November-December 2015

November/December 2015

Volume 112, Number 6

CMS President Michael Volz, MD

Breaking barriers to create “The New CMS�

Award-winning publication of the Colorado Medical Society

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Colorado Medicine for November/December 2015

contents Nov/Dec 2015, Volume 112, Number 6

Features. . .

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U.S. Sen. Michael Bennet delivers AMA/COMPAC luncheon keynote–Sen. Bennet discussed current health

care politics, the state-federal working relationship and other issues important to physicians.

Cover story

Newly inaugurated president Michael Volz, MD, anticipates a busy and challenging year ahead. In addition to important policy issues affecting CMS member physicians, Dr. Volz looks forward to implementing the historic reforms to CMS governance passed overwhelmingly by the House of Delegates at the CMS Annual Meeting. He anticipates policy and governance will demand much of his term but “that’s the meat and potatoes of the good work medical societies do.” Read more, including full coverage of the annual meeting, starting on page 6.

Inside CMS 5 30 33 34

Executive office update CMSEF scholarship recipients Looking Forward COPIC Comment

Departments 36 40

Medical News Classified Advertising

Colorado Medicine for November/December 2015

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Health care costs–The Colorado Commission on

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CPEP at 25– CPEP (the Center for Personalized Education for Physicians) was recognized at the CMS Annual Meeting for 25 years of service to the physician community.

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Physician heroes–CMS recognizes Mark Sheehan, MD, and

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Prescribing for pain–The COPIC Medical Foundation

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Transforming clinical practice–Learn more about the Colorado grant that will engage up to 2,000 specialists, primary care physicians and other clinicians to test alternative approaches to care delivery and provide input into the restructuring of the health care system.

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Colorado Ultrafest–Medical students from the University of Colorado School of Medicine and Rocky Vista University collaborated to present Colorado Ultrafest, a free one-day symposium that provided hands-on experience with pointof-care ultrasound to more than 200 students.

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Final Word–M. Robert Yakely, MD, and Brigitta Robinson, MD, share what to expect as CMS implements governance changes developed for and by Colorado physicians that will engage more members in meaningful ways.

Affordable Health Care has worked to engage stakeholders on the systemic causes of health care costs and develop strategies to control costs. CMS will continue to be engaged.

Daniel Smith, MD, for their work to provide medical care to the poor of Cambodia and train the next generation of native health care providers. awarded a grant to a company to study the efficacy of a prescription pain medication platform. Colorado doctors are currently being enrolled for participation.

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

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

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2015/2016 Officers Michael Volz, MD

President

Katie Lozano, MD President-elect J.T. Boyd, MD Treasurer M. Robert Yakely, MD

Speaker of the House Brigitta J. Robinson, MD

Vice-speaker of the House Alfred D. Gilchrist

Chief Executive Officer Tamaan Osbourne-Roberts, MD

Immediate Past President

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

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

COLORADO MEDICAL SOCIETY STAFF Executive Office

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

Division of Communications and Member Benefits

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

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

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

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

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

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

Mike Campo, Staff Support, Mike_Campo@cms.org

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

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

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

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

Printed by Spectro Printing, Denver, Colorado

Inside CMS

executive office update Alfred Gilchrist, CEO Colorado Medical Society

Health insurance industry mergers The state and federal agencies with antitrust enforcement authority have begun the methodical and mindnumbingly complex task of determining whether the two proposed mega mergers (Aetna Inc. and Humana Inc., and Anthem Inc. and CIGNA Corporation) are sufficiently anticompetitive to limit or block those deals. Local market calculations by state and federal regulators will determine whether the elimination of two competitors consolidates enough market power to influence prices generally, and more specific to medicine’s concerns, gain monopsony power.

A monopsony is a market similar to a monopoly except that a large buyer (in this case a health insurance company) not seller (physicians in our case; or fragmented suppliers in economic speak) controls a large proportion of the market and drives prices down. Also sometimes called a buyer’s monopoly, a point of regulatory scrutiny is whether lower prices resulting from these mergers will be passed through to consumers in the form of lower premiums or out-of-pocket costs without offsetting harm (the reduction of the quantity or quality of services below the level that is socially optimal).

In an October letter to William J. Baer, assistant attorney general, Antitrust Division, U.S. Department of Justice, we joined the American Medical Association in asking for “close scrutiny” of both mergers. The Anthem-Cigna merger would be presumed likely to enhance market power in the commercial combined (HMO+PPO+POS) markets in the state of Colorado as well as in metropolitan statistical area (MSA) level markets including Grand Junction, Fort CollinsLoveland, Greeley, Pueblo, Colorado Springs, Boulder and Denver-Aurora.

The Aetna-Humana merger is presumed

likely to enhance market power or potentially raise significant competitive concerns that often warrant scrutiny, for example, in MSAs including Colorado Springs, Grand Junction, Greeley, Boulder, Pueblo and Fort Collins-Loveland.

In a contested 2008 health insurance industry acquisition, analysts conducted physician surveys to assess how local physicians would respond to increased market power of a dominant insurer. A sample of the printable answers included the following.

• Go to another state.

• Close my practice.

• Leave town.

• Would irreparably hurt my practice, don’t know what to do.

• Make do with remaining plans.

• Be an out-of-network provider.

• See a lot less patients (if they bailed on the contract).

• Lay off staff and reduce the number of physicians on staff.

In Congressional testimony on the proposed mergers, the health insurance company CEOs argued that the consolidations will achieve greater efficiencies, improve the value of those services and lead to greater innovation, as well as provide a competitive pressure on health systems that they suggest have monopolistic powers to artificially keep prices higher than what a competitive market would sustain. These and other arguments for the mergers are plausible and will be carefully scrutinized by regulators, state and federal, with our full cooperation and assistance.

Do CMS members care one way or the other about these mergers? Should CMS stand down or further step up?

Our conversations with the DOJ, our

Colorado Medicine for November/December 2015

insurance commissioner and other public officials are underway and will continue in what is likely to be a protracted process lasting well into next year. Taking the next step requires additional, thoughtful evaluation on our part. We will invite Anthem and Aetna to make their case directly to our members on their rationale and business model should their petitions prevail. We will focus group and survey our members, and share those results and related inquiries with state and federal regulators, and the proponents. We will gain insights from the activities among the 15 or so state medical societies facing similar or higher levels of consolidation as well as AMA’s continuing response.

We will gather further perspective from consumer groups, business and unions.

These mergers are far from being resolved. Be on the watch for and participate in our outreach. Let us know what you think. This is not our first antitrust rodeo and member input will guide our advocacy. n

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

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

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CMS President Michael Volz, MD

Breaking barriers to create “The New CMS�

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Colorado Medicine for November/December 2015

Cover Story STORY HIGHLIGHTS • Michael Volz, MD, a boardcertified allergy/immunology specialist, was installed as president of the Colorado Medical Society at the 145th Annual Meeting in Breckenridge on Sept. 19.

• In his inaugural speech, he identified two topics that will likely consume his presidential year: public policy and governance reform.

• CMS member physicians identified payer issues as a high priority. CMS is currently in talks with health plans about how they build, manage and trim down their physician networks.

Additionally, CMS is monitoring the potential mergers of two major health plans doing business in Colorado.

As your newly inducted Colorado Medical Society president, I am honored to take the baton and run a leg of the race in these very challenging times in medicine. Looking down the road at what we are up against in the next 12 months, I can’t help but think that I wasn’t handed a relay baton but rather a live grenade with the pin removed. Indeed, we are in some tumultuous times.

At the CMS Spring conference in May, I discussed three topics: 1. The theme for the next year, “Breaking Down Barriers,” which resonates very closely with the theme for the CMS Annual Meeting, “The New CMS.” 2. My passion and commitment, which is not only why I entered medicine but also how I came to be involved in CMS and policy issues.

3. How and why we must continue to work in order to make a difference.

You might also remember a Mark Twain quote from that presentation: “The two most important days in your life are the day you are born and the day you find out

why.” Many of us are here because what we do in medicine is the “why.” Our passion and commitment to medicine instills in us the interest and desire to help our patients and colleagues, without which – especially if we are not organized – all of us will suffer. When I ran for this office I had a few specific issues I wished to address during the next year. However, it is now clear that the next year will mostly be consumed by two topics: public policy and governance reform. And that’s okay because addressing policy and governing are the meat and potatoes of the good work medical societies do.

At September’s Annual Meeting, the House of Delegates made monumental changes to our governance that will enable CMS to reach out and engage more of our colleagues in meaningful ways to generate positive consequences at the exam-room level. In that context, can there be anything more relevant, basic and important than how health plans build, manage and trim down their physician networks?

We are currently in conversations with the plans on those very questions, and this conversation may lead to a policy framework that guides the plans to make legitimate business decisions, while assuring those decisions are made transparently and affording physicians our rights while we fulfill our clinical responsibilities to our patients.

