May-June 2016

May/June 2016

Volume 113, Number 3

Seeking common ground

Strengthening support for patients with advanced illness Award-winning publication of the Colorado Medical Society

contents May/June 2016, Volume 113, Number 3

Features. . .

12

Physician-assisted death: Reflections from Oregon–A noted Oregon professor reflects on the state’s “death with dignity” statute and how it affects patients and physicians.

16

Polling shows divided membership on physicianassisted death–Pollster Benjamin Kupersmit presents

areas of agreement and disagreement within the results of an all-member survey on physician-assisted death.

Cover story The issue of physician-

assisted death can be divisive and polarizing, but physicians on both sides of the debate agree that medical professionals and society as a whole can do more to create better, more consistent and more reliable systems of end-of-life support. Read more about this topic starting with the president’s letter, continuing with the cover story starting on page 8, and throughout this issue.

Inside CMS 5 7 36 41 42 43

President’s letter Executive office update CMS candidates for all-member elections COPIC Comment Reflections CMS Member Benefits

20

Legislative overview–Now that the 2016 legislative session has concluded, Susan Koontz, CMS’ general counsel, gives a report on the wins for medicine.

24

Confronting the opioid crisis–The American Medical Association president writes an open letter to America’s physicians on playing a role in reversing the opioid epidemic.

26

Physician Hero–Colorado Medicine honors Centennial

29

Division of Insurance listening session–Physicians from

30

Legal update–John Conklin, Esq., explains the ruling from a Denver district court on a document CMS seeks access to filed by Aetna in the proposed Aetna-Humana mergers.

33

Chronic pain management–A physician reflects on his experience participating in Project ECHO Pain through the Colorado Accountable Care Collaborative.

37

Annual meeting preview–Make plans to join CMS in Keystone for the re-engineered annual meeting, Sept. 1618, where you can connect with your peers from across the state and engage the state and country’s top health care policy and political experts.

50

Final Word–Lynn Parry, MD, vice-chair of the Council on Ethical and Judicial Affairs, talks about the council’s work on physician-assisted death, and the resulting board decision to study the issue further and educate members.

Departments 44 48

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Colorado Medicine for May/June 2016

family physician Kenneth Atkinson, MD, who rushed to help in a neighborhood shooting and tragically lost his life. around the state met with leaders of the DOI, DORA and Gov. John Hickenlooper’s cabinet to discuss the challenges of doing business with the health plans.

3

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2015/2016 Officers Michael Volz, MD

President

Katie Lozano, MD

President-elect J.T. Boyd, MD

Treasurer

Alfred D. Gilchrist

Chief Executive Officer Tamaan Osbourne-Roberts, MD

Immediate Past President

Board of Directors Charles Breaux Jr., MD Laird Cagan, MD Sami Diab, MD Curtis Hagedorn, MD Mark B. Johnson, MD Aaron Jones, MS Richard Lamb, MD David Markenson, MD Gina Martin, MD Christine Nevin-Woods, DO Edward Norman, MD David Richman, MD Charlie Tharp, MD Kim Warner, MD

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

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

Division of Health Care Financing Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Adrienne Abatemarco, Program Manager Adrienne_Abatemarco@cms.org

Division of Health Care Policy Chet Seward, Senior Director, Chet_Seward@cms.org JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

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

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, Colorado, and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office.

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

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

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

Printed by Hampden Press, Aurora, Colorado

Inside CMS

president’s letter Michael Volz, MD President, Colorado Medical Society

Designing an intelligent process to examine physician-assisted death It was clear early in my tenure as president-elect that CMS would be facing an unusually large number of public policy issues important to our members during my time as president, in addition to transitioning the organization’s governance and communications processes. Now, seven months into my presidency, it’s not unusual to be speaking with and listening to physicians in one area of the state in the evening and the next day meeting with a state official or being interviewed by the media back in Denver. It’s nonstop action, intellectually stimulating and engaging beyond imagination. Thank you once again for the opportunity to be your CMS president.

You already know from previous issues of Colorado Medicine that we are advocating on network adequacy rulemaking, fighting the health insurance industry megamergers, working to maintain Medicaid E&M code parity with Medicare, addressing physician burnout, dealing with the complexity of out-of-network billings, analyzing ColoradoCare/Amendment 69, and conducting and promoting peerto-peer discussions on – take your pick – physician-assisted suicide, physicianassisted death, medical aid in dying or death with dignity. Irrespective of the name, this subject among all others is challenging to me and to our colleagues because the notion of hastening death raises significant clinical, ethical, legal and religious concerns. And while I’ve given careful attention to all of our issues, I’ve been particularly sensitive to this one issue over all others due to the passion and intensity of our members’ feelings.

You know you’ve caught the car when the chief lobbyist and general counsel explains in your first policy briefing that: Colorado Medicine for May/June 2016

1. The bill sponsors will want you to testify in committee; 2. The media is already asking for comment; 3. The advocates have lobbied and hired a PR firm so the issue is not going away; 4. Members appear to feel strongly on both sides of the issue; and 5. CMS policy on the issue is 16 years old.

Where would you like to start?

In September 2015, we elevated physicianassisted death (PAD) to a board of directors-level issue, and in January of this year, following several strategic discussions, the board asked the Council on Ethical and Judicial Affairs (CEJA) to: 1. Re-evaluate the 16-year old policy; 2. Garner member input through a survey and listening sessions; and 3. Consult with experts in the field of palliative care.

The board’s discussion centered on the idea of positioning CMS in the patient’s interest for the inevitable public policy debate.

CEJA members got right to work. Not only did they respond to the board’s request, they consulted the latest literature, reviewed and studied the laws in the five states that currently permit PAD, and examined the experience and data from those states. In March, CEJA delivered a report and recommendations for the board’s consideration (see page 50 of this magazine). By this point, I had listened in on three separate CMS member focus groups, talked to many of our colleagues and read all of the open-ended responses submitted by members through our survey.

And I took one extra step in advance of the March board meeting where the CEJA report was scheduled for a vote.

I sent the CEJA report to the 618 CMS

members that took the survey and not only asked for their opinion on the recommendations but promised to share their perspective with the board. By the time the board meeting rolled around, a sizeable number of our colleagues had replied. The responses ranged from “good job” to “I’m quitting if the board approves the recommendations.” I answered every email personally and promised again to share each perspective with the board, which I did.

At the March board meeting, our professional advocates reported that the 2016 General Assembly would not pass PAD legislation but the board should anticipate that a constitutional amendment authorizing PAD would be on the general election ballot in November. Armed with this new information and member feedback on both sides of the CEJA report, the board voted to delay the vote until September and encourage more peer-topeer discussion on the CEJA report. I subsequently made this request to the entire membership and asked every component and specialty society board of directors to have an in-depth discussion on the report. In response, numerous component societies have held all-member meetings and discussions.

Thank you for taking time to read the CEJA report and to discuss the many facets of end-of-life care with your colleagues.

Please continue to let me know your views.

I can promise I’m listening and learning with every encounter. I hope that you find the suite of stories in this issue helpful to you and your practice of medicine. In addition, PAD will be the focus of a plenary session at the Annual Meeting and I would encourage you to attend and lend your voice to the discussion. n 5

THE STRENGTH TO HEAL

and a loan repayment program that gives me the freedom to focus on patients.

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Whether your Reserve experience on the U.S. Army health care team takes place in a hospital close to home, at an Army medical center or on a humanitarian mission, you’ll encounter learning experiences and leadership opportunities that will further your career and enrich your life.

For more information, visit healthcare.goarmy.com/ey54 or contact the Aurora Medical Recruiting Center at 303-873-0491. .

Š2011. Paid for by the United States Army. All rights reserved.

6

Colorado Medicine for May/June2016

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Experience The New CMS through the re-engineered annual meeting in September This September Colorado physicians will come together as a community in Keystone for the first annual meeting to be held without a House of Delegates to engage state and national experts in the most pressing subjects for our medical community.

A CMS work group built the agenda from the ground up, drawn from a statewide physician survey of what is keeping medicine (and your advocates) up at night, and a methodical series of interviews and conversations with their peers. It has been reengineered as a motivational sanctuary for physicians to share, argue and learn from the best of the best; it’s not the sort of thing you can get from a website. In an era of burnout and unrelenting change and stress, this gathering is intended to stimulate, entertain and help peers remember why they are doctors.

Colorado health policy, market innovations and the applied politics that drive them are among the factors that keep Colorado a vanguard state, which means expressing your ideas in Keystone this fall will have consequences beyond our state.

Programs will include: • A comprehensive and up-close discussion with the proponents and opponents of the statewide ballot initiatives: ColoradoCare single payer referendum and the Oregon-Washington state adaptation regarding physician-assisted death.

• A deep dive into the complexities of the impending radical realignment of Medicare payments from fee for service into the universe of performance/ quality-based reimbursement, followed Colorado Medicine for May/June 2016

by an informed conversation and workshop sessions on the what ifs and howto’s, led by experts from the AMA, who have developed a range of support tools, and our longtime friend and regional medical liaison from Medicare.

• A motivational kickoff led by one of Colorado’s most highly regarded wellness experts, followed by a series of breakouts on how to get healthy and stay healthy conducted by our top physician trainers.

• Recurring breakout discussions (eligible for CME credit) by the beenthere-doing-that experts on hot topics of broad medical interest: best practices on how to wean a patient off pain medications, how to manage a dangerous patient with a firearm, and a doctorfriendly discussion with top antitrust experts on the trajectory of the proposed health plan mega mergers.

• And of course, given this is an election year, we will host a lively lunch discussion called “Voters hold the Trump card,” where Colorado’s top nonpartisan analyst, the AMA’s federal and congressional affairs guru, and our veteran lobby team will assess the downballot consequences of the presidential contest and speculate on the various win-lose scenarios and their respective influence on the direction of state and federal health policy. You will even get to vote your own preference, or lack thereof.

In fact, every session will include electronic straw polling opportunities before, during and after to challenge, agree with or simply inquire about these influencers

and thought leaders. The panels will share recent Colorado physician polling measuring their views on the hot topics – such as physician assisted death, the single payer proposal, the mega merger wars, and the health plan pain points and policy pushback options we will pursue, all analyzed

“In an era of burnout and unrelenting change and stress, this gathering is intended to stimulate, entertain and help peers remember why they are doctors.” by our crack pollster, Benjamin Kupersmit, who has been measuring physician opinions and insights for us for nearly a decade.

As the first mass-gathering manifestation of CMS’ reinvented horizontal, grassroots interactive governance model, your opinions and levels of interest will be a realtime direct pipeline to the CMS Board of Directors, who will be asking you for very pointed assessments on where and to what degree medicine should weigh in on these pressing and mutual concerns.

If there is a consensus to be found for advocacy in the public affairs arena, this will be where it starts. And you will be the first to test-drive the sophisticated Internet technologies that will connect your ideas with CMS policies and priorities.

See you in Keystone. n 7

Seeking common ground

Strengthening support for patients with advanced illness

by Daniel Johnson, MD, FAAHPM

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Colorado Medicine for May/June2016

Cover Story STORY HIGHLIGHTS • Palliative care is specialized medical care for people with serious illnesses; it is focused on providing patients with relief from the symptoms, pain and stress of serious illness to improve the quality of life for both the patient and the family.

• Expanding primary and specialty palliative care support is critical to ensure consistent access to high quality advanced illness support.

Through combined research, policy, education, payment and practical approaches, expanding palliative care support across Colorado will improve the quality of care while bending the cost curve.

• The issue of physician-assisted death and is often a divisive, polarizing issue for reasons that include personal, religious, cultural and practical values.

There will never be a single solution that will satisfy every stakeholder, but most agree that we must create better, more consistent and more reliable systems of end-of-life support.

Nellie looked older than age 59. Despite a youthful spirit, her body was tired – a physique failing from the ravages of longstanding COPD, diabetes and progressive frailty. Nellie loved life – or at least she used to – before her afflictions stripped her of independence and the one thing she loved most: time with her family. She was short-changed the latter luxury on account of four lengthy hospital admissions in just three months. Still, Nellie managed a bright smile as she shared her story of teaching Ray, her 7-year-old grandson, how to paint (something now too taxing given severe breathlessness with even the trivial exertion of raising the paintbrush to canvas).

Nellie’s words later that evening in the Colorado Medicine for May/June 2016

ICU should not have caught me off guard, but they did. As a then-medical sub-intern, I was scared. I sensed something was coming, and I’m sure Nellie read my trepidation. When the moment came, she reached out, held my hand, and declared: “Dr. Johnson, I’m taking off my oxygen. I’m ready to die now.”

It was at that moment that I realized how unprepared I was to support Nellie. Almost nothing in my training had taught me how to respond – what to say next – or how to bring her comfort. My mind swirled with questions. Can’t we do something more? Was she depressed?

How could I just allow her to die? Worse yet, what if I actually stop her? I had so much more to learn.

Although Nellie’s journey – now nearly 20 years ago – is not one of “physician-assisted death” (i.e., a terminally ill patient’s ingestion of a lethal dose of a prescribed medication), the parallels are striking.

Her experience mirrors many of the major findings of the Oregon PAD experience. Nellie wanted control of her own death. She worried about losing herself – her dignity – and feared she had become a burden to those whom she most loved.

Nellie wasn’t depressed, she just wanted death to come so that she could stop worrying about dying.

Over the past two years, I’ve had the opportunity to talk with many Coloradans – ill people, caregivers, doctors, clinicians, lawyers, legislators and others – about PAD. Several things are clear. PAD stirs much passion. It’s also often a divisive, polarizing issue for reasons that include personal, religious, cultural and practical values. There will never be a single solution that will satisfy every stakeholder.

