May-June 2018 Colorado Medicine

May/June 2018

Volume 115, Number 3

CMS AND COMPONENTS LAUNCH “KNOW YOUR LEGAL RIGHTS” No need to read the fine print: New online tool puts a decade of hard-fought physician protections at your fingertips

Award-winning publication of the Colorado Medical Society

contents May/June 2018, Volume 115, Number 3

Features. . .

Cover story Although it may

sometimes seem like the deck is stacked, Colorado physicians have an arsenal of state laws at their disposal thanks to decades of work by the Colorado Medical Society, component medical societies and our allies over the course of many legislative sessions and regulatory hearings. Do you know how to find and deploy these rights to counter health plan barriers to care? We do, and now you can too with Know Your Legal Rights. Read more starting on page 6.

Inside CMS

5 President’s Letter 25 COPIC Comment 26 Annual Meeting preview 28 Reflections 30 Introspections

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Legislative success–With the 2018 Colorado General Assembly coming to a close, CMS physician members celebrate a strong 2018 legislative session.

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Honors and awards–Donald Stader, MD, an emergency physician and leader in the movement to combat the opioid epidemic, was honored as one of 40 extraordinary metro Denverites under 40-years-old recognized for their commitment to community and business leadership.

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State Innovation Model–A new report issues a call to action to address the mental health of males of all ages.

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Performance review–The CMS Board of Directors is pleased with the first year of implementation of Central Line and will continue to fine-tune this tool for optimal member satisfaction and engagement.

23 Opinion/editorial–Two emeritus physicians reflect on the humble stethoscope and how it can be used to detect useful information – with patience and proper practice.

38

Final Word–Longtime COMPAC chairperson Lee Morgan, MD, reflects on CMS’ tremendous track record in advocacy to obtain the physician protections summarized in Know Your Legal Rights.

Departments 32 33

37

Medical News CMS Corporate Supporters and Member Benefit Partners Classified Advertising

Colorado Medicine for May/June 2018

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and STAFF

2017-2018 Officers M. Robert Yakely, MD

President Debra J. Parsons, MD, FACP

President-elect David Markenson, MD

Treasurer Alfred D. Gilchrist

Chief Executive Officer Katie Lozano, MD, FACR

Immediate Past President

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

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

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

Division of Health Care Financing Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org Division of Information Technology/Membership Tim Roberts, Senior Director, Tim_Roberts@cms.org Krystle Medford, Director, Membership, Krystle_Medford@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org Division of Government Relations Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Emily Bishop, Program Manager, Emily_Bishop@cms.org Colorado Medical Society Foundation Colorado Medical Society Education Foundation Mike Campo, Staff Support, Mike_Campo@cms.org

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

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

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

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

Printed by Hampden Press, Aurora, Colo.

Inside CMS

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

There ought to be a law…and there probably is The Colorado Medical Society and our component societies around the state are pleased to launch the Know Your Legal Rights database: an online, searchable compilation of all of the Colorado laws in place to protect you and your patients from the unfair, predatory and unscrupulous practices of health plans. You can find the database at www.cms.org/kylr.

These physician protections have been secured through more than a decade of hard-hitting advocacy by CMS and our allies in the General Assembly and the rule-setting process, but many physicians are unaware that these laws exist or how to find and utilize them. With Know Your Legal Rights, CMS members and their practice staff can now easily access a robust guide to these rights that is searchable by topic or keyword.

Read more about the tool in the cover story starting on page 6 and in the Final Word column on page 38.

Colorado Medicine for May/June 2018

Go to www.cms.org/kylr to access the Know Your Legal Rights database. Sign in with your CMS username and password.

If you're like me and have forgotten your username or password, don’t worry, there is a link on the page to easily recover them using your email address. In addition, CMS members’ practice managers can request a separate login from the CMS Membership Department.

Once logged in, scroll through the topic list or enter keywords in the search bar at the top of the page to find laws relevant to the problem, a summary of the law, and details about how the law affects physicians. The exact references to Colorado statutes are available in the sidebar of each entry.

We have much more planned to make Know Your Legal Rights as effective and valuable as possible for Colorado physicians, and for more projects that com-

bine the collective strengths of the Colorado Medical Society and component medical societies to demonstrate our commitment to physicians around Colorado. I invite you to explore this tremendous tool and share your comments with me on this and future initiatives by emailing president@cms.org n

“These physician protections have been secured through more than a decade of hardhitting advocacy by CMS and our allies in the General Assembly and the rule-setting process.”

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“KNOW YOUR LEGAL RIGHTS�

A new and exclusive benefit for CMS members Searchable, online database compiles years of public policy victories for physicians to use in disputes with health plans Marilyn Rissmiller, Senior Director, Division of Health Care Financing

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Colorado Medicine for May/June 2018

Cover Story Although it may sometimes seem like the deck is stacked, Colorado physicians have rights in disputes with health plans. Lots of them. And thanks to a new tool from the Colorado Medical Society and the statewide network of CMS component societies, these rights are easily searchable in one place.

The arsenal of state laws that grant important provider protections comes from decades of work by CMS and allies over the course of many legislative sessions and regulatory hearings. But these legal rights are spread across numerous statutes and before now were not readily available, making it difficult to find and deploy these rights to counter health plan barriers to care. CMS staff combed years of statutes to produce helpful summaries of physician rights and incorporated this information into a list of topics easily searchable in a new

members-only online database: Know Your Legal Rights.

With the deployment of Know Your Legal Rights, available at www.cms.org/ kylr, Colorado physicians and their practice staff are now just a keystroke away from knowing the legal tools already available and how to use them effectively.

A few of the highlights from the new tool include summaries and citations for: • Protections from physician profiling, • Expedited prior authorization and referrals, • Guaranteed telehealth coverage, • Protection against anti-retaliation, • Help with narrow networks, • Guaranteed timely payment, • Fairness in contracting, and

• The right to appeals.

See the highlight box below for a full list of topics covered.

A two-minute instructional “how-to” video on the Know Your Legal Rights database is available on the database landing page. Members must be logged into the CMS website to access the tool. Staff of CMS members can request a login by contacting membership@ cms.org with your name, the name of the practice, and a list of the physicians at your practice (one of whom must be a CMS member).

The launch of Know Your Legal Rights and the years of work that secured these rights are your medical society dues dollars at work. Annual CMS member

Physician protections contained in Know Your Legal Rights The Know Your Legal Rights database is your exclusive doctorfriendly way to search and find what you need to know about your rights under Colorado law.

• • • •

Access plan [Network adequacy] Advance payment tax credits Appeal of designation Assignment of benefits [nonprofit] • Assignment of benefits • Carrier-provider dispute resolution • Clean claim requirements • Continuity of care • Contracts with health care providers • Coordination of benefits • De-selection, termination, nonrenewal or tiering • Dispute resolution • Eligibility verification • Experimental/investigational • External review • Fee schedule • Gag clause • Grace period • ID card • Independent external review

Colorado Medicine for May/June 2018

• Interest payment • Intermediaries • Internal review, utilization review • Investigational • List of plans, product offerings with participation status • Material change to contract • Medical necessity denial • Network adequacy standards • Non-participating physician services • Non-renewal of contract • Notification of administrative policies • Out-of-Network emergency services • Out-of-network services at in-network facility • PCP standing referral • Participation list • Physician designation and disclosure • Physician terminating contract • Pre-authorization (prior authorization, pre-certification) • Pre-certification • Prior authorization • Prior authorization [form] -

drug benefits • Procedure for denial of benefits [internal review] • Profiling • Prompt payment of claims, interest, penalty • Provider directory requirements • Recoupment • Rental network • Required contract provisions • Requirements for carriers and participating providers • Retaliation • Retroactive adjustments • Second opinion • Selection standards/ reconsideration • Standard I.D. cards • Step therapy • Telehealth • Telemedicine • Termination of contract • Tiering • Timely Payment • Transparency of charges by health care providers • Uniform credentialing application • Utilization review

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Cover story (cont.) surveys continue to demonstrate that health plans have too much power over physicians and that care quality, access and professional satisfaction are negatively affected by this imbalance. CMS’ focus on the many inequities in the current multi-payer system is critical so that interactions between physicians and insurance companies can center on value rather than market share and volume.

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

Serving medical professionals is all we do.

