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Colorado Medical Society Policy Manual Adopted September 2013 Table of Contents 100 Abortion .................................................................................................................................... 1 100.998 Termination of Pregnancy ...........................................................................................................1 100.999 Medical Treatment for Infants Born Alive During Induced Abortion .............................................1 105 105.994 105.995 105.996 105.997 105.998 105.999 Acquired Immunodeficiency Syndrome (AIDS) .................................................................... 1 Counseling and Testing of Pregnant Women for HIV ..................................................................1 Needle Exchange Programs ........................................................................................................1 Testing for AIDS ..........................................................................................................................1 HIV Infection in Health Care Workers ..........................................................................................2 School Attendance for Children with AIDS ..................................................................................2 Treatment of AIDS Patients .........................................................................................................2 110 Aging ......................................................................................................................................... 3 110.999 Elderly Drivers .............................................................................................................................3 115 Alcohol and Alcoholism .......................................................................................................... 3 115.997 Blood Alcohol Content Infraction .................................................................................................3 115.998 Driving Under the Influence (DUI) Blood Alcohol Level ...............................................................3 115.999 Age Requirement for Purchase of Non-Alcoholic Beer................................................................3 120 120.993 120.994 120.995 120.996 120.997 120.998 120.999 Children and Youth .................................................................................................................. 3 Health School Lunch Pilot Programs ...........................................................................................3 Mandated Physical Education in Public Schools .........................................................................3 Physical and Healthy Nutrition Education in Schools ..................................................................3 Religious Exemption to Child Medical Neglect ............................................................................4 Confidential Health Services for Adolescents ..............................................................................4 School Bus Safety .......................................................................................................................4 School Children with Herpes .......................................................................................................4 125 Civil and Human Rights ........................................................................................................... 5 125.999 Discrimination ..............................................................................................................................5 130 Complementary and Alternative Medicine ............................................................................ 5 130.999 Alternative Therapies ...................................................................................................................5 135 135.986 135.987 135.988 135.989 135.990 135.991 135.992 135.993 135.994 135.995 135.996 135.997 135.998 135.999 Continuing Medical Education ............................................................................................... 5 Mission Statement .......................................................................................................................5 Program Accreditation .................................................................................................................5 Financial Support of Accreditation Program ................................................................................5 Policies and Procedures ..............................................................................................................5 Educational Programs of Other Organizations ............................................................................5 Endorsement of Outside Educational Programs .........................................................................6 Committee on Professional Education and Accreditation ............................................................6 Access in Rural Communities ......................................................................................................6 Liaisons With Other Organizations ..............................................................................................6 Issuance of Credit ........................................................................................................................6 Educational Support Services......................................................................................................6 Voluntary Continuing Medical Education .....................................................................................7 Medical Education in Colorado ....................................................................................................7 Tour/Travel Continuing Medical Education ..................................................................................7 140 Disabled .................................................................................................................................... 7 140.999 Evaluation of Permanent Impairment ..........................................................................................7 145 Drug Abuse ............................................................................................................................... 7 145.996 Recreational Marijuana ............................................................... Error! Bookmark not defined. 145.997 Physician Leadership on National Drug Policy ............................................................................7 i Table of Contents 145.998 Drug Abuse and Drug Testing in Youth Athletics ........................................................................7 145.999 Prevention of Abuse and Diversion of Prescription Drugs ...........................................................8 150 Drugs: Advertising ................................................................................................................... 8 150.998 Inappropriate Pharmacy Advertising ...........................................................................................8 150.999 Oversight of Direct-to-Consumer Advertising of Prescription Drugs............................................8 155 155.992 155.993 155.994 155.995 155.996 155.997 155.998 155.999 Drugs: Prescribing and Dispensing ....................................................................................... 8 Public Health and Safety Challenges of Treating Chronic Pain: The Medical Perspective .........8 RX Data 2008 ..............................................................................................................................8 E-Prescribing of Controlled Substances ......................................................................................9 “Off Label” Prescribing of Medication ..........................................................................................9 Inappropriate Use of Drug Enforcement Administration Number ................................................9 Physician Dispensing of Drugs ....................................................................................................9 Use of Anabolic Steroids .............................................................................................................9 Administration and Use of Prescription Drugs .............................................................................9 160 Drugs: Substitution ................................................................................................................. 9 160.997 Substitution of Class B Generic Drugs ........................................................................................9 160.998 Generic Drug Substitution..........................................................................................................10 160.999 Therapeutic and Pharmaceutical Substitution by Pharmacists .................................................10 165 165.993 165.994 165.995 165.996 165.997 165.998 165.999 Emergency Medical Services ............................................................................................... 10 Emergency Health Information Exchange Mobile Internet “Push” Strategy ..............................10 Registry of Physician Volunteers ...............................................................................................10 Access to Emergency Services .................................................................................................10 Statewide Trauma System Development and Refinement ........................................................11 Continued Funding for Emergency Medical Services in Colorado ............................................11 Pre-Hospital Triage Decisions ...................................................................................................11 Availability of Emergency Transportation at High School Sports Events ..................................11 170 170.987 170.988 170.989 170.990 170.991 170.992 170.993 170.994 170.995 170.996 170.997 170.998 170.999 Ethics ...................................................................................................................................... 11 Health Care as a Fundamental Societal Obligation ...................................................................11 Stem Cell Research ...................................................................................................................11 Code of Medical Ethics ..............................................................................................................11 Patenting Human Genes ...........................................................................................................12 Gene Therapy ............................................................................................................................12 Human Cloning ..........................................................................................................................13 Genetic Testing by Employers ...................................................................................................14 Euthanasia and Physician-Assisted Suicide..............................................................................15 Grievance Reviews ....................................................................................................................16 The Physician-Patient Covenant ...............................................................................................16 Corporate Practice of Medicine .................................................................................................17 Sexual Misconduct ....................................................................................................................17 Obligation to Report Impaired, Incompetent or Unethical Colleagues .......................................17 175 175.996 175.997 175.998 175.999 Health Care Costs .................................................................................................................. 19 Choosing Wisely ........................................................................................................................19 Patient Tax Deduction for Health Care Expenses .....................................................................19 Profiteering by Third Party Payers in Health Care .....................................................................19 Cost Containment Programs and Intrusions from Third Party Payers .......................................19 180 180.986 180.987 180.988 180.989 Health Care Delivery .............................................................................................................. 19 Advertising Standards ................................................................ Error! Bookmark not defined. Patient Safety ............................................................................................................................19 Accountability ............................................................................................................................19 Store Based Clinics ...................................................................................................................20 ii Table of Contents 180.990 180.991 180.992 180.993 180.994 180.995 180.996 180.997 180.998 180.999 Freedom of Practice in Medical Imaging ...................................................................................20 Telephonic Communication Guidelines .....................................................................................20 Observation Care ......................................................................................................................20 Electronic Communication Guidelines .......................................................................................21 Use of Current Knowledge in Palliative Medicine ......................................................................22 Termination of Physician/Patient Relationship Notification .......................................................22 Transition of Care for Patients with Special Needs and Circumstances ...................................23 School-Based Health Centers ...................................................................................................25 Encouragement of Physician Participation in Project USA ........................................................25 Vertical Divestiture in the Health Care System ..........................................................................25 185 185.988 185.989 185.990 185.991 185.992 185.993 185.994 185.995 185.996 185.997 185.998 185.999 Health Care System Reform ................................................................................................. 25 Integration of Physical and Behavioral Health Care ..................................................................25 Practice Evolution Recommendations .......................................................................................25 Interference in Patient Counseling ............................................................................................27 Physician Practice Evolution .....................................................................................................27 Joint Principles of the Patient-Centered Medical Home ............................................................29 Matrix Reform Plan ....................................................................................................................30 Health Care Reform Systems of Care .......................................................................................32 A Matrix Based Reform Plan Using A Non-Profit Approach ......................................................34 Health Systems Reform Evaluation Matrix ................................................................................34 Individually Selected and Individually Owned Health Insurance................................................39 Health System Reform ..............................................................................................................39 Principles for Care of the Medically Indigent .............................................................................43 190 Health Education.................................................................................................................... 43 190.997 Character-based Sex Education in Schools ..............................................................................43 190.998 Journal Exchange ......................................................................................................................44 190.999 Medical Library ..........................................................................................................................44 195 Health Insurance .................................................................................................................... 