When I find myself in a difficult family meeting facing similar circumstances, I rely on “principled negotiation” – skilled, respectful dialogue aimed at finding common ground. Regardless of PAD preferences, I’ve observed diverse stakeholders express a common and consistent theme: we must – both as a medical profession and society – create better, more consistent and more reliable systems of end-of-life support.

Enter palliative care. Palliative care (PC) is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain and stress of serious illness, whatever the diagnosis.

The goal is to improve the quality of life for both the patient and the family. PC is provided by a team of physicians, nurses and other specialists who work with a patient’s other health care providers to provide an extra layer of support. It is ap-

“I’ve observed diverse stakeholders express a common and consistent theme: we must – both as a medical profession and society – create better, more consistent and more reliable systems of end-of-life support.” propriate at any age and at any stage in a serious illness and can be provided together with curative treatment.1 Too often the term palliative care is considered synonymous with “end-of-life care” but in reality, PC provides personalized, team-based support for patients across the broad trajectory of serious illness. Some patients may be undergoing curative treatments with many years or more to live. Others may be close to the end of life, but not yet ready or wanting traditional hospice support. Studies have shown that answering “no” to the question “would you be surprised if this patient died in the next year” identifies individuals who might be at particularly high risk for having unmet palliative needs.

Another common misconception is that palliative care is synonymous with hospice care. While both share a focus

9

Cover story (cont.) on quality of life, hospice is one type of PC. Hospice care is provided under the Medicare Hospice Benefit (MHB). For a person to be eligible for hospice services, the patient’s physician must certify that the person’s life expectancy is less than six months, and the patient must elect to forego further life-prolonging therapies.

Hospice support is delivered across many settings: home, assisted living, nursing home, hospital and free-standing hospice facilities. For people not yet ready or eligible for hospice services, PC services can provide a much needed extra layer of support.

Importantly, not all palliative support is considered to be specialty palliative care.

As with any medical discipline, certain core elements of PC, such as aligning treatment with a patient’s goals and basic symptom management, should be routine aspects of care delivered by any practitioner. This type of support is described as “primary” or “generalist” PC. Given a growing shortage of PC specialists, closing the gap to ensure consistent, high quality advanced illness care will require extensive primary PC education.2 Other skills are more complex and take years of training to learn and apply, such as negotiating a difficult family meeting, addressing veiled existential distress and managing refractory symptoms. Specialty PC teams leverage the expertise of palliative-trained and certified physicians, nurse practitioners, nurses, social work-

ers, chaplains, pharmacists and others.

Specialty PC has been shown to increase patient/family satisfaction, reduce pain and symptom distress, support complex decision-making, increase longevity and reduce acute care utilization and total costs.

A growing number of organizations and communities offer PC services. More than 70 percent of hospitals with more than 50 beds offer specialty PC consultation.3 Team composition varies widely, but often will include some combination of physicians, nurses, social workers, chaplains and/or pharmacists, among others. Most inpatient programs do not yet offer 24/7 access to specialty PC support.

Access to outpatient specialty PC services is much more limited despite growing evidence of Triple Aim efficacy. Some hospice programs offer community-based PC services in home, nursing home, assisted living or other community settings.

Unfortunately, these programs are often small as a result of inadequate staffing and limited resources. Only five of Colorado’s 47 rural and frontier counties have any access to specialty PC services from a hospital or hospice facility.4 Insufficient insurance reimbursement is a major barrier to specialty PC access. Outside the MHB, Medicare does not yet offer a specific palliative care benefit. While PC physicians and nurse

Payers starting to provide incentive for end-of-life discussion Medicare and some commercial payers will pay physicians to have end-of-life discussions with their patients, demonstrating the growing recognition of the importance of having these conversations before the timing and circumstances become difficult.

Medicare began paying for voluntary advanced care planning in 2016 as an optional element of the annual wellness visit through CPT codes 99497 and 99498. Voluntary ACP means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. An advance directive is a legal document that spells out what medical treatment a person would allow or refuse in the event that he or she is unable to communicate with doctors.

Anthem Blue Cross and Blue Shield includes advance care planning in their per-member-per-month payment for their Enhanced Personal Health Care (EPHC) or patient-centered medical home (PCMH) program. And Aetna has their Compassionate Care Program through which Aetna case manager nurses are available to counsel patients and their families by phone on arranging for care, managing benefits and planning for advanced care.

Other payers either pay for these services or likely will in the future as they tend to follow Medicare’s lead, particularly as all trend toward a holistic and more cost-effective approach to patient care.

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practitioners may code for consultative services, team-based care is not incentivized or reimbursed. A growing number of insurance companies and health plans offer limited PC benefits and services.

Accountable Care Organizations and bundled payment models should encourage PC growth given clear data showing improved outcomes at lower costs.

In summary, regardless of whether Colorado passes PAD legislation, investing in more robust primary and specialty PC support is critical to ensure consistent access to high quality advanced illness support. It is our common ground. Through combined research, policy, education, payment and practical approaches, expanding PC support across Colorado will improve the quality of care while bending the cost curve.

Reflecting on my early experiences, I now appreciate the gift that Nellie left me. Her honest words taught me respect for end-of-life’s often delicate balance of quality and quantity. She helped me to appreciate the critical importance of creating a safe space for authentic dialogue – ongoing conversations that ensure that the care delivered is consistent with what matters most to our patients and their loved ones.

Nellie was fortunate to have an “easy out”– an opportunity to end her life by foregoing further life-sustaining treatments. Many, if not most, of us will be afforded the same opportunity. Nellie passed away naturally only two hours after removing her oxygen. She died comfortably with her family at her side. All were at peace with her decision. n Resources: 1 Centers to Advance Palliative Care. www.CAPC.org.

2 Quill TE et al. Generalist plus Specialist Palliative Care – Creating a More Sustainable Model. NEJM, 2013.

3 Centers to Advance Palliative Care.

Growth of Palliative Care in U.S. Hospitals Snapshot. www.CAPC.org, 2015.

4 Center for Improving Value in Health Care (CIVHC). Palliative Care in Colorado. May, 2015.

HealthTeamWorks. Palliative Care Guideline. 2011.

Colorado Medicine for May/June2016

Growth of Palliative Care in U.S. Hospitals 2015 Snapshot (2000 – 2013) What is Palliative Care?

Palliative care is specialized medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other specialists, who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness, and can be provided along with curative treatment.

Palliative care improves health care quality in three significant ways: → Relieves physical and emotional suffering → Strengthens patient-family-physician communication and decision making → Ensures well-coordinated care across health care settings

PALLIATIVE CARE IN U.S. HOSPITALS with 50 or more beds, 2000–2013

than 50 beds reported palliative care programs; in 2013, 72.3% (1,744) of such hospitals reported a program.

100.0

• • • • • • • • • • • • • • • • • • • • • • • • • •

1600

1200

800

80.0

60.0

40.0

20.0

400

0

0 2000

Percent of Hospitals, >50 Beds with a Palliative Care Program

In 2000, just 24.5% (658) of hospitals with more

Percent of Hospitals with a Palliative Care Program

Count of Hospitals with a Palliative Care Program

2000

Number of Hospitals >50 Beds with a Palliative Care Program

Palliative care prevalence in U.S. hospitals has shown a steady increase since 2000.

•

2001

2002

2003

2004

2005 2006

2007

2009 2010

2008

2011

2012

2013

Source: Center to Advance Palliative Care, April 2015

Data Sources: 1) American Hospital Association (AHA) Annual Survey Database™, FY 2000-2013. Chicago, IL: Health Forum, an American Hospital Association affiliate, and 2) the National Palliative Care Registry™, a project of the Center to Advance Palliative Care and the National Palliative Care Research Center.

Methodology: The AHA Annual Survey asks hospitals to self-report the presence of a palliative care program at their hospital. In 2008, the AHA survey expanded to include inpatient palliative care units. Hospitals that participated in the National Palliative Care Registry™ are included in the 2008–2013 figures regardless of their participation in, or response to, the AHA Annual Survey. For the same time period, children’s general medical and surgical hospitals are also included. For this report, all counts for 2008-2013 were recalculated to ensure consistent definitions across years.

The Center to Advance Palliative Care (CAPC) and the National Palliative Care Research Center (NPCRC) are dedicated to increasing quality palliative care services for people facing serious illness.

Contact: Maggie Rogers, CAPC Research Associate, at 212-824-9571 or maggie.rogers@mssm.edu Copyright  2015 Center to Advance Palliative Care. All rights reserved.

www.capc.org

www.getpalliativecare.org

www.npcrc.org

Features

Physicianassisted death Courtney S. Campbell, PhD, Hundere Professor of Religion and Culture, Director, Program in Medical Humanities, Oregon State University

Courtney S. Campbell

Reflections from Oregon STORY HIGHLIGHTS • Colorado is one of a dozen states that has seen renewed legislative efforts to pass a “death with dignity” statute similar to what exists in Oregon and California.

• For terminally ill patients, the core question is whether they have a legitimate right to request assistance in dying from a physician.

• Physicians need to explore whether a filling a request for a prescription to end life fits within their personal philosophy of care and within the profession’s understanding of its broader purposes – for example, to heal, to show compassion and empathy, to do no harm and to cultivate a trusting relationship with patients.

• The debate over legalized physician-assisted death is part of a much larger public conversation about end-oflife options and the meaning of death that can serve as a catalyst for exploring, identifying and revising core personal and professional values. Physicians must be active in this conversation for their patients and provider communities.

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Brittany Maynard was a newly married 29-year-old when she was diagnosed in the winter of 2014 with terminal brain cancer. After receiving medical treatments that proved ineffective, Maynard and her husband moved from California to Portland, Ore., so that she could take advantage of Oregon’s “Death with Dignity” statute. Per the statute, Maynard received a medication from a physician to end her life, and did so following widespread publicity on Nov. 1, 2014.

Her story and legacy was influential in the passage of the new California Endof-Life Option Act, effective February 2016, as well as in renewed legislative efforts in over two dozen states, including Colorado, to enact state laws permitting physician assistance in the death of a terminally ill patient (PAD).

The pioneering voter referendum that gave legal permission to physicians to write a prescription for a qualified terminally ill patient seeking to end their life in a “humane and dignified manner” was passed by Oregon voters in November 1994. The enacted statute sought to achieve three basic aims: (1) expand the recognized rights of terminally ill individuals to refuse medical treatments to include rights to request medical assistance in hastening the timing and circumstances of death; (2) provide participating physicians with immunity from prosecution; and (3) institute a model of reasonable regulation of this practice that would assure professional and public oversight.

Patient choice Patient rights: The core question regarding patient choice is whether or not terminally ill patients have a legitimate

right to request assistance in dying from a physician. Medical ethics and law have long recognized that, consonant with our general right of non-interference against others in deciding and enacting a life plan, terminally ill patients have basic rights to refuse life-extending medical treatment. This right is enacted through an informed and voluntary choice by a competent patient (or an authorized proxy) and is supported by such values as personal autonomy, privacy, bodily integrity and human dignity. A patient who makes such a decision may rely on various “last resort” end-of-life procedures, such as hospice, palliative care, voluntarily stopping eating and drinking, or palliative sedation.

There is a significant ethical, professional, philosophical and policy dispute over whether the right to refuse life-extending medical treatments is separable from, or instead logically entails, a right on the part of terminally ill patients to assist in bringing about or hastening their death by requesting a physician prescription to end life. Our rights to assistance from others are much more restricted than our rights to non-interference, and generally require a moral and legal justification that is different from autonomy or patient choice alone. The right to non-interference can be recognized by others as simply “staying out” of the decision or action; by contrast, recognizing assistance as a moral or legal right requires some other person to cooperate or participate to achieve the goal of the action. That is, a right to assistance implies a duty to assist on the part of another. In medicine, the duty of a physician or health care professional to prevent and remove harm and promote Colorado Medicine for May/June2016

Features patient welfare is structured by the duty of beneficence.

Decision-making capability: The argument over the scope of patient rights is complicated by disagreements over the required decision-making capabilities of terminally ill patients. Ezekiel J. Emanuel, MD, has written that “depression, hopelessness and psychological distress” are the primary factors motivating the majority of patients’ requests for physician assistance in death. At least in principle, there is concurrence that decisions of terminally ill patients on end-of-life choices can be compromised by depression or other factors culminating in impaired judgment. The prospect of psychiatric referral to assess decisionmaking capability in circumstances of diagnostic uncertainty is recognized within the “death with dignity” statutes.

Such referrals have declined in Oregon from 27 percent of patients in 1998 to 4 percent in 2015. However, this decline is primarily a function of patient screenings by advocacy groups such as Compassion & Choices, and of a more informed public and professional community. There is insufficient warrant for the view that just by making an inquiry or request for a hastened death, a patient has displayed depression or a clinically significant manifestation of impaired judgment. Insofar as patients have been empowered with all sorts of decision-making authority with respect to refusing life-prolonging medical treatments, it’s difficult to see just why a person would suddenly lose that capability when requesting that their death instead be hastened through a medication prescribed by a physician.

1998-2015) are referred for a psychiatric evaluation.

• Physicians report that the primary concern for patients who request a physician prescription is loss of autonomy (n=903 or 91.6 percent from 1998-2015).

