability of our member benefit partners and their offerings, we do not guarantee any product or service will be right for you. Before you make a purchase, we recommend you perform your own due diligence.

AUTOMOBILE PURCHASE/ LEASE US Fleet Associates 303-753-0440 or visit usfacorp.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit copicfsg.com * CMS Member Benefit Partner Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit callcopic.com *CMS Member Benefit Partner MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or visit coloradodrugcard.com *CMS Member Benefit Partner MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, or visit medjet.com/cms *CMS Member Benefit Partner University of Colorado Hospital/CeDAR 877-999-0538 or visit CeDARColorado.org PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit alnmm.com CARR HEALTHCARE REALTY 303-817-6654 or visit carrhr.com Dynamic Physician Billing Solutions 303-913-0508 or visit dynamicphysicianbilling.com

PRACTICE VIABILITY, CONT. Eide Bailly 303-770-5700 or eidebailly.com/healthcare Favorite Healthcare Staffing 720-210-9409 or medicalstaffing@ favoritestaffing.com *CMS Member Benefit Partner First Healthcare ComplianceTM 888-54-FIRST or visit 1sthcc.com *CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com * CMS Member Benefit Partner Officite 866-508-9176 or officite.com/webcheck/cms * CMS Member Benefit Partner The Legacy Group 720-440-9095 or visit www.legacygroupestates.com TSYS 877-841-0606 or visit transfirstassociation.com/cms *CMS Member Benefit Partner Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net TSI 800-873-8005 or visit web.transworldsystems.com/npeters * CMS Member Benefit Partner

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Medical news (cont.)

CMS President M. Robert Yakely, MD, to receive humanitarian award CMS President M. Robert Yakely, MD, has been named the 2018 recipient of the University of Colorado School of Medicine Alumni Association HuM. Robert Yakely, MD manitarian Award for his leadership in Colorado and his humanitarian contribution in the British Virgin Islands. He will receive this award at the Silver and Gold Banquet at the Grand Hyatt on May 24.

Yakely has had a 45-year history of service to organized medicine in Colorado through the Clear Creek Valley Medical Society and the Colorado Medical Society as well as the Rocky Mountain Urologic Society and American Medical Association.

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

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His contributions in the British Virgin Islands started in 1996 when he and his wife, Rosemary, started their annual tradition of living on a sailboat in this area for five months each year.

During this time Yakely recognized the need in Tortola in the BVI for prostate cancer screening. Through an involved process, he was able to set up a clinic, find volunteers to work, and together he and Rosemary provided services and education on prostate cancer screening. The prostate cancer clinic screened 50 men the first year.

By 2007, the clinic was screening 1,500 men per year. Later the BVI legislature made the Yakelys honorary citizens in recognition of their achievement.

Watch for more coverage of the award in a summer issue of Colorado Medicine. n

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Colorado Medicine for March/April 2018

Colorado Medicine for March/April 2018

45

Features

the final word Christopher Unrein, DO COMPAC chair

Four concrete ways physicians can engage in advocacy right now Throughout this issue of Colorado Medicine, physicians and advocacy experts have made the case for getting involved in public policy for the benefit of your patients and practice. But where should you start?

As chair of COMPAC, the Colorado Medical Political Action Committee, which determines endorsement and support of candidates and legislation, I present four concrete ways CMS members can get involved today.

First, any CMS member in the state can volunteer to be a part of a candidate screening committee. Candidate interviews happen right in a member’s district and, following the interview, the screening committee recommends a candidate for endorsement to COMPAC Board of Directors for final decision. These endorsement decisions must be based on the candidate’s philosophy and positions on medical issues, the candidate’s voting record on medicine’s issues (if the candidate is an incumbent), and the demographics of the district and his or her ability to win – not his or her political party. COMPAC is not a political-party-centered organization; it is a physician- and patient-centered organization – just like CMS. Then, following the election, local physicians – particularly those who made up the screening committee – are encouraged to reach back to the candidates they interviewed to congratulate them and offer to meet to discuss issues further. In this way, grassroots relationships, which are as important as the issues and often more valuable than financial donations, are fostered.

The 2018 election cycle in Colorado features an open seat for the office of the governor, and open seats in both the Colorado House of Representatives and Senate.

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Over the next months of this vital election cycle, COMPAC will aggressively pursue the cultivation of the grassroots relationships in as many of these open seats as can possibly be achieved. What we do now, not next January when the 2019 General Assembly convenes, will determine the course of medicine’s agenda in 2019 and 2020. Participate in the COMPAC local candidate screening process and/or pick the candidate of your choice. Learn more by contacting emily_bishop@cms.org.

Second, contribute to COMPAC and become a regular dues-paying member. Dues are the fuel by which we can help support our endorsed candidates. The secure, online payment system is available at www. cms.org/contribute.

COMPAC works side by side with the American Medical Association Political Action Committee, AMPAC, in the national arena and Colorado physicians have the opportunity to conduct candidate interviews of federal candidates, similar to our process on the state level.

Third, increase your involvement by downloading and using the CSAE Colorado Legislative App. This free app, available through your smart phone’s app store from the Colorado Society of Association Executives (CSAE), allows users to find and quickly communicate with their legislators. Those unable to download the app could alternatively identify your legislators and find their contact information through the Colorado General Assembly’s Find Your Legislator tool on their website: https://leg.colorado.gov/find-my-legislator.

To use the tool, enter your address information in the search bar located on the left side of the screen, and click the search button.

COMPAC periodically sends email alerts asking members in key districts to contact legislators regarding critical pieces of legislation. When our voice is strong and loud at the capital thorough these grassroots outreach efforts, it does and has made a difference.

Fourth, if you are particularly interested in the public health crisis caused by opioid abuse and misuse, physicians and students can help to reverse the crisis by volunteering to participate on one of 10 subcommittees of the Colorado Consortium for Prescription Drug Abuse Prevention. Contact the consortium staff through their website, www.corxconsortium.org. It will also be important to lobby your legislator about any or all of the six bills that came out of the Opioid and Other Substance Use Disorders Interim Study Committee and are currently being considered by the Colorado General Assembly. And any CMS member can join the CMS Committee on Prescription Drug Abuse, which meets periodically in person or by video conference.

As a bonus way to increase your involvement in advocacy in the area that most interests you, I’d encourage you to explore the many opportunities available to engage in your Colorado Medical Society. We need members from all practice settings, life stages and geographic areas to participate in the CMS all-member election by running for office or voting for candidates, join CMS committees or workgroups, develop policy through Central Line, and attend leadership development programs and other CMS events.

You already make a difference in the exam room. Use your expertise to make a difference outside of the exam room as well. n Colorado Medicine for March/April 2018