44 195.999 Informed Consent for Insurance Subscribers ............................................................................44 200 Health Insurance Benefits and Coverage ............................................................................ 44 200.997 Consumer Comparative Data ....................................................................................................44 200.998 Insurance Aspects of Comprehensive Pediatric Care ...............................................................44 200.999 Reimbursement for Voluntary Home Treatment of Terminally Ill ...............................................44 205 205.995 205.996 205.997 205.998 205.999 Health Planning ...................................................................................................................... 44 Physician Signature on Cardiopulmonary Resuscitation (CPR) Directives ...............................44 Withholding or Withdrawing Life Sustaining Medical Treatment ...............................................45 Care of Dying Patients ...............................................................................................................46 Nursing Home Resident Destination Issues ..............................................................................46 Patient Wishes Regarding Medical Treatment ..........................................................................46 210 210.990 210.991 210.992 210.993 210.994 210.995 210.996 210.997 210.998 210.999 Hospital Medical Staff............................................................................................................ 47 Privileges ...................................................................................................................................47 Standardization of Credentialing Forms ....................................................................................47 Physician Profile and the Prospective Payment System ...........................................................47 Bylaws .......................................................................................................................................47 Self-Government .......................................................................................................................47 Definition ....................................................................................................................................47 Legal Counsel ............................................................................................................................48 Self-Governing Medical Staff .....................................................................................................48 Renewal of Staff Reappointments .............................................................................................48 Participation in Decision Making................................................................................................48 iii Table of Contents 215 Hospitals ................................................................................................................................. 48 215.999 Status and Disbursement of Profits ...........................................................................................48 220 Legal Medicine ....................................................................................................................... 48 220.998 Position Paper: Expert Witness .................................................................................................48 220.999 Expert Testimony and Fees .......................................................................................................49 225 Licensure and Discipline ...................................................................................................... 49 225.995 Maintenance of Licensure .............................................................. Error! Bookmark not defined. 225.996 Voluntary License for Retired Physicians ..................................................................................49 225.997 Medical License Fees ................................................................................................................49 225.998 Support of Colorado Physician Health Program ........................................................................49 225.999 Support of Board of Medical Examiners ....................................................................................50 230 Long-Term Care ..................................................................................................................... 50 230.997 Clinical Knowledge of Long Term Care for the Elderly ..............................................................50 230.998 Case Management ....................................................................................................................50 230.999 Standards and Credentialing for Case Managers .....................................................................50 235 235.976 235.977 235.978 235.979 235.980 235.981 235.982 235.983 235.984 235.985 235.986 235.987 235.988 235.989 235.990 235.991 235.992 235.993 235.994 235.995 235.996 235.997 235.998 235.999 Managed Care ........................................................................................................................ 50 Prior Authorization .....................................................................................................................50 Physician Profiling .....................................................................................................................51 National Care Project Physician Input .......................................................................................52 Physician Networks ...................................................................................................................52 Request for Ongoing Reporting from the UnitedHealthcare Physician Advisory Committee (PAC) .......................................................................................................................................52 Drug Formularies .......................................................................................................................52 Admitting Officer and Hospitalist Programs ...............................................................................53 Health Plan Opt Out ..................................................................................................................53 All-Products Clauses .................................................................................................................53 Managed Care Contract Participation Listing Deadline .............................................................54 Accurate Reporting of Health Plan Expenditures for Patient Care ............................................54 Ethical Implications of Capitation...............................................................................................54 Managed Care Utilization Review and “Hold Harmless” Clauses .............................................54 Position Paper: Prior Authorizations ..........................................................................................55 Managed Care Policy ................................................................................................................55 Managed Care Network Adequacy ............................................................................................58 Access to Care (Gatekeeper Systems) .....................................................................................58 Ethical Issues in Managed Care ................................................................................................59 Quality of Care in Managed Care Plans ....................................................................................60 Managed Care and Antitrust......................................................................................................60 Position Paper: Physician Affiliation/Disaffiliation ......................................................................60 Discrimination Against Physicians by Health Care Plans ..........................................................64 Punitive Protections for Physicians Participating in Health Care Plans .....................................64 Point of Service Option for Managed Care Enrollees ................................................................64 240 240.993 240.994 240.995 240.996 240.997 240.998 240.999 Medicaid.................................................................................................................................. 64 Medicaid Expansion ..................................................................................................................64 Medicaid/Medicare Parity in Reimbursement Rates ..................................................................65 Remove Exemptions from Medicaid Prescribing .......................................................................65 Medicaid Guiding Principles ......................................................................................................65 Medicaid Pharmacy Benefits .....................................................................................................66 Medicaid Reimbursement and Patient Access to Physicians ....................................................67 Medicaid Position Paper ............................................................................................................67 245 Medical Education ................................................................................................................. 67 iv Table of Contents 245.988 245.989 245.990 245.991 245.992 245.993 245.994 245.995 245.996 245.997 245.998 245.999 Unified Graduate Medical Education .........................................................................................67 Discrepancies in Clerkship Cost ................................................................................................67 Workforce-Centered Education Funding ...................................................................................67 Adolescent and Young Adult Cancer in Medical Education ......................................................67 Health Policy Education in Medical School................................................................................68 Medical Student Tuition and Debt..............................................................................................68 “All Payer” Funding for Medical Education ................................................................................68 Training or Retraining Physicians for Rural Practice .................................................................68 Specialty Choice Requirements for Student Financial Aid ........................................................68 Topics and Responsibility for the Annual Meeting Educational Program ..................................68 Resident Working Hours ............................................................................................................68 Maternity Leave for Residents ...................................................................................................68 250 Medical Records .................................................................................................................... 68 250.998 Medical Record Fees-Guidelines ..............................................................................................68 250.999 Access to Physicians’ Individual Medical Records ....................................................................69 255 Medical Societies ................................................................................................................... 69 255.999 Unified Voice for Physicians ......................................................................................................69 260 260.994 260.995 260.996 260.997 260.998 260.999 Medicare ................................................................................................................................. 69 Medicaid/Medicare Parity in Reimbursement Rates ..................................................................69 Analysis of Individual Procedures for Payment Reduction ........................................................69 Correction of Medicare Under-reimbursement to Colorado Physicians.....................................69 Terminating Participation in Medicare - Managed Care Plans’ Responsibility to Patients ........69 Medicare Changes to Ensure Patients’ Access to Physicians ..................................................70 Control of Medicare Spending Growth.......................................................................................70 265 Mental Health ......................................................................................................................... 70 265.998 Nondiscrimination in Mental Health and Substance Abuse Insurance Benefits ........................70 265.999 Parity for Mental Health in Medical Benefits Programs .............................................................70 270 270.992 270.993 270.994 270.995 270.996 270.997 270.998 270.999 Non-Physician Providers ...................................................................................................... 70 CMS and Specialty Society Principles Regarding APN Scope of Practice ................................70 Scope of Practice ......................................................................................................................71 Naturopaths ...............................................................................................................................72 Physical Examinations...............................................................................................................72 Opposition to Psychologists Prescribing Medication .................................................................72 Non-Physician Providers ...........................................................................................................72 Collaboration Among Physicians, Physician Assistants, Nurses and Pharmacists ...................73 Regulation of Allied Health Professionals ..................................................................................73 275 Nurses and Nursing ............................................................................................................... 75 275.999 Aid to Nursing Profession ..........................................................................................................75 280 280.991 280.992 280.993 280.994 280.995 280.996 280.997 280.998 280.999 Occupational Health .............................................................................................................. 75 Workers’ Compensation Benefit Caps .......................................................................................75 Workers’ Compensation Utilization Review ...............................................................................75 Division of Workers’ Compensation Peer Review Activities ......................................................75 Workers’ Compensation-Level 1 Accreditation ..........................................................................75 Independent Medical Examination ............................................................................................75 Patient Solicitation .....................................................................................................................75 Workers’ Compensation and Health System Reform ................................................................75 Unfair Treatment of Occupationally Injured Patients .................................................................76 Continued Improvements to the Colorado Workers’ Compensation System .............................76 285 Peer Review .............................................................................................................................76 v Table of Contents 285.993 285.994 285.995 285.996 285.997 285.998 285.999 Colorado Professional Peer Review Act Sunset .......................................................................76 Quality of Care and Medical Staff Review .................................................................................77 Support of Physician Peer Review ............................................................................................77 Health Plan External Grievance Review ....................................................................................77 Peer Review, Corrective Action and Exclusive Contracts .........................................................78 Center for Personalized Education for Physicians (CPEP) .......................................................78 Peer Review Organization (PRO) Data Dissemination..............................................................78 290 Physician Fees ....................................................................................................................... 