Physician responsibility Goals of medicine: Precisely because terminally ill patients request assistance from a socially entrusted professional, the ethical and policy issues cannot be resolved solely on grounds of patient selfdetermination. The medical profession has cultivated a distinctive ethos and identity that is rooted in a set of formative purposes. These include preventing disease and promoting health, relieving pain and ameliorating suffering, curing disease and caring when cure is not possible, and preventing premature death.

These professional values and commitments are independent of, and cannot be reduced to, patient self-determination. If the issue were only about physician respect for patient autonomy, there would be no reason in principle for proponents of PAD to not also advocate for physi-

cian-administered voluntary euthanasia.

Professional neutrality: The question of legalized physician assistance in death imposes a responsibility of engaged discourse about the integrity of the profession, and the scope of professional vocation and responsibility, upon members of the profession and its various associations and societies. Medicine is simply not a morally neutral profession, nor are physicians merely technicians of the body. Some prominent physicians (Quill, Cassel) have advocated that professional associations adopt a stance of “studied neutrality” on the question of legalization to respect the diversity of views of membership and to encourage “struggle” with the issues of professional ethics; other writers express concern that neutrality will entail that nonphysician organizations will make policy decisions for medicine.

Physicians need to articulate whether filling a request for a prescription to end life fits seamlessly within their personal

There are several indications suggestive that the PAD process in Oregon is structured to advance responsible patient choices: • Relatively few terminally ill patients choose to receive a physician prescription to end their life (n=1,545 from 1998-2015).

• Approximately 64 percent of patients who receive the medication use it, while 36 percent do not use the medication (n=991 from 1998-2015).

• Terminally ill patients are presumed capable of making this decision; relatively few (n=52 or 5.3 percent from Colorado Medicine for May/June 2016

13

PAD Oregon (cont.) philosophy of care and within the profession’s understanding of its broader purposes. The integrity of the profession consists in commitments to heal, virtues of compassion and empathy, principles to not harm and to benefit, cultivating a trusting relationship with patients, and responsibilities of non-abandonment of the vulnerable, without which medicine becomes another, and different, form of social practice. It is not a matter to be resolved by dictates extraneous to the goals of medicine, including economic imperatives, governmental regulation or default to the law.

Protecting physician conscience: While the Oregon law sought to ensure that physicians were not prosecuted for good-faith compliance with the legal regulations, it also did not impose a duty to participate on physicians, other health care professionals or health care institutions. Nor do physicians who refuse to participate in a patient’s request have to refer the patient to a participating provider. The personal autonomy and conscience of physicians can be

14

respected even in states where PAD is legalized.

Palliative care: The first resort of physicians when confronting an inquiry about assistance in death should be the gold standard of hospice and palliative care. This is a priority among Colorado physicians participating in the CMS 2016 PAD survey (see page 16). Physician commitments to palliative care are reflected in the comparatively low frequency with which Oregon physicians report patients who request PAD, indicating a concern about inadequate pain control (n= 248 or 25.2 percent).

Relationship: The legal statute permitting PAD provides minimal, but by no means ideal, standards by which physicians can enact their professional responsibility in relationships with patients.

• The median duration of the relationship between the physician and patient when the patient has ingested a prescription medication to end life is 12 weeks.

• The prescribing physician is present when the patient dies following patient ingestion of the medication in 15 percent of cases.

Social accountability Hospice conflicts: The requested involvement of the medical profession in physician-assisted death entails that a decision to hasten death is not merely a private choice but has implications for the broader society. One intermediate community that has confronted substantive challenges to organizational philosophy of care and ethos are hospice programs. In Oregon, the vast majority of patients who have used a physicianprescribed medication to end life have been enrolled in hospice (n=865 or 90.5 percent). Hospice programs have found their core values of compassion, quality of care, not hastening death and nonabandonment of patients too often pull in different directions when a hospice patient requests PAD (Campbell, Cox).

Costs and duty to die: The societal implications of legalized physician-

Colorado Medicine for May/June2016

Features assistance in death are particularly pronounced in an era of market-based incentives and demands for cost-effectiveness in health care. A resonant concern is that though PAD is formulated as a right of the individual to determine the timing and method of their death, the patient may experience this claim as a duty to die on behalf of the good of others, including family members, to avoid financial burdens. There have been two cases in Oregon in which endstage cancer patients were denied funding by the state insurance program for further cancer treatments even as the state program assured the persons they were eligible for state funding for PAD as a form of “comfort care.” In both instances, the state program eventually backed down, and physicians report that among patients who request PAD, comparatively few (n=30, or 3.1 percent) have expressed concern about the financial costs of treatment.

Protecting vulnerable persons: Death with dignity statutes have been criticized on grounds of their potential for placing vulnerable persons at involuntary risk of harm. This critique has been particularly voiced by members of disability communities and minority cultures who already have substantial experience of marginalization in health care and grounds for distrust of medical authority. However, the demographics of Oregon patients who have utilized PAD are white at a higher proportion (96.6 percent, n=953) than the white demographic in a very homogenous state. This does not mean, though, that issues of symbolic rationality or harm to vulnerable populations are morally insignificant.

Despite minimal changes in regulatory requirements in the Oregon statues over the past two decades, a consistent background issue has been the prospect of relaxing some exclusionary criteria, such as the requirement of patient selfadministration of the medication, the requirement that a patient have a terminal diagnosis, and the requirement of patient decisional capacity at the time of the request. These are meaningful questions if the only moral logic under conColorado Medicine for May/June 2016

sideration is patient autonomy. Some scholars and physicians have looked to countries such as the Netherlands, Belgium and Switzerland, and in the past year, Canada, as systems that permit lethal medication administration by physicians, or permit patients to request medical assistance in death when seriously ill, rather than terminally ill. For the time being in the U.S., these are matters of speculative concern, rather than professional or advocacy realities.

These other models nonetheless bring heightened attention to the social justice imperative to protect vulnerable populations.

Conclusion The debate over legalized physicianassisted death is part of a much larger public conversation needed in our country regarding end-of-life options and the meaning of death. Such discourse need not prove polarizing, but instead be a catalyst for exploring, identifying and revising core personal and professional values. Part of what it means for

medicine to be a “profession” is to assume proactive leadership in advancing conversation and education for patients and among provider communities rather than adopting reactive procedures in response to a legal statute. n NOTES In this essay, I use the language of physician-assisted death (PAD), following the pattern of a survey of members of the Colorado Medical Society conducted by Kupersmit Research in 2016.

REFERENCES Campbell, C., Cox, J.C., “Hospice and Physician-Assisted Death,” Hastings Center Report 40(5):2010, 26-35.

Emanuel, E. (1997). “Whose Right to Die?,” The Atlantic, March 1997, 73-79.

Quill, T. E. & Cassel, C. K. “Professional organizations’ position statements on physician-assisted suicide: A case for studied neutrality.” Annals of Internal Medicine, 138(3): 2003, 208-211.

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Features

Physicianassisted death Benjamin Kupersmit, president, Kupersmit Research

Polling shows a divided membership STORY HIGHLIGHTS • CMS surveyed members on physician-assisted death in early February and a record-number of members responded. Results show 56% in favor of PAD and 35% opposed.

• CMS members are nearly unanimous in demanding that any PAD law passed in Colorado include provisions to protect patients and physicians.

• Heightened awareness around end-of-life care, for patients as well as physicians, is seen as a critical step forward, whether legislation or ballot initiatives proceed or not.

Deep differences exist among CMS members – including among those who are palliative medicine (PM) specialists and those with significant training in PM – on issues surrounding physicianassisted death, or PAD, though there are also areas of agreement. That’s what was revealed by a February 2016 survey of CMS members that focused on personal support/opposition to PAD, desired policy and the role for CMS in regard to efforts to legalize PAD in Colorado, concerns and priorities if a PAD law/ ballot initiative passed in Colorado, and interest in enhanced end-of-life education for patients and physicians.

• Overall, 56% of CMS members are in favor of “physician-assisted suicide, where adults in Colorado 16

could obtain and use prescriptions from their physicians for self-administered, lethal doses of medications,” (including 31% “strongly”), while 35% are opposed (including 25% “strongly”).

• Among those with at least some training in palliative medicine (42% of members overall), support stands at 56% (29% “strongly”) and opposiTable 1

AREAS OF CONCERN Percent of physicians concerned with topics related to a potential law legalizing physician-assisted suicide. % of physicians

Pressure from family to choose death for patients who feel they are a burden

53%

Slippery slope of opting for death instead of treating suffering

48%

Negatively affect image of all physicians as healers and patient advocates

41%

Pressure or legal action pushing physicians who oppose physician-assisted suicide to participate in the system

39%

Financial pressures to push patients, particularly low-income and elderly,

38%

Stands against oath for MDs/DOs not to administer lethal drugs

37%

Not enough oversight of lethal drugs

20%

None of these

22%

Not sure

3%

tion stands at 39% (29% “strongly”). o Among the somewhat narrower audience of those with at least “significant” training in PM (14% of members), support stands at 52% (including 24% “strongly”) and opposition stands at 41% (with 32% “strongly”).

• Among those who “frequently” treat patients in later stages of a terminal disease, support stands at 50% (28% “strongly”) and opposition stands at 41% (32% “strongly”); among those who “sometimes” treat terminally NECESSARY ill PROVISONS patients, support is 51% (28% “strongly”) opposition is that 38% Percent of and physicians who feel (27% “strongly”); among those it is extremely important to very who important that any law such around “rarely” or “never” treat patients physician-assisted includeand support is 65% (37%suicide “strongly”) the following provisions. opposition is 23% (18% “strongly”).

% of physicians

• Physicians in Denver are considerAttending physician must ably more asupportive (62%-24%) determine terminal 92% than those in smaller cities diagnosis and determine thein Colopatient’s competence rado (49%-41%) and those in small towns rural areas (48%-45%).

Legalorimmunity for health care providers for prescribing

90%

• Those who arevoluntarily under 45 exand those Patients must who are over 65 are most supportpress a will to die orally and in 89% ivewriting (at 60% and 66%, respectively), while those 46-64 are less supportive Physicians must document (50%). and report every oral/written request, their diagnosis and the outcome each patient Priorities arefor clear: Protect

88%

patients, Patientsphysicians are offered an opportunity to rescind thelegislature second 88% In the event that at the or request votersoral enact PAD in Colorado, CMS members want tocan seebefundamental No provider compelled proto participate, butboth patients tections included for patients and 83% need to(See be given to physicians. tablea1referral this page.) another provider

write read the folThosePhysician taking cannot the survey prescription at least 15 to know lowing: “While ituntil is impossible 71% days after initial oral request the future, CMS needs to determine its and no less than 48 hours after written request, and must

Colorado for May/June2016 refer to a Medicine second physician for confirmation, as well as

CH PH SU

Perc bar pall one pat

%

%

Pati to d hos

Pati abo of in

Lack spec care

Not refe

Not sign you

Oth

No p com ipat nee refe prov

Features members’ priorities should legislation or a ballot initiative pass that would legalize physician aid in dying, also known as physician-assisted suicide. Please bear in mind that these questions are in no way intended to suggest that CMS is taking a position in favor of physician-assisted suicide; our goal is to understand what members would prioritize in this hypothetical scenario.”

• One-half of CMS members (53%) are concerned that a law regarding PAD could result in pressure from family Table 2

RN

with w icide.

% of ysicians

53%

48%

41%

39%

38%

37% 20% 22% 3%

NECESSARY PROVISONS Percent of physicians who feel that it is extremely important to very important that any law around physician-assisted suicide include the following provisions.

Percent of physicians concerned with % of topics related to a potential law physicians legalizing physician-assisted suicide.

Attending physician must determine a terminal % of 92% physicians diagnosis and determine the patient’s competence Pressure from family to chooseLegal deathimmunity for patients for health53% care 90% who feel they arefor a burden providers prescribing Slippery slope of opting for Patients must voluntarily exdeath instead 48% press a of willtreating to die orally and in 89% suffering writing Negatively affect image Physicians must document of all physicians asevery healers 41% and report oral/written 88% and patient advocates request, their diagnosis and the outcome for each patient Pressure or legal action

AREAS OF CONCERN

pushing physicians who an opporPatients are offered opposetunity physician-assisted 39% to rescind at the second suicideoral to participate request in the system No provider can be compelled Financial tobut patients to pressures participate, push patients, 38% need toparticularly be given a referral to another low-income andprovider elderly,

Stands Physician against oath for write cannot MDs/DOs not to administer prescription until at least 37% 15 days after initial oral request lethal drugs and no less than 48 hours after Not enough oversight of written request, and must20% lethal drugs refer to a second physician confirmation, as well as None offorthese 22% counseling Not sure 3% Attending physician must determine patient’s ability to self-administer medications

No prescription to be filled if psychiatric or psychological illness present

88%

83%

to opt for death and 48% are concerned that such a law could lead to a “slippery slope” of opting for death.

• Two-in-five (41%) are concerned about how such a law would impact the image of physicians, 39% are concerned that there could be pressure or legal actions on physicians who do not want to participate in such a system, 38% are worried about financial pressures to push low-income or elderly patients toward death and 37% are concerned because PAD goes against the oath for MDs/DOs to not administer lethal drugs.

CMSCHALLENGES members are nearlyFACING unanimous in demanding that any such a law include PHYSICIAN-ASSISTED key provisions to protect patients and SUICIDE physicians. (See table 2 this page.)

Percent of physicians who percieve barriers in referring patients to a • Nearly all care physicians say(orthat havpalliative specialist bringing ingone a requirement into the ‘carethat team’the for attending that patient).must determine a terminal physician Percent of physicians who feel that diagnosis is “extremely” it is extremely important to veryor “very” im% of physicians who important that any law around portant (92%), that frequently treat there should be physician-assisted suicide include care proterminally ill legal immunity forpatients health the following provisions.