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

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

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

“Health care delivery and financing is increasingly complex, and our patchwork of payers results in an unnecessarily complicated system,” said Denver ophthalmologist Alan Kimura, MD, MPH. “As a practicing physician, my direct experience of this complexity is at times baffling to comprehend, as it is frustrating to fix. The anxiety all physicians feel is the product of uncertainty and powerlessness. The anxiolytic, if you will, requires working to reduce the uncertainty overlaid upon our practices by the payers, and reclaiming our power as physicians.

Contractual language matters.”

“Serving alongside dedicated physician colleagues in CMS, I bear direct witness that CMS has proven to be our best ally in this struggle against overbearing legislation and regulation,” Kimura said. “Legal rights protecting physicians from payer abuse are not handed to us, but rather must be actively defended.”

The Colorado Medical Society and the component societies will continue to work with the General Assembly and the state’s regulators to enact and refine the laws and rules governing medical practice, all those who review and pay physicians’ bills, provide credentialing, and perform just about any other action that influences physicians’ clinical and business judgement.

And with this work in the legislative and regulatory spheres, the list of provider protections in Colorado will grow.

Much more is planned for this robust tool. Send feedback by email to membership@cms.org. n

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Colorado Medicine for May/June 2018

Compliments of:

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Colorado Medicine for May/June 2018

9 Card Colorado Drug

Features

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

CMS celebrates strong 2018 legislative session The regular session of the 2018 Colorado General Assembly adjourned on May 9 and we are celebrating the bills that died as much as those that passed into law. We expended considerable resources advocating for health care issues that improve patient care, promote physician professional satisfaction and create healthier communities in Colorado.

The following summaries represent only a handful of the bills successfully lobbied

by CMS during the course of the fourmonth legislative session.

The liability climate Colorado’s relatively stable liability and professional review climate was maintained. While no bills were filed, both bodies of law will be under assault in the 2019 legislature (stay tuned).

Reversing the opioid crisis Colorado, like virtually every state in the country, is struggling with ways to mitigate the medical and economic consequences of an opioid-addicted patient cohort of overwhelming magnitude.

Five of six bills resulting from a 2017 interim legislative opioid abuse study passed into law. They include measures that increase funding for access to treatment, enhance misuse prevention, require health plans to cover certain FDAapproved drugs for medication-assisted opioid dependence treatment without prior authorization, and enact safer opioid prescribing.

SB18-022, Clinical Measures for Safer Opioid Prescribing This legislation will, for acute pain circumstances, limit initial prescriptions to seven days for patients who have not had an opioid prescription in 12 months by 10

that physician, with the discretion to include a second fill for a seven-day supply.

The limits on initial prescribing do not apply, if, in the judgement of the physician the patient: • Has chronic pain that typically lasts longer than 90 days or past the time of normal healing as determined by the physician, or following transfer of care from another physician who prescribed an opioid to the patient; • Has been diagnosed with cancer and is experiencing cancer-related pain; • Is experiencing post-surgical pain that, because of the nature of the procedure, is expected to last longer than 14 days; • Is undergoing palliative care or hospice care focused on providing the patient with relief from symptoms, pain, and stress resulting from a serious illness to improve quality of life.

The bill also requires prescribers to check the PDMP (Prescription Drug Monitoring Program) prior to prescribing the first refill, with certain exemptions.

While these provisions will repeal in three years, legal protections for PDMPgenerated report cards were included over the initial objections of the Colorado Trial Lawyers Association and will remain in effect. Additionally, failure to check the PDMP before prescribing a second fill only constitutes unprofessional conduct when done repeatedly.

We urge all physicians to be on the watch for more detailed information on SB18-022 in the near future. CMS will be providing a full explanation of the new law, the obligation of physicians and additional resources.

Status: Passed, awaiting the governor’s signature.

HB18-1003 Opioid Misuse Prevention The bill establishes the following specific measures to combat opioid misuse in Colorado: • Creates the Opioid and Other Substance Use Disorders Study Committee; • Requires the governor to direct the Colorado Consortium for Prescription Drug Abuse Prevention to report on recovery services and approaches in other states to the General Assembly; • Authorizes school-based health centers to apply for grants to expand behavioral health services to include substance use disorder treatment; • Directs the Department of Health Care Policy and Financing to award grants supporting substance abuse screening, brief intervention and referral programs; • Establishes programs to prevent youth addiction and support youth whose family members experience addiction; and • Establishes continued education programs for prescribers of pain medications to safely and effectively manage patients with chronic pain.

Status: Passed, awaiting the governor’s signature.

HB18-1007 Substance Use Disorder Payment and Coverage This legislation seeks to require all individual and group health benefit plans to provide coverage without prior authorization for a five-day supply of at least one FDA-approved drug for medicationColorado Medicine for May/June 2018

Features assisted opioid dependence treatment for a first request within a 12-month period.

Status: Passed, awaiting the governor’s signature.

HB18-1136 Substance Use Disorder Treatment This bill adds residential and inpatient treatment coverage to Colorado Medicaid.

Status: Passed, awaiting the governor’s signature.

SB18-024 Expand Access Behavioral Health Care Providers The final bill introduced from the 2017 interim legislative study, it amends the Colorado service corps program by expanding the availability of behavioral health care providers in shortage areas in the state by establishing a system for school loan repayment and a scholarship for providers trained in addiction counseling.

Status: Passed, awaiting the governor’s signature.

HB18-1211 Medicaid Fraud Control Unit CMS was committed to passing this legislation and worked closely with stakeholders to secure necessary amendments.

This legislation establishes the Medicaid Fraud Control Unit in the Department of Law and will set specific, but higher, criteria for defining fraud that does not exist in current law. Responsible for investigating and prosecuting Medicaid fraud and waste, the unit is also responsible for monitoring patient abuse, neglect or exploitation. The bill also creates offenses related to making false statements on applications, Medicaid fraud, and credit and recovery of Medicaid payments.

Kickbacks, bribes and rebates related to Medicaid administration are also made unlawful.

HB18-1245 Prohibit Mental Health Care Conversion Therapy This bill, supported by CMS, sought to prohibit a mental health care provider from using conversion therapy with a patient under 18 years of age.

Status: Passed the House; died in the Senate.

HB18-1365 Primary Care Infrastructure Creation This bill, supported by CMS, would have established a primary care payment reform collaborative to evaluate primary care investment based on data compiled from plans and physicians.

Status: Died in the House.

Bills opposed by CMS HB18-1279 Mandatory Electronic Prescribing Controlled Substances CMS strongly and successfully opposed this bill, which sought to mandate electronic prescribing for all schedule II, III

Status: Passed and signed by the governor.

Status: Passed, awaiting the governor’s signature.

Other bills supported by CMS HB18-1006 Infant Newborn Screening This bill seeks to make newborn hearing screenings more timely and requires the state Board of Health to develop rules concerning the requirements for newborn genetic and metabolic disorders, information reporting and follow-up services for infants at risk of hearing loss or who fail to receive screenings.

Status: Passed, awaiting the governor’s signature.

HB18-1187 FDA Cannabidiol Use Use of a prescription drug that contains cannabidiol and is approved by the U.S. Food and Drug Administration would automatically be approved in Colorado under this bill. Drug products containing cannabidiol that are approved by the FDA are excluded from the definition of marijuana; however this change does not restrict or otherwise affect regulation of marijuana and industrial hemp authorized under state statute.

Colorado Medicine for May/June 2018

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Legislative success (cont.) and IV controlled substances. Supported by retail pharmacies on the basis that counterfeit and fraudulent prescriptions will be reduced, the bill will undoubtedly emerge in some form in 2019. CMS was not convinced that mandatory e-prescribing would meaningfully assist in reversing the opioid crisis nor could CMS agree to the violation provision of the bill making failure to e-prescribe grounds for unprofessional conduct under Colorado Medical Board jurisdiction.

Status: Died in the Senate.

HB18-1128 Consumer Data Protections Except for conduct in compliance with applicable federal, state or local law, this bill requires covered and governmental entities in Colorado that maintain paper or electronic documents containing personal information to develop and maintain written policy regarding their proper disposal.

Additionally, the bill expands existing laws governing notifications in the event of a data breach.

CMS opposed the introduced version of this bill, which did not provide exceptions for HIPAA compliers. The bill passed the General Assembly with amendments rectifying some of CMS’ concerns but still requiring physicians to comply with a shorter notification timeline.

Status: Passed, awaiting the governor’s signature.