78 290.999 Medicare Fees ...........................................................................................................................78 295 295.985 295.986 295.987 295.988 295.989 295.990 295.991 295.992 295.993 295.994 295.995 295.996 295.997 295.998 295.999 Physician Payment ..................................................................................................................78 Physician Preparedness for Payment Reform ...........................................................................78 Payment Reform ........................................................................................................................79 Budget Neutrality Factor ............................................................................................................79 Delivery of Multiple Services to Patients at a Single Encounter ................................................79 Medical Directors’ Responsibility in Denial of Procedures ........................................................79 National Prompt Payment ..........................................................................................................79 Reimbursement for Telephonic and Electronic Communications ..............................................79 Retroactive Denial of Payment ..................................................................................................80 Physician Charge Audit Procedures ..........................................................................................80 Reimbursement for Paperwork Completion ...............................................................................80 Fair and Equitable Payment ......................................................................................................80 Standardized Eligibility for Health Benefits ................................................................................80 Reimbursement of Expenses Incurred with Office Procedures .................................................80 Excessive Requests for Information ..........................................................................................80 Endorsement of Resource-Based Relative Value Scales..........................................................80 300 300.994 300.995 300.996 300.997 300.998 300.999 Physicians .............................................................................................................................. 81 Physician Rights ........................................................................................................................81 Diversity in Medicine..................................................................................................................81 Commitment to Physician Rights ...............................................................................................81 Increase in the Numbers of Primary Care Physicians ...............................................................81 Second Opinions .......................................................................................................................81 Definition ....................................................................................................................................81 305 Practice Parameters .............................................................................................................. 82 305.998 Clinical Practice Guidelines .......................................................................................................82 305.999 Guidelines for Use of Standards in Physician Office Assessment ............................................82 310 Pregnancy and Child Birth .................................................................................................... 83 310.998 Home Delivery of Newborns ......................................................................................................83 310.999 Length of Hospital Stay Following Obstetric Delivery ................................................................83 315 Prisons .................................................................................................................................... 83 315.998 Executions .................................................................................................................................83 315.999 Health Care and Corrections .....................................................................................................83 320 320.996 320.997 320.998 320.999 Professional Liability ............................................................................................................. 83 Reporting on Applications ..........................................................................................................83 Colorado Tort Reform Priority ....................................................................................................83 Governmental Immunity ............................................................................................................84 Malpractice Liability/Tort Reform ...............................................................................................84 325 325.975 325.976 Public Health .......................................................................................................................... 84 Inquiry of Gun Ownership ..........................................................................................................84 Firearm Safety Policies ..............................................................................................................84 vi Table of Contents 325.977 325.978 325.979 325.980 325.981 325.982 325.983 325.984 325.985 325.986 325.987 325.988 325.989 325.990 325.991 325.992 325.993 325.994 325.995 325.996 325.997 325.998 325.999 Preventing Violent Crime through Expanding Mental Health Services ......................................84 Body Art .....................................................................................................................................85 Disaster Communication/Preparedness ....................................................................................86 National Immunization Registry .................................................................................................86 Childhood Vaccinations .............................................................................................................86 Opposition to Importation of Radioactive and Toxic Waste Materials .......................................86 Firearm Safety ...........................................................................................................................86 Medical and Dental Care for Persons who are Developmentally Disabled ...............................86 Protective Headgear ..................................................................................................................87 Support for Colorado Coalition for the Medically Underserved ..................................................87 Elimination of Tuberculosis in the United States .......................................................................87 Statewide Immunization Tracking System .................................................................................87 Immunization of Children, Adolescents and Adults ...................................................................87 Rocky Flats Environmental Technology Site .............................................................................87 Family Planning .........................................................................................................................87 Health Promotion .......................................................................................................................88 Routine Screening of Newborn Infants ......................................................................................88 Asbestos Abatement in Public Buildings and Schools ..............................................................88 Joint Statement Regarding Smoking .........................................................................................88 Indoor and Outdoor Air Pollution ...............................................................................................88 Mandatory Seat Belt Use ...........................................................................................................88 Nuclear Power Generation ........................................................................................................89 Motorcycle Helmet Law .............................................................................................................89 330 Quality of Care ....................................................................................................................... 89 330.999 Restricting Communication Between Physicians and Patients .................................................89 335 Research ................................................................................................................................. 89 335.999 Biomedical Research and Animal Activism ...............................................................................89 340 340.998 340.999 345.998 345.999 Rural Health ............................................................................................................................ 89 Rural Health ...............................................................................................................................89 Support of Colorado Rural Outreach Program ..........................................................................90 Laser Surgery ............................................................................................................................90 Post-Operative Care ..................................................................................................................90 350 Technology ............................................................................................................................. 90 350.998 Statewide Master Patient Index .................................................................................................90 350.999 Office Automation ......................................................................................................................90 355 355.992 355.993 355.994 355.995 355.996 355.997 355.998 355.999 Tobacco .................................................................................................................................. 91 Smoking Ban .............................................................................................................................91 Display of Tobacco Advertisements ..........................................................................................91 Tobacco Settlement ...................................................................................................................91 Tobacco Related Research .......................................................................................................92 State Excise Taxes on Tobacco Products .................................................................................92 Smoke-Free Colorado Medical Society .....................................................................................92 Reducing Tobacco Sales to Children ........................................................................................92 Limitation on Distribution of Tobacco ........................................................................................92 360 360.996 360.997 360.998 360.999 Violence and Abuse ............................................................................................................... 92 Violence in Society ....................................................................................................................92 Colorado Medical Society Condemns Terrorism .......................................................................92 Domestic Violence .....................................................................................................................93 Domestic Abuse ........................................................................................................................93 365 War .......................................................................................................................................... 93 vii Table of Contents 365.999 Condemning the Use of Children as Soldiers and Weapons of War .........................................93 370 Women .................................................................................................................................... 93 370.999 Female Genital Mutilation ..........................................................................................................93 900 900.975 900.976 900.977 900.978 900.979 900.980 900.981 900.982 900.983 900.984 900.985 900.986 900.987 900.988 900.989 900.990 900.991 900.992 900.993 900.994 900.995 900.996 900.997 900.998 900.999 Administration and Organization ...........................................................................................93 Spring Conference .....................................................................................................................95 Strategic Plan ............................................................................................................................95 Policy Manual ............................................................................................................................95 Investment Guidelines ...............................................................................................................95 Mileage Reimbursement ............................................................................................................97 Funding Requests from Outside Entities ...................................................................................97 In-State Travel ...........................................................................................................................97 Out-of-State Travel ....................................................................................................................97 Participation in the Provider Coalition ........................................................................................97 Conduct of Representatives of the Colorado Medical Society ...................................................97 Use of Dues Monies ..................................................................................................................97 Requests for Money, Time or Endorsements ............................................................................97 Gender Neutrality ......................................................................................................................98 Exhibit Space .............................................................................................................................98 Guidelines for Financial Contributions, Co-Sponsorships and/or Endorsements ......................98 Relationship with the University of Colorado School of Medicine ..............................................99 Spending from the Reserve Fund ..............................................................................................99 Antitrust Guidelines .................................................................................................................100 Expense Report Submission ...................................................................................................102 Registration Fees ....................................................................................................................102 Sources of Non-Dues Revenue ...............................................................................................102 Budget Recommendations ......................................................................................................102 Budget Information ..................................................................................................................102 Member Representatives ........................................................................................................103 Evaluation of Chief Administrative Officer ...............................................................................103 905 905.994 905.995 905.996 905.997 905.998 905.999 Board of Directors ............................................................................................................... 