NECESSARY PROVISONS

viders (HCPs) for prescribing under % of all physicians % of the terms of the law (90%), that paphysicians tients must voluntarily express a will Patients do not want Attending physician must to die (89%), that physicians 27% must 47% to discuss palliative/ determine a terminal 92% stage document and report at every hospice options the diagnosis and determine patient’s competence (88%) andconcerns that patients should be ofPatient fered a chance to rescind at the secLegal immunity forcosts, health care 26% about high lack 90% 23% ond oral request (88%). providers for prescribing of insurance coverage PatientsLack must exof voluntarily palliative care • Almost as or many physicians press aspecialists will to die orally and in 19% 89%(83%) hospice 18% writing also feel it is important that “no procare in the area

vider must can document be compelled to particiPhysicians Not included in your pate,” but patients should12% receive6% a and report every oral/written referral networks 88% request, theirto diagnosis referral anotherand provider.

Not sure the outcome forthere each are patient 5% 6% significant benefits for Patients are offered an opporOpportunity: Heightened your patients tunity to rescind at the second 88% awareness of end-of-life care

71%

71%

62%

Colorado Medicine for May/June 2016

oral request 11%end-of13% Other awareness around Heightened No provider can patients be can compelled No provider beas well as physilife care, for tocians, participate, patients compelled is seenbutasto aparticcritical step83% forward, need toipate, be given a referral to but patients whether legislation or ballot26% initiatives 28% anotherneed provider to be given a proceed or not. referral to another Physician cannot write provider prescription until at least 15

• 3% ofinitial the CMS physicians71% in active days after oral request 13% 1% None practice in the survey report that and no less than 48 hours after they are a and palliative written request, must medicine (PM) refer specialist, to a secondanother physician 11% have received for confirmation, well as in PM, and an“significant”astraining counseling other 28% have had “some” training; Attending physician must 56% have had “none.” determine patient’s ability to self-administer medications No prescription to be filled if psychiatric or psychological

• Overall, 26% of CMS members “frequently” care for patients who are “in a later stage of a terminal illness, or are in a stage of their life where they need to consider options for their final stages of life.” Another 28% say they “sometimes” care for such patients, while 22% say “rarely” and 12% say “never.” (11% say “not sure,” mostly among medical students.) o Among physicians who say “frequently,” 30% report either being a palliative medicine specialist or having “significant” training in PM, while 41% say they have had “some” training and 28% say “no training.” o Among those who say “sometimes,” 12% have had “signifiTable 3

CHALLENGES FACING PHYSICIAN-ASSISTED SUICIDE Percent of physicians who percieve barriers in referring patients to a palliative care specialist (or bringing one into the ‘care team’ for that patient). % of physicians who frequently treat terminally ill patients % of all physicians

Patients do not want to discuss palliative/ hospice options

27%

47%

Patient concerns about high costs, lack of insurance coverage

26%

23%

Lack of palliative care specialists or hospice care in the area

19%

18%

Not included in your referral networks

12%

6%

Not sure there are significant benefits for your patients

5%

6%

Other

11%

13%

No provider can be compelled to participate, but patients need to be given a referral to another provider

26%

28%

None

13%

1%

71%

17 62%

PAD survey (cont.) cant” training, 41% have had “some” training and 54% say “no training.”

ing available for patients locally scored much higher among members from towns/rural areas.

• Among those who “frequently,” “sometimes” or “rarely” take care of patients in later stages of terminal illness, one-half refer to a palliative care specialist either “every time” (19%) or “most of the time” (35%), while another one-quarter do so either “sometimes” or “rarely,” and 8% do so “never” (while 15% say “not sure”). o Among PCPs who take care of patients in later stages of terminal illness, 27% refer to a palliative medicine specialist “every time,” 50% do so “most of the time” and 19% do so “sometimes” or “rarely” (while only 3% say “never”).

• Three-quarters (76%) say it is either “extremely” (45%) or “very” (31%) important that CMS “explore programs (webinars, trainings, connection to expert resources in Colorado, connection to peers in Colorado) focused on helping providers better address endof-life care issues with their patients,” while 18% say this is “somewhat” important and 3% say it is “not very” or “not at all” important.

• The most significant barrier to greater referrals to palliative medicine or hospice care cited by physicians who care for patients in later stages of terminal illness is patient reticence to discuss these issues (with 27% among all CMS members, and 47% among those who “frequently” care for such patients). (See table 3 previous page.) o Other barriers include high costs, insurance coverage (26%) and lack of PM specialists in their area (19%). o Notably, concern about access to PM specialists or hospice care be-

18

• A somewhat greater percentage (81%) say it is either “extremely” (52%) or “very” (29%) important that CMS “encourage a stronger focus among health care providers in Colorado around public education on end-of-life issues,” while 14% say this is “somewhat” important and 2% say “not very” or “not at all.”

Conclusions Members want to see CMS promote better education of the public and physicians around end-of-life care. Increased awareness among the public of the options that are available, including palliative medicine and hospice care, would be very welcome. Efforts to ease discomfort for patients and their families around discussing these issues can

help Colorado’s physicians care for the vast majority of patients who will not seek PAD, so they can die with dignity with the support and care of a trusted physician at their side. n Methodology This survey was administered online by the Colorado Medical Society. The survey was in the field from Feb. 2-16, 2016.

A total of 618 Colorado Medical Society members (including medical students and physicians) responded to the survey, for a margin of error of +3.9% at the 95% confidence level. A series of three focus groups was held to inform the development of the survey questions, including a group each with supporters, opponents and those “in the middle” regarding PAD. A note on terminology Given what we learned in the focus groups, the survey was introduced as being about “physician-assisted suicide, also referred to as physician aid in dying and physician-assisted death.” After much deliberation, we chose these terms (as opposed to “Death with Dignity” or others) because physicians who oppose PAD noted that phrases like “Death with Dignity” do not recognize the fact that physicians already help patients die with dignity via current practices (such as palliative sedation or voluntary withdrawal of food/water). We felt this was the least biasing language, and proceeded accordingly.

Colorado Medicine for May/June2016

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Features

2016

Legislative

Overview

Susan Koontz, JD, CMS General Counsel

The Colorado Medical Society advocates for Colorado physicians and their patients during the legislative session.

During the 2016 regular session of the Colorado General Assembly, legislators once again addressed out-of-network provider issues, including surprise bills, as well as issues concerning scope of practice, freestanding emergency rooms and the hospital provider fee, to name a few.

Over 1,800 bills were introduced this session and the CMS Council on Legislation (COL), along with their policy and public affairs professionals, reviewed each bill to understand its intent, its possible outcomes and the political landscape to collectively determine how and at what level CMS should engage.

physician’s bill, made it difficult for physicians to get paid, and expanded the value of a lawsuit by creating a private cause of action for plaintiffs against physicians for deceptive trade practices exposing physicians to three times the amount of actual damages (treble damages).

Following is an overview of the key bills on which CMS engaged this year.

CMS, along with various component and specialty societies, stakeholders and lobbyists worked together in opposing this bill, which was heard on March 16 before the Senate State, Veterans and Military Affairs Committee. On that day, CMS President Michael Volz, MD, along with physicians Bryan Coffing, MD; Randy Clark, MD; Jamie Dhaliwal, MD; and Caleb Hernandez, MD; and attorney John Conklin testified in opposition to this bill. The bill was killed at that hearing by a vote of 3 (Republicans) to 2 (Democrats).

Wins SB16-152: Changes and Notices for Health Care Services One of the significant bills CMS opposed was SB 152, which would have created ambiguity as to the carrier’s existing responsibility to pay the out-of-network

HB16-1374: Disclosures by Freestanding Emergency Rooms CMS also opposed HB16- 1374, which would have required a freestanding emergency room that provides emergency services in a facility, charges a facility fee and is not attached to a hospital to post

20

notices throughout the facility indicating that the facility is an emergency room that provides emergency services to treat emergency medical conditions.

Additionally, a freestanding emergency room, after performing an initial medical screening examination, would have had to inform a patient who is determined not to have an emergency medical condition verbally and in writing that the freestanding emergency room charges rates comparable to those charged by a hospital emergency room, including a facility fee; that the freestanding emergency room or a physician providing medical care at the center may not be a participating provider under the patient’s health benefit plan; that the physician providing medical care at the freestanding emergency room may bill the patient separately from the center; and that for non emergency medical conditions, the patient may wish to confer with his or her primary care physician or other primary care provider.

EMTALA prohibits any process that discourages patients from remaining in the emergency department before undergoing a screening exam. CMS voted to oppose Colorado Medicine for May/June2016

Features the bill due to concerns about possible EMTALA violations and increased liability. The bill passed through the House with amendments, but was defeated in the Senate State, Veterans and Military Affairs Committee by a vote of 3 (Republicans) to 2 (Democrats).

SB16-169: Emergency 72-hour Mental Health Holds The COL voted to monitor SB 169. The rationale behind the bill was the realization that some areas of Colorado lack the adequate resources to properly care for some individuals who are experiencing a mental health crisis or psychiatric emergency. Colorado statute currently specifies that a person who is placed on an emergency hold may be taken to a facility designated by the executive director of the Department of Human Services for a 72-hour mental health hold for treatment and evaluation; however designated facilities are often not available.

This bill clarifies the difference between facilities (medical facility or law enforcement facility), prioritizes the facilities where a patient should be taken, defines the terms under which these individuals may be taken to such facilities, among other provisions.

COL voted to support this bill, which passed through the Senate and the House and is awaiting the governor’s signature.

SB16-127: Repeal of the Medical Clean Claims Transparency Uniformity Act After working for the past five years toward development of a standardized set of claim edits, the Clean Claims Task Force (CCTF) has finished their work. This bill repeals the CCTF and was signed into law by the governor on April 5. In addition, both the Senate and the House passed Resolution SJR16-029, which recognizes the work of the CCTF. SB16-135: Collaborative Pharmacy Practice Agreements Collaborative pharmacy practice agreements are voluntary agreements between a licensed pharmacist and a physician or advanced practice nurse and patient that allow a pharmacist to provide evidencebased health care services to one or more patients pursuant to a specific treatment protocol delegated to a pharmacist by a physician or advanced practice nurse.

This bill passed the both the Senate and

the House and awaits the governor’s signature.

HB16-1095: Health Insurance for Prescription Eye Drop Refills This bill requires health insurance plans, except for supplemental policies which cover a specific disease or other limited benefit, to provide coverage for the renewal of prescription eye drops if the renewal is being requested within a specified amount of time. It is dependent upon how many days the prescription is for, whether the original prescription states that additional quantities are needed, and does not exceed the number of quantities needed.

COL voted to support this bill, which the governor signed into law on March 9.

HB16-1142: Rural and Frontier Health Care Preceptor Tax Credit It is vital for the well-being and quality of life that excellent health care be available in all regions of Colorado, including

After several amendments, the bill passed through the Senate and the House and is awaiting the governor’s signature. CMS, along with COPIC, the American College of Emergency Physicians and the Colorado Hospital Association, worked tirelessly to ensure that the final bill was not detrimental to emergency physicians working in emergency departments and hospitals or to their patients who are experiencing a mental health crisis and require evaluation and treatment.

SB16-158: Physician Duties Delegated to Physician Assistant This bill expands how physicians and physician assistants work together within the Colorado Medical Practice Act by clarifying what duties a physician may delegate to physician assistants (PA) within his or her scope of practice, improving access to care in underserved communities within the structure of the act, and by retaining physician supervision and the delegation of PA activities.

Colorado Medicine for May/June 2016

21

Legislative overview (cont.) rural and frontier areas which currently suffer from a shortage of primary health care providers. CMS policy supports and encourages training residency programs to assist physicians in rural areas. This bill offers a $1,000 personal income tax credit per year on or after Jan. 1, 2017 to a health care professional who serves as a preceptor during the applicable income tax year. The tax credit is available to a taxpayer who has practiced his/her primary health field of medicine in a rural or frontier area during the portion of the tax year the credit is being claimed. This bill caps at 300 the number of preceptors that may claim the tax credit for any one income tax year.

COL voted to support this bill, which passed the House and Senate and is on its way to the governor for his signature.

HB16-1047: Interstate Medical Licensure Compact To strengthen access to health care, this bill authorizes the governor to enter into an interstate compact with other states to recognize and allow physicians licensed in a compact member state to obtain an expedited license, enabling them to practice medicine in Colorado or another member state. The AMA has created policy to facilitate credentialing for state licensure to develop greater reciprocity between state licensing jurisdictions.

CMS voted to support this bill, which passed through the House and the Senate and is on its way to the governor for his signature.

HB16-1101: Medical Decisions for Unrepresented Patients This bill addresses the issue of orphan or “unrepresented” patients, i.e. patients without the capability of making their own medical decisions and who do not have an interested person (a spouse, parent, adult child, sibling, grandchild or close friend) who is willing or able to explain the patient’s wishes. This bill allows an attending physician to designate another willing physician to serve as proxy decision-maker – after reasonable efforts to locate an interested person to make medical decisions on behalf of the patient have failed – to make those deci 22

sions without being subjected to civil or criminal liability or regulatory sanction for acting as a proxy decision-maker.

After several amendments, the bill passed the House and the Senate and awaits the governor’s signature. We wish to thank COPIC for providing input and legal analysis on this bill.