Fortunately we enjoy strong working relationships with the medical leadership of Colorado’s health plans and we may find those relationships can transcend differences and lead to workable and sustainable policies as they have so many times before. I remain optimistic but not naive.

Network adequacy, whether we are in or out, has the potential to consume considerable staff and advocacy resources alone, but we also now have before us the pressing challenge of setting reasonable standards of accountability for the impending consolidation of two major health plans doing considerable business in Colorado. Many of you might recall that when United Healthcare acquired PacifiCare several years ago, United ap-

Colorado Medicine for November/December 2015

proached us at CMS and agreed to a Division of Insurance-supervised set of undertakings and a working collaboration with a physician advisory body.

“Network adequacy, whether we are in or out, has the potential to consume considerable staff and advocacy resources alone, but we also now have before us the pressing challenge of setting reasonable standards of accountability for the impending consolidation of two major health plans doing considerable business in Colorado. ” You may recall that the issue of Colorado Medicine addressing that merger had a picture of a 1,000-pound gorilla on the cover and a rhetorical question on that consolidation. But we worked with United and the result was several precedentsetting public policies.

So, the question before us at this time is, “Will this next acquisition/merger morph into a doctor-consuming alien or a collaborative gentle giant?” With good policy and governance we increase the possibility of the latter being true.

Considering the comments I’ve made, one might think we are surrounded, outnumbered and certainly outspent. But in my mind, we’ve got them right where we want them. As the optimists in this crowd know, our CEO, Alfred Gilchrist, likes to say that every pile of manure has a pony in it. I suggest that we need to find, nurture and tame that pony.

The X factor in Colorado – the big pony

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Cover story (cont.)

Michael Volz, MD, right, takes the presidential oath of office from outgoing president Tamaan Osbourne-Roberts, MD, left. or the horse – is our pool of health policy and business leaders who have the maturity, vision and a long history of commitment to fixing problems rather than assigning blame. A most recent manifestation of this commitment is how we have moved the needle on coverage over the last three years, reducing the margin of uninsured by more than 50 percent.

We have achieved policy advancements in system delivery that are to this day still unapproachable and not possible in many states, and we are fully engaged even now on multiple fronts pursuing a statewide agenda to make Colorado the healthiest state in the nation. These accomplishments are turtles on fence posts; they didn’t get there by themselves. They came from our homegrown leaders and their constituencies and their hard work, not national vendors or hired guns.

It is an honor to be holding the grenade for CMS, which I will throw in the general direction of our adversaries, whomever they might eventually be, if the cir 8

cumstances require, or try to put the pin back in it, should diplomacy prevail. As an aside, I want to share Will Rogers’ definition of diplomacy: “The art of saying ‘nice doggie’ until you can find a rock.”

I look forward to working with you on many matters of mutual importance that extend well beyond what I have briefly outlined as emergent priorities. Thank you for this opportunity to help advance our community, our profession and our state’s health. n Meet your new president Dr. Volz is board certified in Allergy/ Immunology and a native of Wisconsin.

He is currently a solo-practice physician with two offices in Denver in addition to providing coverage in rural Eastern Kansas twice per month.

He was awarded a medical degree by Medical College of Wisconsin, completed an internal medicine residency at the University of Miami, and completed his sub-specialty training in allergy/immu-

nology at the National Jewish Center for Immunology and Respiratory Disorders in Denver.

As a medical student and later as an intern and resident, Dr. Volz represented his peers at the American Association of Medical Colleges. He has served as the president of the Colorado Allergy and Asthma Society and the Clear Creek Valley Medical Society (CCVMS), the medical director for the American Association of Colorado asthma camp, and as a board member of the CCVMS Board of Trustees, the CMS Board of Directors and the Lung Association of Colorado Board of Directors.

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

Colorado Medicine for November/December 2015

Cover Story

CMS physicians make historic changes CMS staff report, photos by Kate Alfano

House of Delegates votes overwhelmingly to re-engineer CMS into a grassroots-centric model Kate Alfano,governance CMS contributing writer designed to engage all physicians At the Colorado Medical Society’s 145th Annual Meeting, the House of Delegates, in response to a comprehensive set of governance retooling proposals developed over the past year by a special CMS task force, voted overwhelmingly to dissolve themselves into a realigned governance model that connects a streamlined board to the widest possible spectrum of its physician constituencies.

“The governance reforms adopted over the weekend were about member voice and empowerment and the ability of CMS to recruit and harness the intellectual and political muscle of physicians,” said CMS President Michael Volz, MD. “We will then infuse that expertise into the boardrooms and halls of the legislature and Congress.”

The adopted revisions contemplate extensive interactions between board members and the array of medical communities on policy direction and deployment, as well the recruitment and involvement of emergent leadership drawn from a methodical process of issue-centric policy development.

“We will be building a farm system of our best and brightest, and engage them where their ideas and insights will have real-world consequences,” Volz said.

Additional highlights from the meeting include the following.

• Katie Lozano, MD, was elected CMS president-elect. In addition, Drs. Ray Painter, Lynn Parry and Brigitta

Newly elected CMS President-elect, Katie Lozano, MD, center, is escorted to the podium to address the House of Delegates by CMS President Michael Volz, MD, left, and CMS Immediate Past President Tamaan Osbourne-Roberts, MD, right.

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Robinson were elected AMA Delegates while Drs. David Downs, Jan Kief and Tamaan OsbourneRoberts were elected AMA Alternate Delegates.

• Michael Volz, MD, was installed as CMS president. In his inauguration speech he predicted that public policy would be the topic to dominate his year but he remains hopeful for positive outcomes because of Colorado’s health policy and business leaders who have a long history of commitment to fixing problems rather than assigning blame. “We have policy advancements in system delivery that are to this day still unapproachable and not possible in many states, and we are fully engaged even now on multiple fronts.”

• The Board of Directors and the House of Delegates voted to highly prioritize network adequacy and access for the rest of the decade based on the results of an all-member survey on managed care pain points.

• Additional priorities will be maintaining Medicaid primary code parity with Medicare and the impact of impending insurance industry mergers on physicians and patients.

• U.S. Sen. Michael Bennet was the keynote speaker at Saturday’s AMACOMPAC luncheon (see article on page 15).

“Stark” results from all-member survey on managed care CMS pollster Benjamin Kupersmit presented “stark” findings from an all-

Colorado Medicine for November/December 2015

The New CMS:

7 Changes That Will Keep You Engaged, Informed and Empowered Welcome to the changing Colorado Medical Society – a medical society that places members first by keeping you more engaged, informed and empowered than ever before.

HERE IS WHAT THESE CHANGES MEAN TO YOU:

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You will have an unprecedented voice in CMS.

In 2016, CMS will introduce a virtual grassroots policy communications process that allows you to submit a policy idea 24 hours a day, 7 days a week, and to provide input and advice on subjects that are important to you and your patients — all from the convenience of your laptop or smartphone.

You will have the power to choose your representation.

CMS has replaced the House of Delegates process with an all-member election system for the CMS President-elect and AMA delegates.

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You will have a direct connection to a more empowered board.

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You will be represented by a diverse, informed and responsive board.

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A system of checks and balances will ensure your needs are met.

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Policymaking authority will be placed in the board of directors, with robust input and influence from you and other CMS members. You will have the ability to quickly learn about upcoming board policy votes and voice your opinion directly to your board representative. The board will automatically be required to reconsider if the majority of CMS members who respond to a request for post-vote input disagree.

The board of directors will reduce in size from 36 to 15 members (plus sections) to ensure accountability; and, with direction on expertise and experience, component societies and sections will appoint board members to build a more diverse, representative group.

Open board meetings and listening sessions with component societies and physician groups will ensure transparency and accountability; and member input before and after board policy votes will assure the board’s decisions reflect member wants and needs.

CMS will recruit and train the CMS and component leaders of the future.

CMS will aggressively recruit and train the next generation of physician leaders by providing advanced leadership training opportunities.

You will have access to a highly relevant Annual Meeting attractive to all CMS members.

In the coming months, CMS will work to revamp the structure of the Annual Meeting to maximize its relevance to members, boost its educational content and optimize opportunities for collaboration, communication and collegiality.

FOR MORE INFORMATION:

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

We want to hear from you and are available to answer your questions.

Please contact CMS President Michael Volz, MD, at president@cms.org.

Colorado Medicine for November/December 2015

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

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www.cms.org

Cover story (cont.) member survey on managed care pain points at the Sept. 18 Board of Directors meeting. When informed of the survey results, the House of Delegates voted to make payer issues a high priority for the remainder of the decade.

The survey was sent to all CMS members in active practice. The normal number of responses to CMS surveys falls between 400 and 500; nearly 900 physicians completed this year’s survey, demonstrating its “incredible relevance,” Kupersmit said.