103 Medical Student Representation .............................................................................................103 Presentations to the Board of Directors ...................................................................................103 Attendance at Board of Directors Meetings .............................................................................103 Proxy Voting by Members of the Board of Directors ...............................................................103 Minutes of Board of Directors Meetings ..................................................................................103 Business of the Board of Directors ..........................................................................................103 910 Councils and Committees ................................................................................................... 104 910.997 Meeting Attendance.................................................................................................................104 910.998 Approval of Council Recommendations ..................................................................................104 910.999 Minutes of Council Meetings ...................................................................................................104 915 915.992 915.993 915.994 915.995 915.996 915.997 915.998 915.999 House of Delegates ...............................................................................................................104 Annual Meeting and House of Delegates ................................................................................104 Medical Student Advisory Board (MSAB) ................................... Error! Bookmark not defined. Establishment of a Residents’ and Fellows’ Section ...............................................................104 Use of Consent Calendar at House of Delegates Meetings ....................................................105 Reference Committee Schedules ............................................................................................105 Family Friendly Colorado Medical Society ..............................................................................105 Approval of Budget by House of Delegates .............................................................................105 Annual Meeting Scheduling .....................................................................................................105 920 Membership and Dues ........................................................................................................ 105 viii Table of Contents 920.996 920.997 920.998 920.999 Medical Student Support–Rocky Vista University....................................................................105 Medical Student Support .........................................................................................................106 Processing of Membership Applications..................................................................................106 Medical Society Jurisdiction ....................................................................................................106 925 925.996 925.997 925.998 925.999 Nomination, Election and Tenure ....................................................................................... 106 Campaign Reform ...................................................................................................................106 American Medical Association Delegation ..............................................................................106 Distribution of President-elect Resumes .................................................................................107 Implied Resignation .................................................................................................................107 930 930.996 930.997 930.998 930.999 Political Action ..................................................................................................................... 107 Unified Position of Colorado Medical Society and its Component Medical Societies ..............107 Colorado Medical Society Leadership .....................................................................................107 Political Effectiveness ..............................................................................................................107 Support Priorities .....................................................................................................................107 ix CMS Policy Manual September 2013 100 Abortion 100.998 Termination of Pregnancy The Colorado Medical Society (CMS) supports early health education and the distribution of safe, more effective methods of family planning for males and females as primary methods of birth control. The termination of pregnancy by a licensed physician in an approved medical setting is a safe medical procedure surrounded by moral and ethical implications. Neither the State nor the Federal government should interfere with the physician/patient relationship and the ability of physicians to counsel their patients on all options for the management of unwanted pregnancy unless there is compelling state interest in which case the regulations must be limited to those reasonably related to those interests. The CMS encourages the development of comprehensive programs including more contraceptive research, mandatory health education for school children, sex education and family life programs for school children, and thorough counseling of persons with unintended pregnancies regarding the pros and cons of all options available as well as prevention of future unintended pregnancies. (RES-53, AM 1989) 100.999 Medical Treatment for Infants Born Alive During Induced Abortion The Colorado Medical Society (CMS) believes that the proper medical treatment of infants born alive prematurely, whether by abortion or spontaneously, is a matter which must be resolved on the basis of each individual case. The CMS opposes legislation that would have the effect of implying a predetermination of the nature or extent of medical treatment or care that should or should not be furnished to infants born prematurely under whatever circumstances. (RES-7, IM 1977) 105 Acquired Immunodeficiency Syndrome (AIDS) 105.994 Counseling and Testing of Pregnant Women for HIV The Colorado Medical Society supports confidential HIV counseling and testing of all pregnant women at the earliest prenatal visit, except when there is a specific, signed refusal for testing, to ensure that pregnant women are educated regarding the risk of vertical transmission of HIV and the benefits of treatment and to allow HIV positive women the opportunity to improve their own health and that of their child. (RES-65, AM 1996) 105.995 Needle Exchange Programs The Colorado Medical Society supports the use of needle exchange programs in Colorado as part of a comprehensive harm reduction strategy for the express purpose of decreasing the transmission of bloodborne pathogens including Human Immunodeficiency Virus and Hepatitis. (RES-7, IM 1996) 105.996 Testing for AIDS The Colorado Medical Society (CMS) supports removing barriers to enable physicians more easily to obtain AIDS testing on patients. The CMS supports confidential testing and the use of such testing and partner notification process as an integral part of the control of HIV infection and AIDS. The CMS also recognizes that although there are downsides to anonymous testing (e.g., decreased ability to do partner notification, difficulty in differentiating duplicate HIV and AIDS case reports, difficulty in monitoring epidemiologic trends, difficulty in monitoring infected persons who continue to practice unsafe behaviors, inability of physicians to confirm test results), the availability of an anonymous test site (ATS) fills an unmet need for a part of the population. Therefore, the CMS supports the continuation of the existing ATS. The CMS also recommends that the ATS be allowed to offer the option of confidential testing. The CMS does not recommend expansion of anonymous testing to additional sites. (Motion of the Board, November 1992) 1 CMS Policy Manual September 2013 105.997 HIV Infection in Health Care Workers The Colorado Medical Society (CMS) acknowledges that there is a theoretical risk of transmission of HIV infection from health care worker to patient; however, the risk is extremely low. The CMS supports the American Medical Association’s position on HIV infected physicians which states: “ An HIV-infected physician should refrain from conducting exposure-prone procedures or perform such procedures with permission from the local review committee and the informed consent of the patient. A physician or other health care worker who performs exposure-prone procedures and becomes HIV-positive should disclose his/her serostatus to a state public health official or local review committee.” Such panel may be constituted within each hospital or as an independent program within the medical community. As is done by similar programs (e.g., Colorado Physician Health Program), the panel/program could accept referrals from persons other than the health care worker. The peer review panel/program should be charged with determining, periodically, the health care worker’s ability to continue to practice based on three criteria:(1) fitness for duty; (2) contagion; and (3) scientific evidence regarding risk of transmission from health care worker-to-patient. The panel/program would re-evaluate the activities of the health care worker based on changes in the status of any of the three criteria. The CMS recommends that all persons who are at risk of acquiring HIV infection should determine their HIV status. Furthermore, the CMS supports the concept of voluntary, periodic testing for all health care workers if confidentiality can be guaranteed. The CMS does not support any mandatory testing of health care workers as a reasonable, reliable or effective approach. An HIV positive health care worker who does not pose an identifiable risk based on the application of the above criteria would not need to inform patients of their HIV seropositivity. However, the HIV positive health care worker who performs procedures with an identifiable risk of transmission as determined by the panel using the above criteria is obligated to inform his/her patients of his/her HIV status as part of the informed consent process. Patients always have the right to discuss their concerns about these issues with their health care providers and to ask their providers about their HIV status and risks of transmission. The CMS does not support mandatory public disclosure of anyone’s HIV status. The voluntary process described herein allows for a case-by-case determination of professional activities that pose an identifiable risk of transmission to the patient. It protects the patient. It also provides some protection to hospitals and health care workers and enables them to be proactive in advocating on behalf of both the provider and patient. (RES-43, AM 1992) 105.998 School Attendance for Children with AIDS The Colorado Medical Society believes that children with HIV seropositive or AIDS-related complex should be allowed to attend regular elementary or secondary school classes. The child’s physician is the best judge of whether a child with AIDS or AIDS-related complex should attend school based on the medical factors associated with this condition. (RES-35, AM 1986) 105.999 Treatment of AIDS Patients The Colorado Medical Society (CMS) is committed to the concept of treating AIDS patients and the AIDSvirus infected person in a compassionate and professional manner, which is consistent with the most current medical knowledge, and which protects both the public safety and individual civil liberties. The CMS encourages the treatment of AIDS patients, as in any other chronic but progressive disease, to be primarily in the outpatient setting until such time as the progression of the disease requires another treatment setting. (RES-38, AM 1986) 2 CMS Policy Manual September 2013 110 Aging 110.999 Elderly Drivers The Colorado Medical Society recommends that: 1. Physicians increase their awareness of the medical conditions, medications, and functional deficits that might impair an individual’s driving performance, and 2. Physicians familiarize themselves with community resources such as formal driver assessment programs and driver rehabilitation services, and refer when appropriate, and urge physicians to know and adhere to Colorado’s reporting statutes for medically at-risk drivers, and 3. Physicians utilize the Physician’s Guide to Assessing and Counseling Older Drivers, a valuable tool available through the American Medical Association. (Late RES-35, AM 2003) 115 Alcohol and Alcoholism 115.997 Blood Alcohol Content Infraction The Colorado Medical Society (CMS) advocates for the retention of the 0.05% BAC Driving While Ability Impaired (DWAI) infraction. The CMS opposes plea-bargaining from an alcohol and/or drug related offense to a non-alcohol and/or non-drug related offense. (RES-13, AM 2003) 115.998 Driving Under the Influence (DUI) Blood Alcohol Level The Colorado Medical Society supports the definition of Driving Under the Influence (DUI) blood alcohol level as 0.08% or less. (RES-5, IM 1998) 115.999 Age Requirement for Purchase of Non-Alcoholic Beer The Colorado Medical Society (CMS) supports accurate and appropriate labeling disclosing the alcohol content of all beverages including so-called “non-alcoholic” beer and of other substances as well, including over-the-counter and prescription medications with removal of “non-alcoholic” from the label of any substance containing any alcohol. The CMS supports efforts to educate the public and consumers relating to the alcohol content of so-called “non-alcoholic” beverages and other substances, including medications, especially as related to consumption by minors. (RES-22, IM 1992) 120 Children and Youth 120.993 Health School Lunch Pilot Programs The Colorado Medical Society supports efforts to expand healthy school meal programs in Colorado schools. (RES-7, AM 2010) 120.994 Mandated Physical Education in Public Schools The Colorado Medical Society supports legislation for mandatory Physical Education (PE) in public schools. School systems, in conjunction with PE, shall also be encouraged to teach nutrition and exercise physiology. (RES-17, AM 2008) 120.995 Physical and Healthy Nutrition Education in Schools The Colorado Medical Society supports and encourages the development of physical education programs and healthy nutrition education in all Colorado schools grades kindergarten through 12. 