HB18-1263 Medical Marijuana Use for Autism and Acute Pain Under current law, PTSD is a disabling medical condition eligible for treatment by medical marijuana. This bill adds autism spectrum disorder as diagnosed by a licensed mental health provider or physician to this list.

An earlier version of the bill also sought to insert acute pain, which CMS strongly opposed. A House amendment removed acute pain and the Senate went a step further, adding an amendment establishing a grant program to gather research regarding the efficacy and safety of ad-

ministering medical marijuana for pediatric conditions.

Status: Passed, awaiting the governor’s signature.

HB18-1286 School Nurse Give Medical Marijuana at School Currently, a primary caregiver may possess medical marijuana and administer it to a student at school as long as the marijuana is in a non-smokable form. This bill allows school personnel to administer and possess the medical marijuana, specifically a school nurse or school nurse’s designee, or other personnel designated by a parent.

The bill requires that the medical marijuana be stored securely with clear dosage, timing and delivery instructions provided by the student’s physician and that the physician deliver the medical marijuana directly to a person designated by the school for this task. The student would not be allowed to handle the medical marijuana on the grounds of the school, school bus or during a schoolsponsored event.

While under consideration, the Senate adopted an amendment regarding establishing a written plan for administration and a school’s ability to opt out.

Status: Passed, awaiting the governor’s signature.

HB18-1358 Health Care Charges Billing Required Disclosures CMS was concerned by the administrative burden of this bill and the complicated nature of health care charges, which the bill sought to further require disclosures of by health care facilities, providers, pharmacies and health insurers. A ballot initiative which will require the disclosures is expected to appear on the November ballot.

Status: Died in the House.

SB18-214 Request Self-Sufficiency Waiver Medicaid Program This bill sought to direct the Department of Health Care Policy and Financing to request authority from the

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Colorado Medicine for May/June 2018

Features federal government to implement selfsufficiency provisions as part of Medicaid. Specifically, the provisions revolved around employment status and monthly income verification. The bill would also have created a lifetime limit on Medicaid benefits of five years and imposed copayments on ambulance and emergency services to deter their use for nonemergency services. CMS opposes increasing obstacles for at-risk individuals and families to receive Medicaid.

Status: Died in the Senate.

Other bills of interest SB18-237 Out-Of-Network Providers/ Carriers Required Billing Disclosures CMS has consistently been at the forefront of this long-standing issue of out-ofnetwork disclosures and payment. This year was no different, as CMS worked with the bill drafters and sponsors for months advocating on behalf of physicians.

The resulting bill sought to address unexpected charges for out-of-network services, requiring notices of a facility or provider’s insurance affiliations. In addition, the bill required out-of-network providers and facilities to refund any overpayments within 45 days, or risk paying interest on the overpayment.

While CMS is committed to solving the out-of-network issue, the Council on Legislation was concerned about the overpayment refund period and subsequent interest accrual. Because of these concerns, CMS chose to monitor the bill.

The Senate Health and Human Services Committee postponed the bill indefinitely; however, CMS worked hard to subsequently draft a late bill based on the feedback from the committee and stakeholders.

Status: Postponed until next year.

SB18-082 Physician Noncompete Exemption for Rare Disorder This bill provides an exception to noncompete agreements in cases where the physicians are providing continued care to patients with rare disorders.

Colorado Medicine for May/June 2018

CMS worked with the House sponsors to secure an amendment limiting liability for a departing physician’s post-termination treatment of a patient. CMS is a strong supporter of facilitating patient access, especially in cases of rare disorders.

Status: Passed and signed by the governor.

HB18-1313 Pharmacists to Serve as Practitioners The purpose of this bill is to clarify that a licensed and qualified pharmacist, under the Colorado Medical Assistance Act or pursuant to a collaborative pharmacy practice agreement, may serve as a practitioner and prescribe over-thecounter medication. CMS ensured that an amendment was added to this bill to clarify that pharmacists do not have independent prescriptive authority.

Status: Passed, awaiting the governor’s signature.

HB18-1433 Naturopathic Doctor Terminology and Disclosure In a bill killed earlier this session, HB181068, naturopaths sought to remove the requirement to use the title “registered naturopathic doctor” or the initials

“R.N.D.” After HB18-1068 was postponed indefinitely, the Council on Legislation Scope of Practice Subcommittee met with stakeholders to craft language that would clarify naturopathic terminology and patient disclosures as well as remove “registered” from their title.

All sides approved the drafted language and it was introduced as a late bill. Rep. Lontine stated, “It was (Sen. Tate’s) intent to be sure that any Colorado resident would clearly know that a Colorado registered ND is not a licensed physician.”

Status: Passed, awaiting the governor’s signature.

CMS continually demonstrates influence at the Capitol thanks to strong lobbying efforts and through the engagement and involvement of dedicated physicians on the Council on Legislation.

Active involvement in advocacy is crucial to Colorado physicians and patients, and CMS encourages those interested to get involved. Go to www.cms.org/ advocacy for more information.

Watch for additional coverage of the session in the July/August issue of Colorado Medicine. n

New member benefit for CMS members only!

Know Your Rights database Physician practices have rights under Colorado law that can be exercised to mitigate health plan barriers to care.

These rights have been summarized and incorporated into a members-only online database – Know Your Legal Rights – at www.cms.org/kylr for easy access.

The members-only tool is searchable, and will help physicians and practice managers understand what their rights are in disputes with health plans.

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Features

Honors and awards Kate Alfano, CMS Communications Coordinator

Donald Stader, MD

CMS leader in opioid epidemic awareness honored as one of Denver’s “40 under 40” Donald Stader, MD, an emergency physician, innovator and entrepreneur who works for CarePoint Healthcare and practices at Swedish Medical Center in Englewood, Colo., has been selected as one of the Denver Business Journal’s “40 under 40.” This honor recognizes 40 extraordinary metro Denverites under 40years-old for their commitment to community and business leadership. In the award’s 22nd year, the journal received nearly 500 nominations for 259 individuals. Stader was recognized at the annual awards luncheon on March 21 and profiled in a special report on March 23.

At Swedish Medical Center, he serves as the associate medical director and emergency medicine section chief.

Swedish Medical Center is a level-one trauma center, nationally recognized stroke center, cardiac cath center and burn center that sees approximately 60,000 Coloradans annually. Swedish Medical Center also holds the distinction of being the first Colorado emergency department to adopt the Alternatives to Opioids (ALTO) first approach for pain control, a program that Stader championed and implemented that is now being adopted across Colorado.

Stader holds a medical degree with honors from Baylor College of Medicine, where he was an Albert Schweitzer Fellow, and he completed an emergency medicine residency at Carolinas Medical Center. He serves on the Colorado chapter of the American College of Emergency Physicians (ACEP) board of directors and chairs Colorado ACEP’s Opioid Task Force; was the editor-inchief of Colorado ACEP’s 2017 Opioid Colorado Medicine for May/June 2018

Stader was honored by the Denver Business Journal at a March 21 awards lunch.

From left: CMS President-elect Deb Parsons, MD, FACP; wife Andi Stader; Donald Stader, MD; daughter Josephine; John Hughes, MD, chair of the CMS Committee on Prescription Drug Abuse; and Neal O'Connor, MD, CMO, Carepoint PC. Prescribing and Treatment Guidelines, which the Colorado Medical Society Board of Directors voted to adopt in September 2017; is an opioid clinical consultant for the Colorado Hospital Association; and served as CMS’ representative to the Colorado General Assembly’s bipartisan Opioid and Other Substance Use Disorders Interim Study Committee.

Stader is a renowned expert on the opioid epidemic, and a member of the Colorado Consortium on Prescription Drug Abuse Prevention. He has lectured locally and nationally on how to best confront the opioid epidemic.

Stader and Colorado ACEP partnered with the Colorado Hospital Association

to launch one of the largest emergency-department-based opioid reduction pilots in the nation. As the physician lead, he trained physicians in 11 emergency departments across Colorado.

The pilot returned remarkable results: a 36 percent reduction in opioid administrations when compared to the same time period in 2016, which amounted to 35,000 fewer individual opioid administrations between the 2017 pilot and the 2016 baseline period.

In addition to medicine, Stader has a passion for the arts. He works as a film producer and was the creative force behind an emergency medicine documen-

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Honors and awards (cont.) tary. In an interview for the profile, he named this as his proudest professional achievement: “In residency, I led the creation of the documentary ‘24/7/365: The Evolution of Emergency Medicine.’

