November-December 2014

November/December 2014

Volume 111, Number 6

CMS President Tamaan Osbourne-Roberts, MD

Finding a way forward Colorado Medicine for November/December 2014

Award-winning publication publication of the Colorado Award-winning Colorado Medical MedicalSociety Society

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Colorado Medicine for November/December 2014

contents Nov./Dec. 2014, Volume 111, Number 6

Features. . .

Cover story

Newly inaugurated president Tamaan Osbourne-Roberts, MD, believes physicians’ best chance to find a way forward through what is "a very challenging time to be a doctor" is to unite as members of the Colorado Medical Society. Read more starting on page 6.

Inside CMS 5 34 37 38 42 44 46 48

Executive Office Update Scope of practice strategy session CMS Board work plan Annual meeting highlights CMSEF scholarship recipients Physician wellness Reflections COPIC Comment

Departments 49 56

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2014 midterm election–CMS contract lobbyist Jerry Johnson reflects on this year’s election results and how physician engagement strengthens advocacy efforts.

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Leadership in family medicine–Gina Martin, MD, discusses her advocacy experience at the GME summit in Washington, D.C.

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Increasing access to specialty care in Colorado Medicaid–The CMS medicaid reform committee presents survey results on barriers to specialists accepting Medicaid.

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Mind your ‘P’s and Q’s’–Learn more about the incentives and penalties of PQRS as the series on Medicare’s approach to cost containment and quality improvement continues.

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All Payer Claims Database–Learn more about CIVHC’s new public website that gives patients and physicians access to meaningful data on how much medical services cost.

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Health care transformation–Colorado’s State Innovation Model will integrate physical and behavioral health and promote health care delivery system transformation.

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Ebola virus preparedness–Read more about how CMS and CDPHE are collaborating to prepare physicians for the possible spread of Ebola in Colorado.

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The Supreme Court and the ACA–Edward Dauer of the University of Denver examines the basis of a new court challenge and why it matters to physicians.

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Final Word–Floyd Ciruli discusses the new composition of the Colorado General Assembly and U.S. Congress, and what it means for Colorado physicians.

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

Colorado Medicine for November/December 2014

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2014/2015 Officers Tamaan Osbourne-Roberts, MD

President Michael Volz, MD President-elect Kay D. Lozano, MD Treasurer M. Robert Yakely, MD

Speaker of the House Brigitta J. Robinson, MD

Vice-speaker of the House Alfred D. Gilchrist

Chief Executive Officer John L. Bender, MD, FAAFP

Immediate Past President

Board of Directors JT Boyd, MD Charles Breaux Jr., MD Laird Cagan, MD Leslie Capin, MD Cory Carroll, MD Joel Dickerman, DO Naomi Fieman, MD Curtis Hagedorn, MD Jan Gillespie, MD Mark Johnson, MD Richard Lamb, MD Lucy Loomis, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD Daniel Perlman, MD Scott Replogle, MD Floyd Russak, MD Joshua Tartakoff, MS Charlie Tharp, MD Theodore Timothy, MS Michael Welch, DO Jennifer Wiler, MD

Allison Wood, MS Harold “Hap” Young, MD Lena Young, MS AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Kay Lozano, MD Tamaan Osbourne-Roberts, MD AMA Past President Jeremy Lazarus, MD CMS Historian W. Gerald Rainer, MD CMS Connection Mary Rice, President

COLORADO MEDICAL SOCIETY STAFF Executive Office

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

Division of Communications and Member Benefits

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

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

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Vynessa Robinson, Executive Legal Assistant, vynessa_robinson@cms.org

Mike Campo, Staff Support, Mike_Campo@cms.org

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

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

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

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Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Chet Seward, Editor.

Colorado Medicine for Assistant November/December Printed by Spectro Printing, Denver, Colorado

2014

Inside CMS

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

Colorado voters show independence in split vote “Democracy,” as George Bernard Shaw once wrote, “is a device that insures that we shall be governed no better than we deserve.” Or put more cynically by satirist Andy Borowitz after this cycle’s near-historic low national voter turnouts, “voters who didn’t vote say America is headed in the wrong direction.”

Colorado voters continue to show remarkable discretion, even in relatively lower turnout years. We will have a split – some could argue balanced – state government with a Republican-led Senate by a one-vote margin, a Democraticled House by a one or two vote margin (at press time one race was still up for grabs), and an executive branch that starts with a Democratic governor reelected with 49.2% of the vote. Our red or in recent past blue ‘waves’ are not of the same magnitude as many other states. These dynamics create a level of stability as we shift back and forth between election cycle and policy-making.

As our political leaders prepare for this next phase and their ultimate purpose, let’s take a look what might be on the horizon in terms of health care policy.

First, with all due respect to his worthy and thoughtful opponent, Gov. John Hickenlooper’s vision of a Healthy Colorado, which as we noted in our endorsement is virtually synonymous with ours, will stay on course.

The four years of collaboration with stakeholders like CMS and the General Assembly can pretty much pick back up where it was moving before sine die adjournment. Legislators can be expected to debate the balance between the market’s and government’s role in health care delivery, but many of the advocates

in that space on both sides of the aisle we have talked to over the election cycle seem determined not to reverse directions.

For the third year in a row, Colorado’s unique, homegrown version of Medicaid managed care is producing award winning results and savings. Our nominee, Sue Birch, a Hickenlooper Cabinet member who leads this locally-run effort through the RCCOs, won the AMA’s prestigious Nathan Davis Award for her work earlier this year. Substantial federal grants called SIM, designed to align physical and behavioral health, are in the pipeline – and frankly Colorado’s application may have taken a giant step over other states in that queue post election.

Colorado has a Cost Commission created this year with prime, bipartisan sponsors in both chambers of the state legislature: Senator-physician Irene Aguilar MD, (D-Denver), Sen. Ellen Roberts (R-Durango), Rep. Amy Stephens (RMonument) and Rep. Sue Schafer (DWheat Ridge). This blue ribbon panel of experts and influencers will make recommendations over the course of the next three years on how to improve the value of health care services and bend the cost curve to improve coverage, affordability and access.

As our longtime contract lobbyist Jerry Johnson observes in his guest column this month on page 10, the State House and Senate members-elect have spent quality time with CMS and the physicians in their communities long before they packed their bags for the Capitol.

As Yogi Berra observed, “I hate to make predictions, especially about the future.”

Colorado Medicine for November/December 2014

Nonetheless, based on our conversations with them back in their districts, our decade-long defense of Colorado’s relatively stable tort environment just got stronger. Our perennial conflicts

We will have a split – some could argue balanced – state government with a Republican-led Senate, a Democratic-led House and a Democratic governor. over the scope of practice with other health care professionals are also likely to remain within the possibilities of collaborative arrangements with physicians. Unless the U.S. Supreme Court detonates the subsidies to the thousands of new enrollees in states without homegrown exchanges and that decision negatively harms Colorado, we should expect the work of our exchange to expand coverage to continue. I urge you to read our friend and eminent law professor Ed Dauer’s take on the case just accepted for review by the Supreme Court on page 30.

Imbalances in political systems can be unfair to the minority voice, and potentially dangerous to society. Colorado seems to have a sixth sense about avoiding extremes, and has produced a new wave of legislators and leaders that are more likely to continue our long-held tradition of fixing problems instead of affixing blame. n

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Finding a way forward

CMS President Tamaan Osbourne-Roberts, MD

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Colorado Medicine for November/December 2014

Cover Story It is a very challenging time to be a doctor here in Colorado.

Part of the reason for this stems from national policy trends. The multiple changes in health system delivery and financing wrought by the Affordable Care Act have brought new health insurance coverage to millions of Americans, at the same time as practices are struggling with issues of physician undersupply and the new administrative burdens wrought by the very same law.

The rise of electronic health records has the potential to improve the care of many patients, while at the same time decreasing physician efficiency and contributing to physician stress. The national conversation on cost and quality promises to revolutionize the way patients understand, receive, and pay for care … while contributing substantially to doctors’ uncertainty about the profession’s future, and sharpening the divide between physicians, payers, and hospitals.

National social and economic trends also play a role in the difficulties our profession faces. The Millennials – that tech-savvy, financially-disadvantaged, wide-eyed youthful generation – promise to bring countless new health care consumers into the market, who will demand flexible new models of care and physician access to suit their lifestyles (including many models of care that haven’t been invented yet). And their huge numbers will drive the very nature of our industry … at the same time as their low incomes, and the increasing wealth gap in the U.S., will provide new challenges to the viability of current practice business models.

Of course, local political concerns, as always, play a role in physician malaise.

As the public (and legislators) in our freedom-loving, politically independent, purple-but-always-slightly-libertarian state engage in increasingly sharpened debate about reevaluation of provider scope, we find ourselves continuously needing to remind our patients of the unique skills we bring to bear as a member of their health care team. And, as always, some wings of the legal profes-

sion continue to make challenges to the stable liability climate here in Colorado, at the very same time as other parts of the legal profession continue their excellent and tireless defense on behalf of doctors.

show similar numbers of physicians displaying signs of clinical burnout.

So then, how do we get through? How do we find our way forward?

The answer is that we do it together.

The problems are substantial. The question, of course, is how do we solve them?

There was a time when, given all that our training demands, sheer grit and determination would have led us through all of this on an individual basis. Indeed, just to find our way into our profession sometimes seems to take near-Herculean effort and persistence. Organic chemistry, the MCAT, medical school interviews … gross anatomy, residency applications, the multiple steps of the USMLE … internship, residency, board certification exams … and of course, those first few unsteady steps through the hospital or clinic door as independently practicing physicians (and the busy days, sleepless nights, and heartache that come along with the privilege of tending to the sick and dying) all represent a very long, very hard road.

The very act of physician practice itself speaks of years of dedication, strength, empathy, toughness, and sheer will. For years, the lessons learned from this have held our profession together, bonded us, and given us what we needed to make it through the daily ups and downs, in both our practices and our lives.

But the evidence, rather alarmingly, is mounting that this hard-nosed approach is no longer enough. The rate of suicide amongst physicians is amongst the highest of any profession. Multiple national surveys show that the majority of doctors would not recommend their profession to their children. Tell-all books about the difficulties and vagaries of daily practice are proliferating … and flying off the shelves, into the hands of physicians and the general public. And the AMA-Rand study on physician satisfaction published last year is just one of many showing that physician job stress has reached epidemic proportions, with some specialties reporting more than 50 percent of practitioners dissatisfied with their practice, while other studies

Colorado Medicine for November/December 2014

It is our nature, as doctors, to bear all of our burdens on our own; this is a habit that most of us learn very early on in our training. We bear witness to tragedy on a regular basis, but hold it in so that we can continue to serve the people counting on us. We function as part of a team, but are told, repeatedly,

It is a very challenging time to be a doctor here in Colorado. So then, how do we get through?

How do we find our way forward? The answer is that we do it together. that the only correct approach is “trust but verify.” We go home at night to the people we love the most … and understand that they very well may be the people least able to relate to the many difficult things that we’ve seen, or done, that day. Ironically, for one of the most humane of the professions, our profession is also one of the most isolating.

But these habits cannot continue. The problems are too large, and the need to overcome them too critical, to stand alone when our combined force is what is needed to steer this wave of changes, to keep moving forward, to shape our profession and the whole of the health care industry into something that makes the world both better for our patients, and for our profession.

And it is my firm belief that, as a means of bringing the physicians of Colorado together and providing the tools and forum we need to advocate for ourselves and for our profession, there is no more

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Cover story (cont.) powerful or effective force than the Colorado Medical Society (CMS).

Indeed, CMS already provides multiple investments in such. CMS invests in our grassroots, through support of our component societies, and the physicians they represent; it also sows seeds for new support, through the creation and rejuvenation of new components, such as the recently re-established Chaffee County Medical Society, which is anticipated to join the other components in January of 2015. CMS invests in physicians’ health and professional success, through initiatives such as the Physician Wellbeing Toolkit, developed and recently released for use by all the doctors of Colorado, and through its continuing support of partners such as the Colorado Physician Health Program and the Center for Personalized Education for Physicians. CMS invests in the leaders of medicine’s present, through programs such as the Advanced Physician Leadership Program, which will be producing its second class of graduates in the upcoming months. And CMS

invests in the leaders of medicine’s future, continuing to support our medical students, residents, and young physicians and bring them into the family of our profession.

But staying put is not enough; we must find our way forward. To this end, the CMS Board of Directors has approved a work plan for the next year that is bold, innovative, and exceptionally ambitious. Amongst other things, it directs CMS to continue the excellent work of our legislative team in defense of Colorado’s stable liability climate, as well as multiple other legislative issues; to examine our work in defending scope of practice, and look at new and innovative ways to conduct that work; to modernize our governance and policymaking processes in an effort to remain nimble in defense of the profession; to explore new means of communicating with our membership and the public; to further support our medical students; and to more directly integrate the health of the public into the regular priorities and operations of the organi-

zation. The leadership of CMS is excited about this work, and looks forward to bringing all of these projects to fruition, continuing to serve as the convener for physicians on the issues that matter to us most.

Of course, even with such a substantial agenda, CMS will not be able to solve every problem that the physicians of Colorado face. Some challenges will take years of work to solve; other new challenges will arise even as we are addressing those I’ve listed. But, together, we can continue to meet whatever we face … and to ensure that the future remains bright for the physicians, and the patients, of Colorado.

This is exciting work, at an exciting time. And I am happy, and honored, that you will be joining me for it.

Let’s move, friends.

Forward. n

Incoming CMS President Tamaan Osbourne-Roberts, MD, takes the oath of office from outgoing CMS President John L. Bender, MD, FAAFP, at the presidential gala of the 144th annual meeting of the Colorado Medical Society.

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Colorado Medicine for November/December 2014

Colorado Medicine for November/December 2014

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Features

2014 midterm election Jerry Johnson, CMS contract lobbyist

CMS lobbyist Jerry Johnson applauds physicians’ role There’s a parable often told by lobbyists as an object lesson on the fundamentals of political engagement: An obviously frustrated and struggling farmer is plowing his field with his prize bull when his neighbor pulls up and offers to loan him his tractor. The farmer steps back from the plow and replies “my tractor works fine. I’m teaching this bull there is more to farming than chasing heifers and knocking over fences.”

Just as with the farmer’s situation, there was more to medicine’s role in this election than making a contribution or having our picture taken with a politician.

COMPAC’s candidate briefing and interview process is a model for professional and trade associations. Local physicians, working with CMS and component society staff, brief candidates on medicine’s priority issues.

The candidate receives a “Candidate Briefing Document” well before the interview that lays out the background on each issue: Colorado’s stable liability climate, health care reform, managed care, scope of practice and so forth. The CMS lobby team is available to answer questions about the issues, in person or by telephone. The interview is conducted

at a location in the candidate’s district where possible, or at a component society office, a process led by local physicians.

The interview provides a two-way information flow. Physicians and lobbyists get to “size up” the candidate and hear how he or she thinks about issues. The candidate learns about the passion that physicians have for issues affecting patients and practice.

Rep. Leroy Garcia (D-Pueblo), now a newly elected member of the State Senate, had this to say about the process. “As

Colorado Medical Society honors Jerry Johnson for 20 years of advocacy The Colorado Medical Society honored longtime lobbyist Jerry Johnson at the 2014 Annual Meeting in Vail for his service in advocacy to CMS, its members, and the patients and communities of Colorado.