Results showed significant levels of concern regarding prior authorization, reimbursement, network adequacy and determination of out-of-network status – and these concerns intensify for smaller practices, particularly solo practitioners.

There is “intense support” among members for a range of suggested reforms to address some of the challenges physicians have reported regarding payer networks, including the following.

• Require insurers to publish and

maintain accurate, real-time online directories for patients and providers (84 percent of respondents strongly support and 11 percent somewhat support this action).

• Require health plans to explain in writing why a physician or practice has been rejected or removed from a network (83 percent strongly support, 11 percent somewhat support).

• Require insurers to give patients a card that can be swiped or scanned at any office to determine eligibility, co-pay, deductible, etc., including a reader or app that will work for all Colorado health plans (74 percent strongly support, 16 percent somewhat support).

• Mandate clear standards for the criteria to determine that a health plan’s network has an adequate number of physicians in a given specialty to serve a given geographic area (72 percent strongly support, 17 percent somewhat support).

• Require health plans to publish clear guidelines and requirements for physicians wishing to join their networks

Board of Director members vote for the top CMS priorities for 2016.

(70 percent strongly support, 17 percent somewhat support).

• Require health plans to regularly send written, individualized notice to physicians of their participation status in each of the health plan’s product offerings (54 percent strongly support, 26 percent somewhat support).

This survey establishes a data baseline on the current interaction between physicians and insurance companies in Colorado, identifying what is and is not working in terms of access to networks, network de-selections, payment for outof-network care and what can be done to repair problems in these areas.

Issues around networks and insurance industry mergers will be debated in the executive and legislative branches of the state government next year and CMS will continue to follow the issues in play, engage members to be involved in advocacy and solicit member feedback on further issues that need attention.

www.HomeBuyMD.com Serving Colorado’s Physicians

“Your specialty is medicine and serving patients. Our specialty is real estate and serving you.”

Kupersmit said addressing these concerns is “vital to the survival” of solo practitioners and “critical to the future” of small-to-medium practices with physician owners. “Ideas with 70 percent strong support or higher represent a tremendous opportunity to make a difference for members in their day-to-day practice.”

Thank you to all physicians and guests who participated in the 145th Annual Meeting. Save the date for next year’s restructured annual meeting, Sept.

16-18, 2016, at the Keystone Resort in Keystone, Colo. n

Each RE/MAX® Office is Independently Owned and Operated. Equal Housing Opportunity.

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Colorado Medicine for November/December 2015

Cover Story Looking forward to a long, rich future with “The New CMS” Leto Quarles, MD, President, Boulder County Medical Society

The 2015 CMS Annual Meeting left me proud and excited to be a part of our unique brand of organized medicine in Colorado.

We are very diverse: rural/ urban, primary care/specialists, all different models of practice, first-year medical students through seasoned retirees, and a broad spectrum of politics and ideologies. What unites us is a common passion for the practice of medicine, the well-being of our patients, and the values to which we each committed when we swore our oath as physicians.

I see the overwhelming support for and passage of the governance reform package as a positive step forward. CMS is an organization that can keep our focus on our values as we – today’s CMS members – bring issues forward and weigh in on our areas of interest.

We are replacing annual deadlines, endless parliamentary procedures, and trying to manage an entire year’s agenda in one weekend with ongoing year-round robust discussions, active outreach to the full CMS membership to weigh in on issues in real time as they come up, and broader and deeper opportunities for every CMS member to raise and discuss concerns with CMS leadership in a robust array of formats (email, text, voice, social media, polls and live conversation).

Top: Members of the medical school component and their guests enjoy the Friday night exhibitor reception. Middle: CMS members celebrate 50 years since graduating from medical school. Bottom: Cory Carroll, MD, presents awards to two students for their state science fair projects: Jayden Durbin, left, and Laura Clark, right.

Colorado Medicine for November/December 2015

I look forward to an engaging year and a long, rich future ahead of us as we revitalize CMS with the best of what each of us brings to the conversation. n

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Cover story (cont.)

Top left: Members of the Young Physicians Section enjoy the presidential gala Saturday night. Top right: CMS Immediate Past President Tamaan Osbourne-Roberts, MD, and his family hit the dance floor during the gala. Bottom: Donald Patrick Jr, MD, of Pueblo, left, and Gina Martin, MD, of Delta, right, address the House of Delegates. n

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Colorado Medicine for November/December 2015

Features

Sen. Bennet keynote Kate Alfano, CMS Communications Coordinator

U.S. Sen. Michael Bennet headlines AMA/COMPAC luncheon This was the second time Sen. Bennet addressed annual meeting attendees and he expressed his gratitude for the invitation. (U.S. Sen. Cory Gardner was also invited but unable to attend.)

Sen. Michael Bennet engages physicians on health care issues as the keynote speaker at the AMA/COMPAC luncheon.

U.S. Sen. Michael Bennet was the honored keynote speaker at the 145th CMS Annual Meeting AMA-COMPAC luncheon in Breckenridge. He spoke about current health care politics, the statefederal working relationship and other issues important to physicians, answered many questions from the audience and asked many questions of his own. The interactive discussion was well received.

Sen. Bennet was elected United States Senator for Colorado in November 2010.

He is a member of the Senate committees on Health, Education, Labor and Pensions; Agriculture, Nutrition and Forestry; and Finance. Before his appointment to the Senate in 2009 and subsequent election to a full six-year term in 2010, he served as superintendent of Denver Public Schools. Prior to that time, he served as chief of staff to then-Denver Mayor John Hickenlooper and as managing director at the Anschutz Investment Company.

While introducing Sen. Bennet, COMPAC chair Mark Johnson, MD, called for a round of applause for the senator’s high achievements, in particular for his work to push through repeal of the flawed sustainable growth rate (SGR) formula. “We want to honor and congratulate Sen. Bennet for his success in getting the SGR repealed. We have been involved in lobbying the Hill for this result for many years.”

The SGR was originally put in place to control spending by Medicare on physician services. Congress voted 17 times for short-term fixes and he was a sitting senator for 11 of those votes. “I think it’s safe to say that all of you at some point have reached out to me about our favorite perennial issue, fixing the SGR,” Sen. Bennet said.

“You helped shape the law that will move us away from the current fee-forservice system to one that rewards quality over quantity and while it’s never easy to make these changes, Colorado has always been ahead of the curve.”

Colorado Medicine for November/December 2015

“Your organization’s involvement in alternative payment models – medical home, accountable care organizations – will make the transition easier,” Sen. Bennet said. “So on behalf of patients all over Colorado, I really want to say thank you. The Colorado Medical Society has always had an innovative and collaborative approach to these issues and I would encourage all of you to continue working with our office to make sure that as the law is implemented, it’s done in the right way.”

“I know many of you will miss talking about the SGR,” he joked, “but thankfully we have more than enough problems in health care to discuss.”

He encouraged members to continue reaching out to him on any issue, particularly if something reported on cable television or seen while watching the floor of the senate doesn’t make sense.

“There is no need to accept the political conversation or discussion or fight that we’re having in Washington, DC.” n

CMS past presidents Ben Vernon, MD, left, and Mark Laitos, MD, right, greet Sen. Michael Bennet in advance of his keynote speech at the AMA-COMPAC luncheon.

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Features

Health care costs Kate Alfano, CMS Communications Coordinator

CMS task force informs state commission on cost drivers STORY HIGHLIGHTS • The 12 commissioners of the Commission on Affordable Health Care have worked over the last year to identify systemic causes of excessive and unnecessary health care costs.

• The commission put out a call for information for thoughts on fundamental cost drivers, barriers to reducing costs and their strategies to address costs.

Fifteen organizations responded, including all of the major players in Colorado health care.

• The CMS Task Force on Health Care Costs and Quality guided the Colorado Medical Society’s efforts and will continue to be engaged for the duration of the commission’s work.

Health care costs have been rising dramatically for the past two decades, in Colorado and across the country, cancelling any economic progress of the middle class and forcing legislators into Hobson choices (no horse or a bad horse). Despite progress on expanding access to health care, unchecked health care expenditure growth will continue to crowd out other vital needs unless state and local governments can find effective cost-containment strategies to implement in the coming years.

That’s one reason why, during the 2015 Colorado General Assembly, state policymakers established the Commission 16

on Affordable Health Care, tasking its 12 appointed members from a broad spectrum of settings and experiences with identifying systemic and other underlying causes of excessive and unnecessary health care costs and proposing specific legislative, regulatory and market-based strategies to reduce costs and improve care value. Jeffrey Cain, MD, is the sole physician member on the commission.

meetings will be held in Arapahoe County, Greeley, Colorado Springs, Alamosa, La Junta, Grand Junction, Summit County, Denver and Adams County, and will provide input and build grassroots support for the eventual recommendations. Their final report and recommendations are due at the end of 2017. Stay updated on the work of the commission by visiting their website, www.colorado.gov/cocostcommission.