3 CMS Policy Manual September 2013 (RES-30, AM 2003) 120.996 Religious Exemption to Child Medical Neglect The Colorado Medical Society supports the removal of barriers (including the religious exemption) to appropriate medical care for children and dependents. (RES-42, AM 1996) 120.997 Confidential Health Services for Adolescents The Colorado Medical Society: 1. Affirms that confidential care for adolescents is critical to improving their health; 2. Encourages physicians to allow emancipated and mature minors to give informed consent for medical, psychiatric and surgical care without parental consent and notification, in conformity with state and federal law; 3. Encourages physicians to involve parents in the medical care of the adolescent patient, when it would be in the best interest of the adolescent. When, in the opinion of the physician, parental involvement would not be beneficial, parental consent or notification should not be a barrier to care; 4. Urges physicians to discuss their policies about confidentiality with parents and the adolescent patient, as well as conditions under which confidentiality would be abrogated. This discussion should include possible arrangements for the adolescent to have independent access to health care (including financial arrangements); 5. Encourages physicians to offer adolescents an opportunity for examination and counseling apart from parents. The same confidentiality will be preserved between the adolescent patient and physician as between the parent (or responsible adult) and the physician; 6. Encourages county medical societies to become aware of the nature and effect of laws and regulations regarding confidential health services for adolescents in their respective jurisdictions and to provide this information to physicians to clarify services that may be legally provided on a confidential basis; 7. Urges undergraduate and graduate medical education programs, and continuing education programs to inform physicians about issues surrounding minors’ consent and confidential care, including relevant law and implementation into practice; and 8. Encourages health care payers to develop a method of listing of services, which preserves confidentiality for adolescents. (RES-62, AM 1992) 120.998 School Bus Safety The Colorado Medical Society supports the position that all school buses should be equipped with 28-inch padded seats and seat belts for the maximum safety of their riders. (RES-12, AM 1991) 120.999 School Children with Herpes The Colorado Medical Society (CMS) concurs with the American Medical Association that public elementary and secondary schools should not exclude a child from school attendance or otherwise discriminate against a child only because he has been diagnosed as having a herpes simplex virus. The CMS believes that the child’s physician continues to be the best judge of whether a child with herpes simplex virus should attend school based on the medical factors associated with this condition. (RES-36, AM 1986) 4 CMS Policy Manual September 2013 125 Civil and Human Rights 125.999 Discrimination Colorado Medical Society and its physicians shall not discriminate on any basis, including, but not limited to, sexual orientation, age, gender, religion, national origin, skin color, race or disability. (RES-27, IM 1993) 130 Complementary and Alternative Medicine 130.999 Alternative Therapies The Colorado Medical Society (CMS) encourages physicians to inquire about the use of alternative or unconventional therapies by their patients. The CMS encourages scientific research to evaluate the efficacy of alternative therapies. (RES-1, IM 1998) 135 Continuing Medical Education 135.986 Mission Statement The Colorado Medical Society adopts the mission statement contained in the Program of Accreditation for Continuing Medical Education Policies and Procedures revised April 2003 and approved by the Committee on Professional Education and Accreditation. (RES-70, AM 2003) 135.987 Program Accreditation The Colorado Medical Society (CMS) is committed to providing value to its membership by accrediting quality continuing medical education (CME) programs that are accessible. The CMS is currently recognized by the Accreditation Council for Continuing Medical Education (ACCME) as an accreditor of intrastate providers of CME. The Committee on Professional Education and Accreditation has the responsibility of maintaining and improving the program for accreditation on behalf of the CMS and in accordance with the standards established by the ACCME. (RES-30, AM 1996) 135.988 Financial Support of Accreditation Program The Colorado Medical Society retains the responsibility for the Accreditation Program and seeks to make it financially a self-supporting program. (RES-46, AM 1993) 135.989 Policies and Procedures The Colorado Medical Society (CMS) and the Committee on Professional Education and Accreditation have adopted the American Council for Continuing Medical Education policies and procedures for standards of commercial support and disclosure. All providers accredited by the CMS must comply with the current standards for commercial support found in the Program for Accreditation of Continuing Medical Education Policies and Procedures. (Motion of the Board, October 1991) 135.990 Educational Programs of Other Organizations The Colorado Medical Society (CMS) frequently receives requests from other organizations/institutions to co-sponsor or joint sponsor educational events directly or indirectly related to the broad field of medicine and health care. The CMS is no longer accredited by the American Council for Continuing Medical Education to co-sponsor or joint sponsor educational activities. All such requests will be declined. (RES-1, AM 1991, Motion of the Board, July 2001) 5 CMS Policy Manual September 2013 135.991 Endorsement of Outside Educational Programs Any outside organization/institution desiring endorsement of its program by use of the Colorado Medical Society (CMS) name must submit its request to the Manager for Continuing Medical Education for preliminary investigation after which the request shall be directed, as efficiently as possible, to the appropriate CMS committee or council for further recommendation, then to the Board of Directors for final approval/disapproval. (RES-1, AM 1991) 135.992 Committee on Professional Education and Accreditation The Colorado Medical Society is the final authority for the accreditation of Colorado intrastate organizations/institutions that provide continuing medical education (CME). The Committee on Professional Education and Accreditation (CPEA) is responsible for the operation of the accreditation program. Each application for accreditation will be reviewed by the CPEA and actions of the CPEA are final, subject to appeal. The accreditation process and available types and duration of accreditation are described in the Program of Accreditation of Continuing Medical Education Policies and Procedures that are available, upon request, from the Department of Health Care Policy. (RES-1, AM 1991) 135.993 Access in Rural Communities The Colorado Medical Society supports the efforts of rural physicians to access community-based accredited programs in continuing medical education. (RES-1, AM 1991) 135.994 Liaisons With Other Organizations The Colorado Medical Society (CMS) maintains liaison on educational matters with organizations local, state and national that are concerned with continuing medical education. The CMS participates, when appropriate, in the educational activities of such national organizations as the American Medical Association, the Accreditation Council for Continuing Medical Education, the American Hospital Association, the Association for Hospital Medical Education, the Association of American Medical Colleges, the Alliance for Continuing Medical Education. The CMS also maintains similar relationships with such Colorado organizations as the Colorado Alliance for Continuing Medical Education, the Colorado Hospital Association, the State Departments of Education and Health, and the medical specialty societies; keeps informed concerning the medical education activities of community hospitals, component medical societies, medical groups and individuals; and works with and supports them when appropriate. (RES-1, AM 1991) 135.995 Issuance of Credit In the state of Colorado, only organizations accredited by the Colorado Medical Society and the American Council for Continuing Medical Education are accredited to extend Category 1 Continuing Medical Education credit toward the American Medical Association Physicians Recognition Award to physicians. These organizations are responsible for maintaining records regarding physician attendance and credits earned. (RES-1, AM 1991) 135.996 Educational Support Services 1. The Colorado Medical Society (CMS) provides or helps provide educational support services for physicians, as individuals or for continuing medical education programs. 2. When requested, the CMS will assist accredited and non-accredited hospitals and specialty societies to develop or improve their continuing medical education programs (CME). 3. When requested, the CMS will assist physicians who also teach in CME programs to improve their instructional techniques. 6 CMS Policy Manual September 2013 4. The CMS sponsors conferences for Colorado continuing medical educators to provide systematic opportunities for them to improve the quality of their educational programs. Participants and speakers from other states, especially adjacent states, will be invited. 5. The CMS encourages the dissemination of innovations in CME by sponsoring or supporting demonstrations of new educational techniques or technologies. (RES-1, AM 1991) 135.997 Voluntary Continuing Medical Education The Colorado Medical Society supports the concept of voluntary continuing medical education for Colorado physicians. (RES-1, AM 1991) 135.998 Medical Education in Colorado It is Colorado Medical Society (CMS) policy to accredit qualified organizations to extend American Medical Association Physicians Recognition Award Category 1 Continuing Medical Education credit to physicians in order to improve the quality of medical education in Colorado and to improve health care in Colorado through education. (RES-1, AM 1991) 135.999 Tour/Travel Continuing Medical Education The Colorado Medical Society does not sponsor, endorse, or otherwise become involved with tour/travel continuing medical education programs, whether on a profit or non-profit basis. (RES-44, AM 1987) 140 Disabled 140.999 Evaluation of Permanent Impairment The Colorado Medical Society supports adoption, by the appropriate regulatory agencies, the most recent edition of the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment. (RES-26, AM 2000) 145 Drug Abuse 145.996 Recreational Marijuana CMS does not have an opinion on the criminality of recreational marijuana use. CMS recognizes the published scientific data that recreational use of marijuana has a deleterious effect on the health of individuals and public health, particularly on the developing brains of adolescents. (RES 6-P-AM’11, AM 2012) 145.997 Physician Leadership on National Drug Policy The Colorado Medical Society (CMS) adopts and supports the consensus statement on “Physician Leadership on National Drug Policy.” The CMS supports the continual review of evidence to identify and recommend medical and public health approaches that are likely to be more cost-effective, in both human and economic terms. The CMS encourages professional organizations to endorse and implement these policies. Additional Information: Physician Leadership on National Drug Policy (RES-14, AM 1999) 145.998 Drug Abuse and Drug Testing in Youth Athletics The Colorado Medical Society (CMS) supports educational activities at the elementary school through high school level on drug abuse in athletes; the CMS supports drug testing for anabolic steroids of middle school and high school athletes in competitive sports. 7 CMS Policy Manual September 2013 (RES-39, AM 1989) 145.999 Prevention of Abuse and Diversion of Prescription Drugs The Colorado Medical Society (CMS) supports the Colorado Prescription Drug Abuse Task Force and supports its charge to prevent the diversion of abused prescription drugs from individual practitioners, pharmacies, hospitals and clinics through the provision of a statewide resource for the problem identification and program development. The CMS supports efforts to develop a data collection system which would collect, analyze and disseminate qualitative and quantitative data on controlled substances. The CMS supports the Colorado Prescription Drug Abuse Task Force activities in developing and implementing comprehensive professional standards for prescribing and dispensing of controlled substances. The CMS supports efforts to implement comprehensive professional and consumer education programs designed to prevent and remediate prescription drug abuse. The CMS supports improved coordination and communication among regulatory and enforcement agencies, practitioners and professional associations to prevent and correct prescription drug abuse. (RES-27, AM 1986) 150 Drugs: Advertising 150.998 Inappropriate Pharmacy Advertising The Colorado Medical Society (CMS) shall explore mechanisms for prohibiting the inclusion of drug advertising, including making a request the Colorado Board of Pharmacy promulgate regulations and other mechanisms to prohibit the inclusion of drug specific advertising (for a drug that was not prescribed), as part of patient education materials that are provided relating to the drug that the physician has prescribed. (RES-6, AM 2010) 150.999 Oversight of Direct-to-Consumer Advertising of Prescription Drugs The Colorado Medical Society (CMS) supports national legislation that will reduce direct to consumer (DTC) advertising and improve review and enforcement of DTC ads by requiring the Federal Drug Administration to review and approve all DTC ads before they are distributed or aired to the lay public. The CMS supports state and national legislation to direct liability concerning misleading, confusing, and deceptive information found in DTC ads to the marketing firms and pharmaceutical firms that have produced such ads. (Revised RES-20, AM 1999) 155 Drugs: Prescribing and Dispensing 155.992 Public Health and Safety Challenges of Treating Chronic Pain: The Medical Perspective The Colorado Medical Society Workers’ Compensation and Personal Injury Committee (WCPIC) were asked by the board to review current CMS policy on prescription drug abuse and make strategic recommendations for moving forward. WCPIC created the platform “Public Health and Safety Challenges of Treating Chronic Pain: The Medical Perspective,” which encompasses 31 recommendations. It was presented to and passed by the CMS House of Delegates at the 2013 Annual Meeting in September. The platform focuses on five planks: the Prescription Drug Monitoring Program (PDMP), licensing boards standardization, physician education, law enforcement, and prescription drug abuse as a public health issue. Click here to view the 31 recommendations. (BOD-1, AM 2013) 155.993 RX Data 2008 The Colorado Medical Society shall work with the Colorado Board of Pharmacy to make changes in the Electronic Monitoring of Prescription Controlled Substances law to extend access of the program to 8 CMS Policy Manual September 2013 residents and fellows with active Colorado training licenses in good standing and support a funding mechanism to sustain program longevity. (Late RES-22, AM 2008) 155.994 E-Prescribing of Controlled Substances The Colorado Medical Society (CMS) will support the ability of properly licensed physicians to prescribe controlled substance medications using E-prescribing technology. The CMS Delegation to the American Medical Association (AMA) shall bring a similar resolution to the AMA to actively pursue changes in national regulations so that this may occur. (RES-11, AM 2008) 155.995 “Off Label” Prescribing of Medication The Colorado Medical Society recognizes the therapeutic importance of “off label” prescribing of medicine which is an established, safe, and necessary strategy widely utilized by physicians in compliance with community standards of care around Colorado. (RES-34, AM 2004) 155.996 Inappropriate Use of Drug Enforcement Administration Number The Colorado Medical Society supports the position of the Drug Enforcement Administration (DEA) which strongly opposes the health insurance industry’s requirement that physicians provide their DEA registration number on all prescriptions for identification and reimbursement purposes. (RES-55, AM 1996) 155.997 Physician Dispensing of Drugs The Colorado Medical Society supports the American Medical Association’s (AMA) policy on physician dispensing which states that physicians have a “right to dispense drugs and devices when it is in the best interest of the patient and consistent with AMA’s ethical guidelines.” (Motion of the Board, February 1988) 155.998 Use of Anabolic Steroids The Colorado Medical Society (CMS) considers the prescription, recommendation, or use of anabolic steroids for the purpose of the hormonal manipulation of athletes that is intended as a performance aid for athletes to increase muscle mass, strength, or weight manipulation without a medical necessity to do so to be unethical and reason for immediate investigation by the Council on Ethical and Judicial Affairs of the CMS and prompt reporting to the Colorado Board of Medical Examiners. (RES-40, AM 1987) 155.999 Administration and Use of Prescription Drugs The Colorado Medical Society opposes relaxing the restrictions in the laws of the State of Colorado to permit anyone not now licensed to administer or use in any way a prescription drug except under the direction or supervision of one so licensed. (RES-4, AM 1976) 160 Drugs: Substitution 160.997 Substitution of Class B Generic Drugs The Colorado Medical Society (CMS) reminds its membership of the provisions of CRS 12-22-124 (2) which provides “if, in the opinion of the practitioner, it is in the best interest of his patient that an equivalent drug not be substituted”, that prescriptions may be ordered “dispense as written” by writing such orders or initialing a preprinted box to that effect. The CMS encourages its members to become informed of the equivalence problems of drugs listed as Class B in the Federal Food and Drug Administration published