Lee Morgan, MD, with all of CMS’s past presidents standing behind her, presented the award, titled “In Summa Medicorum Patronus,” which means “the main patron of doctors.”

“For two decades, the unflappable Jerry Johnson has tried to teach, persuade, and perhaps gently threaten several generations of state legislators on our behalf, which explains his anxiety when he sees legislation with the bill title ‘relating to scope of practice of chiropractors,’” Morgan said.

She praised his patience, diligence, and “artful” manner of legislative diplomacy that has cultivated positive relationships with other lobbyists, staffers, and politicians of all stripes and persuasions. “He is quite literally a tireless champion of our causes and unfailingly optimistic,” Morgan said. “He is a paragon; the best of the best.”

Longtime CMS contract lobbyist Jerry Johnson receives a standing ovation from the House of Delegates as he receives CMS extends its sincere appreciation to Jerry for his steadthe "In Summa Medicorum Patronus" award from Lee Mor- fast support and guidance over the past 20 years and looks gan, MD, for his years of service to Colorado physicians. forward to working together for years to come. n 10

Colorado Medicine for November/December 2014

Features a paramedic, I work with physicians all the time. But the interview process was an eye opener. It gave me an early look at the full range of issues affecting health care at the state Capitol. No other group does such a complete interview.”

New Douglas County Rep. Kevin Van Winkle (R) elaborated further saying, “I met with six ADEMS physicians, Susan Koontz and Jerry Johnson for about 90 minutes. The Candidate Briefing Document was great preparation. After the interview I had a much better sense of which issues my physicians support – and which ones give them heartburn.

What a great learning experience!”

After the interview of both candidates is complete, physicians vote to recommend the endorsement of one of them to the COMPAC board. Occasionally, the local physicians recommend staying out of the race.

During the election cycle just completed, COMPAC endorsed 82 federal and state candidates. Seventy-seven were elected. Our goal is to help them all know or get to know better their local medical community leaders.

The important relationships between elected officials and physicians in their community evolve over time, but they start every election cycle when a candidate or legislator first talks health policy with their medical community at the time they are seeking, or seeking to retain, a seat in the General Assembly.

upon as those issues move through the process.

3. The number of politically active physicians grows – those who make the connection between activism, local relationships and public policy.

4. It establishes a priority list of medicine’s “do’s and don’ts,” which is often enough to deter an elected official from sponsoring or co-sponsoring a bill that physicians oppose. It gives a candidate a clear sense of the bright

lines around issues from the perspective of the physician community. Because of that, legislators often avoid sponsoring or co-sponsoring bills they understand that physicians will oppose, and they will often champion bills physicians support.

Perhaps most important, a candidate who has been through the COMPAC process understands that physicians in his or her community care, and are engaged. n

COMPAC makes great gains for medicine thanks to statewide physician engagement; 77 out of 82 endorsed candidates win With the results in from the 2014-midterm elections, the Colorado Medical Political Action Committee is pleased to report strong gains for medicine.

COMPAC endorsed 82 federal and state candidates and 77 were elected.

Wins and losses aside, this was a significant election in that it reestablished the balance for which Colorado is known. The voters sent a clear message to legislators that they want elected officials to rise above partisanship and work together to tackle big issues.

Though Republicans captured a one-vote majority in the state Senate and will send Rep. Cory Gardner to Washington as a U.S. senator, incumbent Gov. John Hickenlooper will remain in office and Democrats will keep control of the state House by a thin margin.

The bipartisan Colorado Commission on Affordable Health Care has a strong probability of being very influential with Gov. Hickenlooper, and the Colorado Medical Society is very engaged with this group. CMS is forming a Blue Ribbon Task Force on Health Care Cost and Quality to ensure interactions with the commission are well planned. (Go to www.cms.org to apply; applications must be received by Dec. 1.)

Once they are in office and the session kicks into high gear, Legislators are swamped, and can’t devote the same bandwidth or attention to issues that are typically complex and require insights not readily apparent to the casual student of health policy.

The house of medicine in Colorado remains in a good position chiefly because of the COMPAC candidate briefing and interview process. Through this process, local physicians – working with CMS and component society staff – brief candidates on medicine’s priority issues, including the liability climate, health care reform, managed care, and scope of practice. It’s a dialogue: Physicians and lobbyists get to hear how the candidate feels about the issues and the candidate learns about the passion that physicians have for issues affecting patients and practice.

The COMPAC interview process accomplishes four things.

1. It jump-starts the learning curve, exposing the candidate to a range of complex issues, often for the first time.

2. The candidate acquires a pool of physicians in his/her district to rely

The interview process serves the organization well because, regardless of whether candidates agree with COMPAC’s position on these issues, they get to know their local medical community leaders better and understand that doctors in his or her community are engaged. This engagement is paramount. COMPAC thanks every physician who participated in the 2014 candidate interviews and encourages all members to get involved in future elections. n

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Colorado Medicine for November/December 2014

Features

Leadership in family medicine Gina Martin, MD, and Kim Marvel, PhD, executive director, Commission on Family Medicine

Lesson in advocacy complements local doctor’s practice Editor’s note: Gina Martin, MD, practices in Delta, Colo., and wrote this article in collaboration with Kim Marvel, PhD, who is the executive director of the Commission on Family Medicine.

As a senior resident, I was accustomed to advocating on behalf of my fellow colleagues. However, the GME Summit provided me with the opportunity to take my advocacy skills to a new level.

The summit was an exciting change of roles that expanded my appreciation of the wide range of skills and expertise required by a leader in family medicine.

In mid-June I was on the resident team for the inpatient medicine service at St. Mary’s Hospital in Grand Junction; three days later I was standing before 120 congressional health care staffers in the Capitol Visitor Center in Washington, D.C., delivering a message of reform. How did this happen?

I had jumped at opportunities for leadership roles throughout my education, beginning as an undergraduate at Oregon State University. I was president of the Student Health Advisory Committee, organized bone marrow donor registration drives and was vice president of morals in my sorority. I received an international award for my advocacy and work to increase the number of minorities registered to be bone marrow donors. During medical school at Oregon Health and Sciences University I continued my volunteer efforts with the National Marrow Donor Program. Further I was very involved with our Health Policy Group where I worked with a team of students to create a large-scale annual free health clinic for the homeless. We were successful in serving more than 450 uninsured and underinsured

patients in a single day by providing health screening exams, vaccinations, medications and referrals to local clinics.

Thankfully in medical school I also became involved with my county and state medical societies, which led me to attend an AMA conference and be introduced to CMS leadership. It was there that I decided a residency in Colorado would be the best environment to grow my involvement in organized medicine and advocacy. While I had hoped to train at a residency on the Front Range in order to be more involved with CMS, I fell in love with St. Mary’s Hospital and was lucky to match to their program in 2011. After moving to Grand Junction, I immediately joined the Mesa County Medical Society (MCMS). Under the guidance of exceptional leaders, such as Michael Pramenko, MD, Chuck Breaux, MD, and Sherm Straw, MD, I

expanded my leadership by becoming MCMS president in 2013. Eventually my involvement led to my introduction to Kim Marvel of the Colorado Commission on Family Medicine (COFM), who asked me to join in an educational summit in Washington, D.C. Pushing for GME overhaul For several years, the COFM has been pushing for the graduate medical education (GME) payment system to be overhauled. The commission was established in 1977 when two legislators saw the need for a board to advise the legislature about the primary care needs of the state, including the training of family physicians. At that time, Sen. Harvey Phelps, a pulmonologist from Pueblo, and Rep. Tilly Bishop from Grand Junction, established the commission by state statute. Today, the commission

Gina Martin, MD, shares her journey to becoming a family physician in Delta, Colo., in support of an effort in D.C. to address inefficiencies in the current GME payment system.

Colorado Medicine for November/December 2014

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Advocacy (cont.) is composed of 19 members including nine program directors of the state’s family medicine residency programs, seven governor-appointed citizens from the congressional districts, the deans of the University of Colorado School of Medicine and Rocky Vista University College of Osteopathic Medicine, and a representative from the Colorado Academy of Family Physicians.

Frustrated by the chronic underfunding of family medicine residencies and the 1997 cap placed on the number of residency training positions, the commission brought together leaders of family medicine education from throughout the West and Midwest in 2011. The meeting, deemed the GME Initiative, resulted in a letter signed by seven U.S. senators requesting the Institute of Medicine (IOM) conduct a study of the GME payment system.

Fast forward to the spring of 2014. The IOM has announced that the Committee on GME Governance and Finance will soon release their recommendations. In response, the commission planned the GME Summit in Washington, D.C., to coincide with the release of the IOM report. The summit was designed to educate legislative health care aides about the deficiencies of the current GME payment system and to recommend specific changes. For example, the current system is not producing sufficient primary care physicians and pro-

vides significantly higher payments per trainee for residencies on the East and West coasts compared to the middle of the country.

Suggested changes are to set a goal to increase the primary care workforce to at least 40 percent of physicians and make payments directly to programs and sponsoring organizations where primary care training occurs, such as teaching health centers, educational consortia, and residency programs rather than teaching hospitals. I was thrilled to be invited to join the team to carry this message to policymakers at the nation’s Capitol June 19-20.

Our two-day itinerary included individual meetings in congressional offices and a “Hill briefing” in the Capitol Visitor Center. To prepare for the individual meetings the first day, we split into two small groups, identified a primary speaker, and reviewed a list of responses to frequently asked questions.

The challenge was to provide succinct explanations about the extremely complex GME payment system.

Both groups had a tight schedule to meet with 10-12 offices. We had 15 minutes to make our case then walk quickly to the next office, often catching a taxi between the Senate and House office buildings. We found the knowledge base of GME funding varied widely among the health care aides. While all health

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care aides were familiar with GME, many were not aware that current GME bills, written to increase the primary care workforce, if passed will actually continue to produce more sub-specialty physicians while the percent of primary care physicians will continue to decline.

We were pleased with the interest shown by health care aides and their appreciation for understanding the specific wording needed in bills to increase the primary care physician workforce.

On the second day we conducted a 90-minute panel presentation to a standing-room-only audience of health care aides and media representatives in the Capitol Visitor Center. The first speakers made the case for GME payment reform. During my time at the podium, I told my journey of choosing to become a family physician. I described the challenge of mastering a broad range of skills, the satisfaction of building relationships with patients and their families, and the important role family physicians play as advocates for their patients’ health. As we recently learned at the CMS spring meeting, I found that my personal stories added meaning to the data provided by researchers and national experts.

There is one more personal dimension to this experience. A basic tenet of family medicine is treatment of the whole person. One could say the same for family physicians – they commit their whole person to their work. At the time of the GME Summit, my fourmonth-old daughter was home with my husband. During the two-day event, I periodically ducked into private rooms to pump breast milk. In retrospect, my roles of mother, physician, leader and advocate were seamlessly intertwined on this journey.

A short two weeks after the GME Summit I graduated from residency and joined a small practice in Delta, Colo.

In my new location, I will continue to provide full-scope patient care, look for new leadership and advocacy opportunities, and spend time with my family. n

Colorado Medicine for November/December 2014

Features

Medicaid specialty access gap Kate Alfano, CMS contributing writer

Redefining the problem, seeking solutions In November 2013 the Colorado Medical Society Board of Directors voted to place a high priority on access to specialty care in the Medicaid Accountable Care Collaborative (ACC) program, while also advocating to maintain primary care reimbursement at least at Medicare parity levels. At that time primary care physicians were receiving Medicaid payments on par with Medicare under the Affordable Care Act and the Regional Care Collaborative Organization (RCCO) program was paying per-member permonth fees to primary care. With those gains for primary care, the next big obstacle was increasing access to specialty care.

Access to specialty care is important for many reasons – reasons related to the patient’s needs, reducing emergency department visits, and for fully functioning medical neighborhoods.

Because the issue is so complicated, the board of directors created a Medicaid Reform Committee and tasked the committee with addressing the problem.

Chaired by Deb Parsons, MD, the committee is comprised of Colorado RCCO medical directors and other practicing physicians, and is routinely attended by RCCO policy staff and the Colorado Department of Health Care Policy and Financing (HCPF), the agency that oversees the state’s Medicaid program. This summer, the committee polled CMS specialist members to gain their insight on what is and is not working in Medicaid, and how to move forward on preferred strategies to common problems.

“This is an important topic because we now have one million people in Colorado on Medicaid,” said Meredith A. Niess, MD, MPH, the study’s designer.

Niess is a NRSA primary care research fellow in the Department of General Internal Medicine at the University of Colorado. “That’s 20 percent of our population, approximately. It’s the second largest insurer in the state.” One out of three outpatient providers do not accept Medicaid and more accept only a limited number. The access gap is real, she said.

no-show rates; patient non-adherence; high administrative burden; the floodgates idea, where if you accept some Medicaid you’ll be inundated; and patients who are socially complicated.

She polled 1,600 specialists and, with a 52 percent response rate, found a balanced perspective on the real and perceived barriers to accepting Medicaid patients. Specialists reported that they are most concerned with low reimbursement rates; high patient

Jeff Perkins, MD, a practicing rheumatologist and the founder and CEO of Colorado Center for Arthritis and Osteoporosis, carefully studied the financial impact to his practice. “Some

“Yes, reimbursement is still the biggest concern but there is a bigger picture here,” Niess said. “The survey shows that Colorado physicians need more support, like care management and access to behavioral health care, in order to provide quality care for Medicaid patients.”

Alan Kimura, MD, MPH, a partner in Colorado Retina Associates, discusses his experiences as a specialist accepting Medicaid patients.

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Medicaid (cont.) common perceptions made my practice anxious about this whole process.

One of the best cures for anxiety is data so we started looking at the data from our patient population.” After examining a host of metrics, he found no significant reason – financial or otherwise – to justify excluding this patient population from his practice.

Judy Zerzan, MD, MPH, chief medical officer and director of HCPF’s Client and Clinical Care Office, addressed the concern about slow payment, citing the fact that Medicaid pays over 90 percent of claims in less than eight days. “Certainly there are other ad-

ministrative burdens but I think that is super fast.”

She described some of the delivery system reforms Medicaid is embarking on to help both providers and Medicaid clients. Most significant is the Accountable Care Collaborative program, which has saved between $44 million and $64 million over two years with fewer emergency room visits and fewer re-hospitalizations and imaging.

For specialists specifically, Medicaid is using targeted reimbursements and e-consultations. Next up is telehealth and Project ECHO, Zerzan said, which

Have an idea you want to share?

Do you like something CMS is doing?

Are we heading on the right or wrong track with our strategic plan?

E-mail: Letters to the editor at dean_holzkamp@cms.org

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will arm primary care providers with the confidence to treat issues they would have previously referred to a specialist to free up specialists’ time for more complex issues. “We’re excited with what we’re doing with specialty care.”

“This is challenging for our practice on many fronts. We’re not participating at the rate Meredith said would be ideal, but we are trying to do our part,” said Alan Kimura, MD, MPH, a partner in Colorado Retina Associates.

“Medicaid gives those who would be outside the health care system a chance to preserve or recover their health, and that’s why we’re in this field.”