This fall the commission put out a call for information for interested stakeholders to share their thoughts on fundamental cost drivers, barriers to reducing costs and their strategies to address costs. Fifteen organizations responded, including all of the major players in Colorado health care representing physicians, hospitals, health plans, business and others. The CMS Task Force on Health Care Costs and Quality, cochaired by Laird Cagan, MD, and Alan Kimura, MD, MPH, guided the Colorado Medical Society’s efforts and will continue to be engaged for the duration of the commission’s work.

CLINICNET

The commission published a synopsis of responses organized by key topic areas.

The following boxes summarize key points from those submissions.

The commission will present the firstyear report to the Colorado General Assembly in mid-November. In their second year of work, commissioners will continue analyzing the fundamental drivers of health care spending and seek input from Coloradans. Early in 2016, the commission will go on the road to conduct nine community meetings to gather reactions and feedback on its work and recommendations. These

• State requirements and administrative burden are real issues; assisting complex patients requires a lot of resources and providers are rarely paid for care coordination and patient health literacy.

• Colorado’s Community Safety Net Clinics (CSNCs) manage costs by implementing staffing models that rely on volunteers for clinical and administrative roles, tapping into the charitable capacity of health care systems, and giving patients copies of X-rays and labs to take to specialty visits to reduce duplication.

COLORADO ACADEMY OF FAMILY PHYSICIANS • Transparency in health insurance pricing and consumer cost-sharing would help make insurance more accessible and affordable.

• Colorado should increase the number of family physicians in the right places.

• Accelerate the transition away from the fee-for-service payment system toward a payment system that compensates providers for activities that make patients healthier.

Colorado Medicine for November/December 2015

Colorado Medicine for November/December 2015

17

Health care costs (cont.)

COLORADO ASSOCIATION OF HEALTH PLANS AND AHIP

COLORADO FOUNDATION FOR UNIVERSAL HEALTH CARE

• Costs to transparency can be a barrier and, in certain situations, transparency can lead to reduced competition and harm to consumers.

• The system experiences unnecessary services due to the fee-for-service model that generates incentives for high volume.

• Utilize bulk purchasing market power to contain excessive costs of pharmaceuticals and durable medical equipment.

• Decrease duplication and increase efficiency through a records system that allows one provider’s medical system to communicate with all others.

COLORADO BUSINESS GROUP ON HEALTH

COLORADO HOSPITAL ASSOCIATION

• Employers should change how they purchase and provide health care services by employing value-based purchasing and value-based design.

• The main barrier to improving outcomes and reducing avoidable costs is a lack of incentives for enrollees – particularly those with or at risk of a chronic condition – to select and seek care from primary care physicians.

• Price transparency must offer clear information that is readily accessible to patients and enables them to make meaningful comparisons.

• Issues come from a payment system that incentivizes volume, the structure and supply of the workforce, and costs of billing due to a complex system, among others.

COLORADO COALITION FOR THE MEDICALLY UNDERSERVED • Inequalities in care among different racial and ethnic groups yield high costs.

• Most health care costs are generated by administrative inefficiencies; simplify them by encouraging electronic exchange of information.

COLORADO COMMUNITY HEALTH NETWORK • Primary care providers’ inability to access timely, actionable patient data prohibits them from doing proactive follow-up.

• CHC reduces costs by providing comprehensive and integrated primary care with behavioral and oral health, providing care to individuals and families regardless of insurance coverage, and focusing on preventive care and additional services such as care coordination.

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COLORADO MEDICAL SOCIETY • Colorado health care would benefit from the development of payment and incentive systems that encourage value as well as care coordination and integration.

• There is currently a focus on compliance rather than care.

• CMS sees value in the Choosing Wisely campaign, educating physicians on payment reform and needed capabilities, the development of a task force to review and develop evidencebased proposals to reduce costs, and supporting a strong foundation of primary care.

COLORADO NURSING ASSOCIATION • Continue to advance optimal utilization of advanced practice registered nurses throughout the state.

• Compiling patient-level costs across multiple settings will allow for improved financial reporting and benchmarking of costs and resources expended for patient care.

COLORADO TELEHEALTH NETWORK • Telehealth has been shown to reduce costs when utilized as an alternative to in-person visits when medically appropriate.

• Barriers to telehealth include access to reliable bandwidth and cost of workflow redesign.

COPIC • Health care is heavily regulated. The cost to comply with federal and state laws as well as the cost to educate and train physicians will continue to be barriers.

• The current liability system is often inefficient with significant money spent on attorneys’ fees rather than compensating patients who suffered from negligent care. These fees also represent money that could otherwise be invested in patient safety initiatives with long-term benefits.

HEALTH CARE FOR ALL COLORADO FOUNDATION • The public has a right to know in advance what charges are for each hospital; all chargemasters should be public.

• Private health insurers’ administrative overhead is limited by 20 percent compared to 3 percent for Medicare.

LIVEWELL • Reducing the extensive costs of obesityrelated illnesses requires multifaceted, innovative approaches. Strategies must address the environmental and systemic obstacles to healthy eating and active living.

PHRMA • Hospital spending is three times the amount of prescription drug costs.

• There is suboptimal use of prescriptions because of required out-of-pocket costs and high cost sharing. n

Colorado Medicine for November/December 2015

Colorado Medicine for November/December 2015

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Features

25 years of excellence Bill O’Neill, CPEP Director, Outreach and Communications

CPEP anniversary celebrations continue STORY HIGHLIGHTS • The Center for Personalized Education for Physicians (CPEP) is celebrating its 25th anniversary this year.

• The Colorado Medical Society adopted a resolution at the Annual Meeting recognizing CPEP for their service to the Colorado medical community.

• CPEP also recently held their anniversary gala.

The Center for Personalized Education for Physicians is celebrating its 25th anniversary this year. CPEP was founded to fulfill the critical mission of promoting quality patient care and safety by enhancing the competence of physicians and other health care professionals. The organization has helped more than 4,000 professionals over the years, and continues to fulfill its mission as a vibrant, independent non-profit organization.

CMS recognizes CPEP’s impact in Colorado At its recent Annual Meeting, the Colorado Medical Society adopted a resolution recognizing CPEP for 25 years of service to the Colorado medical community. The resolution specifically noted CPEP’s role in providing “a fair, objective, mechanism for assessing clinical competence” and its goals of “restoring participating physicians to safe clinical practice, retaining them in the workforce and treating all participants with dignity and respect.”

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CPEP CEO Beth Korinek, MPH, presents CMS President Michael Volz, MD, left, and COPIC CEO Ted Clark, MD, right, with awards honoring their organizations’ support of CPEP. CPEP CEO Beth Korinek recognized the support CPEP has received over the years from both CMS and COPIC. “CMS and COPIC have been pillars of support since our earliest days, and we are extremely grateful for their insight and generosity through the years,” she said.

Anniversary gala CPEP also recently held a 25th anniversary gala luncheon on Sept. 2 at the University of Denver. Speakers recognized CPEP’s impact and service to physicians both in Colorado and nationally. At the luncheon, CPEP awarded Ed Dauer, LLB, MPH, dean emeritus of the University of Denver School of Law, with the George Dikeou Award. The award

recognizes Dauer’s profound impact on physician education and patient safety throughout his career.

“It is remarkable that through these years of change, CPEP’s purpose and mission have only become more relevant,” Korinek said. “We need to keep physicians and advance practice professionals in practice – and practicing well – and help them develop the skills they need to thrive in the changing practice environment. It is critical for their workplace, their communities, their patients and for their colleagues who cannot bear the burden of the expanding patient population on their own.” n

Colorado Medicine for November/December 2015

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Features

Physician heroes: Heeding the call Kate Alfano, CMS Communications Coordinator

Mark Sheehan, MD, and Daniel Smith, MD, work to heal health care in Cambodia Mark Sheehan, MD, and Daniel Smith, MD, have worked for 16 years in the country of Cambodia providing medical care for the poor and medical education to native health care providers. Deeply religious Christian men, they humbly decline the title “Physician Heroes,” seeing their journey as a calling that has changed their own lives in monumental ways.

Sheehan, a cardiologist with South Denver Cardiology Associates, and Smith, a retired cardiothoracic surgeon from Denver, are co-founders of Christian Medical Ministry to Cambodia/ Jeremiah’s Hope, a nondenominational, international ministry that brings a half-dozen American health care teams to Cambodia each year, supports a permanent Cambodian clinic staff of five physicians and 16 nurses, and has

provided education to more than 300 native medical students.

In the mid-1990s, despite being at the top of their game professionally, they both went through periods of “being broken,” as Sheehan describes it, “emotionally, spiritually, psychologically – and had to be put back together again.”

