Kate Alfano, CMS Communications Coordinator
Colorado physicians achieve outstanding victories in 2017 General Assembly
In every session there are issues that arise outside of CMS’ platform that require strategic maneuvering. Continuing our report on achievements in the 2017 Colorado General Assembly from the cover story are the issues below. They also required attention and action to educate lawmakers on how bills would help or hurt physicians and patients. CMS recognizes the many physicians who testified in support or opposition to bills and responded to COMPAC “Code Blue” alerts.
BLOCKED: NDs scope of practice expansion
One defensive maneuver came as a result of a House amendment to SB17-106, the bill to extend the regulation of naturopathic doctors (NDs). The legislation was the result of the state’s required sunset review process that mandates periodic study of all state agencies. However, an advocacy group for NDs attempted to use SB17-106 as a vehicle to inappropriately and dangerously expand their scope of practice by giving NDs the prescriptive authority to obtain, administer, dispense, prescribe and treat with intravenous minerals, amino acids and hormones with a collaborative agreement with a physician or APN. Physician advocates responded in force by urging their legislators to strike the amendment. Ultimately, CMS was successful.
“There is no scientific evidence of a benefit from infusion of minerals and amino acids. Inappropriately administered hormones can be dangerous,” said Sen. Irene Aguilar, MD, D-Denver. “I thought it was important to block the House amendments to the registration of naturopathic doctors because patients place a lot of trust in professionals whose title includes the word ‘doctor.’ And they see state registration as a sign that the authenticity of the practitioner is verified.”
BLOCKED: Removal of limits on non-economic damages cap
CMS opposed a bill that would have removed all limits for any wrongful death action involving anyone under age 21 against a physician or health care defendant. HB17-1254 would have produced a series of cascading side effects that would have inevitably compromised young patients’ timely access to care, perversely in circumstances where their health is in greatest jeopardy and they require the most skilled kinds of medical care. Physicians would have faced a flood of new litigation; a spike in professional liability premiums; a compression of available settings for general pediatric and high-risk care, especially in rural and underserved regions; and a further compromised recruitment of specialists to those settings and regions.
“Starting as a medical student I learned from my mentors that you don’t have to do anything wrong to get sued, and you don’t have to do anything wrong to lose that lawsuit,” said CMS President Katie Lozano, MD, FACR, in her testimony against the bill. “This is a sobering realization but one that you have to learn to live with as you provide care for your patients. Uncapping liability for non-economic damages, however, will cause predictable new responses by physicians, which will not benefit the people of this state.”
She explained: “New physicians will avoid specialties or settings where they provide care to a very sick child, adolescent or young adult. Physicians will increase the number of diagnostic tests to document their professional decisions and judgment, also known as defensive medicine, which would increase the use of imaging in pediatric care and expose Colorado children to more radiation. And the need to protect and establish medical decisions will force highly trained pediatric subspecialists and emergency physicians to order more tests that they would not currently need to back up diagnoses.”
“The death of a child is a terrible, terrible thing,” Lozano said. “No amount of money can possibly replace that unthinkable loss. And that is the point. A lawsuit without limits does not make those who are suffering whole and will demonstrably compromise the availability and cost of pediatric and obstetric care for the people of Colorado.”
ACHIEVED: Medicaid pay increase for most providers
Entering the 2017 session, it was common knowledge under the golden dome that a $500 million budget gap – the difference between required expenditures and available revenues – would constrain legislative asks. However, the CMS coalition persisted in support of a pay increase for physicians who care for Medicaid patients and achieved a 1.4 percent provider rate increase for most physicians. A few services, including primary care evaluation and management codes that received an increase in 2016, were excluded from the 2017 increase.
“Starting in August, we were meeting with members of the Legislative Joint Budget Committee to emphasize the importance of community provider rates,” said Ed Bowditch of Bowditch and Cassell Public Affairs, retained by CMS. “Our work continued through the fall and winter, and we worked with our medical lobby colleagues to keep this important issue on the radar of the budget committee members. Our efforts will continue starting in July as the executive branch starts formulating its FY 2018-19 budget request.”
ACHIEVED: Prohibition of “step therapy” for certain patients
Many health plans have formularies that require a patient to use the lowest-tier medication before the plan will consider another medication with the same indications. While this may be appropriate in some cases, there are many patients with chronic conditions who have been treated for these conditions under coverage by a different plan and have already tried and failed on several medications. SB17-203 – by Sen. Nancy Todd, D-Aurora; Rep. Chris Kennedy, D-Lakewood; and Rep. Phil Covarrubias, R-Brighton – allows patients to remain on an effective medication they are currently using instead of reverting to an ineffective medication because of lack of coverage.
“Requiring step therapy when a patient already has tried and failed the required medication can be unsafe – particularly in conditions that I treat as a neurologist, such as epilepsy, where changes in a successful medication regimen may result in increased seizure activity, status epileptics and even death,” said Lynn Parry, MD, CMS past president. “Requiring step therapy in this group of patients is neither cost-effective nor safe.”
ACHIEVED: Interim study on the opioid epidemic in Colorado
Rep. Brittany Pettersen, D-Lakewood, who has a personal connection to the opioid epidemic in Colorado, requested that an interim study be formed to study prevention, intervention, harm reduction, treatment and recovery support strategies for opioid and other substance use disorders in Colorado. The taskforce is expected to produce as many as six bills for consideration in the 2018 legislative session. CMS member Don Stader, MD, an emergency physician with Swedish Medical Center and nationally recognized expert on the opioid epidemic, will represent physicians on the special taskforce that will advise the legislative study.
“As part of the interim taskforce on opioid and substance use disorders, I hope to bring a strong physician perspective and evidence-based ideas on how Colorado can address our state’s opioid epidemic,” Stader said. “I hope to champion funding for a more accessible and user-friendly Prescription Drug Monitoring Database [PDMP], advocate for improved substance abuse treatment resources, and push for legislative changes that de-stigmatize addiction and advance harm reduction initiatives for our IVD-using patient population.”
Colorado is fortunate to be ahead of other states in the fight against the opioid epidemic. The CMS board of directors has prioritized this issue since 2013 and has fully cooperated with the governor’s office and the Colorado Consortium for Prescription Drug Abuse Prevention to provide the physicians’ perspective.
ACHIEVED: Increased access to direct primary care (DPC)
The Colorado Academy of Family Physicians took the lead on a bill to increase patients’ access to direct primary care, or DPC, an increasingly popular payment model in primary care that allows for physicians to directly contract with patients for health care.
As proponents attest, DPC offers a model for some physicians to take a different path, emphasize the patient-physician relationship, and reduce the administrative burden from insurance billing. Numerous DPC physicians testified that the model offers a solution to the burnout they were experiencing in a fee-for-service practice.
Because DPC is not an insurance product, HB17-1115 clarifies that DPC practices are not subject to insurance company regulations. The bill’s sponsors were Rep. Perry Buck, R-Windsor; Rep. Joann Ginal, D-Fort Collins; Sen. Jack Tate, R-Centennial; and Sen. John Kefalas, D-Fort Collins.
Monica Morris, DO, CAFP president and CMS member, said, “This important legislation helps protect greater choice and affordable care for our patients and an interesting and fulfilling practice for physicians.”