Perkins challenges all specialists to address their fears. “Consider re-examining your practice’s policies regarding Medicaid. Gather as much data as you can about how things are now, and then design and implement a test to change your policy on Medicaid.

Analyze the data once you implement that test and if it didn’t work out the way you thought, make adjustments and repeat. In graphic form, plan, do, check, act and repeat. Not only with Medicaid but with any challenge you face in your practice, if you approach problems in this way – it’s amazing what you can accomplish and the problems you can solve.” n

Colorado Medicine for November/December 2014

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Features

Mind your ‘P’s and Q’s’ Marilyn Rissmiller, senior director, Colorado Medical Society

PQRS could benefit practices and patient health Editor’s note: This piece is part of an ongoing series Colorado Medicine will publish about Medicare’s approach to cost containment and quality improvement.

With Medicare turning up the heat on quality-improvement programs such as PQRS (Physician Quality Reporting System), CPCI (Comprehensive Primary Care Initiative) and VBPM (Value-Based Payment Modifier), doctors might feel as if they are submerged inside a big, steaming pot of alphabet soup.

And while the analogy might not sound appetizing, many providers will sink or swim in this rapidly changing environment. Programs like PQRS are designed to alter Medicare compensation – with ramifications on the broader payer market that Medicare influences, the physicians’ competitive field, the fiscal health of their practices and (most important) the health of their patients.

Chances are good that if you’re already seasoned in the tenants of HIT (Health Information Technology) and EHR (Electronic Health Record) and Meaningful Use, your practice is already soaking in the data gathering and the elaborate system of incentives and penalties inherent in the Centers for Medicare and Medicaid Services’ (federal CMS) quality-improvement push.

Not to suggest that late adopters to these concepts are “up alphabet soup without a paddle,” but they will certainly be better equipped to face the roily waters of this payment sea change and even land ashore safely if they begin paddling their way toward the calmer waters of compliance.

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Last month, Colorado Medicine teed off its series about the cost-containment and quality-improvement measures implemented by the federal CMS with an overview of how these different programs work together. (See “Aligning the big picture: Medicare incentives turn into penalties,” Sept.-Oct. 2014 edition).

This part of the series will take a closer look at PQRS – a key ingredient to stirring health care from a fee-for-service model to a system that encompasses the principles of evidence-based medicine, prevention and chronic-disease management.

As with the other pieces of the federal CMS’s strategy, PQRS aims to ultimately improve the patient experience of care and the health of populations, and cut costs in large part by improving the quality of available data. It does so by providing “carrots” for providers to report the data and “sticks” for not providing the data or for improving their measures.

Though the federal CMS’s logic in aligning these programs seems well-reasoned, it remains to be seen whether this approach will actually move the needle in improving clinical outcomes or reducing costs. What is certain, however, is that providers that don’t participate may feel a pinch in the not-too-distant future for their refusal to play. And in the case of PQRS, they might miss out on an opportunity to make their practices more effective and efficient and to help improve the health of entire populations.

What is PQRS? Simply put, PQRS uses a combination

of incentive payments and payment adjustments to report recording of quality information by eligible professionals.

Launched in 2007, the program started as a pay-for-reporting program for collecting clinical quality measures.

“It didn’t matter how the data reflected on the practices, they just wanted you to report it,” said Devin Detwiler-Cunningham, an HIT quality improvement specialist at Telligen, a Des Moines, Iowabased population health management company with offices in Englewood, Colo.

Detwiler-Cunningham works with individual practices on using their qualitybased measures. Telligen is contracted by the federal CMS under the Quality Improvement Organization (QIO) Program to provide such consulting services at no cost to the practice. QIOs work with local health care providers in all settings of care on data-driven quality initiatives to improve patient safety, reduce harm, engage patients and families, and improve clinical care at the community level.

Though PQRS data started rudimentarily (in the beginning, most PQRS data was derived from insurance claims), Detwiler-Cunningham notes that it has evolved significantly in recent years. It now includes more than 300 measures – most written by the National Committee for Quality Assurance, a physician-led nonprofit dedicated to improving health care quality, or the American Medical Association.

These comprehensive measures – based on evidence-based best practices for care

Colorado Medicine for November/December 2014

Features – range from rates of aspirin given at arrival for patients with acute myocardial infarction to flu shot percentages within a family practice. In recent years, the measures have branched out to such specialties as oncology, radiology and bariatric surgery.

“It’s a way to communicate evidencebased medicine and get it into the provider offices,” Detwiler-Cunningham said. “The move has been to go electronic, because EHRs are such a great tool.”

But while an EHR could make implementation of PQRS easier, the federal CMS has made efforts to accommodate practices that might not have taken advantage of EHRs yet. Detwiler-Cunningham notes that the federal CMS accepts the information in a number of ways, including claims, third-party registries and clinical registries. The hope is that through PQRS, the federal CMS could amass a growing body of data that will ultimately inform and improve care.

“It’s basically a carrot and a stick that encourages physicians to actually look at their data,” Detwiler-Cunningham said.

“It encourages benchmarking and informs best practices.”

Incentivizing participation The federal CMS launched PQRS with a bonus payment of 1.5 percent for successful participation based on the estimated total charges. On the reverse side, physicians who elect not to participate or are found to be unsuccessful during the 2013 program year will receive a 1.5 percent payment penalty, and 2 percent thereafter. (See chart: “PQRS incentives and penalties, page 20.”)

However, 2014 is the last year physicians can receive an additional incentive for participating in the PQRS Maintenance of Certification (MOC) program. Once that phase sunsets, physicians will be rewarded or penalized for falling on the right side or the wrong side of a clinical measures “bell curve.”

“Every single provider who bills and collects Medicare B is going to be graded in the bell curve,” Detwiler-Cunningham

said. “Every doctor will be assigned a value modifier. If you are in the lower 7 percent, you’ll get penalized; if you’re in the upper 8 percent, you’re going to make more money. What’s going to happen is 85 percent of the providers are going to stay the same. Probably 8 to 10 percent will lose money and 8 to 10 percent will gain money.”

Hospitals are already accountable to similar quality-improvement measures from the federal CMS, such as penalties that essentially ding the institutions when their 30-day readmission rates creep above the acceptable norm. Likewise, PQRS holds doctors accountable for their performance in myriad quality measures.

Not only do providers stand to gain or lose money from PQRS, but the data gathered will be used to feed Physician Compare, the federal CMS’s consumeroriented website that shows how doctors measure up with other doctors. In addition to being used by prospective patients seeking care, the site could also be utilized by practices looking to assess their competition.

“Providers are very competitive, so once they see they’re on the lower end of the bell curve, it’s incumbent on them to improve those numbers,” DetwilerCunningham said. “But the beauty of this program is that all of these measures can be improved upon. The data comes directly out of every physician’s EHR, claims or charts, so they have the power to change it or ignore it.”

Unlike the data collected by private insurers, PQRS comprehensively reflects how individual practices are doing – giving them a baseline for improving their operations and health of their patients.

In the federal CMS’s grand scheme, the program encourages practices to make sure their patients are receiving chronicdisease management and preventative care.

Though PQRS is intended to improve care, Detwiler-Cunningham said it would theoretically reduce costs in the long run.

Colorado Medicine for November/December 2014

“If you can prevent colon cancer, it will save a lot of money. If you can prevent a diabetic or a heart-failure person from going to the hospital because their meds and chronic conditions are managed, that will save money.”

Since Medicare often leads the charge in payment reform, it’s possible that private insurers will inevitably follow the lead set by the federal CMS – potentially putting participating physicians ahead of the changes in payment reform.

However, not everyone is a fan of the federal CMS’s carrot-and-stick approach in rolling out PQRS. Even though he classifies himself as an “early adopter” of EHR and the federal CMS’s qualityimprovement initiatives, Mark Hinman, MD, says he doesn’t like the punitive effect PQRS has on physicians who might not have the resources to incorporate such systems into their practices.

“These penalties are going to hurt the slower adopters the most,” said Hinman, a Longmont-based physician whose family practice has already reaped the benefits of EHR and quality-improvement programs such as PQRS. “They don’t have the funds to make the changes they need to do.” (Hinman’s success with PQRS is detailed in a sidebar to this article, “Patience pays off for Longmont practice, patients,” page 20).

The case for participating Though Medicare’s reimbursements generally cover about 55 percent of billed services and the program constitutes a small portion of most private practices’ funding, it is critical to maintaining cash flow – particularly for internal medicine practices.

“A lot of people really like Medicare because you bill them and get paid electronically within two weeks,” DetwilerCunningham said. “It’s pretty straightforward. If you have a question, you call them and they answer you. In that way, they’re very good in terms of cash flow.

A lot of private payers take 45-90 days to process a claim. That’s what some people

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PQRS (cont.) like about Medicare, but again, in some cases it doesn’t even cover your overhead.”

Because of the growing frustration with Medicare’s low reimbursements combined with mandated carrot-and-stick programs like PQRS, Detwiler-Cunningham said she’s heard that some practices are threatening to stop seeing Medicare patients altogether. But doing so – or refusing to participate in PQRS and other qualityimprovement programs – could only effectively remove practices from the competitive playing field or unfairly skew their results in the public eye.

Savvier Colorado practices such as Hinman’s have already embraced PQRS and other federal CMS programs, and made it

work to their practice’s advantage.

And though the benefits of PQRS and likeminded programs might not be apparent in the short run, they will pay off in time in the form of improved efficiencies and patient health. Though it may be too late for lagging practices to realize the incentives of participating in PQRS, they could still avoid future penalties and prepare themselves for the future of health care reimbursement by getting on board.

If those reasons aren’t enough, DetwilerCunningham asked physicians to consider how data-driven programs like PQRS essentially collect and distribute information that fundamentally belongs to the patients.

“The patient should be able to access their record no matter where they are,” she said.

“It’s not the doc’s record anymore, it’s the patient’s. It needs to be documented so the patient can actually read it and share it.”

Medicare PQRS incentives and penalties 2013: 0.5% incentive

(performance year for 2015 penalty) 2014: 0.5% incentive

(performance year for 2016 penalty) 2015: -1.5% penalty 2016: -2.0% penalty For more information about the Quality Improvement Organization, visit www.

QIOProgram.org n

Patience pays off for Longmont practice and its patients with PQRS-related efficiencies Longmont family practice physician Mark Hinman, MD, was an early adopter of the Electronic Health Record (EHR) system decades before the acronym and the term were commonly used in health care circles.

In fact, when the Hinman joined his father John Hinman, MD, at his small family practice in 1993, the father-son duo built their own EHR from a word processing system because “a good one wasn’t available at the time,” said Hinman.

“We saw the benefits right away,” Hinman recalled, citing legibility and ease of typing as the most immediately obvious benefits.

“All records were easy to find,” he said. “It helped us organize things and track immunizations. It worked very well.” Hinman remembers being able to check medical records from his home during late night calls rather than driving back to the office – a practice almost everyone takes for granted now.

Eventually, better technology caught up with the practice, which recruited Aprima Medical Technology to upgrade its EHR in 1996. To fully utilize its new tools, the practice established its own diabetic registry and began to more closely assess its cardiovascular patients through EHR. Fast-forwarding more than 20 years, the elder Hinman is retired and still active in the community, while the younger Hinman remains at the 20

cutting edge of EHR implementation at the twoperson practice (Hinman now serves roughly 2,500 patients with Leila Hanag, MD).

The practice’s long-standing embrace of EHR enabled it to more easily provide the kind of data that the Centers for Medicare and Medicaid Services (federal CMS) recently began mandating from health providers. When the federal CMS announced incentives for reporting medical data, through the Physician Quality Reporting Systems (or PQRS), the Longmont practice was more than prepared.

“We were actually involved with taking some of the early steps already, so it wasn’t really a big stretch for us for getting ready for PQRS,” Hinman said.

Many physicians grouse about the federal CMS’s data-driven quality-improvement measures, which provide incentives for participation and enforce penalties for non-compliance. They also voice concerns about the “hassle factor” of gathering and providing the information to the federal CMS – not to mention staying within the bell curve of best practices to avoid additional penalties.

Hinman said his practice has not only improved efficiencies through the data gathering, but has also used the data to improve the health of its patients.

“It’s just a matter of learning to collect the data and use it to actually make improvements,” he said. “It takes a period of time to learn how to do that efficiently.”

For example, the EHR helps the practice follow up with diabetic patients whose hemoglobin levels fall within a certain range. “We share the information and teach [patients] how to use it.

That way, they have a better guideline of how to better control their diseases and will ultimately have fewer complications down the road.”

Though Hinman’s practice received some monetary incentives for participating in the federal CMS’s PQRS program, he believes the benefits of using data transcend higher reimbursements.

“Again, we’re already using quality measures already, so I’m not sure if the incentive program added that much to our patients’ health beyond what we were already doing,” he said.

Though the benefits of embracing technology to inform best practices and evidence-based medicine and prevention may require some initial investment and “sweat equity,” Hinman insists the payoff is great for practices and patients alike.

“In preparing for the future, we’ll need to be better able to manage groups of patients – and we’ll need more registry function in order to do that,” he said. “I think there’s no way to do it with the paper record. We need a computer to pull data from and have it actually work for you. The front end – getting people into the system – is where it takes the most time and energy. But it’s the backend where you’ll see the rewards. My recommendation is to stick with it and the efficiencies will start showing up.” n

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Features

All Payer Claims Database Jonathan Mathieu, director of data and research, The Center for Improving Value in Health Care

APCD harnesses the power of the Internet In recent years, the Internet has empowered consumers to make informed choices on products and services for everything from restaurants to books to plumbing. Yet, when it comes to health care, we’ve been essentially stuck in the horse-and-buggy days.

That’s because, until recently, there’s been a dearth of reliable performance data to help patients, employers, physicians and medical practices make informed decisions to improve quality and reduce costs. For example, how are consumers supposed to know a reasonable price to pay for a knee-replacement surgery if they can’t compare pricing among those who provide the service? On the other side of the examination table, physicians focused on making their practices more efficient are hamstrung given the lack of meaningful data on how much medical services cost.

Fortunately, in Colorado and elsewhere around the country, the times are changing as the floodgates begin to open up for reliable data and transparency in health care begin to open up. Importantly, this is also an opportunity for physicians to step up to help make sure that this information is meaningful and valuable for patients and physicians.

Key in the state’s health-data revolution is the All Payer Claims Database (APCD) and public website developed by the Center for Improving Value in Health Care (CIVHC) and seeded through generous grants from the Colorado Health Foundation and The Colorado Trust.

Comparative data Colorado’s APCD currently includes

2009-2013 historic claims data from commercial payers plus Medicaid. Medical services prices are currently based on 2012 claims and will be updated to reflect 2013 data in December of this year.

Because of legal and other barriers, selffunded commercial insurance claims data and claims for patients 65 and over are not currently reflected on the website. CIVHC will add information for Medicare beneficiaries to the public website beginning in December 2014.

In July of this year, CIVHC launched consumer-focused information on the public APCD website (comedprice.org) to provide comparative price and quality data on medical facilities and providers.

Equipped with transparent information, consumers can better determine if there is significant variation in what they might be asked to pay for medical services – and whether it might be worth their while to shop around.

Beginning in December, the website will include data for ambulatory surgery centers and endoscopy centers. CIVHC will also add mild- and moderate-complexity

emergency room visits, along with eight procedures that are performed in both hospitals and outpatient settings including tonsillectomies, colonoscopies, gall bladder surgeries and hernia repair.