It was through this process that they became friends; they started a Bible study that still meets to this day. It was also through this group that they were invited by Rev. Setan Lee and Jim Groen of Global Connection International to visit Phnom Penh, Cambodia’s capitol, for a nine-day trip to Cambodia in June 2000 to evaluate the medical conditions there.

What they found was “atrocious and inadequate,” Smith said. To provide

2015 cardiac and general surgery team for CMMC/Jeremiah's Hope.

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historical context to the great need in the country, which is about the size of Colorado, a civil war broke out in the 1970s that put communist insurgents Khmer Rouge in power. Their almost four-year reign of terror is commonly known as the “killing fields,” during which 30 percent of the seven million Cambodians were killed. The most highly educated were hunted and executed – intellectuals; military officers; medical professionals; and religious, civic and political leaders.

When the killing fields ended, there were only 35 physicians left in the entire country and roughly half of those then fled to other countries, Sheehan said.

The physicians weren’t sure what exactly they were going to do in the country until the last day of the trip when they visited what was called the soldier’s hospital. It was the worst facility they had ever seen. But while they were there, children kept coming up to them to touch their hands and after a half-hour of walking around, both of them had two children holding each of their hands. They saw what they called “God’s goodness” in those children, and realized that what they were going to do was not going to be just a medical or humanitarian effort. It would also be a ministry to the medical teams who would travel with them.

They officially formed Jeremiah’s Hope in 2004. Though they have worked in several facilities over the years, they currently operate a clinic and surgery center adjacent to the Sihanouk Hospital Center of Hope. Over the years more than 520 team members have seen more than 2,250 consults

Colorado Medicine for November/December 2015

Features They’re now raising about 50 percent of their operational costs and aim for full self-sufficiency in five to 10 years. “The long-term goal of any mission is to make them self-sufficient,” Sheehan said. “You can’t go over there forever and do this.

But we’ve given them support and things are moving in the right direction.”

Mark Sheehan, MD, teaches medical students in Phnom Penh, Cambodia. and performed 650 operative procedures plus 150 cardiac surgical procedures.

There have been four patients whose conditions were too severe to care for them in Cambodia and they have been flown to the United States for treatment. One in particular stands out in Sheehan’s mind as the most memorable.

It was 2001 when they received a call from Kendrick Kahler, MD, an American family physician who worked with them at the beginning of their ministry.

He told them about a 13-year-old girl with tricuspid valve endocarditis, an infection in her heart valve.

“She was seizing and dying in Cambodia so we talked to the administration at Porter Hospital [in Denver] and they agreed to provide the necessary care if we could fly this young girl over,” Sheehan said. “We had already talked to all of the physicians: the infectious disease doctors, surgeons, anesthesiologists, neurologists, cardiologists, and everyone agreed to do this for free. We brought her over, had her evaluated by all these specialists, and Dr. Smith did the surgery to close the hole in her heart and repair the valve. She subsequently is back in Cambodia and at 27 years of age is doing great.”

Smith said that while it’s frustrating to

see severe disease in patients who could have benefited from early intervention, going to a third-world country to practice medicine is encouraging and enlightening. “It helps you get back to why you went into medicine: to take care of people.”

When the clinic opened, all of the care was free but as Cambodia’s economy has improved, Jeremiah’s Hope and the permanent clinic staff began charging a fee based on the patient’s ability to pay.

Until then, they will continue to accompany and sponsor medical teams to travel to Cambodia to assist with health care and the education of the next generation of medical professionals. Sheehan said often that the American physicians and nurses who go to Cambodia think they’re going to do great things but realize when they return that the great things have happened to them. “They come back thankful for what they have in the United States and thankful they can contribute what they can.”

“The problems in Cambodia are so big that no one can write a check to make it right,” he added. “You can only go do your best. It really changes the hearts of the team members. The people who go over there are touched and have been changed.” n Find out more about Christian Medical Ministry to Cambodia/Jeremiah’s Hope on their website at www.cmmcjh.com

Daniel Smith, MD, operates on the 13-year-old patient with tricuspid valve endocarditis after transporting her from Cambodia to Porter Hospital in Denver.

Colorado Medicine for November/December 2015

23

Features

Prescribing for pain Jessica Ennis, Marketing and Communications Manager, RxAssurance

COPIC-funded study aims to optimize pain prescriptions The COPIC Medical Foundation recently awarded a grant to Denver-based prescription optimization company, RxAssurance. The grant will fund a study of the efficacy of RxAssurance’s prescription pain medication platform for improving patient safety and outcomes.

Colorado doctors are currently being enrolled for participation at www. rxassurance.com/copic.

The six-month study will evaluate a new tool to help Colorado physicians prescribe opioids safely and effectively, monitor their patients to improve outcomes, and document high quality provision of care. The tool, called OpiSafe, promises to make it easier for physicians to safely prescribe opioids. Of course, this tool must be proven in the real world of medical practice to demonstrate its value to

clinicians and patients alike. Prescribers are well aware of the opioid epidemic and of the many recommendations for doctors to safely prescribe these medications, and this study will test a new tool to help simplify the process, save time and improve adherence.

According to Rob Valuck, PhD, RPh, chief strategy officer at RxAssurance, this study will generate important evidence to show that physicians and patients using OpiSafe can, and will, more easily adhere to bestpractice guidelines for opioid prescribing and achieve better outcomes. “Our goal is to make it easier for doctors and patients to do the many things that are recommended so they can use pain medications safely and minimize risks,” he said.

The first 100 physicians to sign up will

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be able to use the OpiSafe system at no cost for the six-month study period. Enrollment will help establish how well the system works, how it can be improved and how it can make it easier to prescribe opioids safely. The OpiSafe system helps prescribers do complete, guideline-adherent prescribing, including baseline pain and function assessment, risk stratification, automated PDMP checking (once a patient is on-boarded into OpiSafe the system does it for prescribers), guidelinerecommended monitoring (done for prescribers by OpiSafe with an app or web interface used by patients), random UAs, and a clinical decision support dashboard for prescribers to check at each subsequent visit to see how patients are progressing clinically, or if any aberrant behaviors or problems have been detected.

AMERICAN COUNC ILS

To provide additional incentive to join the study, COPIC will offer its insured physicians two COPIC points for study participation (to be awarded at the end of the six-month study period). Participation is free and benefits prescribers by providing a tool to help clinical practice, reducing patients’ risk of untoward outcomes and reducing liability risk. After the completion of the study period, participating physicians will be offered discounted pricing on ongoing, monthly subscriptions to OpiSafe (regularly priced at $159/month; study physicians may choose to subscribe at a rate of $129/ month, a savings of 20 percent), or a prescriber may choose to opt out, and not subscribe beyond the free study period.

Sign up is easy, only takes a few minutes and is open to the first 100 physicians who enroll. For more information and to enroll, visit www.opisafe.com/copic. n

Colorado Medicine for November/December 2015

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Features

Transforming clinical practice Carol Greenlee, MD, Western Slope Endocrinology, and Allyson Gottsman, Colorado Health Extension System

New opportunity to communicate, connect and deliver care STORY HIGHLIGHTS • Colorado was awarded a grant that will give physicians the opportunity to test alternative approaches to care delivery and provide input into the restructuring of the health care system, utilizing models developed by practicing clinicians.

• The Transforming Clinical Practice Initiative (TCPI) will engage 2,000 clinicians, including specialists and primary care physicians.

• Participants will benefit from peer-to-peer learning networks sharing best practices and receive support for high-value referrals, EHR data validation, value-based payment models and efficient workflows.

The state of Colorado is one of 29 regions recently awarded a grant from the Center for Medicare and Medicaid Innovation (CMMI). This “Transforming Clinical Practice Initiative” gives Colorado physicians an opportunity to test alternative approaches to care delivery and provide input into the restructuring of the health care system, utilizing models developed by practicing clinicians.

The initiative comes at a critical time.

Advances in medical science continually transform the way conditions are diagnosed, treated and cared for each day.

This expansion of medical knowledge offers the potential for better health as 26

well as preventive opportunities; however, systems of care have not changed adequately to adapt to and support these advances and their associated demands.

Nor have medical systems or individual practices adapted well to the even more rapid changes in technology in our society. Attempting to simply add all of these changes into and on top of current, long-standing methods of care delivery has resulted in marked increases in the burden of care borne by most clinicians with more chaos, fragmentation and disconnection within the system.

As a result, we are seeing not only huge gaps in care with missed opportunities to apply the advancements in scientific knowledge, but also excessive duplication of care and unnecessary (low value) care. The costs in terms of clinician frustration and burnout, can’t be sustained without weakening the health care system.

A mandate to move to value-based payment will require practices, hospitals and other providers to demonstrate the value of the care they deliver. From a preliminary glance, these expectations appear to just pile more straws on that overburdened camel’s back of already collapsing medical clinicians.