list of generic drugs (the Orange Book) 9 CMS Policy Manual September 2013 and encourages the cooperation of registered pharmacists with respect to filling of prescriptions through a joint committee of the CMS and the Colorado Pharmacology Association. (RES-38, AM 1990) 160.998 Generic Drug Substitution 1. In the interest of cost savings, prescriptions should be written by generic name or without prohibition of substitution whenever the physician can be confident that the generic product is theoretically equivalent to the innovator product; 2. The physician should be cautious in permitting generic substitution for any drug, in which bioequivalence problems have been documented or extensively anecdotally reported. Examples of such problems include generic substitution for dose critical drugs such as anti-convulsants, digoxin, anti-arrhythmics, L thyroxine, oral contraceptives, and certain neuroleptic drugs; 3. The physician should insist that pharmacists consult the Federal Food and Drug List (the Orange Book) before substituting generic equivalents; 4. The physician and pharmacist should take necessary steps to eliminate confusion by the patient when labels of prescriptions are changed from trade name to generic name, and when the physical appearance such as color, shape, and taste of generic substitutes vary from the originally prescribed product; 5. The pharmacist should provide a product that is coded and identifiable; and 6. Pharmacy drug substitution practices should be monitored by the appropriate Colorado State Agency, and the results of the monitor must be shared with physicians. (Motion of the Board, June 1988) 160.999 Therapeutic and Pharmaceutical Substitution by Pharmacists The Colorado Medical Society (CMS) is opposed to any concept of therapeutic substitution of drugs by pharmacists and to any legislation or regulation that would authorize them to do so. The CMS is also opposed to pharmaceutical substitution by pharmacists. (RES-45, AM 1987) 165 Emergency Medical Services 165.993 Emergency Health Information Exchange Mobile Internet “Push” Strategy The Colorado Medical Society supports a “proof-of-concept project” demonstrating that clinical data can be securely and effectively “pushed” from existing PHR/EMR* secure servers based on a digital “trigger” signal transmitted on behalf of distressed patients from a location-aware device to nearby receiving facilities via existing secure and robust technology directly from distressed patients to the nearest appropriate emergency departments or other appropriate receiving facilities. (RES-1, AM 2009) 165.994 Registry of Physician Volunteers The Board of Directors voted that Colorado Medical Society will establish a registry containing names of Colorado physicians who are willing to volunteer their services should a national emergency necessitate a need for such services. (Motion of the Board, September 2001) 165.995 Access to Emergency Services The Colorado Medical Society adopts the American Medical Association’s “Prudent Layperson” definition of an emergency as follows: health care services that are provided in a hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in: 1. Placing the patient’s health in serious jeopardy; 10 CMS Policy Manual September 2013 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. (RES-69, AM 1996) 165.996 Statewide Trauma System Development and Refinement The Colorado Medical Society supports the implementation and refinement via physician input of an integrated statewide trauma system that is fair and effective and is consistent with recognized national standards. (RES-39, AM 1993) 165.997 Continued Funding for Emergency Medical Services in Colorado The Colorado Medical Society supports: 1. The continued funding for the Emergency Medical Services (EMS) Account, 2. Continued funding of such account from the highway users tax fund, 3. The appropriation of such monies goes toward grants to emergency medical services providers pursuant to the EMS grant program, planning and coordination of county EMS services, and the development and improvement of the statewide EMS system, and 4. A portion of the funding allocated to obtain the services of an in-house medical director for the Emergency Medical Service Division. (RES-10, AM 1991) 165.998 Pre-Hospital Triage Decisions The Colorado Medical Society (CMS) believes that strict adherence to medical protocols should govern pre-hospital triage decisions, not economic circumstances of patients. Furthermore, the CMS believes that emergency medical technicians and paramedics should not make pre-hospital triage decisions based upon a patient’s insurance status. (Motion of the Board, December 1986) 165.999 Availability of Emergency Transportation at High School Sports Events The Colorado Medical Society believes that emergency transportation must be available on the scene or within five minutes from any potentially hazardous high school event and that it is necessary to have a working communication system available at the scene of the event. (Motion of the Board, January 1983) 170 Ethics 170.987 Health Care as a Fundamental Societal Obligation CMS formally recognizes that every member of society deserves an adequate level of protection from illness and avoidable pain and suffering related to health problems and that this fundamental societal obligation is derived from the sum of the diverse ethical considerations of our values of equality of opportunity, justice and compassion. (RES-3, AM 2007) 170.988 Stem Cell Research The Colorado Medical Society (CMS) supports stem cell research conducted within appropriate ethical guidelines. CMS opposes federal funding restrictions on stem cell research conducted according to ethical guidelines established by the medical community. (RES-10, AM 2006) 170.989 Code of Medical Ethics The Colorado Medical Society (CMS) House of Delegates authorizes the Council on Ethical and Judicial Affairs to recommend changes in the CMS Bylaws and/or the CMS Policy Manual to reflect adoption of 11 CMS Policy Manual September 2013 the American Medical Association Code of Medical Ethics as the CMS Code of Medical Ethics except where CMS has adopted independent opinions. (RES-17, AM 2002) 170.990 Patenting Human Genes A patent grants the holder the right, for a limited amount of time, to prevent others from commercializing his or her inventions. At the same time, the patent system is designed to foster information sharing. Full disclosure of the invention-enabling another trained in the art to replicate it-is necessary to obtain a patent. Patenting is also thought to encourage private investment into research. Arguments have been made that the patenting of human genomic material sets a troubling precedent for the ownership or commodification of human life. DNA sequences, however, are not tantamount to human life, and it is unclear where and whether qualities uniquely human are found in genetic material. Genetic research holds great potential for achieving new medical therapies. It remains unclear what role patenting will play in ensuring such development. At this time the American Medical Association Council on Ethical and Judicial Affairs concludes that granting patent protection should not hinder the goal of developing new beneficial technology and offers the following guidelines: Patents on processes-for example, processes used to isolate and purify gene sequences, genes, and proteins, or vehicles of gene therapy-do not raise the same ethical problems as patents on the substances themselves and are thus preferable. Substance patents on purified proteins present fewer ethical problems than patents on genes or DNA sequences and are thus preferable. Patent descriptions should be carefully constructed to ensure that the patent holder does not limit the use of a naturally occurring form of the substance in question. This includes patents on proteins, genes, and genetic sequences. One of the goals of genetic research is to achieve better medical treatments and technologies. Granting patent protection should not hinder this goal. Individuals or entities holding patents on genetic material should not allow patients to languish and should negotiate and structure licensing agreements in such a way as to encourage the development of better medical technology. (RES-13, AM 2002) 170.991 Gene Therapy Gene therapy involves the replacement or modification of a genetic variant to restore or enhance cellular function or to improve the reaction of non-genetic therapies. Two types of gene therapy have been identified: (1) somatic cell therapy, in which human cells other than germ cells are genetically altered, and (2) germ line therapy, in which a replacement gene is integrated into the genome of human gametes or their precursors, resulting in expression of the new gene in the patient’s offspring and subsequent generations. The fundamental difference between germ line therapy and somatic cell therapy is that germ line therapy affects the welfare of subsequent generations and may be associated with increased risk and the potential for unpredictable and irreversible results. Because of the far-reaching implications of germ line therapy, it is appropriate to limit genetic intervention to somatic cells at this time. The goal of both somatic cell and germ line therapy is to alleviate human suffering and disease by remedying disorders for which available therapies are not satisfactory. This goal should be pursued only within the ethical tradition of medicine, which gives primacy to the welfare of the patient whose safety and 12 CMS Policy Manual September 2013 well-being must be vigorously protected. To the extent possible, experience with animal studies must be sufficient to assure the effectiveness and safety of the techniques used, and the predictability of the results. Moreover, genetic manipulation generally should be utilized only for therapeutic purposes. Efforts to enhance “desirable” characteristics through the insertion of a modified or additional gene, or efforts to “improve” complex human traits “eugenic development of offspring” are contrary not only to the ethical tradition of medicine, but also to the egalitarian values of our society. Because of the potential for abuse, genetic manipulation to affect non-disease traits may never be acceptable and perhaps should never be pursued. If it is ever allowed, at least three conditions would have to be met before it could be deemed ethically acceptable: (1) there would have to be a clear and meaningful benefit to the person, (2) there would have to be no trade-off with other characteristics or traits, and (3) all citizens would have to have equal access to the genetic technology, irrespective of income or other socioeconomic characteristics. These criteria should be viewed as a minimal, not an exhaustive, test of the ethical propriety of nondisease-related genetic intervention. As genetic technology and knowledge of the human genome develop further, additional guidelines may be required. As gene therapy becomes feasible for a variety of human disorders, there are several practical factors to consider to ensure safe application of this technology in society. First, any gene therapy research should meet the Council’s guidelines on clinical investigation (Opinion 2.07) and investigators must adhere to the standards of medical practice and professional responsibility. The proposed procedure must be fully discussed with the patient and the written informed consent of the patient or the patient’s legal representative must be voluntary. Investigators must be thorough in their attempts to eliminate any unwanted viral agents from the viral vector containing the corrective gene. The potential for adverse effects of the viral delivery system must be disclosed to the patient. The effectiveness of gene therapy must evaluated fully, including the determination of the natural history of the disease and follow-up examination of subsequent generations. Gene therapy should be pursued only after the availability or effectiveness of other possible therapies is found to be insufficient. These considerations should be reviewed, as appropriate, as procedures and scientific information develop. (RES-14, AM 2002) 170.992 Human Cloning “Somatic cell nuclear transfer” is the process in which the nucleus of a somatic cell of an organism is transferred into an enucleated oocyte. “Human cloning” is the application of somatic nuclear transfer technology to the creation of a human being that shares all of its nuclear genes with the person donating the implanted nucleus. In order to clarify the many existing misconceptions about human cloning, physicians should help educate the public about the intrinsic limits of human cloning as well as the current ethical and legal protections that would prevent abuses of human cloning. These include the following: (1) Using human cloning as an approach to terminal illness or mortality is a concept based on the mistaken notion that one’s genotype largely determines one’s individuality. A clone-child created via human cloning would not be identical to his or her clone-parent. (2) Current ethical and legal standards hold that under no circumstances should human cloning occur without an individual’s permission. (3) Current ethical and legal standards hold that a human clone would be entitled to the same rights, freedoms, and protections as every other individual in society. The fact that a human clone’s nuclear genes would derive from a single individual rather than two parents would not change his or her moral standing. Physicians have an ethical obligation to consider the harms and benefits of new medical procedures and technologies. Physicians should not participate in human cloning at this time because further investigation and discussion regarding the harms and benefits of human cloning are required. Concerns include: 13 CMS Policy Manual September 2013 1. Unknown physical harms introduced by cloning. Somatic cell nuclear transfer has not yet been refined and its long-term safety has not yet been proven. The risk of producing individuals with genetic anomalies gives rise to an obligation to seek better understanding of and potential medical therapies for the unforeseen medical consequences that could stem from human cloning. 2. Psychosocial harms introduced from cloning, including violations of privacy and autonomy. Human cloning risks limiting, at least psychologically, the seemingly unlimited potential of new human beings and thus creating enormous pressures on the clone-child to live up to expectations based on the life of the clone-parent. 3. The impact of human cloning on familial and societal relations. The family unit may be altered with the introduction of cloning, and more thought is required on a societal level regarding how to construct familial relations. 4. Potential effects on the gene pool. Like other interventions that can change individuals’ reproductive patterns and the resulting genetic characteristics of a population, human cloning has the potential to be used in a eugenic or discriminatory fashion-practices that are incompatible with the ethical norms of medical practice. Moreover, human cloning could alter irreversibly the gene pool and exacerbate genetic problems that arise from deleterious genetic mutations, resulting in harms to future generations. Two potentially realistic and possibly appropriate medical uses of human cloning are for assisting individuals or couples to reproduce and for the generation of tissues when the donor is not harmed or sacrificed. Given the unresolved issues regarding cloning identified above, the medical profession should not undertake human cloning at this time and pursue alternative approaches that raise fewer ethical concerns. Because cloning technology is not limited to the United States, physicians should help establish international guidelines governing human cloning. (RES-16, AM 2002) 170.993 Genetic Testing by Employers As a result of the human genome project, physicians will be able to identify a greater number of genetic risks of disease. Among the potential uses of the tests that detect these risks will be screening of potential workers by employers. Employers may want to exclude workers with certain genetic risks from the workplace because these workers may become disabled prematurely, impose higher health care costs, or pose a risk to public safety. In addition, exposure to certain substances in the workplace may increase the likelihood that a disease will develop in the worker with a genetic risk for the disease. 