In 2015, the website will include up to 20 imaging procedures and, eventually, five types of primary preventative care-type visits on a named physician-group basis.

While not identifying individual group physicians by name, the website will include comparative price and quality data at the physician-group level. Once that occurs, consumers will have price and quality information for primary care services, and physicians will gain the ability to compare their performance to that of their peers – albeit, at a very high level.

Physicians driving change While private sector companies, like Castlight Health and Healthcare Bluebook, are collecting, analyzing data and publicly reporting comparative performance data without any interaction with physicians on whom they’re report-

Colorado All Payer Claims Database facts • Colorado is only one of 12 states to have an APCD, and we are only one of three that have consumer price information available.

• The Colorado APCD received the national 2013 Innovation in Data Dissemination Award from the National Association of Health Data Organizations (NAHDO).

• Colorado is one of the few states that offer custom reports and analytic data sets based on the APCD data to providers to support Triple Aim related projects.

• Visit www.civhc.org for more information about Colorado’s APCD.

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APCD (cont.) ing, the Colorado APCD and CIVHC present an opportunity for physicians to really understand and shape how they’re being evaluated. Rather than using black box methodologies and choosing poorly understood performance measures, CIVHC has intentionally and consistently sought physician feedback and participation to help: • identify appropriate measures; • improve the rigor of the methodologies; • design reporting templates; • verify the accuracy and complete-

ness of results to ensure that they are meaningful and actionable for physicians and patients; and • highlight relative performance and opportunities for potential improvement.

Though it’s unlikely that Colorado’s APCD public website will ever be completely comprehensive – there are simply too many different procedures to ever make that possible or practical – CIVHC aims to highlight information that reflects typical experience for Colo-

radans for the most common medical procedures and services.

Shaping public policy and private decisions For those seeking value in health care, the benefits of the APCD website are obvious. As the database becomes more robust in the years to come, it will evolve into an increasingly useful tool for health care consumers and employers mindful of health to manage their health care costs.

The information, especially the data on variation in utilization and spending, is of keen interest to policymakers who are crafting legislation that could influence the future of health care. The governor’s office and other advocacy organizations are also carefully watching this development.

Over the next year, CIVHC will look for opportunities to provide additional information that helps people make betterinformed medical decisions. The organization will also do a lot more outreach and education as it develops reports that go back to physician practice groups to help them understand their own performance in the Colorado marketplace.

In doing this, CIVHC has forged a number of partnerships with the medical community (including the Colorado Medical Society) to develop the kind of information that physicians need to understand their performance and identify quality measures that are meaningful to go along with comparative price information.

Physicians and their practice teams are strongly encouraged to explore the APCD site to understand what information is currently available. While some may find only limited utility now, those that want to look beyond global insights to understand their population and costs can also get a deeper dive through custom reports using the APCD data request process.

If you would like to help shape this process, please contact Chet Seward in the CMS offices or Jonathan Mathieu at CIVHC. n

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Features

Health care transformation Kate Alfano, CMS contributing writer

Colorado’s State Innovation Model driving transformation The State of Colorado has qualified for second-round funding for the State Innovation Model, or SIM, grant. SIM Phase 2 will facilitate the integration of physical and behavioral health and accelerate public and private sector collaboration on multi-payer models and delivery system transformation. It opens unique opportunities for the Colorado Medical Society to drive innovation and health plan standardization, and CMS is proactively positioned to promote payment and delivery system reform priorities for members and patients.

The State of Colorado has been working on the SIM initiative for two years, explained Katherine Blair, senior policy advisor on health to Gov. John Hickenlooper. The Colorado SIM team first submitted an application to the federal government for funding in September 2012; they received a planning grant in

March 2013 to refine the original proposal and submitted this new proposal in July 2014.

SIM will allow the state to “pull the pieces together,” said Judy Zerzan, MD, MPH, chief medical officer and director of client and clinical care at the Colorado Department of Health Care Policy and Financing. This includes federal initiatives like the Affordable Care Act and the Comprehensive Primary Care Initiative; community health needs assessments and public health improvement plans; the governor’s “State of Health” initiative and existing SIM work; HIT infrastructure; and recommendations from the 208 Commission and the new Commission on Affordable Health Care.

“This isn’t one more separate effort,” she said. “Really we see SIM as a pro-

Katherine Blair Mulready, left, senior policy advisor on health to Colorado Gov. John Hickenlooper, and Judy Zerzan, MD, MPH, chief medical officer and director of client and clinical care at HCPF, present the latest on the State Innovation Model.

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cess that’s linking the things that are already happening and trying to have a platform so it can all come together and make sense. We see the SIM effort as how we get health care transformation in our state.”

The goal of the SIM initiative is to improve the health of Coloradans by providing access to integrated primary care and behavioral health services in coordinated community systems, with value-based payment structures, for 80 percent of the state’s residents by 2019.

It is widely acknowledged that the current health care system is inefficient and expensive; patients are often treated one condition at a time when evidence shows that caring for the whole person – body and mind – leads to better health.

SIM will “get everyone on the bus,” Zerzan said. “We will form a strong partnership between public health and health care that coordinates clinical, public health, technology and community resources.”

The SIM team has six different roles on which they’re looking to focus work, Zerzan said: • Patients will have an easier time getting the care they need and will experience seamless care delivery addressing both physical and behavioral health needs.

• Providers will work side-by-side to treat patients’ physical and behavioral health needs with ongoing support from SIM to smooth the transition.

• Policymakers will ensure that rules and laws support the transition and evaluate the reform progress.

Colorado Medicine for November/December 2014

Features • Public health will partner with providers to improve population health.

• Health information technology will help provide interconnected medical records and support telehealth.

• Payers will move toward models based on quality and value of care.

SIM will provide practice transformation services to 400 practices as they integrate behavioral health and primary care starting in 2016. The management team is in the process of determining selection criteria and processes for practices and will consider provider/patient panel size, geographic location, community support, affiliation with payers and health systems, and current integration status.

The implementation plan “stair-steps” in its progression. SIM practices start in the observation phase during which they will identify current spending and future benchmarks for spending, understand needs to transform the practice, and identify outcome and quality baselines. Second is care coordination and savings where practices will demonstrate increased coordination through additional payments, receive support in practice transformation, and measure performance and quality.

The third step is shared risk and savings, during which providers will have more responsibility and accountability with extra payments built into the total cost of care. Practices will continue to receive support in practice transformation and report on performance and quality. Fourth is payment and budgeting for comprehensive primary care; this stage includes a learning collaborative, payment based on total cost of care and coordination, and continued performance, quality and cost measurement.

Zerzan invites CMS members to consider joining one of the SIM workgroups: HIT, Data and Quality Measures; Payers, Purchasers and Payment Reform; Service Delivery and Practice Transformation; Population Health and Consumer Engagement; Workforce; and Evaluation. For more information on the workgroups and to sign up, visit www.ColoradoSIM.org. n Colorado Medicine for November/December 2014

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Features

Ebola virus preparedness Kate Alfano, CMS contributing writer

CMS CDPHE Kate Alfano,and CMS contributing writer working closely on physician education The 2014 Ebola epidemic is the largest in history, affecting multiple countries in West Africa and impacting countries around the world. National, state, and local public health officials are actively monitoring the situation and taking precautions to prevent the spread of Ebola in the United States.

To help prepare Colorado physicians for a possible case of Ebola in the state, the Colorado Medical Society hosted a webinar on Nov. 4, “Ebola Preparedness in the Outpatient Setting.” CMS targeted outpatient physicians following direction from leaders who felt that education for this group was lacking compared to their hospital-based colleagues.

All physicians – member or non-member – were encouraged to participate in the hour-long presentation and question-and-answer session with speakers Tamaan Osbourne-Roberts, MD, CMS president; Connie Savor Price, MD, chief of infectious diseases and medical director of infection prevention at Denver Health and Hospital; and Lisa Miller, MD, state epidemiologist. The on-demand webinar is available online for CME credit. Go to tinyurl.com/cmsebola-webinar to access it.

Since the first case of Ebola was diagnosed in the U.S. in October, CMS has been working with the Colorado Department of Public Health and Environment (CDPHE), the Colorado Hospital Association, the Colorado Nurses Association, the Colorado Association of Local Public Health Officials, and others to prepare and implement a state plan.

“By working closely with all of our health care partners, we are helping to ensure Colorado’s preparedness for any potential Ebola virus exposures. Indeed, it is by coordinating efforts throughout the health care system that Colorado best can prepare,” said CMS President Tamaan Osbourne-Roberts, MD. “Together, we will make every effort to inform providers and the public on policies and procedures to contain the Ebola virus, if necessary, in order to maintain the health and safety of Coloradans.”

CMS has pledged full cooperation and support to the Office of the Governor and to CDPHE. The society strongly supports the department’s goal of making sure that public health, health systems, health care professionals and other partners are prepared to recognize a potential Ebola case, to halt its transmission efficiently and quickly, and to protect frontline health care providers.

Physicians are asked to take the following steps with every patient encounter.

CDPHE Executive Director Larry Wolk, MD, MSPH, discusses Colorado's Ebola preparedness efforts with CMS physicians.

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Ask • Ask whether the patient has visited Sierra Leone, Guinea or Liberia within 21 days, and • Ask about symptoms consistent with Ebola Virus Disease.

• Ask everyone, every time.

Isolate • If both criteria are met, isolate the patient in a single patient room (with private bathroom) with the door closed.

Call • Call hospital leadership, and • Call CDPHE at 303-692-2700 (after hours, 303-370-9395). Also notify CDPHE of any patients reporting exposure to Ebola, even if they have no symptoms.

CMS physician members received the first Ebola communication on Oct. 15, which gave guidance on detecting and responding to a potential Ebola case.

This same communication was sent to physician practice managers through the Colorado Medical Group Management Association and to practice managers through CMS’s LiveWire e-newsletter. CMS created an Ebola resource page at www.CMS.org that is continually updated with new federal and state resources. All Colorado physicians, regardless of membership, have access to this resource page.

Also on Oct. 15, CMS and CDPHE issued a joint statement with CHA, CALPHO, and CNA. Osbourne-Roberts answered media questions at a press conference called by Gov. John Hickenlooper on Oct. 21. Mark Johnson, MD, a public health official who will soon begin service on the CMS Board of Directors, represented CMS at a legislative hearing on Oct. 23.

The CMS Board of Directors gave priority attention to the issue at its Nov. 14 meeting and approved the formation of a board advisory committee on Ebola. n

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Features

Edward A. Dauer, LL.B., M.P.H.

It’s baaack – the Supreme Court and the ACA Editor’s note: Edward A. Dauer is Dean Emeritus and Professor Emeritus of Law at the University of Denver; and an Adjunct Professor in the Department of Health Systems, Management and Policy at the Colorado School of Public Health. During 2014 he served as the inaugural Gitenstein Distinguished Visiting Professor of Health Law and Policy at the Fuchsberg Law Center of Touro College. He holds an LL.B. from Yale Law School and an M.P.H. from the Harvard School of Public Health.

Just as this issue of Colorado Medicine was going to press, the United States Supreme Court announced that it would consider another legal challenge to a central part of the Affordable Care Act – commonly known as “Obamacare” or, more politely, the ACA. Needless to say, the reams of legal briefs and supporting materials that will eventually be filed with the Court won’t be available for some time, making it dicey at this point to say exactly where the good and not-so-good arguments lie, or even what the fuller implications of a decision one way or the other might be.

But the legal issues are already reasonably clear; and the political context, particularly given the outcomes of the 2014 midterm elections, is compelling enough to make an overview of the case and its stakes worth doing even now. I agreed to give it a try.

What’s the case about? – Part 1: The role of the “exchanges” Much of the ACA was designed to bring the un- and under-insured within the tent of health insurance coverage. Two of the 30

major pieces of the Act that do that are the expansion of Medicaid, and subsidies in the form of tax credits. The subsidies are designed to offset some of the cost of health insurance for individuals and families whose incomes are greater than the Medicaid limit but less than enough to buy even modest health insurance coverage without that help. The group eligible for subsidies is large – by the government’s count more than 6 million people have applied for the subsidies, and about three times that many eventually might.

The marketplaces or “exchanges” where these subsidies are available exist in some fashion in every state, but some have different parentage than others. The ACA provided that if a state didn’t set up its own, the federal government would create an exchange for the residents of that state. Fourteen states, including Colorado, created their own exchanges. Two others are still trying to but haven’t done so yet. The other 34 have either joint state-federal programs (7), or exchanges established by the federal government alone (27).

The question raised in the case coming before the Supreme Court is whether the tax credit subsidies are available to people buying health insurance in all of the exchanges – that is, in all 50 states – or only in those exchanges created by the states, i.e. somewhere between 14 and 23.

What’s the case about? – Part 2: The language of the Act The legal issue in the case turns (mostly) on one phrase in the ACA. That phrase says that the tax credit subsidies are

available to people who are “enrolled . . . through an exchange established by the State . . . ” Does that phrase mean that people buying their insurance through a federally-created exchange, rather than through an entirely state-created exchange, aren’t eligible for subsidies?

The Internal Revenue Service (the agency responsible for administering the tax credit subsidy system) answered that question in a regulation that it issued in 2012: the subsidies are available in all of the exchanges, not only those created directly by a state. The question before the Supreme Court is technically whether the IRS had the authority to issue that regulation, given the language of the statute itself. For reasons we needn’t get into here, that question isn’t exactly the same as the underlying question of what the statutory language means; but for present purposes the “what does it really mean” question is central enough.

Two federal Circuit Courts of Appeal have reached opposing conclusions on that question, though as I will explain below the situation is actually even more interesting than that.

The Court of Appeals for the Fourth Circuit, which includes Maryland, North Carolina, South Carolina, and Virginia, held, first, that the critical language in the ACA is not “clear and unambiguous;” second, that the “broad policy goals” of the Act were to increase the number of Americans covered by health insurance; third, that where a statute is ambiguous (among other things) the courts may defer to interpretations by the appropriate

Colorado Medicine for November/December 2014

Features federal agency; and finally, that given its consonance with the statute’s broader goals the IRS’ interpretation should stand. That is to say, everyone gets their subsidies. That decision – styled as King v. Burwell – is the decision for which the Supreme Court granted review.

Almost simultaneously a three-judge panel of the Court of Appeals for the District of Columbia reached the opposite conclusion in the case of Halbig v. Burwell. That court held that, first, statutes must be interpreted so as to implement Congressional intent; second, that the best evidence of Congressional intent is the language Congress actually enacted; third, that the history and context of the ACA’s legislation do not make a substantial case contrary to the words that appear in the Act; and, finally, that courts must abide by what Congress said, not by what a judge might think Congress probably meant to say. Therefore, the D.C. panel held, the IRS rule is not valid; and residents of states where the exchanges were federally created are not eligible for premium subsidies.

Where the two lines of reasoning conflict, neither in my view is a slam-dunk.

Determining “Congressional intent” is often an imponderable thing because Congress, taken collectively, seldom has any singular intent. In the case of the ACA, for example, it is absolutely certain that some legislators intended the law to do whatever would expand coverage the most. At the same time, one of the Administration’s chief legislative architects publicly stated more than once that making tax credits available only on state-created exchanges would serve as an incentive for the all of the states to create them.