It won a regional Emmy Award, several Telly Awards and had a nice film festival

“Imagination helps solve problems, create opportunities, build new partnerships and create a better, more just world.”

- Donald Stader, MD run. It is an enduring tribute to many of my medical heroes, whom I was able to meet and learn from during the course of our documentary production.”

He also prides himself on giving back to the community, and has founded two Colorado-based non-profit organiza-

tions: The Emergency Medical Minute and The Last Words Project. The Emergency Medical Minute provides free online emergency medical education to improve the medical knowledge and care of doctors, nurses, paramedics and health professionals working in emergency medicine. The Last Words Project allows individuals with terminal conditions or dangerous vocations to speak “their last words on their terms” by recording messages for their loved ones.

In the interview he identified the No. 1 quality for professional growth as “imagination,” which “helps solve problems, create opportunities, build new partnerships and create a better, more just world.”

His advice for others looking to grow professionally: “Find work you are passionate about, with people you like to spend time with. If you find a company or vocation that has these two ingredients, you’ll be able to invest yourself and your talents completely and have fun doing it.” n

Please help support the Colorado Medical Society Foundation In March 1997, Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization.

The foundation’s mission is to administer and financially manage programs that seek to improve access to health care and health services, with the potential to improve the health of Coloradans.

The Board of Trustees of CMSF is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado.

The spirit of Colorado is alive in the many ways that we help our neighbors.

Call 720-858-6310 for more information and to learn how you can donate.

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Colorado Medicine for May/June 2018

Colorado Medicine for May/June 2018

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Features

State Innovation Model Heather Grimshaw, Communications Manager, SIM

Mental health call to action focuses on males in Colorado New partnerships that stretch beyond health care clinics are key to addressing a mental health crisis in Colorado and nationwide, according to a new report issued by health care experts convened by the Colorado State Innovation Model (SIM) and released during Mental Health Month.

“The multi-disciplinary approach to addressing the mental health of boys and men will help us change the health care dynamic in our state,” said Gov. John Hickenlooper. “When health care experts work alongside other partners, we ensure Coloradans receive the care they need when they need it most.”

Strategies in “Raising the bar on behavioral health awareness, prevention and treatment for boys and men: A call to action” will help increase awareness of mental health conditions that influence all aspects of a person’s life.

The 42-page call-to-action report represents a year of work initiated and led by the SIM population health workgroup, one of seven workgroups that guide the federally funded governor’s office initia-

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

Access the CMS website at www.cms.org to stay current on the latest news affecting your practice.

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tive, which helps hundreds of primary care practice sites and four community mental health centers integrate behavioral and physical health.

in indicators for methamphetamine, heroin and prescription opiate abuse as well as fatal overdoses related to each.

Answering the call for help “This actionable report will lead to meaningful change that results in healthier Coloradans,” says SIM Director Barbara Martin, RN, MSN, ACNPBC, MPH. “As we expand partnerships with communities, schools, employers and faith-based organizations, we increase our ability to improve health across Colorado.”

“This call to action will be used to shape behavioral health in Colorado to ensure better health outcomes,” says Tista Ghosh, MD, MPH, director of public health programs and deputy chief medical officer, Colorado Department of Public Health and Environment, co-chair of the SIM population health workgroup.

Examples of targeted outcomes published in the report: • By 2023, develop and implement local mental health resiliency training programs for boys and men that are used in community organizations including schools, employment settings, faith-based organizations and other community settings.

• By 2028 Colorado will see a decrease in the percentage of men who report poor mental health.

• By 2028 Colorado will see a decrease in suicide rates for boys, working-age men and older men.

• By 2028 Colorado will see a decrease in prescription drug overdose deaths for boys, working-age men and older men.

Statistics cited in the report that highlight the need for a more collaborative approach to mental health: • In Colorado, one in five people need mental health services.

• Colorado consistently ranks in the top 10 states for suicide death rates, ranking as fifth in 2016.

• Colorado is seeing an upward trend

With a timeline that stretches through 2028, the report is intended to redefine how we talk about mental health, screen for conditions, enable appropriate interventions and expand access to the right care at the right time in the right places.

Publication of the report is a culmination of time, energy and passion for SIM workgroup members, who will play active roles in disseminating findings and engaging partners in activities.

Implementation strategies “I can already see ways this will be used in local public health agencies across the state,” says John Douglas Jr., MD, executive director for the Tri-County Health Department, co-chair for the SIM population health workgroup.

The report’s focus on boys and men is appreciated by SIM partners at the Jefferson Center for Mental Health, one of four bidirectional health homes that is integrating physical and behavioral health with SIM funding. The team started paternal and primary child caregiver depression and anxiety screenings in January and have received positive Colorado Medicine for May/June 2018

Features feedback from new fathers about what they see as a welcome interest in their health. Additionally, Jefferson Center has started screening all parents and primary child caregivers for Adverse Childhood Experiences (ACEs). Studies have shown that high ACEs can affect a person’s physical and mental health and possibly affect their parenting skills and the family’s health.

“After a baby is born, there is a strong focus on the mother and we have noticed the father is often ignored,” says Megan Swenson, MA, LPC, LAC, manager of integrated care and care coordination for Jefferson Center. “It’s opened a lot of conversations and given us the opportunity to delve into the health of the family, the health of the child and the health of the father. We talk to fathers about why they are important to the health of their family.”

Shannon Tyson-Poletti, MD, assistant medical director of Jefferson Center, concurs. “This has been a passion of mine and for our team for a long time,” she says. “We focus a lot on moms and

Colorado Medicine for May/June 2018

Features parenting with moms but we haven’t focused on parenting and mental health of the dads, which is equally important for the development of the family and child.”

The team screens all primary child caregivers for depression and anxiety, and offers healthy relationship counseling for adolescent young men and women, two practical examples of helping the population highlighted in the SIM report.

“Our hope with that is to prevent trauma, domestic violence, future child abuse, substance abuse and mental illness in these young people,” explains Tyson-Poletti. “Men and boys are equally important in this equation and cannot be ignored. Early intervention, rather than later intervention, leads to improved physical and mental health outcomes. We think this is a real opportunity.”

Read the report for more information and context about how you can participate in this call to action. n

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

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Features

Performance review Kate Alfano, CMS Communications Coordinator

CMS Board of Directors reviews Central Line, fulfilling promise to members to ensure its effectiveness in engagement The Colorado Medical Society Board of Directors requested and conducted a performance review of Central Line, the first-in-the-nation virtual policy forum, at their March 16 meeting. This is the second year of implementation of this member engagement platform. Central Line was launched in November 2016 as a result of an extensive two-year study of CMS governance and communications that revealed that CMS members want more direct and relevant communication, want their voice heard in policy decisions, and want a more balanced approach to governing.

Following a robust discussion in March, the board agreed that ideas generated would be returned to the board for further discussion and possible action at the May 18 meeting. View the graphic on the opposite page for statistics on member participation, geographic participation, interest area participation, accessibility and use.

“Board members were pleased with Central Line’s first year performance,

Plug in to your reinvented medical society! www.cms.org/central-line 20

specifically the number of members that have engaged and how the program has opened new lines of communication with members,” said CMS President M. Robert Yakely, MD. Points surfaced for discussion in May include application upgrades to allow board members to identify names of physicians and their votes and comments when reviewing votes by district, how to make the platform more mobilefriendly, and how to increase awareness and usage of the Central Line platform.

The CMS Board of Directors encourages all members to use Central Line to submit policy proposals, review and vote on policy proposals submitted by their colleagues, and give feedback to the board before and after board meetings.

Most important, members are encouraged to designate interest areas in their profile section of Central Line. An interest area is a subject matter area that a member is interested in or in which a member has particular expertise. Central Line assigns policy proposals to interest areas and gives physicians in these designated areas the first opportunity to review and provide input on proposed CMS policy. It’s like a committee without any in-person meetings, and there is no requirement for physicians in these groups to respond to each proposal assigned to their interest area.

Interest areas include: • Cost Control • Direct Primary Care

• Health Care Reform • Health Information Technology and Telemedicine • Medicaid • Opioid-Abuse/Misuse • Patient Safety and Professional Liability • Payment Reform • Physician Wellness • Political Action • Private Payer Issues • Public Health • Quality Improvement, Transparency and Public Reporting • Scope of Practice • Workers Compensation • Workforce Central Line does not replace in-person meetings, which the board of directors feels are still imperative – particularly during a time when physicians feel isolated and desire peer interaction. The annual meeting has been transformed into a more relevant gathering for a broader demographic of CMS members, and regional forums held throughout the state give members the opportunity to network and discuss critical issues in person. This is in addition to the opportunity to provide input and feedback on policy-making electronically 24/7 through Central Line.