Not just for primary care All Colorado physicians are invited to join this initiative and the Colorado Practice Transformation Network. The goal is to engage 2,000 clinicians, from specialists and primary care physicians to physician assistants and advanced practice nurses.

This project will develop new and improved systems to reduce the burden

of care by practice reorganization and better use of technology to capture data needed to not only meet the upcoming mandates but also to assist with reducing the gaps and the waste in the current system. Importantly, the initiative aims to reconnect care between all providers through improved communication, coordination and continuity both within a practice and/or institution as well as between them.

Participation has its privileges Participating practices will enjoy the benefit of being a part of a vibrant learning network, working with peers across Colorado to share best practices and prepare for value-based payment. Successful compensation models in the very near future will require greater communication and collaboration among physicians caring for the same patients, reducing duplication of testing, and proactively managing complex patients to provide care in the most cost-efficient setting.

High-value referrals mean effective use of resources – the right patient, with the right data, seeing the right specialist, with the right allocation of specialist time. Optimizing the referral process means more access to more specialists by not taking up time with inappropriate or unproductive consults. Enhanced access reduces delays in treatment, reduces duplicate testing, improves the health of patients and has a positive financial impact all around. It’s a win, win, win.

The final program elements are still a work in progress among the many practice transformation organizations

Colorado Medicine for November/December 2015

Features across Colorado. Perry Dickinson, MD, at the Department of Family Medicine, is leading the initiative while working with the Colorado Health Extension System, a collaboration of over 20 Colorado organizations committed to improving health and health care. When the program details are finalized and we are ready to enroll physicians in the program, the Colorado Medical Society will be your source for accurate and timely information.

In the meantime, refer to the Centers for Medicare and Medicaid Innovation website, www.innovation.cms. gov/initiatives/Transforming-ClinicalPractices, or contact allyson.gottsman@ UCDenver.edu. n

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

Colorado Medicine for November/December 2015

27

Features

Colorado Ultrafest Kate Alfano, CMS Communications Coordinator

Medical students learn to improve diagnoses with ultrasound STORY HIGHLIGHTS • Colorado medical students collaborated to present Colorado Ultrafest, a free symposium that gave students the opportunity to learn and practice point-of-care ultrasound.

• Procedure stations gave students experience in ultrasound in trauma, cardiac ultrasound, ocular ultrasound, ultrasound-guided procedures, pulmonary ultrasound, nontraumatic abdomen ultrasound, musculoskeletal ultrasound, and ultrasound in simulated pathology.

• The event was coordinated by the Colorado Ultrasound Interest Group, which comprises students from both Colorado medical schools.

Medical students from the University of Colorado School of Medicine and Rocky Vista University collaborated to present Colorado Ultrafest, a free one-day symposium that provided hands-on experience with point-ofcare ultrasound in a wide variety of applications.

More than 200 students gathered at Anschutz Medical Campus on Oct. 3 to participate in lectures and demonstrations as well as hours of hands-on experience led by faculty from multiple specialties and medical students and residents with advanced ultrasound skills.

28

Medical students from the University of Colorado School of Medicine and Rocky Vista University practice ocular ultrasound at the 2015 Colorado Ultrafest.

Lunchtime “sonogames” gave students the opportunity to use their skills to compete for prizes.

Irvine in 2012 and has since spread to medical schools around the country, including Stanford and Ohio State.

Lane Thaut, a fourth-year medical student at RVUCOM and co-founder and vice president of the RVU USIG, attended a UC-Irvine Ultrafest and, along with fellow USIG members and supporting faculty, worked to bring the event to Colorado.

The event was coordinated by the Colorado Ultrasound Interest Group (USIG), comprising students from both Colorado medical schools, with the purpose of providing medical students with a foundation of ultrasound knowledge and the practical skills and confidence to utilize this knowledge at the patient’s bedside. Over the past seven months, interested members from the USIGs at RVUCOM and CUSOM formed an executive committee; met monthly in person or by web conferencing; and arranged sponsors to provide donations for food, marketing, onsite materials and equipment.

“We saw a benefit to introducing students to ultrasound early on in medical education. The use of point-ofcare ultrasound by medical professionals is increasing and we wanted to introduce and increase medical students’ interest in ultrasound with this event. ‘Get as many hands on probes as possible’ was our goal,” he said.

This event was based on a model that debuted at the University of California-

Thaut plans to pursue emergency medicine and possibly seek an

Colorado Medicine for November/December 2015

Features ultrasound fellowship; he looks forward to using ultrasound in residency and practice. “Not only is ultrasound an excellent diagnostic tool, it fosters a doctor-patient relationship and offers real-time feedback for clinical decisions,” he said.

“Obtaining a patient’s real-time physiology and pathology in a non-invasive manner can really impact a patient’s care and outcome.”

Attendees gave positive reviews for the event, Thaut said.

They were particularly impressed by high-caliber instruction that was often one-on-one; as well as the organization of the event, the number of quality machines, the food and the fact that the event was free. Attendees from schools as far away as Texas attended, as well as a paramedic and a few nursing students.

The Colorado USIG will continue to host ultrasound-related events for members throughout the year to build on new ultrasound curriculums adopted at CU-SOM and RVUCOM. The organizers also hope to see Colorado Ultrafest continue as an annual event. “We really hope students next year pick up the baton to continue this event,” Thaut said. “It was a great success and we hope for it to happen again.” n Top: Students praised the event for the high-caliber instruction and the number of machines available. Bottom, students watch a demonstration by Creagh Boulger, MD, an assistant professor at Ohio State University and one of the event’s keynote speakers.

Colorado Medicine for November/December 2015

29

Inside CMS

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

CMS Education Foundation 2014-2015 scholarship recipients STORY HIGHLIGHTS • The Colorado Medical Society Education Foundation gives out scholarships to first-year medical students each year.

• 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.

• Call 720-858-6310 for more information and to donate to the CMS Education Foundation.

In June, first-year students from the University of Colorado School of Medicine – Andrew Maroncelli, Matthew Minturn, Cameron Niswander and Allison Rippy – were each awarded an $8,750 scholarship from the Colorado Medical Society Education Foundation (CMS EF).

The mission of the CMS EF, a 501(c)(3) private foundation, is to render financial support to select first-year medical students at the 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.

30

“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 clinical professor of surgery at the University of Colorado Anschutz Medical Campus.

The four recipients are as follows.

Andrew Maroncelli is a member of the University of Colorado School of Medicine Class of 2019. For the past year he has worked as a medical assistant at the Stout Street Health Center operated by the Colorado Coalition for the Homeless.

His work at the clinic has provided him with an understanding of the dynamics of a small clinic, including patient flow and integrated teamwork.

Andrew is a nationally certified emergency medical technician (EMT) and is involved in emergency protocol and patient care at the Stout Street Health Center. Andrew first became interested in a medical career while an undergraduate student at Case Western Reserve University in Cleveland, Ohio.

He pursued this interest by volunteering at Denver Health Medical Center, University Hospital’s Case Medical Center and the Stout Street Eye Clinic, and by shadowing physicians in several different medical specialties. Andrew is a Lakewood, Colo. native and enjoys

snowboarding, hiking, playing the piano.

tennis

and

Matthew Minturn is a native of western Colorado. He graduated from Rifle High School in 2005 and later attended Colorado Mesa University in Grand Junction.

He spent the majority of the 10 years following high school graduation working as an EMT in the emergency department at Grand River Medical Center in Rifle, and it was there that he became committed to pursuing a career in medicine. Working alongside physicians caring for members of his own community taught him the value of learning about patients’ lives, the importance of primary care, and the role that physicians play in such communities. He hopes to return to western Colorado to provide comprehensive and holistic health care to rural communities.

Cameron Niswander grew up in Routt County, Colo. and attended high school in nearby Steamboat Springs. Living in this rural community helped shape his interests in medicine, which eventually led him to continue his education at the University of Colorado at Boulder. He

Colorado Medicine for November/December 2015

Inside CMS then took a few years after he graduated before applying to medical school, as he felt he needed to gain real-world, everyday experience. This has given him unique insight and preparation for his future career. Throughout his life he says he has always been filled with passion for the mountains and the outdoors, passion for health sciences and passion for people. With anything he does, he commits all of his energy and resources; it’s something he finds essential to both productivity and happiness. He organizes his time so he can give full attention to all tasks and goals.

He describes himself as “an enthusiastic academic and an outgoing companion who is truly excited to continue this journey in medicine and give back to the communities that helped me find my passion.�

Allison Rippy was born and raised just outside of Glenwood Springs, Colo.