I mentioned that the situation is actually more interesting than just those two decisions, and it is. In the D.C. case the court granted a petition for what is called en banc rehearing – a procedure in which the whole bench, of 11 judges in D.C.’s case, revisits the decision of its threejudge panel. That review is scheduled to take place this December; but because en banc review was granted, the panel’s judgment is for the moment at least “vacated.”

That means that in the law’s version of

reality there is no conflict between the Circuits. Moreover, just last month a federal district court in Oklahoma also held, as the D.C. panel had, that the language of the Act means state-created only. But that case is also now under review, in the Court of Appeals for the Tenth Circuit (which includes Colorado). It is unlikely to be decided for many months more.

All of this is interesting because the Supreme Court tends to await development of a conflict in the circuits before agreeing to take a case on. But in this case some number of justices (at least four) thought the issues worthy of addressing now, even though no circuit split actually exists. Maybe that tells us something.

Maybe not.

What’s the case about? – Part 3: Jurisprudence and the reality Underneath what appears to be a straightforward question – namely, what does “exchange established by the state” mean – there are actually two more fundamental debates. One of them I’ll call the jurisprudential question; others may call it naïve. The other is the political question; some might call that one cynical.

We’ll dispense with the jurisprudence first. The central axiom of statutory interpretation is that, within Constitutional limits, courts must apply the law as the legislature created it, not the way a court might have preferred it be created. This reflection of the “separation of powers” idea is well grounded: legislators are elected, and on a regular schedule they can be unelected. Judges in the federal system, however, have life tenure – once appointed they are essentially unaccountable to the electorate.

Core democratic principles therefore caution against allowing courts to interpret legislative acts however they will. One of the ways of implementing that caution is a rule, that when a legislature says something in words, those words are what the court should enforce. All of the other rules about ambiguity and deference are meant to determine whether the words of a statute do indeed speak for themselves; or, when Congress’s intent isn’t clear from its words alone, how much interpretation

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should be allowed. So, one way of describing the underlying issues in these cases is that they are about competing nuances of the judiciary’s institutional competence and role. When it’s issued, the Court’s opinion(s) will almost certainly read as if that’s what this case is about.

So much for the law professor’s point of view. The realist in me has a different one. I doubt that the parties to these cases care a whit about jurisprudence and institutional competence. Some of them want to gut the ACA. Others don’t.

That raises the question of what and how much is really at stake. In fact, it could be even more than meets the eye.

Why does it matter? – Part 1: How other parts of the ACA are involved This could be a big deal. If the Supreme Court decides that the phrase “exchange established by the state” means only the exchanges in the 14 (or maybe 16) states with nonfederal exchanges, federal premium subsidies will become unavailable for a majority of otherwise qualifying Americans. Colorado, which does have a state-created exchange, might seem not to be at risk. But that appearance could be short-lived, for two reasons. One has to do with how the exchange-based subsidies are connected to other parts of the ACA; the other, with the choices the political process might face if the Act is deeply wounded.

As the petitioners in King v. Burwell have argued, both the ACA’s Employer Mandate and its Individual Mandate are linked by the language of the statute to the workings of the exchanges.

The Individual Mandate requires that (almost) everyone purchase insurance; but it exempts those for whom insurance with “minimum essential coverage” would cost more than 8 percent of their household income. The “cost” in that formula means the net cost – the insurer’s premium minus the available tax credit.

With the tax credits inversely related to income and designed quantitatively to keep net costs below the trigger percentage for as many people as possible, few are

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Supreme Court (cont.) exempted under the percentage formula.

So, with the IRS regulation in place, the mandate applies very broadly.

But if the tax credits are not available, then the net costs of the policies rise to the full premium charge, making a very large number of people exempt from the mandate. To wit, of the 7.3 million people who have already purchased insurance through the exchanges, more than 5 million live in states where the exchange was federally-created; 90 percent of the purchasers are eligible for subsidies; and the subsidies cover on average over 75 percent of the total premium costs.

The individual mandate is essential to preventing what insurers call “adverse selection.” As the premium cost of health insurance rises, the healthier people tend to drop out of the pool, causing an increase in insurers’ average risk and cost.

In that way any significant reduction of the mandate could trigger a premium “death spiral,” or at the very least a substantial increase in premiums for those who do remain insured. The markets, some say, would be seriously destabilized

if the credits were unavailable in any significant number of the 36 states. Whether the Colorado insurance market could isolate itself from that phenomenon is something I cannot say; but it very well may not be able to do so.

how, given the internal dynamics of the whole ACA, a challenge to the subsidies in some of the states risks repercussions even wider than just the loss of affordable insurance, which by itself could be a disaster for the Act.

The Employer Mandate linkage is a bit more tenuous, but still at risk. The statutory discipline which prompts large employers to offer qualifying insurance to their employees is the threat of a penalty called “assessable payments.” That penalty applies if employers fail to offer adequate coverage, resulting in any fulltime employee enrolling in exchangepurchased coverage for which a premium subsidy is allowed or paid. But if no subsidy is available in a federally-created exchange, the mechanism of the assessable payment penalty arguably disappears, effectively relieving the employer from its legal obligation to offer insurance to anyone.

Why does it matter? – Part 2: The politics are the thing This challenge to the subsidies in twothirds of the states is not news. It was well understood even before the IRS first addressed it in 2011. It could have been fixed – and it still can be – by a simple legislative amendment that changes the phrase “in an exchange established by the State” into the more inclusive phrase “in an exchange” (plus a few minor conforming touch-ups.) So why hasn’t that happened?

Whether that undoing actually happens, or whether some plausible work-around can be conjured up, I cannot at the moment say. But this linkage also illustrates

The ACA was passed when the Democrats controlled the House, the Senate, and the Administration. Only one Republican voted for the bill when it was considered in the House. Republicans became a majority in the House in the 2010 elections, many of them running on the promise to undo the ACA tout de suite. It then became impossible to enact any amendment to the ACA at all, because the Administration had vowed to veto any bill that threatened the Act. It seemed inconceivable that a correcting amendment – strengthening the Act against the kind of challenge it is now facing – could have become law. With the Republicans also a majority in the Senate as of the 2014 election, that stalemate is even more the case today.

For its part the United States Supreme Court is, theoretically at least, “above politics.” But the overlapping opinions in the first Constitutional challenge to the ACA in NFIB v. Sibelius left little doubt about the tenor of the justices’ jurisprudential ideologies, in case they weren’t otherwise absolutely clear. Although the meaning of the Court’s merely granting a petition for review is always inscrutable, what we know about judicial propensities makes this case a horse race.

If the challenge fails, life returns to its ACA normal. But if the challenge succeeds, and if there is no court-created fix as there was for the Medicaid expansion in NFIB, insurance premium subsidies

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Features could become unavailable for the residents of as many as 36 of the 50 states.

That would be a major blow to one of the signal social constructions of the 21st century. It would also be at the very least a politically unstable circumstance.

I cannot imagine life going on that way.

Putting aside any follow-up legal challenges to government’s discriminating against some of its citizens on what might be thought an irrational ground, there would in the political arena be the spectre of a massive transfer of money from some citizens to others – taking tax revenue from the 36 states with no subsidies and giving it to the 14 states that retain them. Might the 34 states that haven’t created their own exchanges then fix the problem by doing so now, assuming that could affect their eligibility? I wonder. For one thing, 19 of the states declining to create their own exchanges are among the 20 states that also declined the ACA’s Medicaid expansion. Add to that the political distribution of the governorships...

Again, I am uncertain that Colorado could isolate itself from the national quandary. Could we retain our exchange, and our broadened coverage, and everything else the ACA now provides if in a majority of the sister states there was no ACA? Or if the Act is politically imperiled across the board by some of the destabilizing effects of the Supreme Court’s adverse decision? The last time we looked at it comprehensively it seemed questionable whether Colorado could afford to go it alone. Circumstances are different now; but how one state could replace what the ACA now provides would still be a challenge – if, of course, it comes to that.

So on the one hand, if the ACA survives its current peril, we can all go back to work doing what we do. If it does not survive, all of us – physicians more than

most – will be challenged to craft yet another future for health care, for Colorado as well as for the nation. n

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Other than that, it is beyond my ability to predict how our political institutions will behave if the Court holds that the language of the ACA simply means exactly what it says. Even as these lines are being written, the ground rules of engagement for a divided government are largely unknown. Eventually some bargain will emerge, even if it has to await the outcome of the 2016 elections. I for one simply cannot see a bargain – or the absence of a bargain – that leaves 14 states’ residents forever insured and those from the other 36 states not.

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Inside CMS

Strategy session Kate Alfano, CMS contributing writer

Kate Alfano, CMS contributing writer CMS delegates hold scope of practice strategic discussion The House of Delegates held a strategic discussion on scope of practice at the 2014 annual meeting in Vail. The CMS Board of Directors, as the body charged with implementing CMS policy, brought this issue to the HOD to gather members’ thoughts on whether the society should reassess the traditional issue-by-issue approach to dealing with scope of practice and look for effective, alternative strategies.

There are three things that triggered a review of scope of practice issues, explained Joe Gagen, JD, the discussion’s facilitator and veteran of the realm of legislative and organizational strategy.

The first came about as a result of a meeting of national specialty and state medical society CEOs. The American Medical Association convened the group, which included CMS CEO Alfred Gilchrist, to examine the effects and costs associated with the current strategies dealing with scope of practice. The group commissioned an environmental scan that uncovered a skyrocketing number of legislative and regulatory proposals related to scope across the country and the growing state lobbying expenditures on this issue. “The vast majority of state medical societies are spending between 50 and 85 percent of their total lobbying budget on scope issues,” Gagen said.

Second was the awareness that, in line with a national trend, there will be several scope of practice issues brought forward by allied health professionals and other groups and likely debated by the Colorado legislature in 2015.

Third was a lawsuit before the United States Supreme Court, North Carolina Board of Dental Examiners v. Federal Trade Commission, through which the FTC has challenged the ability of that board to regulate dentists on the basis that – in this case – the board is nominated by the dentists themselves. The FTC doesn’t think it is appropriate for an official state licensing board that regulates scope of practice to be controlled by the individuals who perform that practice.

“Those are three things that led us to the desire to be proactive rather than reactive, to look at the issue ourselves as part of a deliberative process, and get feedback from the Council on Legislation and our House of Delegates,” Gagen said.

The changing landscape Much has changed over the course of the career of Jerry Johnson, longtime CMS lobbyist. “Doctors are no longer seen as the dominant authority figures on health care at the Capitol, and while physicians continue to hold the respect of legislators, it is a shared respect with other providers, especially advance practice nurses.”

At the same time, much has stayed the same, Johnson said. “I cannot recall a year when we did not have to fight at least one scope battle and while we win almost all of them, they are always difficult fights and the battles are not well received by members of the General Assembly.”

“The most consistent dynamic that I have

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Inside CMS observed over the past 20 years is this: Legislators hate scope battles,” he said. “They feel trapped in the middle and would prefer that the warring professions work out their differences without involving the legislature. The reality is this: We will face these same fights over the next 20 years without the same level of success we have enjoyed in the past without a change in our strategy that takes into account the changing perspective of the General Assembly.”

Council on Legislation survey The CMS Council on Legislation was asked to complete a survey on scope of practice in advance of their July meeting.

Gagen presented a few of the questions and their answers. First, the COL was asked to what extent they believe changing health care economics and market forces have impacted broader political support for expanded scope of practice for allied health professionals and others. Eighty-five percent answered either high or very high.

force, and have impacted legislative effectiveness on other issues important to organized medicine. Every single respondent answered “yes.”

Members in the audience then shared their perspective on scope of practice, in the context of the environmental scan, Jerry Johnson’s comments and the survey results.

Gagen summarized: “The overwhelming theme I heard very clearly is the Colorado Medical Society should not abandon its role to ensure that patient safety is put first and that there is accountability for skill and

competency when people treat patients. I did hear that overwhelmingly you believe that it is, in fact, appropriate to reexamine the tactics that are implemented consistent with that overarching principle.”

The Board of Directors will continue to go through this dynamic process to look at new tactics to address the issue, and should any fundamental change be proposed, it will come back before the House of Delegates. All CMS members are encouraged to share their thoughts with CMS staff or officers. n

Another question asked them to choose the major factors that influence the legislature’s decision-making on scope of practice issues. In order of significance: • Lobbying efforts • The perception of the impact of expansion of scope in improving access to and delivery of health care • Not quality of care issue at all, but rather “how you slice the health care dollar pie” • Campaign funds and campaign support • Public support or opposition • Merits of the scope issue • Possible harm to patients In response to a question on whether past specific expansions of scope have impaired the quality of care to patients, the answers were split nearly evenly. To another question on whether past expansions have affected the financial viability of physician practices, 37 percent said “yes” and 63 percent said “no.”

Finally, after reviewing the environmental scan, COL members were asked whether some past and current legislative strategies have not been particularly effective in limiting scope expansion, have undermined legislative respect for physicians as quality of care advocates and as a political Colorado Medicine for November/December 2014

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Inside CMS

CMS Board of Directors Kate Alfano, CMS contributing writer

CMS Board sets ambitious work plan for 2014-2015 The CMS Board of Directors adopted an ambitious work plan for the upcoming year at their meeting on Friday, Sept.

19. The plan will continually evolve to incorporate direction by the House of Delegates and to adapt to new situations and opportunities as they arise. The plan is directly tied to the CMS strategic plan – which was updated earlier in the year and approved by the House of Delegates at the 2014 annual meeting – and previous BOD and HOD actions.

The board broke into three groups to discuss in detail physician well-being and success, health care systems evolution, and organizational excellence. For each work plan item, members reviewed the proposed goal, the proposed objective and the proposed strategy, and then assigned a level of importance. They presented each item to the full board and approved the plan.

on behalf of medicine understand that the words on these pages don’t convey what will be required of our advocates and volunteer physician leaders in terms of grace, magnanimity, diplomacy, risk taking, and consensus building under both internal and external pressure,” said CMS President Tamaan OsbourneRoberts, MD. “The scope of work embodied in the fiscal year 2014-2015 work plan of the CMS Board of Directors is an understatement of what is ahead of us over the coming year. The plan speaks for

itself in terms of content and logic. In this time of market disruptions and realignments, our priorities have been deliberatively and methodically developed from the grassroots and our component organizations.”

CMS leaders hope the plan will effectively advance medicine’s voice in Colorado’s executive suites, the legislative and executive branches of state government, and the judiciary, if needed, on the behalf of Colorado physicians.

Members can review the plan online at www.cms.org. n

Internally, it outlines how CMS intends to upgrade and repurpose communications to physician constituencies, streamline administrative and governance functions, and boost outreach to medical students and other component societies. Externally, the plan top-lines how the society intends to engage and respond to the game-changing issues already in play – including Medicaid reform, repealing the SGR, and maintaining Colorado’s relatively stable liability climate – as well as those that are coming online, such as Colorado’s new Commission on Affordable Health Care and State Innovation Model, the federally funded initiative to integrate physical and behavioral health.