1. It would generally be inappropriate to exclude workers with genetic risks of disease from the workplace because of their risk. Genetic tests alone do not have sufficient predictive value to be relied upon as a basis for excluding workers. Consequently, use of the tests would result in unfair discrimination against individuals who have positive test results. In addition, there are other ways for employers to serve their legitimate interests. Tests of a worker’s actual capacity to meet the demands of the job can be used to ensure future employability and protect the public’s safety. Routine monitoring of a worker’s exposure can be used to protect workers who have a genetic susceptibility to injury from a substance in the workplace. In addition, employees should be advised of the risks of injury to which they are being exposed. 2. There may be a role for genetic testing in the exclusion from the workplace of workers who have a genetic susceptibility to injury. At a minimum, several conditions would have to be met: a. The disease develops so rapidly that serious and irreversible injury would occur before monitoring of either the worker’s exposure to the toxic substance or the worker’s health status could be effective in preventing the harm. 14 CMS Policy Manual September 2013 b. The genetic testing is highly accurate, with sufficient sensitivity and specificity to minimize the risk of false negative and false positive test results. c. Empirical data demonstrate that the genetic abnormality results in an unusually elevated susceptibility to occupational injury. d. It would require undue cost to protect susceptible employees by lowering the level of the toxic substance in the workplace. The costs of lowering the level of the substance must be extraordinary relative to the employer’s other costs of making the product for which the toxic substance is used. Since genetic testing with exclusion of susceptible employees is the alternative to cleaning up the workplace, the cost of lowering the level of the substance must also be extraordinary relative to the costs of using genetic testing. e. Testing must not be performed without the informed consent of the employee or applicant for employment. (RES-15, AM 2002) 170.994 Euthanasia and Physician-Assisted Suicide “Euthanasia” contains the Greek words “eu” + “thanatos” (death) which means an easy death. Only the competent patient or the authentic proxy of the incompetent patient may decide what for each patient constitutes a good death. Medical interventions may be withheld or withdrawn, allowing a disease process to continue its natural course leading to death. Competent patients have a moral right to seek a good death by refusing treatment if that is their wish. Furthermore, physicians have a moral obligation to honor the wishes of their competent patients or the authentic proxy of their incompetent patients, with respect to withholding and withdrawing undesired medical interventions. “Euthanasia” has been used to describe a process in which an intervention by someone other than the patient is intended directly and immediately to bring about the death of a suffering patient at the patient’s request. However, providing treatment or medication with the intention of easing the pain of a dying patient is acceptable treatment and not euthanasia, even though such treatment or medication may foreseeably hasten the moment of death. “Suicide” describes the intentional termination of one’s own life. Refusing a treatment, which may delay the moment of death, is not suicide. However, intentionally taking a lethal dose of medication even when fatally ill would be suicide. A physician who intentionally provides a lethal dose of medication for the purpose of aiding a patient to commit suicide is assisting suicide. This differs from providing an adequate dose of medication for the purpose of pain relief, even though it may foreseeably hasten death. PHYSICIAN-ASSISTED SUICIDE 1. Physicians share with all society a duty to obey the law that currently prohibits both euthanasia and assisting suicide. 2. It is incumbent upon the medical profession to use all means to ensure that dying patients are provided optimal treatment for their pain and other discomfort. This may include the use of more aggressive comfort care measures, including greater reliance on hospice care, which can alleviate the physical and emotional suffering that dying patients experience. Evaluation and treatment by a health professional with expertise in the psychiatric aspects of terminal illness can often alleviate the suffering that leads a patient to desire assisted suicide. 3. Physicians must resist the natural tendency to withdraw physically and emotionally from their terminally ill patients. When the treatment goals for a patient in the end stages of a terminal illness shift from curative efforts to comfort care, the level of physician involvement in the patient’s care should in no way decrease. 4. Requests for physician-assisted suicide should be a signal to the physician that the patient’s needs are unmet and further evaluation to identify the elements contributing to the patient’s 15 CMS Policy Manual September 2013 suffering is necessary. Multidisciplinary intervention, including specialty consultation, pastoral care, family counseling and other modalities, should be sought as clinically indicated. 5. Further efforts to educate physicians about advanced pain management techniques, both at the undergraduate and graduate levels, are necessary to overcome any shortcomings in this area. Physicians should recognize that courts and regulatory bodies readily distinguish between use of narcotic drugs to relieve pain in dying patients and use in other situations. 6. The principle of patient autonomy requires that physicians must respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity. Life-sustaining treatment is any medical treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment includes, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics and artificial nutrition and hydration. 7. The professional and societal risks of involving physicians in medical interventions intended to cause patients’ deaths are too great to condone euthanasia or physician-assisted suicide. Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment even though it may foreseeably hasten death. More research must be pursued examining the degree to which palliative care reduces the requests for euthanasia or assisted suicide. (RES-22, AM 2000) 170.995 Grievance Reviews The Colorado Medical Society (CMS) Grievance Review Committee and all component society grievance review committees and the members of each of these committees individually and as a group are authorized by the CMS Board of Directors to conduct reviews on behalf of the CMS and its members. (Motion of the Board, February 1998) 170.996 The Physician-Patient Covenant Patient-Physician Covenant - Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to be competent and to use their competence in the patient’s best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times. Today, this covenant of trust is significantly threatened. From within, there is growing legitimation of the physician’s materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician’s responsibility degrade the physician-patient relationship that is the central element and structure of clinical care. To capitulate to these alterations of the trust relationship is to significantly alter the physician’s role as healer, care giver, helper, and advocate for the sick and for the health of all. By its traditions and very nature, medicine is a special kind of human activity-one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion, and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest. Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust. Any defection from primacy of the patient’s well being places the patient at risk by treatment that may compromise quality of or access to medical care. We believe the medical profession must reaffirm the primacy of its obligation to the patient through national, state, and local professional societies; our academic, research, and hospital organizations; and especially through personal behavior. As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available. 16 CMS Policy Manual September 2013 Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor our covenant of trust with patients. (RES-11, IM 1996) 170.997 Corporate Practice of Medicine Recognizing the legislative changes regarding the corporate practice of medicine, the Colorado Medical Society supports adherence to the following ethical and legal guidelines, which apply to any type of practice arrangement: 1. Physicians must use their best efforts and skills in the care of patients and must be ever wary of those forces in society that can erode ethical medical practice. 2. The welfare of patients lies above the financial interest of the physician or of any hiring or contracting entity. 3. Clinical decision making must remain in the hands of the physician. 4. Physicians must not deny their patients’ access to appropriate medical services based upon the promise of personal financial reward or the avoidance of financial penalties. 5. No entity that employs or contracts with physicians to provide medical care may offer these physicians any percentage of fees charged to patients for referred services provided by this entity or any other financial incentive to artificially increase services provided to patients. 6. The bylaws of any hospital which employs or contracts with community based physicians shall not discriminate with regard to credentials or staff privileges on the basis of whether a physician is an employee of, or a contracting physician with, the hospital. 7. Hospitals that employ or contract with physicians may not limit hospital-based referrals exclusively to those physicians whom they employ or with whom they contract if such a limitation on referrals compromises patient care. (RES-46, AM 1994) 170.998 Sexual Misconduct The Colorado Medical Society supports the American Medical Association Principles of Medical Ethics and the Board of Medical Examiners’ Policy regarding sexual misconduct by physicians. (Motion of the Board, July 1994) 170.999 Obligation to Report Impaired, Incompetent or Unethical Colleagues 1. Impairment a. Impairment should be reported to the hospital’s in-house impairment program, if available. If no in-house program is available, or if the type of impairment is not normally addressed by an impairment program, e.g., extreme fatigue and emotional distress, then the chief of an appropriate clinical service, the chief of staff of the hospital, or other appropriate supervisor (e.g., the chief resident) should be alerted. b. If a report cannot be made through the usual hospital channels, then a report should be made to an external impaired physician program. The local medical societies or state licensing boards typically would operate such programs. c. Physicians in office-based practices who do not have clinical privileges at an area hospital should be reported directly to an impaired physician program. d. If reporting to an individual or program that would facilitate the entrance of the impaired physician into an impaired physician program cannot be accomplished, then the impaired physician should be reported directly to the state licensing board. 2. Incompetence a. Initial reports of incompetence should be made to the appropriate clinical authority who would be empowered to assess the potential impact on patient welfare and to facilitate 17 CMS Policy Manual September 2013 remedial action, e.g., the chief resident, the chief of an appropriate clinical service, the chief of the hospital staff, or the medical director of a group medical practice. b. The individual who receives a report of incompetence should, in turn, notify the hospital peer review body where appropriate. Physicians who receive reports of incompetence have an ethical duty to critically and objectively evaluate the reported information and to assure that identified deficiencies are either remedied or further reported to the state licensing board. c. Instances of incompetence by physicians who have no hospital affiliation should be reported to the local or state medical society. d. Continued behavior that is potentially injurious to patients must further be reported to the state licensing board. e. If the incompetence is of a sufficiently serious nature as to pose an immediate threat to the health of the physician’s patients, then it should be reported directly to the state licensing board. 3. Unethical Conduct Unethical behavior (which does not fit into the category of either incompetence or impairment) should be reported in accordance with these guidelines: a. Unethical conduct that threatens patient care or welfare should be reported to the appropriate authority for a particular clinical service, i.e., the chief resident, the chief of an appropriate clinical service, or the chief of the hospital staff. b. Unethical behavior, which violates the provisions of the state licensing board, should be reported to the state licensing board. c. Unethical conduct, which violates criminal statutes, should be reported to the appropriate law enforcement authorities. d. Examples of unethical conduct which to not fall into the above three categories, or unethical conduct, which has not been addressed through other channels, should be reported to the local or state medical society. 4. Where the impairment, incompetence, or unethical behavior of a physician continues despite the initial report(s), the reporting physician should report to a higher or additional authority. To aid physicians who report inappropriate behavior of colleagues in carrying out this obligation, the person or body receiving the initial report should notify the reporting physician when appropriate action has been taken. 5. Physicians should work to assure that state laws provide immunity to those who report impaired, incompetent, or unethical colleagues. 6. In certain circumstances, an anonymous report may be the only practical method of alerting an authoritative body to a colleague’s misconduct. Anonymous reports of misconduct should receive appropriate review and confidential investigation by authorities. 7. Principles of due process must be observed in the conduct of all disciplinary matters involving physician participants at all levels. However, the confidentiality of the reporting physician should be maintained to the greatest extent possible within the constraints of due process, in order to minimize potential professional recriminations. 8. The medical profession as a whole must combat the perception that physicians are not adequately protecting the public from incompetent, impaired, or unethical physicians by better communicating its efforts and initiatives at maintaining high ethical standards and quality assurance. (RES-37, IM 1992) 18 CMS Policy Manual September 2013 175 Health Care Costs 175.996 Choosing Wisely CMS endorses the Choosing Wisely campaign as it helps address the cost containment issue and encourages more shared decision-making with patients. (BOD-1, AM 2012) 175.997 Patient Tax Deduction for Health Care Expenses The Colorado Medical Society supports making basic health care related costs for individuals, such as health insurance premiums, co-pays, deductibles and prescription costs, completely tax deductible. (RES-17, AM 2001) 175.998 Profiteering by Third Party Payers in Health Care The Colorado Medical Society supports uniform public disclosure by insurance companies and managed care organizations of specific income and expense categories, so that the amounts actually spent on health care service for subscribers relative to premium are able to be compared. (RES-34, AM 1994) 175.999 Cost Containment Programs and Intrusions from Third Party Payers The Colorado Medical Society (CMS) encourages physicians to continue to demonstrate a real measure of cost effectiveness by continuing to provide patients with honest, conscientious, up-to-date, scientific, and compassionate medical and surgical care. The CMS encourages physicians to look beyond the intrusions of third party carriers and case managers and continue to provide the type of care that is based on valid and proven medical principles. (RES-5, IM 1989) 180 Health Care Delivery 180.986 Advertising Standards ID Requirement for Individuals and Families in Providing Patient Care CMS supports state legislation on advertising standards that will: • Provide accurate representation of credentials of a health care professional when that professional is advertising their services. • Use easily understood language in describing their qualifications when advertising. • Provide verifiable evidence to statements and testimonials made in advertising. • Only use titles/initials authorized by their respective Colorado Licensing Board or Registration Act (RES-3-A/BOD-1, AM 2012) 180.987 Patient Safety The Ad Hoc Workgroup on Patient Safety and Professional Accountability, comprising physicians from numerous specialties and across the state, reiterates its endorsement of Banner Goal 5: • To pursue as a high priority and as an important component of health care reform, the re-design of patient safety systems through approaches that unify all stakeholders in health care delivery and make Colorado the safest state in the nation in which to receive medical care. Using this focus on patient safety as the foundation of our liability reform efforts, the Workgroup outlined a five-year approach for making Colorado the safest state in the country for patients that includes several initiatives. Click here to view the work plan. (LATE ADHOC-1, AM 2010) 180.988 Accountability Colorado Medical Society policy is that physicians should be held accountable only for clinical and administrative factors they can control. 