Go to www.cms.org/central-line to submit policies, view current policies under consideration, vote on these proposals or board actions, and adjust profile settings such as interest areas or communication preferences. n

Colorado Medicine for May/June 2018

2017 PERFORMANCE 2017 PERFORMANCE Line was purposefully designed Central LineCentral was purposefully designed with the goals: following goals: with the following participation member participation in Colorado in Colorado Medical Medical Society Societypolicy policy 1 Empower 1 Empower member making and governance making and governance

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Colorado Medicine for May/June 2018

88% 88%

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Colorado Medicine for May/June 2018

Features

Opinion/ editorial Robert N. Alsever, MD, FACP, FACE, and Carl E. Bartecchi, MD, MACP

The vanishing physical exam: Things we forgot from medical school Editor’s note: Colorado Medicine occasionally accepts and publishes opinion/ editorial columns on topics of interest to Colorado physicians and consistent with topics associated with the Colorado Medical Society operational plan. The opinions expressed in all guest opinion/editorials are those of the author and do not necessarily reflect the views of the Colorado Medical Society.

The stethoscope – commonly seen wrapped around the neck of a physician but now also a nurse, nurse-practitioner, physician assistant, paramedic, emergency medical technician and others – has become the sign of a professional health care provider. It gives credibility by suggesting the person wearing it has special skills to use the diagnostic findings it reveals.

Though the potential to detect useful information – heart valve problems, heart failure, heart rhythm problems, partially occluded blood vessels, pneumonias, lung fluid accumulations, asthma, emphysema and so much more – is there, its effective use and interpretation requires plenty of expert training and knowledge of anatomy and heart and lung pathology.

Before the $300 chest x-ray, the $4,000 CT scan and ECHO, sometimes all a diagnosis requires is a good stethoscope; a careful, well-trained listener; and proper application of the stethoscope to the skin over the part of the body under surveillance. We emphasize SKIN because more and more in the media, in doctors’ offices and in other health care settings Colorado Medicine for May/June 2018

we see the improper use of this valuable tool while examining a patient: stethoscopes placed over shirts, blouses, pants, paper drapes and even sweaters. This greatly diminishes the possibility of detecting the sometimes soft or difficultto-hear sounds that point to the pathologic processes suggested above. The medical literature is replete with guides telling us that the stethoscope should be placed directly on the patient’s skin so as to avoid the distortions caused by clothing – something that we were all taught in medical school. They might as well be examining a shirt and deducing the patient’s problems using the information from the “shirt” exam.

It is true that the stethoscope has declined some in its use and popularity due to the availability of high-tech diagnostic imaging techniques such as echocardiograms and pocket-sized ultrasound devices, which can provide more detailed information. However, there is a place for the use of the stethoscope to rapidly detect and diagnose, in the heart, lungs and bowels, important auscultatory changes that can lead to rapid and effective treatments before scheduling the high-tech, high-priced, high radiation exposure CT scan. This is especially true when more sophisticated imaging tests are not easily accessible.

Failure to take the time to adequately employ the use of the stethoscope has been blamed on practice patterns that has been excused by overworked physicians and nurses with production goals that don’t allow for necessary patient evaluation because of the burdensome

and arguably useless electronic medical record. It pushes physicians away from examination of the patient and toward testing that patient. It is important that we address these barriers to physical examination, a key low-cost and efficient part of the patient evaluation.

Among the things ignored from training or forgotten from our medical school years is the use of stethoscope – a tool that shortens the physical space between the examiner and the patient. It is part of the skill set that makes you a real doctor. A Harvard medical school professor, Elazer Edelman, MD, PhD, summed it up by pointing out that the stethoscope exam is an opportunity to create a bond between the doctor and the patient: “You can’t trust someone who won’t touch you.” n

Plug in to your reinvented medical society! Choose interest areas today to be the first to know about new proposed policies www.cms.org/central-line 23

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Colorado Medicine for May/June 2018

Inside CMS

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

What else can we do to address opioids?

We have become used to seeing headlines about the devastating impact of opioids, and data continues to highlight the scope and severity of this issue. A recent Colorado Health Institute (CHI) report1 noted the following: • Colorado recorded 912 drug overdose deaths in 2016, more than in any previous year.

• That translates to a rate of 16.1 drug overdose deaths for each 100,000 residents, up 83 percent from a rate of 8.8 in 2001.

The report did offer some positive news. Since 2007, overdose deaths in Colorado due to prescription opioids have been leveling off (300 deaths in 2016 versus a high of 338 in 2014). It’s a trend that the report says “is most likely occurring as physicians become more mindful about prescribing opioids.”

Medical providers are shifting their focus from awareness to understanding what approaches are working to address opioids. Like many, COPIC pondered the question of “what else can we do?” We have learned that the most effective contributions draw upon our strengths, reinforce collaboration, and embrace a multi-faceted approach that includes professional education, grant funding, and legislative advocacy.

Education COPIC has been involved with opioid educational initiatives for more than five years, and we have taken our experience to develop a two-part seminar: • The Opioid Crisis Part I: The Pain That Won’t Go Away— Participants examine guidelines and best practices to safely manage opioids. Specific objectives include: o Distinguish the specific risks in the medical treatment of pain, including misdiagnosis, overprescribing or under-prescribing, abandonment and diversion. o Apply prescribing tools in the setting of chronic pain, including risk assessment, opioid agreements and indications for pain specialist consultation.

• The Opioid Crisis Part II: Strategies for Reducing the Burden—A review of opioid dose reduction and discontinuation as well as techniques to encourage patient buy-in.

Specific objectives include: o Review candidate selection and standard-of-care moniColorado Medicine for May/June 2018

toring practices for patients taking chronic opioid therapy (COT). o Learn behavioral strategies to overcome patient resistance and gain comfort with difficult patient interactions around opioid dose changes. o Master dose reduction schedules and aggressive opioid withdrawal management to promote successful weaning and discontinuation.

In addition, we have a close partnership with the Colorado Consortium for Prescription Drug Abuse Prevention to promote its courses on topics such as CDC guidelines, opioid use disorder recognition, and medication-assisted treatment.

Grant support In 2017, the COPIC Medical Foundation provided a grant to the Harm Reduction Action Center for medical provider training that facilitates a better understanding of the health care needs of people who inject drugs. This is an example of how COPIC supports organizations that provide a unique perspective on a complex issue through specialized training.

Participants learn about contributing factors that lead to opioid addiction and overdoses – valuable knowledge to improve patient treatment.

Legislative advocacy COPIC’s dedicated team focuses on monitoring legislative bills in Colorado to ensure that medical liability and patient safety concerns are recognized. With opioids, we are strong advocates for the effective use of the state’s Prescription Drug Monitoring Program. Our team also follows interim study committees on opioid and other substance use disorders.

These efforts allow us to stay connected at a broader policy level and offer our insight throughout the legislative process.

COPIC is committed to providing ongoing support and provider education as well as working with organizations to address opioids and other complex medical issues. Not only do our efforts focus on sharing best practices to improve outcomes, they also take into account the human aspect of the provider-patient relationship. As the CHI report notes, “Colorado lost 912 people to drug overdoses in 2016. Each person had a story. But each is part of a bigger picture as well.” n 1 Death by Drugs Colorado Reaches a Record High for Overdose Fatalities. Again.; www.coloradohealthinstitute.org/research/death-drugs

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Inside CMS

2018 CMS Annual Meeting Sept. 14-15 Vail Marriott, Vail, Colo.

Kate Alfano, CMS Communications Coordinator

Join your colleagues for the premiere event for Colorado physicians, the 2018 CMS Annual Meeting Make plans to join the Colorado Medical Society for the most anticipated event of the year for Colorado physicians: the 2018 CMS Annual Meeting. Building on the success of previous meetings, a workgroup of physicians and medical students is already hard at work to craft entertaining social events and high-quality professional development sessions to help you refresh and recharge in your medical career. The 2018 meeting will be held Sept. 14-15 at the Vail Marriott in Vail, Colo., and we hope you and your family will make plans to join us in this idyllic mountain retreat. As always, there is no registration fee for members and we have secured discounted group pricing on lodging at the hotel.