“Veterans of this extraordinary work Colorado Medicine for November/December 2014

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Inside CMS

Annual meeting highlights Kate Alfano, CMS contributing writer

CMS policy, Kate Alfano,sets CMS contributing writer elects new leaders and presents awards Every year the Colorado Medical Society convenes its House of Delegates to validate and set policy for the upcoming year, elect new leaders, attend edu-

Osbourne-Roberts is a board-certified family medicine physician who lives in Denver. He is a founding member of the hospitalist service at Mount San Rafael Hospital, a 25-bed critical access hospital in Trinidad, Colo., through Innova Emergency Medical Associates.

ciation House of Delegates representing CMS. He also served as alternate delegate and delegate to the American Academy of Family Physicians Congress of Delegates representing CAFP, as coconvener and delegate to the AAFP’s National Conference of Special Constituencies, and as member and chair of the AAFP-NCSC Reference Committee on Health of the Public and Science.

On Sunday, the House of Delegates He serves as a convened for other elections. Michael board member of Volz, MD, was elected president-elect.

CMS, the Denver Volz is board certified in allergy/immuMedical Society, nology and a native of Wisconsin. He is the Colorado currently a solo-practice physician with Academy of Fam- two offices in Denver and coverage in ily Physicians and Colby, Kan., twice per month.

Michael Volz, MD, addresses the House of Delegates after being the Colorado elected 2014-2015 president-elect. He will assume the office of presi- Hospital Asso- He has served as the president of the dent in September 2015. ciation. He is also Colorado Allergy and Asthma Society cational sessions and honor those indi- a member of the Physician Advisory and the Clear Creek Valley Medical Soviduals both in and out of the society Committee on LGBT Health Dispari- ciety, the medical director for the Amerdeserving of praise. ties and an inaugural member of the ican Association of Colorado asthma CMS Health Disparities Committee/ camp, and as a board member of the Although too lengthy to publish here, Diversified Physiall CMS members are encouraged to cians Section. He visit the CMS website at www.cms.org served as chair of to review the policy decisions made at the CMS Memthe annual meeting. What follows is a bership, Unity summary of the rest of the meeting. and Relevance Task Force and as CMS election results: chair and founder Members select, install of the CMS Resinew leaders dents and Fellows First and foremost, Tamaan Osbourne- Section.

Roberts, MD, was installed as the 20142015 Colorado Medical Society presi- On the national dent during the 2014 Annual Meeting level, Osbournein Vail on Saturday, Sept. 20. At age 37, Roberts is an alhe is the youngest president in the orga- ternate delegate CMS Immediate Past President John L. Bender, MD, presents the nization’s history as well as the organiza- to the American Tip of the Spear Award to Elisabeth Arenales, director of the Colotion’s first black president.

Medical Asso- rado Center on Law and Policy’s Health Care Program.

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Inside CMS CCVMS Board of Trustees, the CMS Board of Directors and the Lung Association of Colorado Board of Directors.

Delegates also approved component society and section directors to the CMS Board of Directors and approved members of the Council on Ethical and Judicial Affairs. Robert Yakely, MD, was re-elected as Speaker of the House of Delegates and Brigitta Robinson, MD, was re-elected as Vice Speaker of the House. One delegate to the AMA was elected – Lee Morgan, MD, and one alternate delegate to the AMA was elected – Katie Lozano, MD. W. Gerald Rainer, MD, was re-elected to the office of CMS historian.

Congratulations to the new officers and leaders of the Colorado Medical Society.

Elisabeth Arenales given Tip of the Spear Award CMS honored Elisabeth Arenales with the Tip of the Spear Award at the 2014 Annual Meeting in Vail on Sept. 21.

Elisabeth is the director of the Colorado Center on Law and Policy’s Health Care Program.

The Tip of the Spear Award is one of CMS’s special recognition awards. CMS uses these awards to recognize deserving stakeholders for their significant contributions to the medical profession and the patients of Colorado. “Tip of the spear” is a phrase coined by the special operations community. It can also refer to a person on the cutting edge or a leader in engagement. These latter meanings apply to the Colorado Medical Society’s 2014 Tip of the Spear Award winner.

Arenales carries a law degree with specialization in health care and government programs and a passion for serving the uninsured with a well-earned reputation of respect and humility. She is a tireless advocate for access to quality, affordable health care and envisions a health care system with much more transparency in pricing. She conceived the idea to create a commission to study

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Annual meeting (cont.) health care costs that would have the authority to recommend solutions and not become mired in politics. She gave great thought to the structure and composition of this commission, and she and her organization conducted the pol-

the creation of this commission,” said CMS Immediate Past President John L. Bender, MD, FAAFP. “Because of her actions, Colorado will have a chance to control its own destiny; there is arguably not a more important undertaking to assure the public and economic health of Colorado than getting health care costs under control.”

The Colorado Medical Society strongly supported SB14-187 and has pledged to work in collaboration with the commission CMS leaders Tamaan Osbourne-Roberts, MD, and John L. Bend- to influence how er, MD, center, present 50-year pins to Perry Bach, MD, left, and Colorado's health Herbert Jacobs, MD, right. care system can icy research and drafted a bill to present reduce cost and improve quality. to the Legislature.

CMS presents 50-year pins to Arenales approached Sen. Irene Agui- physicians celebrating 50th lar, a Democrat, and Sen. Ellen Roberts, anniversary of medical school a Republican, with the idea for a health One of the time-honored traditions of care cost commission and helped the the gala is to present 50-year pins to senators pull together former members of CMS members celebrating their 50th the 208 commission – formally known as anniversary of graduating medical the Colorado Blue Ribbon Commission school. This year’s honorees were Herbert for Healthcare Reform – and legislators Jacobs, MD, and Perry Bach, MD. from both sides of the aisle to address this issue of finding bipartisan solutions Outgoing CMS president to the problem. Using her knowledge of and past president honored health care policy, her attention to de- before the House of Delegates tail and her high standing among health Outgoing president John Bender, MD, care experts with respected legislators, FAAFP, was presented with CMS’s she successfully drafted SB14-187. The highest certificate of service award for bill passed in the 2014 General As- his outstanding year as president and sembly and created the groundbreak- outgoing immediate past president ing Commission on Affordable Health Jan Kief, MD, was honored during the Care. She did this while also overseeing Board of Directors meeting for her several important efforts in the Colo- many years of dedicated service to the rado Department of Health Care Policy Society including stints as Vice-speaker and Financing to address Medicaid cov- and Speaker of the House of Delegates, erage issues and spearheading the over- COMPAC board member, and ongoing all health care legislative agenda for the service on the AMA delegation to name just a few.

Colorado Center on Law and Policy.

“CMS applauds Elisabeth’s efforts to consolidate support across nearly the entire spectrum of stakeholders, led by leaders from both political parties, for 40

Youth science fair winners recognized at annual meeting Two Colorado State Science Fair winners were honored with cash prizes

and certificates in recognition of their achievements before the House of Delegates on Sunday, Sept. 21. Each year the CMS Education Foundation presents the Colorado Medical Society Award for Excellence in the Health and Behavioral Sciences to one student from the junior high division of the science fair and one student from the senior high division. CMS invites the students and

CMS board member Cory Carroll, MD, presents Jonathan Snedecker with an award for his state science fair project. their families to the annual meeting to display their projects and receive their awards.

The junior division winner, Madison Werschky, was honored for her project, “Got Gluten?” The purpose of her proj-

CMS Past President Brent Keeler, MD, presents Madison Werschky with an award for her state science fair project. ect was to test meals labeled as “gluten free” at various restaurants to see if they were truly gluten free. She hypothesized that some gluten-free meals actu-

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Inside CMS ally contain traceable amounts of gluten and found this to be true in her blinded study.

The senior division winner, Jonathan Snedecker, was honored for his project, “Are Food Additives Health Subtractives? The Drosophila in the Coal Mine.” Jonathan studied the effects of the anthropogenic food additives saccharin, aspartame, FD&C Red 40, and FD&C Yellow 5 on the health of fruit flies by tracking longevity and reproduction over three generations.

participation brought a youthful vibe to the social events while also giving them an opportunity to weigh in on CMS policy and to meet possible mentors in the practicing physician community.

Friday, Sept. 19, members gath- CMS President Tamaan Osbourne-Roberts, MD, shows off his He found that Yellow 5 caused develop- ered for a Car- moves and raises money for COMPAC in a creative way at the mental issues of both the reproductive n i v a l - t h e m e d exhibitor reception. system and other systems in male fruit reception hosted flies. Red 40 was toxic to both sexes of by the 2014 Exhibitors. Attendees en- act of duty. Following that, he delivered flies and caused physiological develop- joyed food and drinks, live music, a his inaugural address that focused on photo booth and his inspiration to pursue medicine – his giveaways. CMS parents – while giving attendees a perincoming presi- sonal perspective on his Trinidadian dent Tamaan Os- heritage. bourne-Roberts, MD, raised mon- Finally, a capoeira group – a form of ey for COMPAC Brazilian martial arts that combines elby limbo danc- ements of dance, acrobatics and music ing, going lower – performed and taught willing particiand lower the pants some moves. After enjoying dinhigher the dona- ner, attendees feasted on the traditional dessert bar sponsored by COPIC and tions became. danced into the night. n The Presidential Gala on Saturday, As part of the Carnival theme, CMS members and their guests are Sept. 21, honored greeted by stilt walkers as they enter the 2014 Presidential Gala.

Osbour ne-Robmental issues, but not reproductive de- erts. Keeping with the Carnival theme, velopmental issues, in male fruit flies. stilt walkers welcomed guests to the Saccharin was highly toxic to the fruit event and tradiflies, as it acted as a hepatotoxin and as tional dancers in a microflora inhibitor. Aspartame was costume livened toxic to fruit flies, but it also acted as a the dance floor. microflora promoter.

Osbour ne-Roberts took his oath Congratulations to these outstanding of office adminisstudents. tered by outgoing president John Social events big hit at meeting Bender, MD, Besides setting and validating CMS pol- FAAFP. Immeicy and electing new officers, one of the diately following main purposes of the annual meeting is his oath of office, to bring CMS members of all ages togeth- Osbour ne-Rober for fun and fellowship. Medical stu- erts made hondents represented both Colorado medi- oring outgoing CMS past presidents gather for breakfast, fellowship and a healthy cal schools well at the Annual Meeting, president Bender dose of strategic discussion on behalf of the medical society at the breaking records for attendance. Their his first official annual meeting in Vail.

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Inside CMS

CMS foundation helping students Michael J. Campo, PhD, support staff Colorado Medical Society Education Foundation

CMS Education Foundation 2013-2014 scholarship recipients University of Colorado School of Medicine freshmen Louis Fitch, Lindsey Herrera, Ethan Muhonen and Paul Pokrandt were each awarded a $10,000 scholarship from the Colorado Medical Society Education Foundation (CMS EF) in June.

The mission of CMS EF, a 501(c)(3) private foundation, is to render financial support to select first-year medical students at University of Colorado School of Medicine based on criteria such as the student’s financial status, academic achievement and desire to practice in rural or underserved areas upon graduation. In addition to providing scholarships, CMS EF supports education programs such as the Colorado State Science and Engineering Fair and the Education Program at the CMS annual meeting.

there, he was on the Dean’s List from 2009 to 2012; was named the 20102011 Organic Chemistry Student of the Year; was awarded DaVita Bone’s Award for patient care and team support of the dialysis staff in 2007-2010; and was honored with membership in the Golden Key Honor Society, Gamma Sigma Epsilon Honor Society, and Beta Beta Beta Honor Society.

Fitch has a diverse background. Born in Colorado but raised in Scotland

by Tibetan refugees, he has an understanding of being an outsider and of the challenges of growing up in multiple cultures. He uses this as a resource in understanding the complexity of social, economic and cultural barriers. Returning to Colorado after 12 years away, he continued to face similar challenges.

“The CMS EF Board appreciates the generous donations and support from CMS members who make our scholarships possible,” said CMS EF Board Chair W. Gerald Rainer, MD, a distinguished clinical professor of surgery at the University of Colorado Anschutz Medical Campus.

“Serving the underserved is not theoretical or abstract in the slightest; I know what it means to not have access to food, shelter or basic health care. This knowledge drives me and will be a pivotal part of my life as a medical student and a physician – it is my motivation,” he said.

Louis Fitch, prior to his arrival at the University of Colorado School of Medicine, received a Bachelor of Arts degree in Traditional Eastern Arts from Naropa University in Boulder, Colo. While

Lindsey Herrera received a Bachelor of Science degree in Chemistry from Colorado State University - Pueblo.

She was born in Durango, Colo., and raised just over the state line in La Plata, N.M.,

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(population 600), in a very rural area surrounded by several Indian reservations. At age 11 her family relocated to Pueblo, Colo. She volunteered at the Pueblo County Health Department. Growing up in both communities exposed her to different health disparities and she witnessed firsthand the impact that socioeconomic status and cultural differences can have on a person’s access to health care.

“Lack of (medical) access is an increasingly pertinent problem in rural communities. When these citizens are in need of medical care, they often must travel to obtain it, sometimes for several hours at a time. With more and more physicians choosing to practice specialized medicine in urban areas, the rural population has suffered a great loss. Because of all these experiences, I have decided to become a family practice physician,” Herrera said.

While in college she was a varsity cross-country runner. She was team captain in the 2008 season, selected to the 2007 all-conference academic team, and received a number of other honors and served on several national committees. Athletics has provided Herrera many life lessons such as how to cooperate with people of different backgrounds to reach a common goal; the value of hard work and the importance of practice and preparation; effective leadership, perseverance over setbacks and time management.

All of these lessons can be used in the everyday world.

Colorado Medicine for November/December 2014

Inside CMS Ethan Muhonen attended Stanford University and received a Bachelor of Arts degree majoring in Human Biology with Honors. He received two competitive grants to fund his research in 2011 and 2012, the Human Biology Research Exploration Grant (2011) and the Stanford Undergraduate Advising and Research Major Grant (2012).

Muhonen continued with additional research and education at Oxford University.

Muhonen grew up in a log house situated in a valley of the Colorado Rocky Mountains. The desire to explore was ingrained from a very young age. At Stanford he used this desire as fodder for questions in his pursuit of the study of human biology, ranging from biology, psychology, sociology and political science. He then focused his studies and research more precisely in the area of neuroscience and continued his research and education at Oxford University.

During his formative education he was exposed to a number of global rural communities, and became aware of the immense need for health care that exists in economically disadvantaged nations. Closer to home he has been exposed to underserved urban populations in New York City, East Palo Alto, Calif., and most recently Weld County, Colo., which has given him new perspective on the health disparities present in the Northern Colorado community, particularly among immigrant and farming populations.

“Collectively, these experiences have left me with an enduring desire to help alleviate these health disparities as my ability to intervene increases.

This desire, in conjunction with my love of the outdoors, makes applying my medical skills in medically underserved mountain communities one

of the most fulfilling endeavors I can conceive of,” said Muhonen.

Paul Pokrandt received his Bachelor of Arts degree in Chinese Economics from the University of Colorado at Boulder in 2009.

He then continued his education at the Capital University of Economics and Business in Beijing, China, an affiliated program of Hamilton College in New York. Later in 20112013 he studied at the University of Colorado – Denver and majored in Biology.