SB16-042/HB16-1390: Immunity for Persons Involved in Overdose Events Under current law, a person who reports an emergency drug or alcohol overdose event is immune from criminal prosecution for certain drug-related offenses if certain conditions are met. Similarly, underage individuals who call 911 about another underage person who is in need of medical assistance due to alcohol or marijuana consumption are also immune from criminal prosecution. The bill sought to extend this immunity to an underage person in need of such medical assistance.

COL voted to support this bill, which failed in the Senate Judiciary Committee by a vote of 3 (Republicans) to 1 (Democrat) with 1 excused (Democrat).

After SB 042 failed, a similar bill was then introduced in the House (HB161390), which passed through the House and the Senate and is awaiting the governor’s signature.

SB 16-069: Community Paramedicine Regulation Community paramedics provide community-based, out-of-hospital medical services to medically underserved and medically served, yet vulnerable, populations.

Under current law, community paramedics and community paramedicine agents are not subject to regulation by any state agency. This bill authorizes the executive director of the Colorado Department of Public Health and Environment to adopt rules regarding standards by which emergency service providers are granted endorsement in community integrated health care service.

COL voted to support this bill, which passed the Senate and House and is on its way to the governor for his signature.

HB16-1160: Continuation of Surgical Assistant-Surgical Technologist Registration Program Colorado law requires surgical assistants and surgical technologists to register with DORA before they may be employed as surgical assistants and surgical technologists. DORA wanted to sunset this regulatory process, which the COL felt would be potentially harmful to patients. This bill continues the requirement that surgical assistants and surgical technologists register with the director of DORA’s division of professions and occupations before they may be employed as surgical assistants and surgical technologists and perform the duties of a surgical assistant or surgical technologist. The bill requires that the surgical assistants and surgical technologists prior to registration submit to a criminal history record check.

COL voted to support this bill, which passed through the House and the Senate and is on its way to the governor for his signature.

SB16-161: Regulate Athletic Trainers Colorado’s 670 athletic trainers work under the direction of physicians in many settings. The largest employers in our state are secondary schools, medical clinics and hospitals and universities.

In secondary schools they often are the only health care professionals available to treat young athletes. In college and university settings, as in sports medicine or orthopedic treatment centers, they are part of a team led by physicians. The AMA recognizes athletic trainers as allied health professionals. The profession is one of 33 regulated health care providers in Colorado.

Prior to July 1, 2015, athletic trainers practicing in Colorado were regulated by the director of DORA. During the 2015 session, a bill to continue that regulation was unsuccessful, thus beginning a one-year wind-down of the program. This year’s bill reinstates the regulation of athletic trainers.

COL voted to support this bill, which passed the Senate and the House and is on its way to the governor for his signature.

Colorado Medicine for May/June2016

Features Watched HB16-1360: Continue Regulation Direct-entry Midwives This bill implements the recommendations of the Department of Regulatory Agencies as contained in the sunset review of direct-entry midwives (DEM) with some modifications: the regulation and registration of DEMs by DORA will continue for seven years, and DEMs may not perform operative or surgical procedures.

The executive director of DORA is required to convene a working group, consisting of individuals with expertise in risk management and knowledge in the practice of midwifery, to investigate the means to manage risks in the practice of midwifery.

HB1360 passed the House and the Senate and awaits the governor’s signature.

HB16-1420: CO Healthcare Affordability and Sustainability Enterprise – “Hospital Provider Fee” How it works: Hospitals pay the fee into a cash program overseen by the Department of Health Care Policy and Financing (HCPF), and Colorado draws down federal matching funds on a 1:1 ratio.

These additional dollars are used to support coverage for 382,000 vulnerable Coloradans and increase reimbursements for hospitals, reducing the costs of health care for all Coloradans.

This bill sought to change the program into an enterprise under TABOR by repealing the Hospital Provider Fee, thus removing the revenue from the state’s revenue. The funds would have allowed for dollars to go to transportation and cap at $73 million for the Hospital Provider Fee collected, impacting hospitals around the state but allowing for dollars to go to education and beyond.

COL voted to support this bill, which passed through the House, but failed in the Senate Finance Committee by a vote of 3 (Republicans) - 2 (Democrats).

HB16-1405/HB16-1408: Budget Bill for FY2016-17 (the “Long Bill”) The Long Bill has passed through both Colorado Medicine for May/June 2016

the House and the Senate with numerous amendments. Pursuant to the Colorado Constitution, the Legislature balanced the budget. Notable changes to health care were made in HB16-1408. With a significant budget shortfall this year, ($49 million in Medicaid alone) Medicaid reimbursement was cut across the board and rates were rolled back to 2012 reimbursement amounts.

This was caused by the expiration of a “bump” intended to increase access to primary care for Medicaid patients. Many physician specialty organizations as well as CMS participated in an alliance to preserve reimbursement. Unfortunately, with the growth of the budget in other areas, the Alliance was only able to find

$20 million in the budget to sustain reimbursement. The Department of Health Care Policy and Financing, which operates the Medicaid program, took some very hard lines on this issue. The Joint Budget Committee chose to prioritize five primary care billing codes to remain at 100 percent of Medicare, while the rest was cut. The alliance will continue to meet to determine how to increase Medicaid reimbursement for all of medicine in subsequent budgets.

Overall this session was a win for medicine. In an election year, where politics often trump policy, CMS was able to prevail on the vast majority of issues relevant to physicians and their patients. n

Working for you toward Medicaid funding parity with Medicare HB16-1405/HB16-1408, the budget bill, passed the House and the Senate with numerous amendments but maintained critical funding for Medicaid for which CMS advocated. Limits from the Taxpayer Bill of Rights (TABOR) threatened the ability of the state General Assembly to fund Colorado infrastructure, including health care, and the Medicaid evaluation and management (E&M) code parity with Medicare was on the chopping block.

“Cash Fund Transfers for Health Care Programs” addresses part of the proposed decrease in funding for physician services within Medicaid. It creates a Primary Care Provider Sustainability Fund and transfers $20 million in cash funds for the continuation of Medicaid rate enhancements in specific areas including primary care office visits, preventative medicine visits, counseling and health risk assessments, immunization administration, health screening services and newborn care (including neonatal critical care).

Maintaining Medicaid parity with Medicare rates for E&M codes has been a top legislative priority for Colorado Medical Society this year. Colorado is one of the few states that extended parity once the federal Affordable Care Act funds expired. A full rollback of these codes would have likely decreased timely access to care for patients, reduced resources for care coordination and triggered a negative backlash on the state’s highly successful Regional Care Collaborative Organization (RCCO) program.

Colorado has made great gains in the reform of its Medicaid program, namely through the Accountable Care Collaborative (ACC). For three years in a row, the ACC has produced savings and increased patient satisfaction. The program relies on a solid primary care base using the patient-centered medical home (PCMH) model, along with practice analytics and support. The enhanced fees through E&M code parity with Medicare has helped strengthen PCMHs, save taxpayer dollars and improve care; repeal of the enhanced fees threatened these gains.

CMS thanks all physician members, specialty society partners and others who joined advocacy efforts to fight for this critical funding to help ensure access to care for Medicaid patients. It is a hard fought victory.

CMS also recognizes that this achievement is only a partial success. With only $20 million to fill a $49 million hole, some code enhancements were removed from the formula, most notably care in emergency settings. Additionally, these funds are available one time only and not built into the Medicaid rate base.

CMS legislative staff will continue to work to find funding solutions for next year and beyond to ensure physicians are appropriately paid for their care of Medicaid patients.

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Features

Confronting a crisis Steven J. Stack, 170th president of the American Medical Association

An open letter to America’s physicians on playing a role in reversing the opioid epidemic The medical profession must play a lead role in reversing the opioid epidemic that, far too often, has started from a prescription pad.

For the past 20 years, public policies – well-intended but now known to be flawed – compelled doctors to treat pain more aggressively for the comfort of our patients. But today’s crisis plainly tells us we must be much more cautious with how we prescribe opioids.

At present, nearly 2 million Americans – people across the economic spectrum, in small towns and big cities – suffer from an opioid use disorder. As a result, tens of thousands of Americans are dying every year and more still will die because of a tragic resurgence in the use of heroin.

As a profession that places patient wellbeing as our highest priority, we must accept responsibility to re-examine prescribing practices. We must begin by preventing our patients from becoming addicted to opioids in the first place.

We must work with federal and private health insurers to enable access to multidisciplinary treatment programs for patients with pain and expand access for medication-assisted treatment for those with opioid use disorders. We must do these things with compassion and attention to the needs of our patients despite conflicting public policies that continue to assert unreasonable expectations for pain control.

“As a practicing emergency physician and AMA President, I call on all physicians to take the following steps – immediately – to reverse the nation’s opioid overdose and death epidemic: • AVOID initiating opioids for new patients with chronic non-cancer pain unless the expected benefits are anticipated to outweigh the risks. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred.

• LIMIT the amount of opioids prescribed for post-operative care and

acutely-injured patients. Physicians should prescribe the lowest effective dose for the shortest possible duration for pain severe enough to require opioids, being careful not to prescribe merely for the possible convenience of prescriber or patient. Physician professional judgment and discretion is important in this determination.

• REGISTER for and USE your state Prescription Drug Monitoring Program (PDMP) to assist in the care of patients when considering the use of any controlled substances.

• REDUCE stigma to enable effective and compassionate care.

• WORK compassionately to reduce opioid exposure in patients who are already on chronic opioid therapy when risks exceed benefits.

• IDENTIFY and ASSIST patients with opioid use disorder in obtaining evidence-based treatment.

• CO-PRESCRIBE naloxone to patients who are at risk for overdose.

As physicians, we are on the front lines of an opioid epidemic that is crippling communities across the country. We must accept and embrace our professional responsibility to treat our patients’ pain without worsening the current crisis. These are actions we must take as physicians individually and collectively to do our part to end this epidemic.

"TOGETHER WE CAN MAKE A DIFFERENCE" n

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Colorado Medicine for May/June2016

Compliments of:

Free Statewide Prescription Assistance Program The exclusive Rx program of the Colorado Medical Society

Attention!

New Higher Discounts!

RETAIL PRICE

MEMBER PRICE

MEMBER SAVINGS

MEDICATION

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Losartan 25mg

30

$43.19

$11.66

73%

Azithromycin 250mg Tab

6

$39.99

$18.68

53%

Amlodipine 5mg

30

$40.19

$9.84

75%

Hydrocodone/APAP 10-325mg 30

$23.09

$13.51

41%

Lorazepam 1mg

90

$55.99

$24.27

56%

Oxycodone/APAP 5-325mg

30

$23.99

$11.41

52%

Tramadol HCL 50mg

60

$34.69

$16.82

51%

NOTE: Our price is the average price members paid on that prescription during the month of January, 2015.

Retail price was obtained by calling CVS/pharmacy. Pricing varies by pharmacy and by region. Prices are subject to change.

You can help by encouraging your patients to print a free Colorado Drug Card at:

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Cards are pre-activated, no sign-up forms needed.

Discounts on brand and generic medications.

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Colorado Drug Card

Features

Physician hero: Ultimate self-sacrifice Kate Alfano, CMS Communications Coordinator

Kenneth Atkinson, MD

Kenneth Atkinson, MD, rushed to help in neighborhood shooting and tragically lost his life Kenneth Atkinson, MD, a Centennial family physician for the past 30 years, was fatally shot after trying to help his injured neighbor and another woman who were victims of an apparent case of domestic abuse. The Colorado Medical Society honors Atkinson as a physician hero for his heroic act and for his decorated medical career as a beloved family practice physician.

“Ken loved family practice in large part because of the relationships he built with his patients,” said his wife, Jeanne Atkinson. “I have discovered from the scores of letters I have received that he will be remembered for far more than the healing of just their physical bodies.”

“Ken was a good man and I loved him dearly,” she continued. “My family’s sorrow is deep but I am proud of him for the

decision he made that day. I wouldn’t have expected anything different from him.”

Atkinson is remembered by all those who knew him as selfless and caring. “If Doc saw something, he was just going to help.

That was Doc. He probably didn’t even think about himself,” said Mary DeLapp, his medical assistant of 15 years. “He probably just went to help this person because that’s how he was. That was Doc.” “Doc” Atkinson was beloved by his patients and dedicated to his community, known to regularly come in to the office after hours to help patients who needed to be seen. He would often provide free care to help patients who couldn’t pay.

One of Atkinson’s patients and friends, Brad Meuli, president and CEO of Denver Rescue Mission, gave an example of his dedication to patient care in a news

story. “I have four boys and a girl, and he was my physician. I can remember being in his office on Christmas Eve at 9:00 at night. He just drove over to take care of one of my kids."

Following the loss of two of their children to complications from fanconi anemia, a rare form of bone marrow cancer, Atkinson and Jeanne established the Kendall and Taylor Atkinson Foundation to help fund medical and scientific research into the disease. The Foundation also supports programs to enhance the lives of children living with disease, disability and poverty.

At 65, he was close to retirement, and just weeks before his death got to meet a new grandchild. Atkinson is survived by Jeanne, daughters Allison Adams (Scott), Whitney Langlois (Kevin), brother Tom Atkinson (Cathy), sister Marge Atkinson, grandchildren Carson, Mackenzie and Logan Adams, and Kendall and Josie Langlois. He was awarded his medical degree by the University of Colorado in 1977 and completed a family medicine residency at Mercy Medical Center in Denver.

Atkinson’s life was so important to the community that Senators Nancy Todd and Jack Tate presented his family a special commemoration at the Colorado State Capitol on May 5, 2016, that reads:

From left to right: Senator Nancy Todd, Jeanne Atkinson (wife), Allison Adams (daughter), Whitney Langlois (daughter), Marge Atkinson (sister), Senator Jack Tate and Carson Adams (grandson, front row) after Dr. Atkinson was honored by the Legislature.