Growing up in a small town, she developed a strong sense of community and service. After high school, she attended St. Olaf College in Northfield, Minn., where she gained a cross-cultural curiosity and an appreciation for diversity through study abroad in Europe, South America and Asia. She graduated from St. Olaf summa cum laude and Phi Beta Kappa with a degree in biological sciences and a concentration in Asian studies. Her love of medicine is multi-faceted, but was strongly fueled by helping her sister cope with a chronic disease, and understanding the hardships of living in a rural, underserved community. She is in the rural track at CU School of Medicine and plans to pursue a career in primary care. Ultimately, she says her goal is to return to a small town on the Western Slope to provide comprehensive, state-of-the-art health care to her community. n

Colorado Medicine for November/December 2015

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Colorado Medicine for November/December 2015

Inside CMS

CMS and COPIC staff report

Past successes pave the way for productive collaboration During the last year, more than 20 videos have been posted to www.copic pearls.com to highlight the unique partnership between COPIC and CMS. The videos feature comments from physicians, legislators, health care advocates and several others who share their perspectives on how this partnership has benefited health care in Colorado.

Most of this insight focuses on examples that illustrate the positive impact of both organizations. From this strong foundation, we are preparing for the future and looking at how we can help the health care community in a variety of ways.

Advocacy that represents a strong voice for physicians and their patients As health care continues to evolve, COPIC and CMS recognize how important it is to bring an informed perspective to policy discussions. We are gearing up for the 2016 legislative session through ongoing meetings with legislators, involvement with regulatory agencies, and outreach efforts to our insureds and members to make them aware of prominent issues.

Patient safety will continue to be an area of focus as we look at additional ways to reinforce this concept without creating unnecessary barriers.

CMS is in conversations with the health plans on how they build, manage and trim down their physician networks.

We hope these conversations lead to a policy framework that guides the plans to make legitimate business decisions while assuring those decisions are made transparently and afford physicians their rights when they are fulfilling clinical responsibilities to patients. In addition to

network adequacy, we have the pressing challenge of setting reasonable standards of accountability for the impending consolidation of two major health plans in Colorado. CMS has worked with plans before for a favorable outcome and will continue to do so.

Education that prepares for the next generation COPIC continues to invest in technology and resources that help support medical professionals in gaining the knowledge they need. In 2016, we will be launching new courses based on current medical trends, claims data, and the feedback we receive from insureds. These include new on-demand courses and seminar topics that support lifelong learning for providers.

CMS is working to revamp the structure of the 2016 Annual Meeting to maximize its relevance to members, boost educational content and optimize opportunities for collaboration, communication and collegiality. We are recognized by the Accreditation Council for Continuing Medical Education and will continue to serve as an accreditor of providers and engage in joint providership with local organizations that develop and implement CME activities to meet the educational needs of Colorado physicians.

Programs that push innovation forward In September 2015, the Institute of Medicine released a report titled Improving Diagnosis in Health Care, which looked at the issue of diagnostic errors. Besides analyzing the contributing factors, the report also offered ideas for improving and reducing these errors such as:

Colorado Medicine for November/December 2015

• Developing a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses. • Facilitating more effective teamwork in the diagnostic process among health care professionals, patients and their families.

The good news is that COPIC has been at the forefront of these ideas for quite some time, and we plan to be a leader in the years to come. We are enhancing the guidelines used in our practice reviews that help identify and mitigate high-risk areas for diagnostic errors. Our 3Rs Program stands out as a national benchmark for communication and resolution programs, which the report recommends. COPIC continues to encourage provider involvement to enhance the program’s effectiveness.

CMS is a vital partner in many state health care initiatives, working to make Colorado the healthiest state in the nation. Colorado benefits from our health policy and business leaders who have the maturity, vision and commitment to identify the issues and work together to fix them. We have achieved policy advancements in system delivery that are not possible in many states, and we are fully engaged on multiple fronts to continue advancing Colorado medicine.

The 30-year partnership between COPIC and CMS has helped make Colorado one of the safest states in America to be a patient and the greatest state in America to practice medicine. The COPIC Precious Pearls video series has highlighted some of the great stories of our past and present, and an exciting future lies ahead. n 33

Inside CMS

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

A matter of trust – a look back on 2015 As a physician, it is always a little strange when you have an injury or condition that falls under your specialty. The roles are reversed and you become the patient instead of the doctor. I found myself in this position recently with a torn rotator cuff. This shift in perspective reminded me of the inherent trust we place in our physicians and health care team members based on their knowledge, empathy and confidence.

Trust is an important concept in health care. It is something that is established and maintained through a series of actions and interactions over years. When I look at COPIC’s relationships with insureds, I recognize how their trust relies on our ability to provide expert guidance, defend the practice of good medicine and support efforts to improve health care. As I reflect on 2015, there are many ways we reinforced this trust and our commitment to medical professionals and patients.

Supporting the entire health care team – With the changes brought about by the Affordable Care Act, COPIC looked at additional ways to support non-physicians who are part of the medical practices we insure. In 2015, we began to offer separate coverage options for allied health professionals to address their evolving roles. And throughout the year, we focused on challenges faced by practice administrators by offering seminars on human resources management and resources for top-of-mind issues like cyber liability.

Keeping an eye on the changes ahead – In 2015, COPIC reviewed and provided legal guidance or input on an estimated 20 bills during the course of the legislative session.

We also reviewed approximately 50 proposed, amended or drafts of bills that had the potential to impact health care.

COPIC continued its ongoing outreach to legislators and collaborative efforts with key partners. Whether it was providing insight to help define the parameters of telehealth or assessing ways to improve patient safety through public policy, COPIC stayed closely connected to issues that will influence the future of health care.

southeast. This will allow us to share best practices and draw upon each company’s experience so that we can improve how we support insureds and the broader health care community.

Doing what we do well – Results from our bi-annual customer survey showed that 99 percent of respondents want to renew their coverage with us and would recommend COPIC to others. Over 90 percent of respondents said they had overwhelmingly positive interactions with us. This reinforces that we are doing the right things, and it also sets a benchmark for us to strive toward and improve upon.

Strengthening our commitment to community support – Since 1992, the COPIC Medical Foundation has provided grants that help fund innovative ideas in health care. In 2015, the Foundation continued this tradition by funding the following initiatives: • Awareness Campaign on Prescription Drug Interactions – JP Prescription Drug Awareness Foundation • Council on Patient Safety in Women’s Health Care – American College of Obstetricians and Gynecologists • Healthy Living Initiative – Colorado Pediatric Collaborative • Kidney Care Kits – National Kidney Foundation • Leadership Training Program – Gunnison Valley Health Foundation • RxOpioidSafe Pilot Program – Rx Assurance • Spot Vital Sign Digital Devices – Bonfils Blood Center From COPIC’s perspective, there is a continuing trend in lower frequency of medical liability claims. This tells us that improvements are occurring, we are seeing better outcomes and patient safety is a priority. COPIC recognizes the investments you make personally, in your medical practices and with your patients to achieve these results, and we understand why trust needs to be at the heart of everything we do. n

Expanding our capabilities – As detailed in the last COPIC Comment, COPIC recently formed an alliance with MagMutual, the leading medical liability provider in the 34

Colorado Medicine for November/December 2015

Colorado Medicine for November/December 2015

35

Departments

medical news News round-up: Prescription drug abuse and misuse prevention There is no question that the nation’s opioid-related epidemic continues to have devastating effects in nearly every city and state across the country.

Deaths related to prescription opioids remain staggeringly high, and deaths from heroin are growing at an alarming rate. Many in the public and private sector are taking action to combat this epidemic.

Presidential memo President Barack Obama issued a memorandum in late October to federal departments and agencies directing them to provide more training to prescribers

36

and to conduct a review to identify barriers to medication-assisted treatment for opioid use disorders and develop action plans to address these barriers.

New AMA task force and website The American Medical Association formed the AMA Task Force to Reduce Opioid Abuse to help coordinate, develop and implement specific recommendations designed to have a measurable impact. They are working to ensure effective pain management practices and evidence-based prescribing of opioids, promote appropriate referrals and

access to care for patients with opioid use disorders, and take necessary steps needed to reduce opioid-related harm.

As part of the task force’s efforts, the AMA has launched a new, webbased resource, www.ama-assn.org/go/ endopioidabuse, and will soon begin a national ad campaign to increase physicians’ registration and use of prescription drug monitoring programs (PDMPs) as well as promote enhanced education and training to ensure that physicians take the lead in becoming educated about evidence-based care and appropriate prescribing practices.

Colorado Medicine for November/December 2015

Departments

medical news The new website includes state-specific information; and links to PDMPs, CME courses and webinars on preventing opioid abuse and safe opioid prescribing; and resources for providers and patients.

Colorado Medicaid covers naloxone nasal spray The Department of Health Care Policy and Financing announced in early October that Colorado Medicaid will now cover a nasal mist atomizer device that can be used to administer naloxone, an opioid overdose antidote. While the drug is not new, it has historically been administered through an injection and is now available as a nasal mist. HCPF hopes that Medicaid’s coverage of the device will help reduce the number of deaths from opioid-related overdoses by enabling a family member or friend to administer naloxone.

tion Drug Abuse Prevention held its annual meeting on Oct. 15, convening experts from across the state under the goal to reduce the abuse and misuse of prescription drugs by improving education, public outreach, research, safe disposal and treatment.