New this year, the conference will conclude with Saturday night’s presidential gala, giving attendees and their guests more time to explore beautiful Vail, a top Rocky Mountain destination, on Sunday. In addition to the hiking, biking and viewing of fall colors attendees know they will enjoy, Vail Oktoberfest – with Bavarian beer, music and dancing, traditional fare, yodeling and alpenhorn blowing – will be held in Vail Village Sept. 14-16, and the Vail Farmers’ Market and Art Show will be held 26

Hotel accommodations: Reserve your room online at https://book.passkey.com/go/ ColoradoMedicalSociety2018 Register: www.cms.org, available in June Bring your kids for the Children’s Activity Center!

Plan to bring and register your children for fun-filled activities Friday evening and Saturday Sept. 16. Childcare is provided during conference events with advanced registration.

Our annual meeting is devoted to celebrating the community of medicine, bringing Colorado physicians together for social, clinical and intellectual stimulation. Attendees will experience informative panel discussions and worthwhile workshops on the hottest topics in medicine – such as the opioid epidemic and health care reform – led by an impressive slate of state and national speakers. Once again, medical students can experience an engaging medical student track, providing special training to the next generation of

during conference events while you are enjoying highquality programming and social events. Snacks and lunch will be provided. Parents/guardians can, but are not required, to attend and participate. Children will be grouped by age and will participate in age-appropriate activities.

More information: www.cms. org/events/annual-meeting physicians, while also experiencing the main conference.

You won’t want to miss the CMS signature events: Friday evening’s exhibitor reception with great food, live music and fun catching up with your colleagues; the COMPAC Luncheon midday Saturday for insightful political commentary; and the black-tie Presidential Gala and COPIC dessert buffet Saturday evening to kick off the presidency of Debra Parsons, MD, FACP. We can’t wait to welcome you and your family to the 2018 CMS Annual Meeting Sept. 14-15. Find more information and register online at www.cms.org. n Colorado Medicine for May/June 2018

ANNOUNCING THE CANDIDATES FOR THE AUGUST 2018 ALL-MEMBER

ELECTION OF CMS OFFICERS All Colorado Medical Society members are eligible to elect CMS officers via electronic ballot.

The candidates for 2018-2019 office are: President-elect David Markenson, MD AMA Delegates Lee Morgan, MD Katie Lozano, MD Be sure to read the next issue of Colorado Medicine for information on the candidates, including their biographies and personal statements.

Colorado Medical Society is pleased to announce Dynamic Physician Billing Solutions as our newest Corporate Supporter.

RainTech has over 17 years’ experience in Healthcare IT! • • • • • • •

Custom Cloud Solutions No Wait Help Desk Unlimited Support Certified HIPAA Compliant Backup & Disaster Recovery Work from Anywhere Email Encryption and Archiving

• Support of 3rd Party Applications • Vendor Liaison Support • Antivirus and Patch Management • Cyber Theft Protection • Bandwidth Analysis and Consult • Web Content Filtration

Phone: 844-TEL-RAIN • Website: https://rain.tech • Contact: info@rain.tech Colorado Medicine for May/June 2018

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Inside CMS

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

Allison Rippy University of Colorado School of Medicine

Allison Rippy is a fourth-year medical student at the University of Colorado School of Medicine. This fall she will be applying for an obstetrics-gynecology residency position, alongside her fiancé, who is pursuing emergency medicine. They ultimately plan to return to Allison’s home town, Glenwood Springs, Colo., to practice.

Baby in Room 839 Dear baby in room 839, I don’t even know your name. Which seems so wrong because people lead you to believe that you don’t really know someone until you know their name. But I know you.

After I finished my work for the day, I was standing in the work room and starting to cross over into the over-eagerpuppy stage of the day when I really, really wanted to help my team but they had nothing for me to do, so I just ended up asking intermittent questions and slowing up their note writing. I could tell they were starting to get annoyed at me (recognition of this is the most important thing for survival as a third-year medical student. Far more important, it turns out, than having a head full of knowledge about the mecha 28

nisms of various antibiotics or treatment of Kawasaki’s Disease). So, I decided to go on a walk. That’s when I heard you crying.

I walked into your room and looked around for the nurses.

You were so adorable with your big, round blue eyes, purple, child-sized hospital gown with teddy bears on it, and flushed cheeks. I recognized you from rounds when I learned from my senior resident that you were withdrawing from meth.

Our best guess is that you had been exposed through your mother’s milk. I guess we’ll never know because your mom hadn’t been to visit while you were in the hospital even once. You had been so overwhelmed and everything from toys to lights to noises in the hospital seemed to be a stimulus overload. The nurses had written on your whiteboard, “I’m a sensitive guy. Be gentle!”

When I picked you up out of the hospital-issued crib with metal bars that make it seem more like a cage than a bed I’ll never forget how you gently placed your head on my shoulder and your tears quieted as we walked around your room together. At that moment, my heart was simultaneously completely broken and completely full. I knew holding you was the most important thing I would do that day. I loved being able to bring you comfort and dry your tears, but it seemed so wrong that your safe place in this world is in the arms of strangers.

I’m sorry things turned out that way. I’m sorry you don’t have a mother who is able to love you and take care of you the way you need. I wish I could change everything, but I can’t. We will find you a home and everything will be ok. I hope that you will remember nothing of these dark days. So for now, I will dry your eyes and rock you to sleep. Please know that you are loved. n Colorado Medicine for May/June 2018

Colorado Medicine for May/June 2018

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Departments Inside CMS

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

Corinna Ruf Rocky Vista University College of Osteopathic Medicine

Corinna Ruf received her undergraduate degree in Clinical Nutrition from the University of California, Davis. After completing her dietetic internship through a psychiatric forensic hospital, she worked there as a registered dietitian for two years.

Corinna then returned to school to pursue her Master’s in Physiology and Biophysics at Georgetown University. She is now a first-year osteopathic medical student.

Coping in difficult situations My career as a registered dietitian began at a psychiatric forensic hospital, with most patients deemed not fit to stand trial or not guilty by reason of insanity by the California court system. When I walked onto my new unit on my first day, I sat down for the morning rounds to the staff cracking jokes, almost mocking the patients. Comments were made such as “Mr. V won’t let us take his blood again, he thinks he is Jesus Christ and we are vampires” or “Ms. T said someone stole her epiglottis, looks like she can’t eat lunch today,” followed by staff laughter. Initially, I was shocked by the behavior, but the longer I worked that the facility, the more normal I realized it was. Reflecting back on it now, it was likely a coping strategy of the staff members to deal with the stress of working with delusional and difficult psychiatric patients each day. As I entered medical school and began learning more about medical ethics, interactions I saw working at a psychiatric facility continued to weigh on me.

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Health care professionals must maintain confidentiality and demonstrate professionalism. This includes honesty with patients, appropriate professional boundaries in the doctorpatient relationship, and establishment and maintenance of trust by managing conflicts of interest. In that sense, the staff upheld those responsibilities, despite their joking in the meetings. The patients weren’t able to hear the discussions and letting off steam by joking allowed them to provide more patient and empathetic care to the patients.

One might very quickly jump to say that the behavior of my unit staff was unprofessional or unethical, as I did initially.

However, an argument could be made that to maintain professional behavior in front of the patients, the staff needed an outlet and a way to express their feelings. A study published in Rivista di Psichiatria, found that patients that were uninhibited, irritable and apathetic were the most burdensome for mental health workers. Increased work with these patients increased the risk of burnout.1 I found this accurate in my years working there. The patients with the greatest delusions and most erratic behavior not only received most of the staff’s time, but were also those that were joked about the most.

These were the most emotionally demanding patients for the staff and teasing them eased the high stress that came with working with those patients.

There are many articles to be found about coping for families of patients with psychiatric diseases; however, little emphasis is given to the health care workers who dedicate their lives to working with these patients. Working with unstable psychiatric patients, some of whom are violent criminals, certainly takes a toll on these workers. Upon reflection, I believe that the staff used humor as their coping strategy to prevent burnout while working in such a difficult environment. Walking onto this new unit meant that I had no idea of the staff members’ past experiences in the hospital or with the individual patients. The more I got to know them, the more their behavior seemed like a normal and appropriate method of coping in this work setting.

Colorado Medicine for May/June 2018

Inside CMS Conversely, the behavior could not be coping at all, but rather cynicism after years of working with demanding patients. I personally was assaulted during my time at the hospital by a patient, and I know that my perceptions of patients changed over time; I became crasser in my analysis of the patients, less likely to want to go out of my way for dangerous patients, and more likely to take a step back from the patients to prevent harm.