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“The Senate of the Colorado Legislature, convened in the Second Regular Session of the Seventieth General Assembly, hereby honors and remembers the life of Dr. Kenneth Atkinson. The General Assembly would like to recognize the remarkable life of Dr. Kenneth Atkinson, who selflessly gave his life while saving Colorado Medicine for May/June2016

Features the lives of his neighbors. Dr. Atkinson was a beloved Centennial resident and founder of the Kendall and Taylor Atkinson Foundation. He graduated from medical school at the University of Colorado and completed his internship and residency at Mercy Medical Center in Denver. His career in family medicine was spent serving his Centennial community, where he was well loved and respected for his caring an compassionate nature. The members of the Colorado State Senate memorialize the loss of Dr. Atkinson, a Colorado hero who exemplified kindness, service, and courage. We extend our heartfelt sympathies to his family and the community of Centennial.”

The Colorado Medical Society and the Arapahoe-Douglas-Elbert Medical Society mourn the loss of a devoted friend and role model – a true physician hero who dedicated his life to his patients and community.

“Dr. Atkinson represented the finest our medical profession has to offer,” said CMS President Michael Volz, MD. “His dedication to his patients, his family and the community at large will be sorely missed and will serve as an inspiration to all of us left to follow in his footsteps.” n

Kenneth Atkinson, MD, enjoyed an active personal life. He is pictured here after having participated in the New York City Marathon.

Colorado Medicine for May/June 2016

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Features

DOI listening session Chet Seward, Senior Director Health Care Policy

Physicians share realities of dealing with health plans The Colorado Medical Society convened physician leaders from across the state in April to meet with Colorado Insurance Commissioner Marguerite Salazar; her boss, Division of Regulatory Affairs (DORA) Executive Director Joe Neguse; and Gov. John Hickenlooper’s health policy adviser Kyle Brown, PhD. The meeting provided these important policymakers with a chance to hear first-hand from physicians about what it is currently like to do business with health plans. There was no shortage of compelling stories.

Nearly 35 physicians from diverse specialties and practice settings ranging from huge multi-specialty urban groups to solo rural practices shared experiences and offered perspectives during the two-and-a-half-hour listening session.

Topics included delayed payment, prior authorization problems, consequences of narrow networks and the inability to negotiate fair contracts. It didn’t seem to matter whether practices were large or small; these stories showed consistent, negative impacts on care delivery and increased physician burnout. Oculoplastic surgeon Ron Pelton, MD, PhD, summarized: “As a solo practice physician I feel unimportant to insurance companies and powerless to fight against them. I was surprised to find that even big practices feel the same way.” Perhaps more important, many stories about dealing with health plans highlighted how patients suffered as a result.

The listening session was particularly opportune as the DOI is in the middle of developing new regulations regarding network adequacy, along with considering whether or not to block the proColorado Medicine for May/June 2016

posed merger of Anthem and Cigna.

Subsequent to the meeting Commissioner Salazar and Director Neguse announced the creation of a special physician advisory committee to address

some of these issues. CMS is encouraged by this decision because it clearly means that physicians were heard. This is another step in a longer series, and much more work remains. n

DORA Executive Director Joe Neguse listens as Commissioner Marguerite Salazar reacts to physician stories regarding daily interactions with health insurance plans.

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

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Features

Legal update: Health plan mergers John Conklin, Esq., Martin Conklin, PC

Denver district court ruling partial victory A Denver district court judge ruled in late April that the Form E filed by Aetna in the proposed Aetna-Humana merger is not a public document under Colorado law because Aetna is a foreign insurer, but that the Commissioner of the Division of Insurance has the discretion to release the Form E if it is in the public interest.

The judge further ruled that any Form E filed by a domestic insurer, which includes both Anthem and Cigna, is a public document. The ruling came in a case filed by the Division of Insurance in response to a CMS request for the Aetna Form E under Colorado’s Open Records Act (CORA). Aetna joined the case and at a hearing held in court on April 21, before the judge’s ruling, Aetna’s attorney argued to the court in part that the Form E should be confidential because it contains “admissions” regarding the competitive impact the proposed merger will have in Colorado.

This is the precise reason CMS generated the CORA request. The Aetna attorney’s statement is also consistent

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

Visit www.cms.org to learn more about the benefits of becoming a member For more information, call Tim at 720-858-6306 or e-mail tim_yanetta@cms.org

with records obtained from a second CMS CORA request to DOI for all documents about the merger which show DOI concluded the merger violates the competitive standard contained in Colorado law for two lines of health insurance. Despite Aetna’s admissions in the Form E, DOI went on to approve the merger through inaction, ostensibly finding that one or both exceptions apply to permit the merger. The two permissible exceptions under Colorado law are that the proposed merger will not create a statewide monopoly or that it will not substantially lessen competition among health insurers in the lines violating the competitive standard. The problem with these exceptions is that they apply only statewide and do not account for the proposed merger’s impact on the local healthcare markets where providers practice and patients seek medical care.

applies to insurance company mergers contains separate, although overlapping and interacting, parts. The judge concluded that the legislature intended for there to be increased public scrutiny of mergers involving domestic insurance carriers compared to those involving only foreign insurance carriers.

Because the judge held that the Aetna Form E is not a public document, the part of the statute that addresses confidential information applies to it. That section vests discretion in the DOI Commissioner to release otherwise confidential information and documents after giving the carrier notice and an opportunity to be heard when the Commissioner determines that the interest of policyholders, shareholders or the public will be served by publication. CMS will be requesting that the Commissioner release the Aetna Form E under this section as clearly being in the public interest.

Anthem has filed a preliminary notice with DOI of its intent to acquire Cigna, but neither company has yet filed a Form E. Filing a Form E is required under Colorado law. CMS has already initiated one CORA request to DOI regarding the proposed Anthem-Cigna merger and continues to monitor the agency for additional filings.

The judge also distinguished between Form E filings by domestic and foreign insurance carriers since the statute that

This reasoning, even if a valid interpretation of the law, underscores another overarching problem with the law. Even as foreign insurers under Colorado law, Aetna and Humana are both among the top six health insurers in the state and do substantial business in certain health insurance lines and local markets. The competitive impact of this proposed merger involving two “foreign” insurance companies will be as significant and real on providers and patients in those markets as a merger involving “domestic” insurers.

The judge’s recent ruling binds DOI to consider the Anthem Form E, when filed, as a public document. CMS has shared the Denver district court opinion with the AMA’s legal office for possible further use in the home states of Aetna and Humana, and with the Department of Justice that is continuing to review the proposed merger for its competitive impact on federal programs. n

Colorado Medicine for May/June 2016

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Features

Chronic pain management Kenneth Soda, MD, Chief Medical Officer, Colorado Community Health Alliance, RCCO#6

ACC Chronic Pain Management Program: A clinician’s experience nects PCMPs to pain management specialists. Through Project ECHO, the Colorado PCMPs engaged directly with specialists in a real-time online video conferencing system. They consulted directly with an interdisciplinary team regarding client cases and learned best practices with a variety of chronic pain conditions.

integrative approach to addressing the needs of Medicaid patients with perplexing and multifactorial complex pain syndromes. Twice a month, we shared patient cases with a panel of experts from various backgrounds in medicine, pharmacology, behavioral health, social work, alternative and integrative care medicine. A follow-up presentation on topics such as psycho-

While participating, PCMPs like me were provided with an intelligent and

Kenneth Soda, MD An epidemic of inappropriate opioid use in the United States for non-cancer related chronic pain syndromes has captured much attention lately. Medicaidinsured patients represent a challenging population in addressing this health care issue. They and their primary care medical providers (PCMPs) face a lack of access to specialty care providers and social determinants of health resources.

These factors can impact success in decreasing dependence on opioid utilization for pain.

However, providers from 42 practices across the state had a unique opportunity last year to participate in Project ECHO Pain through the Colorado Accountable Care Collaborative. Developed by The Weitzman Institute, the research and innovation arm of the Community Health Center Inc. (CHC), Project ECHO is a HIPAA-compliant teleconferencing program that conColorado Medicine for May/June 2016

Colorado Medical Society is pleased to announce Greenlight as our newest Member Benefit Partner.

GreenLight is the national leader in web-enabled behavioral health testing with over half a million assessments in 35 states.

GreenLight is designed to help physicians enhance patient care, improve population health and add incremental revenue to the practice. Results are easy to read and instantly available to be uploaded into your EMR for compliance, billing, and tracking purposes.

With GreenLight, physicians can now comply with numerous guidelines and recommendations regarding screening for behavioral health concerns.

Visit www.Greenlight.md for more information.

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Project ECHO (cont.) social approaches to pain management, acupuncture therapy, addressing opioid addiction and pain medication tapers augmented the latest in clinical data supporting medical providers’ approach to caring for these patients. A link to other medical providers in the state through a “chat” feature was a valuable tool for sharing challenges, successes and community resources with colleagues in Colorado.

I valued the advice and direction from the panel of experts on the team at Project ECHO Pain. It had a profound impact on the approach to chronic pain related syndromes encountered with my patients. It validated my concerns and permitted me to reassess the strategies and resources currently available to helping my patients. Although success varied among patients, I gained greater confidence in compassionately and honestly addressing my patients’ chronic pain concerns.

I encourage other primary care medical

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providers to renew efforts in addressing this crucial clinical issue facing our practices today. Project ECHO is a good place to start.

Of course, monitoring our success is important. We should be vigilant in reviewing patient clinical performance in achieving the goals of improved outcomes for pain management. Hopefully, this will be seen in the reduction of opiate utilization, improved quality of life indicators for patients, and a reduction in intentional and unintentional opiate overdoses.

Note: Project ECHO Pain and Project ECHO Buprenorphine are available at no cost to Colorado Medicaid PCPs through the sponsorship of the Colorado Department of Health Care Policy and Financing.

• Project ECHO Pain connects primary care providers with chronic pain specialists to learn more holistic, multi-disciplinary approaches to

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

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

For more information about participation in Project ECHO Pain or Project ECHO Buprenorphine, contact Agi Erickson, director of Project ECHO, at 860-347-6971x3741or Agi@chc1.com. n

Colorado Medicine for May/June2016

Colorado Medicine for May/June 2016

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Inside CMS

ANNOUNCING THE CANDIDATES FOR THE AUGUST 2016 ALL-MEMBER

ELECTION OF CMS OFFICERS

For the first time ever, all Colorado Medical Society members will be eligible to elect CMS officers via electronic ballot. Member-wide elections are an important part of The New CMS; yet another step to increase member involvement.

The candidates for 2016-2017 office are: M. Robert Yakely, MD – President-elect Alethia (Lee) Morgan, MD – AMA Delegate Kay (Katie) Lozano – AMA Alternate Delegate Be sure to read the next issue of Colorado Medicine for information on the candidates, including their biographies and personal statements.

And visit www.cms.org to access more information on all of the exciting changes happening through The New CMS.

CALL FOR NOMINATIONS

INTERESTED IN RUNNING FOR OFFICE? Any member can run for the positions of President-elect, AMA Delegate or AMA Alternate Delegate, or sponsor or endorse candidates.

The deadline for candidates to announce their intention to run for office in 20172018 is Jan. 31, 2017. Find more information in the election guide on www.cms. org. This guide provides important information on the duties, eligibility, terms of office and honorarium for each open position, as well as candidate requirements, campaign guidelines, election process and more.

CMS looks forward to all members’ participation in this process.

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Colorado Medicine for May/June2016

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CMS ANNUAL MEETING

SEPT. 16-18, 2016 • KEYSTONE RESORT Come together to engage the experts, both state and national, across the most pressing subjects of immediate relevance and concern to our medical community.

Share, debate and learn from the best of the best.

This year’s CMS Annual Meeting, the very first without a governance structure to work around, will be entirely devoted to celebrating the community of medicine, bringing Colorado physicians together for social, clinical and intellectual stimulation.

Colorado Foundation for Universal Health mergers; Abby Anderson, MD, CPEP, on Care; Michael Cooke of the Denver Metro avoiding the pitfalls of opioid prescribing; Chamber of Commerce; and Benjamin and Mark Levine, MD, and Carol Vargo, Kupersmit, president of Kupersmit Re- AMA director of Physician Practice Sussearch. And the physician-assisted death tainability, speaking on MACRA. panel includes CMS President Michael Volz, TOGETHER MD; Kupersmit; ViceAChair You won’t want to miss the CMS signaSTANDING WECEJA MAKE DIFFERENCE Attendees will experience informative Lynn Parry, MD; and Daniel Johnson, ture events: the Exhibitor Reception on E D I C M worthwhile panel discussions D and work- MD, CEJA consultant.

Friday with great food and fun catching O A L A S shops on the hottest topics in medicine up with your colleagues, the COMPAC R – curated by a CMS work group of your Workshop facilitators and topics include Luncheon midday Saturday for insightful peers – and explore beautiful Keystone, a Doris Gundersen, MD, medical director political commentary, and the Presidential mountain paradise. for CPHP and chair of the CMS Commit- Gala and COPIC dessert buffet Saturday tee on Physician Wellness, and the CPMG evening to kick off the presidency of Katie We welcome your families to join the fun Section, both speaking on physician well- Lozano, MD. too, with morning yoga and an early riser ness; Michael Victoroff, MD, COPIC, hike Saturday led by our own past presi- speaking on active shooter preparation; We can’t wait to unveil the new annual E E dent, Tamaan A Osbourne-Roberts, MD, Henry Allen, JD, AMA Advocacy Group meeting for you and your family Sept. 16N M N U A L as well as ready access to the gondola for and Diana Moss, Ph.D., President, Ameri- 18. Find more information and register onscenic views, miles of bike trails, horseback can Antitrust Institute, on the health plan line at www.cms.org n riding, golf, spa treatments and more.