The meeting was led by Rob Valuck, PhD, director of the consortium and professor at the University of Colorado Skaggs School of Pharmacy at the Anschutz Medical Campus, and included opening remarks by state health care leaders and a discussion of the Centers for Disease Control and Prevention’s

efforts in prescription drug abuse and overdose prevention. Colorado’s strategy to combat prescription drug abuse recently gained the attention of Health and Human Services Secretary Sylvia Burwell, who hosted a roundtable with state health care and consortium leaders in July and announced $99 million in new funding in the president’s 2016 budget to intensify efforts.

For more information, go to www. corxconsortium.org. n

Similarly recognizing the effectiveness of naloxone, CVS pharmacy will now dispense the antidote to patients without a prescription or standing order from a physician in 20 states. CVS is also launching a new drug abuse prevention program called Pharmacists Teach where its pharmacists will make 2,500 presentations in high school health classes. Rite Aid will train 6,000 pharmacists on naloxone use over the next 12 months and expand their naloxone-dispensing program to additional states. The National Association of Chain Drug Stores will continue to educate their 125 chain member companies about opioid overdose and naloxone.

Colorado Consortium for Prescription Drug Abuse Prevention update The Colorado Consortium for PrescripColorado Medicine for November/December 2015

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Departments

medical news New school-based health center named for Lee Morgan, MD A CMS past president and active leader has been honored as the namesake for a new school-based health center.

The Alethia E. Morgan, MD Health Center was dedicated on Sept. 28.

Located on the Florence Crittenton Campus in Denver, the clinic is the first school-based health center in Colorado to provide both pediatric care and obstetrics – everything but ultrasounds and delivery. It is operated

by Denver Health in partnership with Denver Public Schools and Florence Crittenton Services.

Alethia “Lee” Morgan, MD, and her husband, Mark Fall, attend the dedication of the new Alethia E. Morgan, MD Health Center on Sept. 28.

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The school enrolls 145 pregnant and parenting teenagers, as well as 109 of their young children. There’s evidence that school-based clinics improve health access for kids, particularly those who face the greatest barriers in getting care. School leaders believe the on-site clinic will positively impact maternal-child health outcomes and minimize school absenteeism caused by illnesses and travel to medical appointments.

“The Florence Crittenton Campus offers a truly innovative, twogeneration approach that supports both the teen mother and her child,” said Suzanne Banning, president and CEO of Florence Crittenton Services.

Morgan joined the Florence Crittenton Services board of directors in 2011.

She had experience working with teen moms as an OBGYN in Pueblo. When Florence Crittenton Services started looking at expanding the campus to include a health center in 2013, she served on the planning committee, and she committed a significant donation when the group faced funding issues. She continues to serve as the chair of their Program Committee and on the Executive Committee for the Board. n

Colorado Medicine for November/December 2015

Departments

medical news Division of Insurance approves 2016 health insurance plans Twenty carriers, 1073 plans The Colorado Division of Insurance has approved 1,073 health insurance plans from 20 carriers to offer health coverage to consumers and small businesses for 2016. Three carriers from the current year will not be offering plans in 2016, and three new carriers have entered the market for 2016.

Two of the three carriers not offering plans in 2016 have done so voluntarily: New Health Ventures and Time Insurance Company.

The third, Colorado HealthOP, was told by the DOI that they could not sell insurance in 2016 because of a question of their financial viability. The company receives federal funding under a program known as the “risk corridor” and the Centers for Medicaid and Medicare Services announced that they would only reimburse risk corridor insurers 12.6 percent of what they were entitled.

The Colorado HealthOP was expecting to receive $16.2 million in risk corridor payments but will instead receive $2 million. As a result, the HealthOP does not meet the state’s minimum capital and surplus requirements and will not be available in 2016.

to look beyond monthly premiums to consider deductibles and other benefits.

A plan has to fit both the health and financial needs of a consumer.”

2016 premiums will increase Across the state, premiums will increase over 2015 premiums on average 7.04 percent, with individual policies rising an average of 9.84 percent, and 3.17 percent for small group plans (plans that are purchased by small employers, with 2-99 employees). Premiums vary by carrier, age, geographic area and the tier of plan. Premiums also reflect the cost of health care in Colorado and in each of the state’s nine geographic rating areas.

“Rates reflect the cost of health care, and the DOI has verified that information,”

Salazar said in the release. “This is only the third open enrollment under the ACA, and these rates represent the first time carriers had a full year of data to inform their rates. They are still trying to figure out what consumers want in terms of plans, deductible levels, and services, at a price that attracts enrollment, but allows the carrier to keep the lights on and pay their bills.”

Consumers who have questions about their current plans should contact their insurance carrier, Connect for Health Colorado, their insurance broker or their employer. More information about the approved 2016 plans is available online at www.dora.colorado.gov/insur ance; click on the blue “Health Insurance” button. n

Three new carriers have entered the market for 2016: Golden Rule Insurance Company, Aetna Health Inc. and Aetna Life Insurance Company. In addition, UnitedHealthcare of Colorado is entering the individual market for the first time, adding to its existing business in the small group market.

“Even as three carriers leave the Colorado market, three others jump in, so Coloradans continue to have many choices for health insurance, both on and off the exchange,” said Commissioner of Insurance Marguerite Salazar in a press release. “Because we have so many choices, I encourage consumers Colorado Medicine for November/December 2015

39

Departments

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

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Colorado Medicine for November/December 2015

Departments

Colorado Medicine for November/December 2015

41

Features

the final word M. Robert Yakely, MD, and Brigitta Robinson, MD

Moving forward as a more dynamic, responsive organization At the 145th Annual Meeting of the Colorado Medical Society in September, the House of Delegates took a hard look at how we can best serve the needs of more Colorado physicians now and in the future. The decisions made at the meeting may prove to be one of the most significant turning points in our history.

The much-discussed governance reform package was on the table for consideration after more than a year of work from the CMS Governance Reform Task Force, formed the year before to examine how our medical society functions. After much thoughtful discussion, the House agreed by a large majority to implement the changes in governance that were recommended by the CMS Board of Directors.

To put this change in perspective, the governance process as it stood just two months ago was created in 1905! Back then a doctor had to hook a horse up to a buggy to get to the annual meeting to discuss resolutions submitted to formulate policy for the society. We would all agree that we have communication tools available to us today that were unimaginable to our founding fathers. The new model plans to take advantage of these tools to facilitate the formulation of new policy more quickly than once a year. It also envisions empowering more members to be involved in the formulation and implementation of new policies. The technology we are developing is cutting edge and has not been implemented by any other state medical society. Once again, the Colorado Medical society is leading the way.

We want to allow all members to sign up to participate in the policy forum. We 42

currently do not reach many of our members who have great ideas but perhaps lack the ability to spend a weekend away from their practice formulating policy.

We are also aware that although some enjoy the debate on the floor of the House and the amendments to amendments, others are less enchanted with that policy-setting aspect.

M. Robert Yakely, MD, right, and Brigitta Robinson, MD, left, address the House of Delegates at the 2015 CMS Annual Meeting.

We expect all former delegates and alternates will participate in the new process, but we also strongly encourage all members to engage with your peers by electronically submitting ideas, concerns and problems through the virtual policy forum to the smaller, more nimble Board of Directors via your representative board member. We plan to use emails and text messages to communicate with the members of the policy forum; we have been told by our tech savvy members that they will respond to bullet point messages if they can quickly reply with a vote for a “good idea” or “bad idea.” We hope that if a member considers a proposal a “bad idea” they will take the time to explain why.

Another overwhelmingly popular change approved in the reform package is leadership training support to be implemented in a two-pronged approach.

First, the Colorado Medical Society will commit to funding the popular Advanced Physician Leadership Program, which has graduated two cohorts of physicians already, to give physicians the communication and leadership

skills necessary to implement meaningful health care reform. A new medical society leadership course will also train up-and-coming medical society leaders in communication, management skills, public persona and health policy.

These are just a few of the aspects of the reform package implemented at the annual meeting, and much has to be worked out over the course of the next year; we hope you are as excited as we are about the possibilities for our future.

The goal is clear: We aim to provide our members with a dynamic, responsive organization that meets our members’ needs to provide advocacy and support for physicians’ careers in all types of practice settings. We are excited to move forward with the new changes and will keep you all abreast of the progress we make in the months to come. Please keep your comments coming by emailing president@cms.org. We would like to hear all suggestions as we move forward so we can incorporate as many as possible to make the reforms work for all physicians in Colorado. n

Colorado Medicine for November/December 2015

Colorado Medicine for November/December 2015

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