Not only did my analysis of patients change, but the way I approached them also changed over the years. I would not attribute the changes I saw in myself entirely to burnout, but rather to the realization that my safety was my priority. I saw myself transform this way after only three years of working there, and after the more than 20 years that some of the staff had worked at the facility, I can only imagine the changes they saw in themselves since their first day.

I can empathize more with the staff and why they behaved the way they did after working there for years. By the time I left work at that hospital, I had no issues with the behavior of the staff. I can’t say if it was due to my evolution to a more cynical employee, or if I too was using it as a coping mechanism for working with these difficult psychiatric, forensic patients each day. Despite their behavior in private meetings, the staff continued to conduct their patient care by putting the patients’ needs first. Mental wellness of psychiatric workers needs to be addressed more at a hospital level. With appropriate ways to release the tension of the day, these responses may not happen. We need to ensure that there are appropriate outlets and coping strategies for the staff and physicians working with such difficult patients. By doing so, we might be able to prevent burnout and ensure the best care for even the most difficult patients. n References

1. Callegari C., Caselli I., BertĂš L., Berto E., & Vender S. Evaluation of the burden management in a psychiatric day center: Distress and recovery style. Rivista di Psichiatria. 2016;51(4):149-155

Colorado Medicine for May/June 2018

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Departments

medical news CMS honors state science fair award winners for exceptional projects in health and medicine Trista Barnett, and the team of Jayendra Chauhan and Grace Nunnelee won the Colorado Medical Society Award for Excellence in the Health and Behavior Sciences in the junior and senior divisions, respectively, of the 63rd Annual Colorado Science and Engineering Fair held April 5 in Fort Collins, Colo. It was hosted by the College of Natural Sciences Education and Outreach Center at Colorado State University.

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

Trista Barnett, center, winner of the CMS junior division state science fair award, shares her project with CMS judges Donna Sullivan, MD, left, and Cory Carroll, MD, right.

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

The junior division winner, Trista Barnett of Dove Creek Middle School in Dove Creek, presented her project, “Now You See Me…Now You Don't,” through which she developed special “simulation googles” to determine how diabetic retinopathy affects the way a person moves around obstacles. She got the idea from conversations with her father, who has been blinded in one eye from diabetic retinopathy. From the struggles she observed in the obstacle course, she concluded that all patients with diabetes need to understand the importance of properly caring for their blood sugar levels to avoid complications such as diabetic retinopathy.

A team in the senior division won the 2018 prize. Winners Jayendra Chauhan of Rock Canyon High School in Lone 32

Team Jayendra Chauhan, center right, and Grace Nunnelee, center left, won the CMS senior division state science fair award. Shown with judges Carroll, left, and Sullivan, right.

Tree and Grace Nunnelee of Ridgeview Classical Schools in Fort Collins presented “Characterization and In Vitro Differentiation of Myeloid Derived Suppressor Cells.”

They studied myeloid-derived suppressor cells (MDSC), a population of heterogeneous cells whose characterization, they hypothesized, could lead to the development of an antitumor drug. To study these cells, MDSC were differentiated in vitro using bone marrow derived from the C57BL-6 (black-6) laboratory mouse strain and conditioned medium required

for differentiation from BALB/c 4T1, murine mammary carcinoma cells. The amount of G-MDSC and M-MDSC, the two recognized populations of MDSC, present was measured with flow cytometry utilizing the fluorescently tagged CD11b, Ly6C, and Ly6G antibodies. Additionally, an evaluation of the effects of interleukin-6 (IL-6) on MDSC differentiation was performed. The presence of this cytokine was determined through an ELISA, and the overall effects of IL-6 on MDSC differentiation was quantitatively measured through IL-6 depletion and addition assays.

Colorado Medicine for May/June 2018

Departments They concluded that MDSC can be differentiated in vitro, producing significant amounts of M-MDSC and G-MDSC that are physiologically and morphologically similar to those differentiated in vivo. In addition, IL-6 was determined to be crucial to MDSC differentiation.

The experimentation yielded MDSC with a Ly6C+Ly6G+ phenotype, which had not yet been recorded, potentially indicating discovery of a new cell type, or high plasticity of MDSC. Congratulations to these young scientists. Meet them in person at the 2018 CMS Annual Meeting in Vail, Sept. 1415. n

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

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

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

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

Colorado Medicine for May/June 2018

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

AUTOMOBILE PURCHASE/ LEASE US Fleet Associates 303-753-0440 or visit usfacorp.com * CMS Member Benefit Partner FINANCIAL SERVICES COPIC Financial Service Group 720-858-6280 or visit copicfsg.com * CMS Member Benefit Partner Gold Medal Waters 720-887-1299 or visit www.goldmedalwaters.com INSURANCE PROGRAMS COPIC Insurance Company 720-858-6000 or visit callcopic.com *CMS Member Benefit Partner MEDICAL PRACTICE SUPPLIES AND RESOURCES Colorado Drug Card 720-539-1424 or coloradodrugcard.com *CMS Member Benefit Partner MedjetAssist 1-800-527-7478, referring to Colorado Medical Society, or visit medjet.com/cms *CMS Member Benefit Partner

PRACTICE VIABILITY, CONT. Eide Bailly 303-770-5700 or eidebailly.com/healthcare Favorite Healthcare Staffing 720-210-9409 or medicalstaffing@ favoritestaffing.com *CMS Member Benefit Partner First Healthcare ComplianceTM 888-54-FIRST or visit 1sthcc.com *CMS Member Benefit Partner HealthTeamWorks 866-401-2092 or visit healthteamworks.com *CMS Member Benefit Partner Medical Telecommunications 866-345-0251, 303-761-6594 or visit medteleco.com * CMS Member Benefit Partner Officite 866-508-9176 or officite.com/webcheck/cms * CMS Member Benefit Partner RainTech 844-TEL-RAIN or visit https://rain.tec

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

The Legacy Group 720-440-9095 or visit www.legacygroupestates.com

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

TSYS 877-841-0606 or visit transfirstassociation.com/cms *CMS Member Benefit Partner

CARR HEALTHCARE REALTY 303-817-6654 or visit carrhr.com *CMS Member Benefit Partner

Transcription Outsourcing 720-287-3710 or visit transcriptionoutsourcing.net

Dynamic Physician Billing Solutions 303-913-0508 or visit dynamicphysicianbilling.com

TSI 800-873-8005 or visit web.transworldsystems.com/npeters * CMS Member Benefit Partner 33

out of total commitment of $ 8

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medical news

SAV I N GS ATTRI B U TED TO

Prescribing boards 82 practices on reducingrelease emergency revised Fremont County brings physicians working together department visits through expanded access and patient engagement

guidelines for prescribing and dispensing opioids 80 practices

working on reducingThe seven prescribing and dispensing hospitalizations improved access,at the Colorado Division boards housed patient engagementof Professions and Occupations adopted and released revised Guidelines for Prescribing and Dispensing Opioids in April 2018.

These boards – the Colorado Dental Board, Colorado Medical Board, State Board of Nursing, State Board of Optometry, Colorado Podiatry Board, State Board of Pharmacy, and State Board of Veterinary Medicine – embarked on an 18-month stakeholder engagement process in May 2016. The revised policy reflects 27 different specialty their collaboration and thetypes robust stakeholder feedback the boards received.

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worki mana gener

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worki and p value

A BOU T TH E C O L O RAD O P RAC TI C E TRAN SF O RMATION NE TW The Fremont County Medical Society and Colorado Medical Society held a Regional Forum in Cañon City on March 13, bringing local physicians and CMS leaders together for an evening of dialogue about what’s COLORADO new at CMS, CMS advocacy efforts, and the latest on the opioid crisis and physician wellness. FCMS includes the cities and towns of Brookside, Canon City, Coal Creek, Coaldale, Cotopaxi, Florence, Hillside, Howard, Lincoln Park, Penrose, Rockvale, Silver Cliff, Statewide PTN Westcliffe, Wetmore and Williamsburg. n

TCPi practices get top MIPS scores Practices engaged in the Transforming Clinical Practice Initiative (TCPi) are reporting success with the Merit Based Incentive Payment System (MIPS).

Two TCPi practices received a MIPS score of 100 out of 100 and many others scored in the 90s, which means they will get positive payment adjustments.