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CMS presents an impressive slate of state and national speakers to address topics you can’t just pull off the web: ColoradoCare/ Amendment 69, medical aid in dying, Medicare’s radical shift in payment, and what the November general election will mean to health policy, to name a few.

Mary LoVerde, our keynote speaker, will share her innovative strategies for work-life balance and staying connected to what matters most in a humorous and fast-paced presentation. She has been an employee, an employer and an entrepreneur, making her realistic about the challenges of long hours, family commitments, travel, and the desire to have a life that includes sleep.

She served on the faculty of the University of Colorado School of Medicine for 15 years as the director of the Hypertension Research Center.

...because

Our ColoradoCare panel includes Michele Lueke, CEO of the Colorado Health Institute; Ivan Miller, executive director of the Colorado Medicine for May/June 2016

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KEYSTONE RESORT 0633 TENNIS CLUB ROAD KEYSTONE, COLO.

Colorado Medicine for May/June2016

7 REASONS There are many more than just seven reasons to join your colleagues at the reinvented annual meeting of the Colorado Medical Society. This year’s meeting, our very first without a House of Delegates governance structure, will be entirely devoted to celebrating the community of medicine. It will bring Colorado physicians together for social, clinical and intellectual

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stimulation that will be part therapy, part policy exploration and part insider briefings on the hot spots in health care politics, policy and downstream consequences of the November elections. We can’t wait to unveil the new annual meeting for you and your families. Find more information and register at www.cms.org. We’ll see you in Keystone the weekend of Sept. 16-18.

You need a break

You'll find tremendous satisfaction engaging with your peer group on the hottest clinical and political topics with insight from the top experts in the state and from around the country. It's like shooting the breeze around the office water cooler or in the doctors‘ lounge, except you‘ll be in beautiful Keystone, Colo.

Your family and friends will have plenty to do

While you‘re interacting with your peers and the experts, your family and friends can re-energize at yoga, enjoy miles of biking and hiking, participate in a 5K walk/run, or take a gondola ride to the mountain summit for excellent views and photos. (And don‘t worry, you‘ll have time to sneak away and join them, too.)

You will be amazed by the depth and breadth of expertise of the speakers

With so many talking heads often getting medical policy and politics topics wrong, you will amazed by the depth and breadth of expertise of our slate of speakers who will confront topics you can’t just pull off the web – all sides of the ColoradoCare November ballot initiative, what‘s being done to restore balance and fairness with the health plans , how to manage your pain patients, case studies on how to stay out of the courthouse and protect the safety of your patients. And that‘s just the beginning.

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You will be among friends – your peers

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Your opinion and ideas matter

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You will be among your friends, your peers to talk about the big picture and all the small stuff you sweat every day. It’s like a group therapy session – where you will make new friends and reconnect with old friends – but with good food and lots of laughs.

We will employ real-time straw polling to get your opinion and ideas on all the hot topics to share directly with your board of directors. Your ideas translate into policy and advocacy at the statehouse and other points of influence.

You’ll attend worthwhile workshops

We have worked hard to put together workshops that bring to an intimate scale how to get and stay well, how to manage your pain patients and help them recover, how to get ready for the radical shift in Medicare payments, and more.

You can recapture your love of the profession

You will remember why you chose this noble profession, immerse yourself in the community of medicine and all that you care about, and know you are never alone.

THE NEW CMS Colorado Medicine for May/June 2016

FOR MORE INFORMATION VISIT WWW.CMS.ORG

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

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• EXHIBITOR RECEPTION

• EARLY RISER YOGA OR HIKING

• COLORADOCARE/AMENDMENT 69 PANEL DISCUSSION

• KEYNOTE SPEAKER:

• BREAKFAST WITH THE BOARD OF DIRECTORS

MARY LOVERDE On work-life balance and staying connected to what matters most • BREAKOUTS/WORKSHOPS ON ACTIVE SHOOTER PREPAREDNESS, OPIOIDS, MERGERS, MACRA AND WELLNESS • “ VOTERS HOLD THE TRUMP CARD” COMPAC LUNCHEON WITH FLOYD CIRULI, RICH DEEM, JERRY JOHNSON AND MARK JOHNSON, MD

• COPIC EDUCATIONAL SESSIONS (ERS POINTS) • COPIC PRESENTATION WITH COPIC CHAIRMAN AND CEO TED CLARKE, MD

• PANEL DISCUSSION ON PHYSICIAN-ASSISTED DEATH

• PRESIDENTIAL GALA AND COPIC DESSERT RECEPTION

KEYNOTE SPEAKER Mary LoVerde

ON WORK-LIFE BALANCE AND STAYING CONNECTED TO WHAT MATTERS MOST Mary has traveled from Bangkok to Biloxi sharing her innovative strategies for staying connected to what matters most. She has published four books in three languages and has appeared four times on Oprah, a 20/20 special on stress, and was featured on ABC World News Tonight. Her blog is read in

35 countries. Her original work is published in the Wall Street Journal, the New England Journal of Medicine, and the Ladies Home Journal. She served on the faculty of the University of Colorado School of Medicine for 15 years as the Director of Hypertension Research Center.

HELP US — PEER TO PEER — REMEMBER WHY DOCTORS ARE DOCTORS.

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REGISTER TODAY AT WWW.CMS.ORG

Colorado Medicine for May/June2016

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

Inside CMS

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

COPIC Care for the Caregiver® We are all aware of the impact adverse outcomes can have on patients and their families, and the importance of addressing patients’ needs in these situations. Alongside this, we need to consider the effect on the medical providers involved. When a medical provider is facing a lawsuit, COPIC believes we need to do more than just defend our insured. We also believe we need to focus on his or her well-being.

Adverse outcomes can take a significant toll on health care professionals. There is clear evidence that a medical liability claim or lawsuit can trigger severe emotional distress.

A July 2015 Medscape article1 titled “Physician Suicide” provided an overview of this issue, saying that litigationrelated stress can be a key factor that precipitates depression and, occasionally, suicide. It also noted that: • A recent survey of American surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychological help.

• There was a strong correlation between depressive symptoms, as well as indicators of burn out, with the incidence of suicidal ideation. Over 60% of those with suicidal ideation indicated they were reluctant to seek help due to concern that it could affect their medical license.

“Even when healthy, physicians find it difficult to ask for help of any kind. When they are depressed and feeling less than adequate, they find it even more difficult – and when they do bring themselves to ask, they sometimes find that the help they need is remarkably difficult to obtain,” stated the article.

To address this issue, COPIC launched its Care for the Caregiver program in 2015 to help insured individuals deal with the emotional stress of a lawsuit. When the need is identified, a defendant is matched with a specially trained “peer” physician (from a different specialty) who has personally gone through the legal process.

These peers offer a shared perspective to address difficult

Colorado Medicine for May/June 2016

feelings – anger, guilt, fear and isolation – often associated with a medical liability claim. Research shows that most health care professionals will face a claim or lawsuit at some point in their careers. Many describe the litigation process as one of their worst professional experiences. And lawsuits can have a significant impact on their personal well-being as well as their family.

Care for the Caregiver strives to provide added support that complements the overall efforts of the defense team. The program was developed with the following goals in mind: • Facilitate confidential discussions with a peer to encourage open, honest dialogue.

• Focus on the emotional well-being of the individual, not analyzing the medical facts of a case.

• Enhance the individual’s ability to address the situation, build resilience and move forward.

Over the years, COPIC has spoken with numerous insureds involved in lawsuits. One of the pieces of feedback we consistently heard was “if only I could have talked to someone that went through this process.” We knew Care for the Caregiver was an important resource to make available.

Not only does it help everyone navigate through a difficult time, but it also attends to the human aspect of medicine and feelings to which we are all susceptible.

COPIC believes that individuals who participate in this program will see the immediate value it offers. Peers provide a unique understanding that only they can offer, they are able to speak from their own experiences, and more importantly, they are there to listen.

When Care for the Caregiver is made available, along with CMS Physician Wellness resources and the services and programs offered by Colorado Physician Health Program, we are making an important investment in the well-being of medical providers. This is essential in ensuring that physicians remain strong and healthy, enabling them to provide the best care for their patients.

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Inside CMS

Reflections Reflective writing is an important component of the CU School of Medicine curriculum. Beginning in the first semester, all medical students participate by writing essays or poems that reflect what they have seen, heard and felt. This column is selected and edited by School of Medicine faculty members Steven Lowenstein, MD, MPH, and Henry Claman, MD.

“You’re not dying.” She asked me again if I had been doing drugs and turned back to her work.

Robin Christian University of Colorado School of Medicine

Well, I sort of was dying. When I got to the hospital I was rushed to emergency surgery and I was in the hospital for a week.

A lot of that day was a blur, but I think back to that moment in the ambulance often. Why didn’t she hold my hand?

Julie Highland is a second-year medical student at the University of Colorado School of Medicine. She is a Colorado native who spends all of her free time exploring the beautiful outdoors in the Rocky Mountains. She graduated from the University of Colorado at Boulder in 2011 with a degree in Integrative Physiology, and spent the next three years learning Spanish and working in a primary care clinic at Denver Health before medical school. She loves children and plans on going into a sub-specialty of pediatrics.

Turning point I was riding in the back of an ambulance – lights flashing, sirens blaring, tubes and wires hanging in all directions. But this time, I wasn’t the student; I was the patient.

I had never felt this awful in my entire life. I couldn’t breathe, I was drenched in sweat, the muscles in my body were contracting uncontrollably and the room around me was fading.

Something was seriously wrong and I was really, really scared.

An EMT was sitting beside me, and with all of the energy I had left, I said “I think I’m dying.” In all my confusion and intense pain, the only thing I needed in that moment was for another human to be with me – to just hold my hand. I reached out my hand to her. She didn’t take it. She muttered, 40 42

A few months later, when I was feeling much better, I was spending a typical day with my preceptor, a neuro-oncologist.

I met with a patient who had just found out her brain cancer was back. After taking her history, a long silence came. She looked down at her hands and tears began rolling down her face. I didn’t know what to say. I thought back to that moment when I was in the ambulance, and how badly I just needed to be touched. So I took her hand, and I held it. For a while. And she cried, and we didn’t say anything. n

Visit the CMS website

www.cms.org

Colorado Medicine forfor July/August 2015 Colorado Medicine May/June2016

Inside CMS

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 Rocky Mountain Fleet Associates 303-753-0440 or visit www.rmfainc.com * CMS Member Benefit Partner

RXAssurance Visit www.rxassurance.com or www.opisafe.com

FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit www.copicfsg.com * CMS Member Benefit Partner

PRACTICE VIABILITY ALN Medical Management 866-611-5132 or visit www.alnmm.com

Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com

Carr Healthcare Realty 303-817-6654 or visit www.carrhr.com

LendKey 888.549.9050, or visit www.LKrefi.com/co-med * CMS Member Benefit Partner

First Healthcare ComplianceTM 888-54-FIRST or visit www.1sthcc.com *CMS Member Benefit Partner

Sharkey, Howes & Javer 303-639-5100 or visit www.shwj.com * CMS Member Benefit Partner INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit www.callcopic.com *CMS Member Benefit Partner MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or visit www.coloradodrugcard.com *CMS Member Benefit Partner CO-POWER 720-858-6179 or www.groupsourceinc.com *CMS Member Benefit Partner Greenlight 866.602.1778 or www.greenlight.md *CMS Member Benefit Partner

University of Colorado Hospital/CeDAR 877-999-0538 or visit www.CeDARColorado.org

HealthTeamWorks 866-401-2092 or visit www.healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit www.medteleco.com *CMS Member Benefit Partner The Health Law Firm 407-331-6620 or visit www.TheHealthLawFirm.com The Legacy Group at Re/MAX Professionals 720-440-9095 or visit www.legacygroupestates.com/physicians TransFirst 800-613-0148 or visit www.transfirstassociation.com/cms *CMS Member Benefit Partner

MedjetAssist Transcription Outsourcing 720-287-3710 1-800-527-7478, referring to Colorado Medical Society, or visit www.transcriptionoutsourcing.net www.medjet.com/cms *CMS Member Benefit Partner Transworld Systems 800-873-8005 or visit www.web.transworldsystems.com/npeters * CMS Member Benefit Partner Colorado Medicine for May/June 2016

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Departments

medical news Federal CMS launches multi-payer initiative to improve health care quality and cost The Centers for Medicare and Medicaid Services announced its largest-ever initiative to transform and improve how primary care is delivered and paid for in America. The effort, the Comprehensive Primary Care Plus (CPC+) model, will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve. The agency hopes the initiative will provide doctors the freedom to care for their patients the way they think will deliver the best outcomes by paying them for achieving results and improving care.

Building on the Comprehensive Primary Care initiative launched in late 2012, the five-year CPC+ model aims to help pri-

mary care practices support patients with serious or chronic diseases, give patients 24-hour access to care and health information, deliver preventive care, engage patients and their families in their care, and work with hospitals and other clinicians to provide better coordinated care.

Primary care practices will participate in one of two tracks. Both tracks will require practices to perform the functions above, but practices in Track 2 will also provide more comprehensive services for patients with complex medical and behavioral health needs.