After leaving his financial career, he sought work where he could be a part of a team that could make a difference in the lives of individuals who are underserved. To explore his interest in medicine, he began work

as a medical assistant in a pediatric clinic serving the uninsured. “For three years I went to work every day at Goldman Sachs… yet never felt I helped a single person in a meaningful way,” he said. “In contrast, on my first day as a medical assistant, I directly helped 20 different families in my own community.” This experience secured his desire to enter medical school.

While most of his experiences have been in urban environments, Pokrandt says he has spent “a significant amount of time in rural areas” due to his love of the outdoors and as a result of family connections. “In order to get experience in rural medicine, I will be partaking in the “Rural Track” program. I am not sure whether I will ultimately decide to serve the needy in a rural or an urban environment, but I have no doubt that I will certainly continue to serve them in one location or another.” n

CMS Education Foundation Help send a student through school

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

Since 1993 the Foundation has dedicated itself almost exclusively to the funding of scholarships to incoming first-year medical students at the University of Colorado School of Medicine.

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.

Colorado Medicine for November/December 2014

Call 720-858-6310 for more information and to donate 43

Inside CMS

Physician wellness Kate Alfano, CMS contributing writer

CMS launches toolkit of wellness strategies for busy physicians The Colorado Medical Society – in partnership with the Behavioral Health and Wellness Program at the University of Colorado Anschutz Medical Campus – has launched a wellness toolkit for physicians. The toolkit addresses eight dimensions of wellness with a focus on reducing stress and burnout. CMS encourages all Colorado physicians and physician organizations to use and distribute this free resource widely to promote the health of all Colorado physicians.

“While physicians generally possess knowledge about healthy living, this knowledge does not always translate into practicing self-care,” said Doris C. Gundersen, MD, chair of the CMS Expert Panel on Wellness. Approximately 50 percent of physicians report some symptoms of burnout. “Physicians routinely recognize symptoms of burnout and stress in patients, family members and friends, but they often fail to recognize such symptoms in themselves.”

In April 2011, CMS conducted an allmember morale survey that revealed only half of physician members felt that they were able to live a healthy lifestyle with regard to exercise and diet. Even fewer were satisfied with their ability to find time to relax through activities like yoga or reading. Numerous studies correlate physician wellness with increased patient safety, making declining wellness in the physician population a critical concern for patients.

“You have characteristics that make you very successful,” said Chad Morris, PhD, director of the Behavioral Health and Wellness Program. “You know about delayed gratification. You know about perseverance. It’s become so ingrained in who we are and what we do that we push forward often at the cost of our own physical wellbeing, our own mental wellbeing, our own family life. We’re often the first in the office, first not to take a lunch break and the last to leave the office.”

“At some point, all those traits have led us to become successful but we’re trying to figure out where you hit that peak, and how you recognize when you’ve crossed over the peak and you’re getting into a bad situation,” Morris said. “That’s part of what this toolkit is really about.”

“DIMENSIONS: Work and Well-Being Toolkit for Physicians” is a low-burden tool for measuring readiness to change to achieve wellness, providing step-bystep instructions for developing skills to assess one’s wellness, evidence-based strategies for improving wellness, and suggestions for maintaining wellness.

The BHWP staff recognizes that physicians are a very diverse group in all states of wellness and they worked hard to create a resource for physicians across the whole spectrum, said Cindy Morris, PsyD, clinical director for the Behavioral Health and Wellness Program. The toolkit contains a variety of protective practices physicians can integrate into a daily routine to not only prevent burnout but also create more fulfilling professional and personal lives. Whether time permits five minutes or an hour, the toolkit offers strategies to improve wellness that can easily be integrated into the busiest physician’s day.

“Now is the time for physicians to make their own health a priority,” Gunderson said. “In doing so, they are more equipped to meet the needs of their patients and more likely to experience greater career satisfaction.” n

Chad Morris, PhD, left, and Cindy Morris, PsyD, of the University of Colorado Anschutz Medical Campus Behavioral Health and Wellness Program, present “DIMENSIONS: Work and Well-Being Toolkit for Physicians,” developed in partnership with CMS. 44

Colorado Medicine for November/December 2014

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Inside CMS

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

learning of her loved one’s illness, wondering what her next steps will be and how she will go on from here.

Camri Wolf-McGinn University of Colorado SOM

I saw my dreams in the glowing smile and embrace of a brand new mother and her infant, looking at a promising new life.

I saw my helplessness in the confused stare of a delirious senior, resisting my attempts to bring him clarity.

Camri Wolf-McGinn is currently a fourth-year student at the University of Colorado and is in the process of applying for a residency in family medicine. Camri is originally from rural Illinois and attended St. Ambrose University for her undergraduate studies. She has published in “The Human Touch” and “Letters to a Third-Year Student,” both at the University of Colorado.

Creative outlets are something she has always enjoyed, and she plans to continue creative writing as she pursues a career in family medicine.

Third-year reflection Reflection is nothing without a reference. No one will ever see a clear picture without finding his or her perfect mirror.

Wandering the wards and navigating the new world of clinical years, all third-year students need something on which to reflect. Something pure, something honest and something that is ubiquitous.

For me, the reflective surfaces were on the faces of all of my patients.

I saw my future marriage in the couple of 64 years holding hands while one of them went into surgery, fearful but still side-by-side.

I saw my goals for the future while watching interactions between my attendings and their patients, seemingly flawless work and overwhelming appreciation.

I saw someone who I’m afraid to become in the angry, burnt out surgeon who spent little time with his patients, simply trying to push through another exhausting day.

I saw myself hoping for healing in an old woman with an unknown mass, praying together that it didn’t carry a poor prognosis.

These mirrors were everywhere, readily available, and nothing but honest. The long days blurred by, but the reflections stayed with me.

I saw a current version of myself in the young, healthy 24-yearold woman at the family medicine clinic, simply looking for reassurance.

At home after a long day, the bathroom mirror told me nothing. This mirror was too still, too quiet, too cold. It couldn’t smile, cry, dream or laugh. But I still could. My patients’ emotions resonated within me and helped me get a clearer picture of myself.

I saw myself mourning in the tearful face of a granddaughter

I found strength I didn’t know I had, along with every possible

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Colorado Medicine for November/December 2014

Inside CMS emotion from each patient. Their reflections were forgiving, they were empowering, and they were beautiful.

through. I don’t want to forget them.

That mirror will not be easily fixed or replaced.

Some may claim that physicians are supposed to be able to disconnect, to use a different type of mirror. But I don’t think I will; I don’t think I want to. I hope that I continue to navigate through medicine with my patients’ faces guiding me

Colorado Medicine for November/December 2014

And there may be more than seven years of misfortune should it ever break. n

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Inside CMS

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

A look back on 2014 When I reflect back on the last year, there is an appreciation for the different things COPIC accomplished and their common connection to our mission. Health care continues to change and we continue to evolve as a critical partner for medical professionals, groups, and facilities. The following highlights from 2014 demonstrate where we have been and how these efforts reinforce our ongoing commitment to better medicine.

Lending our insight to improve patient care • A January 2014 article in Health Affairs highlighted COPIC’s 3Rs (Recognize, Respond, and Resolve) Program as a national model for “communication-and-resolutionprograms” that encourage the disclosure of unanticipated outcomes to patients and proactively seek resolutions.

• Several of COPIC’s physician leaders were contributors for the new textbook, Patient Safety in Surgery, which was co-authored by Philip F. Stahel, MD, and Cyril Mauffrey, MD, both of the Department of Orthopaedics at Denver Health Medical Center. Topics covered in the book reflect the focus of several of the 100+ education opportunities COPIC offers each year.

• An article in Inside Medical Liability titled “Defense of Claims in a Changing Environment,” recognized COPIC’s “robust” patient safety and risk management programs as an industry leader – a distinction that recognizes our investment in programs and resources that support reduced errors and improved outcomes.

Having an impact on legislative matters COPIC continued to have a strong presence at the state capitol in 2014 along with our partners at Colorado Medical Society (CMS) and the Colorado Hospital Association. We kept on eye on legislation that had the potential to impact health care, including: • House Bill 1283 – This aims to increase participation in the state Prescription Drug Monitoring Program (PDMP).

Efforts here focused on addressing the concerns of expanded liability as the bill mandated registration for providers.

• Senate Bill 162 – This establishes the components of a quality management program for emergency medical services organizations. Our efforts focused on guidance to ensure legal protections for open, honest discussions about care that supports patient safety.

Receiving ACCME accreditation status In March 2014, COPIC was directly accredited by the Ac 48

creditation Council for Continuing Medical Education (ACCME). This created a unique opportunity for us to develop further and offer CME activities that meet the educational needs of health care professionals. COPIC also became one of a small group of medical professional liability carriers in the nation with ACCME accreditation status.

Funding promising initiatives The COPIC Medical Foundation continued its tradition of supporting health care through grant funding. In 2014, we provided more than 10 different grants to help initiatives designed to improve patient safety and quality of care. These initiatives focused on areas such as patient engagement programs, management of chronic pain, recruitment of providers in rural areas, and online training toolkits. To view a list of these grants along with descriptions of the initiatives they funded, please visit www.callcopic.com/who-we-are/copicmedical/grants-in-action/Pages/default.aspx.

Partnering to support better outcomes COPIC maintains a wide range of strong partnerships that are built upon ongoing collaboration. During the last year, these included: • Another year of participation at the annual Telluride Patient Safety Roundtable, a top forum that brings together health care leaders and patient safety advocates to connect with medical residents and students from across the U.S. • COPIC employees were involved in a silent auction where proceeds helped support the opening of the new Stout Street Health Center, an organization essential to providing health care services for Denver’s homeless population.

And in 2014, COPIC celebrated its 30th anniversary as a medical liability insurance carrier. This was also a milestone to recognize our partnership with CMS. We are very thankful for the successful years of working together and this was highlighted in a series of video interviews from partners, physicians and others about our joint contributions in areas such as: • Support for safety net clinics.

• Role in helping physicians remain healthy.

• Defense of good medicine.

• Leadership in tort reform and peer review.

You can watch these video interviews at www.copicpearls. com. Additional interviews will be posted during the upcoming year. n Colorado Medicine for November/December 2014

Departments

medical news CMS and COPIC launch precious pearls video series to celebrate 30 years Editor's note: Colorado Medical Society and COPIC launched the precious pearls video series to celebrate their 30year relationship before the CMS House of Delegates at the CMS annual meeting on September 21, 2014. The following is a preview of the first in a year-long series starting in the January/February 2015 issue of Colorado Medicine that will document and celebrate the many accomplishments achieved together by CMS and COPIC over the past 30 years.

CMS and COPIC have partnered for 30 years to make Colorado the safest state in the country for medical patients. To celebrate this milestone anniversary, CMS and COPIC are presenting a video series throughout the next year in which physicians, policymakers and others share contributions made by our two organizations that benefit their practices, as well as the people of Colorado. The series title, “Precious Pearls,” is a nod to the customary 30-year anniversary gift, as well as to the pearls of wisdom shared by those featured in the videos.

ty-specific so that as a urologist, I could see where our specialty was vulnerable and learn what I needed to change in my practice to limit my risk,” he said.

“As a result, patient safety improved, we got sued less often and our rates never climbed to the rates seen in other states.”

Over the years, COPIC has provided financial support to deserving students attending Colorado’s medical schools and has initiated programs that increased access to care for Coloradans. COPIC and CMS have also helped shape major groundbreaking legislation in Colorado – not the least of which were the 1988 tort reform bills.

“Together, COPIC and CMS have set a high bar for other state medical associations and professional liability companies to meet,” Yakely said.

The main “Precious Pearls” video is currently available, featuring the history of COPIC told through more than two dozen interviews, with four shorter vignettes of individual stories. A new vignette will be released every other week.

See all the videos on the Precious Pearls website, www.COPICPearls.com, and go to http://tinyurl.com/COPIC-Pearls-optin to sign up to receive emails when a new video is available. n

“It has been a 30-year success story,” said Ted Clarke, MD, COPIC chairman and CEO. “The collaboration between the medical society and the physicians they serve and COPIC and the physicians we serve has created this environment that I think we both enjoy and in which we are privileged to practice medicine.”

Robert Yakely, MD, practiced medicine during the last years of the Hartford Insurance Company, before COPIC was founded. He announced the launch of the video series at the 2014 CMS Annual Meeting in Vail, where he shared his own pearl of wisdom.

“I will always remember Bob Britton’s first COPIC seminars that were specialColorado Medicine for November/December 2014

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Departments

medical news Changes make Colorado Prescription Drug Monitoring Program easier, more useful, and will help stop doctor-shopping A new law – as well as other enhancements to Colorado’s Prescription Drug Monitoring Program (PDMP) – will increase functionality and usefulness of the program for clinical care and bring Colorado’s PDMP up to best practices already in place in other states, making it easier than ever for busy prescribers to use.

The PDMP provides prescribers and pharmacists a secure database with immediate access to their patients’ history of controlled substance prescriptions.

Prescribers and pharmacists can view objective information concerning the controlled substances dispensed to a patient, helping them to make more informed decisions when considering prescribing or

Serving the CME 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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dispensing these powerful medications to patients.

PDMP account registration is the law The new law (HB 1283) requires PDMP account registration by Colorado-licensed pharmacists and prescribers who are registered with the U.S. Drug Enforcement Administration (DEA) for prescribing controlled substances. The affected prescribers include: • Dentists • Nurses with Prescriptive Authority • Optometrists • Physicians and Physician Assistants • Podiatrists • Veterinarians The deadlines for affected pharmacists and prescribers to register their accounts are staggered this fall based on license renewals. Advanced practice nurses with prescriptive authority, pharmacists, dentists, optometrists, podiatrists, and veterinarians should have all registered by now. The deadline for physicians and physician assistants is Nov. 30, 2014.

Additional changes The law included other changes in the PDMP, including: • Push notices: Starting in October 2014, prescribers and pharmacies will receive “push notices” when a patient to whom they have prescribed fills prescriptions for controlled substances from multiple sources and in potentially harmful quantities. The information may assist the practitioner in delivering optimal care to the patient, including assessing possible drug misuse or diversion. The report should be interpreted by the practitioner in the context of a complete patient assessment.

• Delegated account access: To make

it easier for prescribers and pharmacists to get the information they need to provide the best care for their patients, they will be able to assign subaccounts to up to three members of their healthcare team. To do so, the prescriber or pharmacist must have a registered account. This feature will be in place beginning January 2015.

More enhancements to the PDMP In addition to the new law, improvements are being made to make the PDMP more usable and functional. An extensive update will make the interface more intuitive with fewer “clicks” to retrieve patient information. The update will also include new functionality, including the ability to recover a forgotten username or password; to view all of the searches performed by the user’s account within a certain timeframe; and to view all of the user’s available reports in one spot.

Additionally, pharmacies are required to upload dispensing data every day starting October 2014. This change will give prescribers and pharmacists more immediate, timely data and make the PDMP that much more current and useful.

More information To register an account and use the PDMP, visit www.hidinc.com/copdmp, or for general questions and information call 303-894-5957 or email pdmpingr@ state.co.us. For technical questions about using the PDMP, call 855-263-6403 or copdmp-infor@hidinc.com.