More than 90 percent of MIPSeligible providers in TCPi submitted their reports and will avoid a negative payment adjustment due to their work.

SIM and TCPi practices have demonstrated success in the Centers for Medicare and Medicaid System Quality Payment Program (QPP) through their work with practice facilitators and clinical health information technology advisors (CHITAs). Get details on what practices need to submit for MIPS as well as advanced alternative payment models (the other track in QPP) 34

through the Colorado QPP website: www.cms.org/coqpp/fast-facts.

TCPi, a governor’s office initiative that is funded by the federal CMS, is helping position providers (specialists, behavioral health centers and primary care practices) for success with alternative payment models (APMs) that reward the value of care delivered.

More than 1,900 clinicians are participating in TCPi throughout Colorado, 87 percent of whom are specialists.

Learn more about how TCPi helps providers in a new episode of the Colorado State Innovation Model (SIM) podcast series Innovation Insights: https:// soundcloud.com/user-118904494/tcpipodcast. n

Moving forward, the boards will continue to evaluate the policy, incorporating new legislation and collaborating with other state agencies, researchers, practitioners, patients, the Colorado Consortium for Prescription Drug Abuse Prevention, and other stakeholders to identify and evaluate outcomes. In a news release, the boards note that the policy is a “living document, reflective of the evolving science, technology, policy and law in their ongoing efforts to address Colorado's opioid crisis.” Written comments may be provided at any time to Holli Weaver at holli.weaver@state. co.us.

A new website – www.colorado.gov/ dora/opioid_guidelines – provides additional information about the new policy, the process for its revisions and stakeholder meeting recordings. n

Colorado Medicine for May/June 2018

Departments

medical news Study finds 22 percent decrease in opioid prescriptions Opioid prescriptions in the United States decreased 22 percent between 2013 and 2017, according to a new study from the IQVIA Institute for Human Data Science titled, “Medicine Use and Spending in the U.S.: A Review of 2017 and Outlook to 2022.”

The American Medical Association praises this progress and encourages continued focus on evidence-based treatment.

“A 22 percent decrease in opioid prescriptions nationally between 2013 and 2017 reflects the fact that physicians and other health care professionals are increasingly judicious when prescribing opioids,” said Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force.

“It is notable that every state has experienced a decrease, but this is tempered by the fact that deaths

related to heroin and illicit fentanyl are increasing at a staggering rate, and deaths related to prescription opioids also continue to rise.

These statistics again prove that simply decreasing prescription opioid supplies will not end the epidemic.

We need well-designed initiatives that bring together public and private insurers, policymakers, public health infrastructure, and communities with the shared goal to improve access and coverage for comprehensive pain management and treatment for substance use disorders.”

The IQVIA report also found that prescription opioid dosage volume – measured in morphine milligram equivalents (MME) – decreased 12 percent in 2017, the biggest annual drop in more than 25 years. Previously, prescription opioid volume had increased each year since 1992, peaking

in 2011. But the report said this trend was reversed due to a combination of regulatory and legislative restrictions, tighter clinical prescribing guidelines and greater reimbursement controls, all of which resulted in decreases of about 4 percent per year from 2012 to 2016.

In 2015, the AMA launched a Task Force to Reduce Opioid Abuse and continues to work with state medical societies to address legislation and regulation ranging from developing effective prescription drug monitoring programs, continuing medical education, restrictions on treatment for opioid use disorder as well as enactment of naloxone access and Good Samaritan overdose protections.

To learn more about AMA efforts to end the opioid epidemic, visit endopioid-epidemic.org. n

ASAM and the AMA announce innovative payment model to improve treatment of opioid use disorder The American Society of Addiction Medicine (ASAM) and the American Medical Association (AMA) jointly announced the release of a concept paper in April 2018 detailing an alternative payment model (APM) that they say could revolutionize how patients with opioid use disorder are treated.

The new payment model, known as Patient-Centered Opioid Addiction Treatment (P-COAT), aims to increase the number of patients with opioid use disorder who are able to lead productive lives through management of their condition, while also reducing health care spending on costs associated with addiction, such as emergency department visits and expensive hospitalizations.

The payment model seeks to increase utilization of and access to medications for the treatment of opioid use disorder by providing the appropriate financial support to successfully treat patients and broaden the coordinated delivery of medical, psychological and social support services. P-COAT is also designed to support office-based opioid treatment to facilitate coordination between multiple treatment providers.

Previously, payment for these services had been segregated, which the organziations say contributes to patient difficulties receiving comprehensive care.

with opioid use disorder, but the current physician payment system offers little support for the coordination of behavioral, social and other support services that patients being treated for opioid use disorder need in addition to their medication. Non-face-to-face services – such as phone calls and email consultations with patients – in addition to better coordination between specialists, outpatient treatment programs and other health providers such as emergency rooms, are essential to the delivery of effective, evidence-based treatment to the individuals who need it.

The P-COAT APM is based on research showing that medications combined with psychosocial supports are effective in treating individuals

For more information about the P-COAT APM, review ASAM’s issue brief online at www.asam.org. n

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Colorado Medicine for May/June 2018

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

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

For more information, call Tim at 720-858-6306 or email tim_yanetta@cms.org

Colorado Medicine for May/June 2018

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Features

the final word A. "Lee" Morgan, MD

Know Your Legal Rights illustrates political muscle of the house of medicine As you have read in Dr. Bob Yakely’s president’s letter in this issue and in the cover story, the Colorado Medical Society and component societies jointly launched Know Your Legal Rights in April, compiling a decade of victories in the regulatory and legislative worlds on behalf of physicians into an easily searchable database exclusively for CMS members.

As the longtime chairperson for the CMS Council on Legislation, I can

2004: Uniform Credentialing Application

personally attest to the involvement of CMS, either leading the charge to fight for these rights and or in supportive roles for our allies to achieve these gains on behalf of all Colorado physicians.

In either case, these wins demonstrate how powerful the house of medicine can be when we work toward a common goal, and in this case, this strength shows through the robust list of rights and tools now illustrated in CMS’ latest resource for members, Know Your Legal Rights.

2007: Standard Contracts with Health Care Providers

Any person or entity contracting with a health All health care plans that care provider must collect information to use a standard form be used in the process contract that includes a of credentialing health summary disclosure of care professionals must payment terms, duration utilize the Colorado of contract, identity of uniform credentialing claims processors and application. dispute resolution terms.

2004

2005

2005: Assignment of Benefits

Health plans must allow a covered person to assign benefits payable under the contract to a physician for covered services.

2006

2007 2008

2010: Clean Claims/ Standardized Edits and Payment Rule

Payment of routine and uncontested “clean claims” must be made within 30 days if submitted electronically or 45 if submitted on paper. If the claim is not settled timely the health insurer must pay interest and possibly a penalty.

2009

2010

2008: Standardized ID Cards

The format and content of health benefit plan identification cards must be standardized, including an indication of whether the health benefit plan is regulated by the state of Colorado.

Physician Designation and Disclosure

Consumers and physicians are protected from improper physician profiling by health plans and physicians have the right to challenge and correct erroneous designations, data and methodologies.

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However difficult it was previously to find these protections among tomes of statutes, it can be even more difficult to grasp the fruits of advocacy over the long term.

Far too often we can get caught up in the details or sidetracked by others’ advocacy goals that conflict with our own.

That’s why I wanted to present a visual representation of just a few of our victories that demonstrate the importance of CMS’ advocacy work and our longevity in the past, present and future. n

2017: Selection/De-selection

Health plans must communicate the applicable standards they use to construct or tier a network, and include a general description in their provider directories.

2015: Telehealth

Covered telehealth services must be reimbursed on the same basis as if the same service had been provided in-person and coverage is not limited to rural areas of the state.

2011 2012

DOI Physician Complaint Pilot Health care providers, in addition to patients, can submit complaints about health plans to the Colorado insurance commissioner.

2013

2013: Prior Authorization Form for Prescription Drugs

2014

2015

2016

2017

2017: Telehealth Fix

When and how to use telehealth falls to the physician rendering the care – not the payer.

Non-urgent prior authorization requests submitted electronically must be responded to within two business days. If the health plan does not respond to the request it is presumed to be approved.

Health Plan Retaliation

A physician can express a disagreement with a health plan’s decision to deny or limit benefits to a patient and seek reconsideration, and health plans cannot retaliate when the physician communicates with regulators or legislators concerning action of the plan.

Colorado Medicine for May/June 2018