In Track 1, the federal CMS will pay practices a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Sched-

ule for activities. In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-forservice payments for Evaluation and Management services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services.

Practices in both tracks will receive upfront incentive payments that they will either keep or repay based on their performance on quality and utilization metrics, which the agency hopes will encourage better health outcomes rather than higher volumes of visits or tests. Practices in both tracks also will receive data on cost and utilization.

The federal CMS will select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. The agency will accept payer proposals to partner in CPC+ through June 1 and will accept practice applications in the determined regions from July 15 through Sept. 1.

Learn more about the CPC+ model on cms.gov. n

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

Visit www.cms.org to learn more about the benefits of becoming a member For more information, call Tim at 720-858-6306 or e-mail tim_yanetta@cms.org 44

Colorado Medicine for May/June2016

Departments

medical news ACCME announces collaborations to simplify the integration of MOC and Accredited CME The Accreditation Council for Continuing Medical Education (ACCME) announced on April 27 two new collaborations with the American Board of Anesthesiology (ABA) and the American Board of Pediatrics (ABP) that aim to simplify the integration of accredited continuing medical education (CME) and Maintenance of Certification (MOC).

The collaborations are designed to expand the number and diversity of accredited CME activities that meet the boards’ MOC requirements for lifelong learning and selfassessment (Part 2), and to streamline the MOC process for accredited CME organizations and board-certified physicians. According to an ACCME press release, they pursued this collaboration in response to the needs and requests of physicians and of accredited CME providers that support physicians’ lifelong learning and improvement.

The collaborations continue the ACCME’s commitment to supporting the goals of MOC. Last year, the ACCME and the American Board of Internal Medicine (ABIM) initiated the first collaboration between a certifying board and the ACCME to streamline the integration of accredited CME and MOC. These latest collaborations will facilitate the ability of ABA- and ABP-certified physicians to access and participate in highquality accredited CME that meets the MOC lifelong learning and self-assessment requirements of their certifying boards.

All accredited CME providers in the ACCME system already use the ACCME Program and Activity Reporting System (PARS) to enter data about each of their CME activities. The ACCME maintains a publicly available list of accredited CME activities registered for ABIM MOC. The list will expand to include accredited anesthesiology and pediatric CME activities approved for MOC credit. CME providers that choose to participate will use PARS Colorado Medicine for May/June 2016

to attest their activities’ compliance with MOC requirements. When physicians complete activities, CME providers will report course completion through PARS to the ABA and ABP.

The ACCME, ABA and ABP expect to have the processes open for accredited CME providers later this year or early in 2017. The ACCME will release additional information as it is available. n

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Departments

medical news Federal CMS clarifies MACRA’s projected impact on solo physicians and small group practices In response to concerns raised by the American Medical Association and others, the Centers for Medicare and Medicaid Services issued a small practice fact sheet that outlines aspects of the proposed MACRA (Medicare Access and CHIP Reauthorization Act of 2015) regulation that were intended to address the needs of smaller physician practices.

MACRA replaced the flawed Sustainable Growth Rate formula for clinician payment in Medicare. The proposed rule would implement these changes through the unified framework called the “Quality Payment Program,” which includes two paths: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

The federal CMS fact sheet explains that the rather alarming impact table projecting a disproportionately severe impact on solo physicians and small groups is based on 2014 data when many small and solo practice physicians did not report their performance, therefore making it misleading. They agency says that the Quality Payment Program as proposed would provide accommodations for various practice sizes and configurations and, in particular, flexibility to small practices through exceptions like low-volume exclusions, alternate scoring, group reporting and others.

sistance to smaller practices and will include their recommendations in formal comments that will be submitted to the federal CMS in late June. The AMA has also updated their MACRA proposed rule summary. Access the most recent version at the following link: www.amaassn.org/resources/doc/washington/macra-summary-05052016.pdf. n

The AMA is working to identify further refinements that could be made to the proposed rule to provide relief and as-

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

Accredited CME is education that matters to patient care.

For more information contact the Colorado Medical Society CME office at 720.858.6309

Departments

medical news CMS honors two state science fair award winners for exceptional projects in health and medicine Nathan Panzer and Laura Fleming won the Colorado Medical Society Award for Excellence in the Health and Behavior Sciences in the junior and senior divisions of the 61st Annual Colorado State Science and Engineering Fair held on April 8 in Fort Collins.

A longtime supporter of the science fair, each year the CMS Education Foundation presents an award to one student from the junior high division and one student from the senior high division.

These students receive $100 and an invitation to the CMS Annual Meeting to display their project and receive recognition before physician attendees.

Nathan Panzer, winner of the CMS junior division state science fair award, shares his project with CMS judges Cory Carroll, MD, (left), and Peter Smith, MD, (right).

Colorado Medical Society members Cory Carroll, MD, and Peter Smith, MD, served as the official CMS judges at this year’s fair.

The junior division winner, Nathan Panzer of North Arvada Middle School in Arvada, presented his project, “Neutrophil Ups and Downs: The Effects of a Granulocyte-Colony Stimulating Factor on White Blood Cell Counts.” Nathan’s project was unique in many ways but most of all because he served as the patient in this case study. He wanted to find out how a granulocyte-colony stimulating factor (G-CSF) drug affects a patient’s white blood cell (WBC) count over a period of 21 days and performed daily manual WBC counts and differentials.

“As a teenager undergoing chemotherapy Nathan was not only the patient but a researcher,” Carroll said. “He monitored his own bone marrow response during treatment and how the G-CSF improved his WBC count. His work was thoughtful and well presented and extremely pertinent to his unique circumstances.”

The senior division winner, Laura Colorado Medicine for May/June 2016

Laura Fleming, winner of the CMS senior division state science fair award, shares her project with CMS judges Cory Carroll, MD, (left), and Peter Smith, MD, (right).

Fleming of Fairview High School in Boulder, presented “Valvular Interstitial Cell Activation in Response to Pro-Inflammatory Cytokine Treatment.” She studied calcific aortic valve disease and the connection between myofibroblast differentiation and pro-inflammatory cytokines. To demonstrate the connection, she cultured valvular interstitial cells (VICs) on 8-arm PEG-hydrogels with matrix metalloproteinase (MMP) degradable cross-linkers and a pendant adhesive peptide to allow the cells to grow throughout the hydrogel and adhere to it. She then added each cyto-

kine individually to mimic the inflammatory response of VICs and found that for two methods of quantification, the addition of TGF-β1 and IL-6 increased the measured level of α-smooth muscle actin, an indicator of myofibroblast activation.

“Laura showed tremendous understanding of the work she presented,” Carroll said. “Knowing that inflammation undermines most of the disease states this was a pertinent project. Her work was robust and novel, and touched on the emerging science of epigenetics.” n 47

Departments

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corresponds to your passion and interest. We are a full-spectrum family practice of four providers. We are located in an attractive office in the historic Highlands neighborhood just west of downtown Denver. We have a diverse and well-established patient base in a growing community with high demand for medical care. We use EMR and are open Monday-Friday. Our providers are able to spend time with their patients at each visit and have good work/life balance. We share light phone call duty only. We seek a dedicated physician to join our providers. Both full and parttime seekers are encouraged to apply.

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

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

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Colorado Medicine for May/June2016

The New CMS

7 Strategies to Achieve Work-Life Balance

The CMS Committee on Wellness is deeply concerned that burnout and work-life balance satisfaction among U.S. physicians is getting worse. The latest study shows that more than half of U.S. physicians experience professional burnout symptoms. Given the extensive evidence that burnout effects quality of care, safety and patient satisfaction, CMS is dedicated to addressing systemic contributing factors in the practice environment and helping physicians to care for themselves. We recommend that you:

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Prioritize what you value, and plan for it.

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Give yourself time to “just be” and feel rooted in the moment.

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Spend more time in planning, preparing and personal development and less time in the “crisis/deadline mode,” which fosters frenzy and imbalance. Suggested reading: “First Things First,” by Stephen Covey.

Perpetual “doing” ends up depleting us, leading to exhaustion and burnout. Through mindfulness, or focusing our awareness on the present moment, we nourish the body and mind. Consider creating a gratitude journal. Every day, list three things you are grateful for and why. Studies show this simple activity improves sleep, increases happiness and lessens depression.

Learn to say “no” to certain tasks, particularly when they are misaligned with your own values.

Saying no is a way to set boundaries and avoid falling prey to overcommitting or overextending yourself. ”No” is an essential step to creating more balance and ensuring you have time to prioritize your wellbeing.

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Practice self-care, focusing on small, actionable steps.

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Encourage your employer to measure workplace satisfaction.

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Learn concrete ways in which to slow the digital fire hose.

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Start by exercising and getting proper sleep. If you do not have time for yoga or the gym, online exercise classes or instructions are options. Keep the physical, emotional, intellectual and spiritual in balance. Realize that all four need to be engaged. Check out the CMS Physician Wellness Toolkit at www.cms.org/articles/category/physician-wellness.

Seventy five percent of U.S. physicians are now employed by large health care organizations. Improving efficiency and support in the practice environment will increase workplace satisfaction. The Mini Z survey developed by Dr. Mark Linzer is one way to measure physician experiences. The Mayo Clinic’s “Listen-Act-Develop” model is another strategy to reduce burnout and involve physicians in an organization’s design and mission.

Create digital limits from work or peers so you can properly rejuvenate. There are specific techniques that can be used to filter and organize information. Suggested reading: “4 Steps to Deal with Digital Overload,” www.nextgov.com/cio-briefing/wiredworkplace/2016/02/4-steps-deal-digital-overload/125767/.

On a yearly basis, review volunteer, charity or community service obligations that are taking up time.

Be honest with yourself about what you are interested in and committed to. Eliminate those activities that you no longer find fulfilling.

This frees up time to pursue other avenues, including self-care!

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

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

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

www.cms.org

Features

the final word

Lynn Parry, MD, CEJA Vice-chair

Council on Ethical and Judicial Affairs studies physician-assisted death; CMS Board votes to study issue further, educate members Physician aid in dying is, without a doubt, a difficult subject for our profession. That’s why when CMS leadership heard discussion around the issue growing louder in the political and public realms, the board of directors asked the members of the CMS Council on Ethical and Judicial Affairs (CEJA) to carefully consider the issue of physician-assisted end-of-life termination and develop a recommendation to bring back to the board in March as to whether CMS should change existing policy that opposes the practice.

To inform our discussion, CEJA sought input from physicians who specialize in palliative care, as well as attorneys, clergy and individuals representing patient organizations. We also reviewed the laws and experiences from the five state laws that currently allow the practice (referred to as physician-assisted suicide, or PAS, in our report). In addition, we also studied AMA ethical guidelines and the most current literature, and referred to the four fundamental principles of physician ethical responsibilities.

Perhaps the most informative were the results of the February 2016 CMS all-member survey. CMS retained Kupersmit Research to design and administer the survey. All members were invited to participate in focus groups to assist the pollster in the survey’s drafting and the overwhelming response allowed for three separate groups plus a fourth with CEJA members. CEJA reviewed the draft survey before it was distributed in early February to all CMS members with an email address on file. A recordsetting 631 physicians completed the survey in slightly less than two weeks, the most in such a short period of time since CMS began surveying members in 2008.

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CEJA then posed and answered the following questions.

1. What are the ethical and clinical guidelines/parameters/safeguards that should guide physicians and patients where adults in Colorado could obtain and use prescriptions from their physicians for self-administered, lethal doses of medications?

2. If it becomes apparent that the issue will become law in the near term should CMS oppose the proposal, support the proposal or be neutral on the proposal and work for patient and physician safeguards that reflect the ethical and clinical guidelines/parameters/safeguards established by CEJA? 3. How, if at all, should current CMS policy be amended?

In answering the first question, we defined the qualifications of a patient and made recommendations to hold physicians harmless. To the second question, CEJA felt that CMS should be neutral, with qualifications. And to the last question, CEJA felt that CMS policy should be amended in a manner that does not formally take a strong position for or against physicianassisted suicide but rather infers a position of thoughtful, studied neutrality.

CEJA recommended that CMS policy: 1. Stress the need for increasing awareness among physicians and the public around end-of-life issues and the importance of palliative or hospice care.

2. Ensure there are adequate protections in state law or in a constitutional amendment for both physicians and patients should such a system be approved by voters or the legislature in the future.

3. Allow options for patients and physicians to pursue mutually acceptable ap-

proaches without violating any party’s fundamental values.

4. Substitute PAS with the term Physician-Assisted Death (PAD).

I presented the full report to the CMS Board of Directors at the March meeting.

Board members were also informed of the current political landscape and reviewed the results of the all-member survey and member feedback after the survey.

After extensive discussion, the board moved to do the following: 1. Circulate the CEJA report to the entire membership, including component and specialty societies, and urge peerto-peer discussion and further input to CEJA. 2. Refer the report back to CEJA to incorporate the recommendations into the policy language and to consider additional member input.

3. Ask the Re-engineering the Annual Meeting Work Group to hold an educational session on physician-assisted death at the Annual Meeting in September.

4. Put the report and recommendations through the virtual policy forum before the November board vote so that the entire membership will have an opportunity to participate.

I am proud of our CMS leadership for giving the members of CEJA and our membership the time and the resources to fully explore our own individual and collective attitudes. The members of CEJA have been extraordinary in their ability to craft an approach that respects physicians and protects patients if PAD acquires legal status in Colorado. Please read CEJA's report in its entirety by visiting www.cms.org n Colorado Medicine for May/June2016

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