Practitioners can find additional guidance in the Policy for Prescribing and Dispensing Opioids at www.dora.colorado.gov/professions, and patients can obtain a copy of their medical information contained in PDMP by completing a form at www. hidinc.com/copdmp/consumers.html. n

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Departments

medical news DORA issues 600 notifications on potential doctor-shopping; Physicians must register for PDMP by Nov. 30 More than 600 prescribers and pharmacies in Colorado received a notification on Oct. 30 from the Colorado Prescription Drug Monitoring Program (PDMP) that a patient they treat obtained potentially dangerous amounts of controlled substances from multiple prescribers and pharmacies.

According to a press release from the Department of Regulatory Agencies (DORA), one patient obtained prescriptions from 11 different prescribers and 10 different pharmacies within 30 days, amounting to potentially harmful quantities of potent prescription drugs. Another obtained more than 1,600 pills of oxycodone and hydrocodone from multiple prescribers and dispensers in one month.

These “push-notices” are the first following legislation passed this year that allows the database to send information to health care prescribers and dispensers.

The legislation also requires all DEAregistered medical board licensees to register a user account with the PDMP by Nov. 30, 2014, but does not require usage.

DORA asks practitioners receiving a push-notice to use their clinical judgment to determine the appropriate response.

“The primary benefit is that it increases the information physicians have about a patient’s behavior, which could potentially be deadly, and gives physicians choices,” said John Hughes, MD, chair of the CMS Committee on Prescription Drug Abuse. “They can do education or get the patient into a safer pain setting where a pain physician monitors their medications and brings other treatments.

It enhances patient safety.”

“On the surface it could be construed as being punitive to patients but, look-

ing beyond that, it gets patients and their doctors to have a real discussion about pain and create an interdisciplinary pain program rather than relying too much on the medication,” he said.

The PDMP is a statewide database of controlled substances dispensed to Colorado patients. The information is made available to prescribers and pharmacists.

It was created in 2005 to help curb doctor-shopping, a tactic used to secure prescription drugs from multiple sources for misuse, abuse or diversion, but this is the first year push-notices were authorized.

Lauren Larson, director of DORA’s Division of Professions and Occupations, which administers the PDMP, said in the press release that states that have implemented push-notices have experi-

enced up to a 74 percent drop in doctorshopping. “The PDMP push-notices help to alert health care practitioners when there may be a problem, and to coordinate care when a practitioner may not otherwise know someone else is prescribing to the same patient.”

The Colorado Consortium for Prescription Drug Abuse Prevention, created in 2013 by Gov. John Hickenlooper, is spearheading the statewide response to the prescription drug abuse epidemic.

The Colorado Medical Society is an active participant in the consortium. CMS supports greater use of the PDMP as one of many strategies to reduce opioid abuse and misuse, and supports the efforts of the Colorado State Board of Pharmacy to make the PDMP more user-friendly for physicians. n

Hydrocodone combination products transferred to schedule II starting Oct. 6 In August, the DEA published in the Federal Register the final rule to transfer hydrocodone combination products (HCPs) from schedule III to schedule II. This rule took effect Oct. 6, 2014. HCPs have been controlled in schedule III since enactment of the Controlled Substances Act in 1971. HCPs are the most frequently prescribed opioid in the United States: Nearly 137 million prescriptions for HCPs were dispensed in 2013.

The DEA has attempted to alleviate any burdens upon registrants caused by a 45-day effective date. For example, the DEA modified quota requirements to allow repackaging/relabeling of HCPs without a quota until Dec. 8, 2014. The department is also permitting legitimate HCP prescriptions issued before Oct. 6, 2014 to be refilled until April 8, 2015, if

Colorado Medicine for November/December 2014

the prescription authorizes refills.

However, the AMA reports that due to state laws, insurance limitations, and some pharmacy processes, some health insurers and pharmacies may not honor refills on or after Oct. 6, 2014. Therefore, prescribers should be prepared to provide new hard copy or electronic prescriptions for patients after Oct. 6, 2014, rather than have patients use what would have been existing refills.

The Notice of Proposed Rulemaking, Final Rule, and its supporting documents (i.e., medical and scientific evaluations, and economic impact analysis) may be viewed online at www.regulations.gov, Docket No. DEA-389. Or, obtain the documents on the DEA website at www.deadiversion.usdoj.gov. n

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medical news Colorado Medicaid program achieves $100 million savings, invests $14 million in providers The Department of Health Care Policy and Financing announced it has achieved about $100 million in gross savings on medical services with its Accountable Care Collaborative program, more than double the savings achieved by the program last fiscal year. After accounting for payments to providers and regional care collaborative organizations, the program’s net savings for state fiscal year (FY) 2013-14 was approximately $31 million.

The ACC program is a central part of Medicaid reform that changes the incentives and health care delivery processes for providers from one that rewards a high volume of services to one that holds them accountable for health outcomes. HCPF brought the program to state lawmakers as a budget reduction item in 2009 with the expectation that the program would not only pay for itself, but reduce expenditures in the future.

HCPF reports in a press release that the program reinvested approximately $14 million into providers. This is up from $6 million in FY 2012-13 and $3 million in FY 2011-12.

Clients in the ACC receive the regular Medicaid benefit package and belong to a Regional Care Collaborative Organization (RCCO). The ACC program has seven geographical regions, each served by a specific RCCO. These regional organizations provide care coordination and connect members to primary care, specialists and community resources as needed. Approximately 610,000 clients were enrolled in the ACC at the end of FY 2013-14.

“The ACC is changing the way we deliver health care,” said Susan E. Birch, MBA, BSN, RN, executive director, in a press release. “It’s a nationally recognized model that puts clients and wellness at the center of care and strengthens Colorado’s health care infrastructure, while also saving taxpayer dollars by avoiding unnecessary services.”

In the release, Deputy Medicaid Director Laurel Karabatsos said the first two

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

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

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years of savings were based on serving a smaller number of people. Now the program covers 60 percent of Colorado Medicine beneficiaries. “The fact that we continue to save money shows that the program is working, and can work on a large scale,” she said.

In FY 2013-14, HCPF had four key performance indicators to measure improvement among clients enrolled in the ACC, compared to clients not enrolled or enrolled for fewer than six months: 30-day hospital readmissions, high-cost imaging, emergency room utilization, and well-child visits. Clients enrolled in the ACC performed better than other populations in all four metrics. n

Claim form transition effective Dec. 1 Currently, Colorado Medicaid providers submit professional claims via the Colorado Medical Assistance Program Web Portal or through the Colorado 1500 (CO-1500) paper claim form. In preparation for the ICD-10 implementation, the Colorado Department of Health Care Policy and Financing is transitioning all professional paper claim submissions to the OMB-0938-1-1197 Form 1500 (02-12) (CMS 1500) paper claim form, effective Dec. 1, 2014. All CO1500 claim forms received after Dec. 1, 2014 will be denied.

Providers are encouraged to submit claims electronically; any provider who submits professional claims by paper will need to purchase the form online or through an available retailer.

Go to www.colorado.gov/hcpf for more information and to view available online training presentations. n

Colorado Medicine for November/December 2014

Departments

medical news Fourth-year CU medical student leader Stephanie Sandhu named 2014 Pisacano Scholar Stephanie Sandhu, a fourth-year medical student at the University of Colorado School of Medicine, was named a 2014 Pisacano Scholar by the Pisacano Leadership Foundation, the philanthropic arm of the American Board of Family Medicine (ABFM).

The Pisacano Leadership Foundation was created in 1990 by the ABFM in tribute to its founder and first executive director, Nicholas J. Pisacano, MD. Each Pisacano Scholar demonstrates leadership, academic achievement, communication skills, community service, and character and integrity.

Stephanie graduated summa cum laude from the University of Miami with a Bachelor of Science in Neurobiology and Women’s Studies English Literature.

During medical school, Stephanie went abroad to Xela, Guatemala to participate in the Somos Hermanos Spanish Immersion program. Stephanie served as a student leader for the Stout Street Clinic, a weekly student-run clinic in Denver for the homeless. She also served as the co-president of the CU School of Medicine component chapter of CMS and was on the CMS Board

Colorado Medicine for November/December 2014

of Directors. She currently serves on the Board of Directors of the Colorado Medical Political Action Committee as the medical student representative.

A press release by the ABFM stated that Stephanie hopes her experience in policy work along with her vision of addressing the social determinants of health inside and outside the office will allow her to justly serve the underserved as she moves forward in her career as a family physician. n

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Departments

medical news Federal CMS to reopen MU hardship applications through Nov. 30 The Centers for Medicare and Medicaid Services will reopen the submission period for Meaningful Use hardship exemption application period through Nov. 30 for certain physicians and hospitals to avoid the 2015 Medicare financial penalties for not demonstrating meaningful use of certified electronic health record technology, the agency announced. Previously, the hardship exception application deadline was April 1, 2014 for hospitals and July 1, 2014 for physicians.

Physicians who have not attained Meaningful Use and have not been granted a hardship exception are subject to the

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2015 Medicare payment adjustments beginning Jan. 1, 2015.

certified electronic health record technology Flexibility Rule.

This reopened hardship exception application submission period applies to professionals and hospitals that:

For more information, go to www.cms. gov and search “Payment Adjustments and Hardship Exemptions.”

• Have been unable to fully implement 2014 Edition certified electronic health record technology (CEHRT) due to delays in 2014 Edition CEHRT availability; and • Eligible professionals who were unable to attest by Oct. 1, 2014 and eligible hospitals that were unable to attest by July 1, 2014 using the flexibility options provided in the 2014

The American Medical Association reminds physicians that they may file for a hardship and file for an incentive. All Medicare physicians have until Feb. 28, 2015 to attest to any 90-day reporting period in 2014 to obtain an incentive.

Go to the AMA’s website, www.ama-assn.org, and search “Medicare/Medicaid EHR Incentive and Penalty Programs” to read more. n

Colorado Medicine for November/December 2014

Departments

medical news AMA details what hospital staff needs to know about Medicare CoPs In May 2014, the Centers for Medicare and Medicaid Services (CMS) published a final rule revising the Conditions of Participation (CoPs) for hospitals. The American Medical Association and its Organized Medical Staff Section (OMSS) have been strongly advocating since 2011 to protect and enhance the role of the medical staff throughout various iterations of these regulations.

The final rule, which became effective July 11, 2014, makes significant changes to the hospital governance structure and has significant implications for the relationship between the medical staff and the hospital governing body and for the relationship between the medical staff and its individual members:

• Sample medical staff bylaws language to assist medical staffs in implementing the new regulations while preserving self-governance and the medical staff’s ability to ensure the delivery of safe, high-quality patient care.

Note: While these resources are available to both AMA members and nonmembers, including non-physicians, you must log in to your AMA account to access them. If you don’t have an AMA account, you will be prompted to create one.

new CoPs and use them to guide your medical staff in updating its bylaws.

Go to https://download.ama-assn. org/resources/doc/omss/x-pub/cops. pdf to download (login required, member or nonmember).

2. Educate your medical staff colleagues about the new CoPs by directing your colleagues to the AMA-OMSS webpage, www.ama-assn.org/go/omss.

3. Contact the AMA-OMSS (keith. voogd@ama-assn.org or 312-4644539) to report and seek assistance on any problems that arise as a result of the new CoPs. n

What you can do now: 1. Review the AMA’s resources on the

• The final rule permits a multi-hospital health system to have a unified, system-wide medical staff, rather than a separate medical staff at each hospital, provided that the medical staff at each hospital votes to accept a unified staff structure.

• The final rule also eliminates a requirement that the hospital governing body include a member of the medical staff. The governing body must now consult at least two times per year with the medical staff.

The AMA has developed resources to guide medical staffs through the process of implementing the new regulations.

These resources, which will be included in a forthcoming edition of the AMA’s “Physician’s Guide to Medical Staff Organization Bylaws,” include: • A discussion guide outlining issues medical staffs should consider when considering whether to accept a unified medical staff structure; and Colorado Medicine for November/December 2014

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Departments

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

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Colorado Medicine for November/December 2014

Departments

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Colorado Medicine for November/December 2014

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Features

the final word Floyd Ciruli political analyst and consultant

Bipartisanship wins in 2014 election Overall, the results of the Nov. 4 election were good for Republicans, bad for Democrats and potentially great for bipartisanship in Colorado.

For the most part, Colorado Republicans rode on a national wave that gave the party control of the U.S. Senate for the first time in eight years – along with the biggest majority they’ve enjoyed in the U.S. House of Representatives since the World War II era.

Yet, this massive political sea change had a bipartisan element in Colorado, where the electorate split their ticket in electing public officials.

Though Republicans captured the state Senate and will send Rep. Cory Gardner to Washington as a U.S. Senator, Gov. John Hickenlooper will remain in office after barely defeating Republican challenger Bob Beauprez. Meanwhile, Democrats will keep control of the state House – but by a wafer-thin margin.

Essentially, this outcome means the 10-year reign of Democratic dominance is over – making Republicans genuine players in a generally bipartisan state. Though Republicans made significant gains throughout Colorado, many did so by running centrist, middle-of-the-road campaigns that clearly persuaded many independents to give them power.

And since Gardner and many of his fellow Republicans emphasized breaking the gridlock and political rancor that has characterized politics on the national scale, they will need to deliver on these promises if they want to retain power.

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Ramifications to health policy In recent years, Colorado’s General Assembly has approved a number of seemingly “progressive” health policies in communion with the Affordable Care Act (ACA) – unlike “purple” and “red” states where legislators have not adopted the provisions because many constituents believe that the ACA is intrusive and makes health care too reliant on the federal government.

In Colorado, some of these ACArelated measures were approved and signed into law with mild bipartisan support (such as the legislation that led to the formation of the Connect for Health Colorado health insurance exchange) and some without (such as the expansion of Medicaid benefits to more Coloradans).

While such legislation most likely would not have been approved if the Republicans controlled one or both chambers of the Capitol, they probably won’t be overturned because the impending balance of power restricts the Republicans’ ability to take immediate action – though such reforms may be more scrutinized than they have been in the recent past.

But while the Colorado General Assembly probably won’t do much to change the health care reforms already in place, the Republicans in Washington are going to be incredibly hostile to the ACA. Party leaders such as Sen. Rand Paul (R-Ky.) and Sen. Ted Cruz (R-Texas) have stated their intentions to repeal the ACA and/or defund the Medicaid expansions.

would certainly veto such Republican actions, I remain somewhat hopeful that Republicans will eventually act to improve and refine ACA – and the president will go along with it.

Despite the relatively moderate composition of Colorado’s General Assembly, the state’s Medicaid expansions are dependent on federal funding.

For that reason, physicians need to be aware that the national dialogue on health policy is going to be very powerful and may impact the dialogue statewide.

The big picture Compared to more polarized states, the people of Colorado have a history of electing leaders who will work for solutions to outstanding problems.

Our elected officials tend to govern from the center – even if it’s sometimes the center-right or center-left.

Generally, Colorado is a state of centrist Democrats and Republicans. And while we broke away from that tradition and became more polarized and ideological in recent years, the results of this election may show things are moderating a bit.

Under the hands of a centrist, Democratic governor and a politically divided legislature, we’re entering an era where all successful legislation will need bipartisan support. The result will be much more accommodating and incremental legislature and hopefully, more thoughtful and consensusbuilding public policy. n

Though President Barack Obama Colorado Medicine for November/December 2014

Colorado Medicine for November/December 2014

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Colorado Medicine for November/December 2014