19 CMS Policy Manual September 2013 It is inappropriate (and unethical) to hold physicians accountable for decisions made by others. CMS supports only those systems of accountability that appropriately align accountability with responsibility and advocate for change in systems of accountability where there is misalignment. (RES-18, AM 2007) 180.989 Store Based Clinics Colorado Medical Society supports various options for the delivery of medical care so long as they meet the quality standards of effectiveness, equity, timeliness, efficiency, patient centeredness and safety as well as increase patient access to care. Colorado Medical Society remains diligent in its opposition to delivery systems that erode the “medical home” and/or do not meet the quality standards outlined above. (RES-9, AM 2007) 180.990 Freedom of Practice in Medical Imaging The Colorado Medical Society encourage and support collaborative specialty development and review of any appropriateness criteria, practice guidelines, technical standards, and accreditation programs, particularly as Congress, federal agencies and third party payers consider their use as a condition of payment, and to use the AMA Code of Ethics as the guiding code of ethics in the development of such policy. The Colorado Medical Society actively oppose efforts by private payers, hospitals, Congress, state legislatures, and the administration to impose policies designed to control utilization and costs of medical services unless those policies can be proven to achieve cost savings and improve quality while not curtailing appropriate growth and without compromising patient access or quality of care. The Colorado Medical Society actively oppose any attempts by federal and state legislators, regulatory bodies, hospitals, private and government payers, and others to restrict reimbursement for imaging procedures based on physician specialty, and continue to support the reimbursement of imaging procedures being performed and interpreted by physicians based on the proper indications for the procedure and the qualifications and training of physicians regardless of their medical specialty. (RES-13, AM 2005) 180.991 Telephonic Communication Guidelines The Colorado Medical Society (CMS) encourages physicians to use proper and adequate written documentation of the problem(s), discussion, and treatment plan/recommendations resulting from the telephonic communication. The CMS has no opinion on the relative value of these services at this time. The CMS believes that telephone services that are reasonable, properly documented and of high quality should be billable services that merit reimbursement by patients and third parties. (RES-20, AM 2004) 180.992 Observation Care The Colorado Medical Society (CMS) will work with third party payers to establish a uniform definition of “observation care” to include the following: 1. The patient should be designated as under “observation care” if the physician’s intent for hospital stay is less than 24 hours. If the physician’s intent and expectation is for a hospital stay of greater than 24 hours, then the stay should be considered inpatient. The use of 24 hours as a threshold for observation is a guideline. It is not unusual for observation to extend a few hours beyond 24 hours or for patients to be admitted to inpatient status before 24 hours. 2. Patients classified as under “observation care” require hospital level-of-care. 3. The patient should be registered as under “observation care” after initial physician evaluation of the patient’s signs and symptoms and appropriate testing. Post day surgical patients should be 20 CMS Policy Manual September 2013 registered as under “observation care” if, after a normal recovery period, they continue to require hospital level-of-care as determined by a physician. The CMS will establish policy on “observation care” and develop model legislation to ensure that: 1. After initial approval of inpatient admission by insurers, there should be no retrospective reassignment to “observation care” status by insurers unless the original information given to insurers is incorrect. 2. Insurers should provide 60 days prior notice to providers of changes to “observation care” criteria or the application of those criteria with opportunity for comment. There should be no implementation of criteria or changes without first following these protocols. 3. Insurers’ “observation care” policies should include an administrative appeal process to deal with all utilization and technical denials within a 60 day time frame for final resolution. An expedited appeal process should be available for patients in the admission process, allowing for a decision within 24 hours. 4. Insurers and HMOs should provide clearly written educational materials on “observation care” to subscribers highlighting differences between inpatient and “observation care” benefits and patient appeal procedures (Res. 808, I-95). The CMS reaffirms that only the attending physician can change the patient’s status under the Medical Practice Act. (RES-21, AM 2004) 180.993 Electronic Communication Guidelines New communication technologies must never replace the crucial interpersonal contacts that are the very basis of the patient-physician relationship. Rather, electronic mail and other forms of Internet communication should be used to enhance such contacts. Patient-physician electronic mail is defined as computer-based communication between physicians and patients within a professional relationship, in which the physician has taken on an explicit measure of responsibility for the patient’s care. These guidelines do not address communication between physicians and consumers in which no ongoing professional relationship exists, as in an online discussion group or a public support forum. 1. For those physicians who choose to utilize e-mail for selected patient and medical practice communications, the following guidelines are adopted. Communication Guidelines: a. Establish turnaround time for messages. Exercise caution when using e-mail for urgent matters. b. Inform patient about privacy issues. c. Patients should know who besides addressee processes messages during addressee’s usual business hours and during addressee’s vacation or illness. d. Whenever possible and appropriate, physicians should retain electronic and/or paper copies of e-mail communications with patients. e. Establish types of transactions (prescription refill, appointment scheduling, etc.) and sensitivity of subject matter (HIV, mental health, etc.) permitted over e-mail. f. Instruct patients to put the category of transaction in the subject line of the message for filtering: prescription, appointment, medical advice, billing question. g. Request that patients put their name and patient identification number in the body of the message. h. Configure automatic reply to acknowledge receipt of messages. i. Send a new message to inform patient of completion of request. 21 CMS Policy Manual September 2013 j. Request that patients use auto reply feature to acknowledge reading clinician’s message. k. Develop archival and retrieval mechanisms. l. Maintain a mailing list of patients, but do not send group mailing where recipients are visible to each other. Use blind copy feature in software. m. Avoid anger, sarcasm, harsh criticism, and libelous references to third parties in messages. n. Append a standard block of text to the end of the e-mail messages to patients, which contains the physician’s full name, contact information, and reminders about security and the importance of alternative forms of communication for emergencies. o. Explain to patients that their messages should be concise. p. When e-mail messages become too lengthy or the correspondence is prolonged, notify patients to come in to discuss or call them. q. Remind patients when they do not adhere to the guidelines. r. For patients who repeatedly do not adhere to the guidelines, it is acceptable to terminate the e-mail relationship. Medicolegal and Administrative Guidelines: a. Develop a patient-clinician agreement for the informed consent for the use of e-mail. This should be discussed with and signed by the patient and documented in the medical record. Provide patients with a copy of the agreement. Agreement should contain the following: b. Terms in communication guidelines (stated above). c. Provide instructions for when and how to convert to phone calls and office visits. d. Hold harmless the health care institution for information loss due to technical failures. e. Waive encryption requirement, if any, at patient’s insistence. f. Describe security mechanisms in place including the use of a password-protected screen saver for all desktop workstations in the office, hospital, and at home. g. Never forwarding patient-identifiable information to third party without the patient’s express permission. h. Never using patient’s e-mail address in a marketing scheme. i. Not sharing professional e-mail accounts with family members. j. Not using unencrypted wireless communications with patient-identifiable information. k. Double-checking all “To” fields prior to sending messages. l. Perform at least weekly backups of e-mail onto long-term storage. Define long-term as the term applicable to paper records. m. Commit policy decisions to writing and electronic form. 2. Communicate the policies and procedures for e-mail to all patients who desire to communicate electronically. 3. Apply the policies and procedures for e-mail to facsimile communications, where appropriate. (RES-31, AM 2003) 180.994 Use of Current Knowledge in Palliative Medicine The Colorado Medical Society encourages physicians to attain and use knowledge of palliative medicine in patient care. (RES-10, AM 2000) 180.995 Termination of Physician/Patient Relationship Notification The Colorado Medical Society (CMS) encourages physicians, medical groups and other corporate entities, such as physician practice management corporations and limited liability corporations to incorporate the following or similar language in their contracts. 22 CMS Policy Manual September 2013 Termination and Patient Notice (The terms in Italics may need to be modified to conform to the terminology used in the contract) Neither party shall terminate this contract except upon at least 60 days advance written notice provided to the other party. The practice group shall make a good faith effort to provide written notice to all patients affected by the termination within 15 working days after receipt of or issuance of a notice of termination. The terminating physician shall make a good faith effort to assist the practice group in identifying those patients who require notice. The patient notification letter shall be in a form substantially similar to that provided as Appendix A to this contract, and shall be issued to patients whether the termination is with or without cause. The practice group shall bear the expense of identifying the patients to be notified and of issuing the notice. If, because of the physician’s loss of licensure to practice medicine, or for any other reason the physician abruptly ceases to provide care to patients without the advance notice required by this contract, the practice group shall nonetheless send the patient notification letter as soon as practicable. The letter may be modified as reasonably necessary to conform to the circumstances that led to the abrupt termination of the physician’s practice. Records of patient care are the property of the practice group and shall remain in the custody and control of the practice group unless the patient requests in writing that the records be forwarded to the terminating physician or elsewhere. These contract provisions shall be effective notwithstanding any non-compete clause or other language, which may be found elsewhere in this contract. Appendix A - Model Patient Notification Letter Dear patient: We regret that effective , Dr. will no longer be associated with this practice. We will be pleased to continue to meet your medical care needs at this office. However, if you prefer to continue your care with Dr. , you may contact (him) (her) at the following office location and phone number: If you wish to transfer your care to Dr. , or to another physician outside this office, please provide us a written request and we will forward your records as requested. You should, however, check with your health insurance provider to ensure that Dr. or your new physician is an eligible practitioner under your insurance plan. We are sorry for the inconvenience these events may cause you. Please contact us if we can answer any of your questions or help make this transition easier. Sincerely, (RES-11, AM 1999) 180.996 Transition of Care for Patients with Special Needs and Circumstances PREAMBLE In the process of transitioning of care from one health plan to another, at times it becomes necessary for a patient to leave an ongoing doctor-patient relationship during treatment of a chronic or protracted 23 CMS Policy Manual September 2013 medical condition and establish a relationship with a new physician. There is great value to the care of the patient in developing a process to facilitate such transfer with minimal disruption to all involved parties. The recommendations presented herein are designed to recognize the special needs of certain patients with chronic or protracted illnesses who are under the care of either a primary care or specialty care physician at the time of transition. They provide a preferred method by which the patient interacts with the two physicians at both ends of the transition and the new health plan. They provide a framework which is simple and flexible, compensates the transferring physician for the time and effort expended, gives highest priority to concern for patient satisfaction, and promotes an effective vehicle for health plans to transition potentially high cost patients into their plan. Developed through discussions between the Colorado Medical Society and the Colorado Association of Health Plans, these recommendations are presented to health plans and physicians for their voluntary adoption. RECOMMENDED ELEMENTS OF TRANSITION 1. Early Notification Typically a patient who will be changing plans involuntarily will have a time delay between the notice of change and the effective date. The patient should advise the current physician practice as soon as possible. Health plans should make available: a. A written description of the process used to facilitate transition of care, (customer service, new member nurses, etc.) b. A written description of its review process of requests to continue services with an existing, non-affiliated provider. 2. Identification of Patients with Special Needs and Circumstances Current physicians are expected to identify patients with unique needs and initiate a process to facilitate their transition to a new provider. a. Health plans should make available to those patients so requesting, names of available participating providers (primary care and specialty practices) and how to contact them to ease referral and selection. b. If requested by the patient, it is appropriate for the current physician to suggest a physician to the patient, and then begin communication with that physician. 3. Transition Planning Visit The current physician and patient should schedule a visit in the period before effective date of new plan to plan a smooth transition to the accepting physician’s practice. 4. Transfer of Patient Information The current treating physician should: a. Collect and prepare for transfer of adequate medical records to inform accepting physician of patient’s past medical history, treatment modes, medication history, pertinent diagnostic measures, current treatment plan, etc. b. Create a letter of referral summarizing pertinent historical and biographical data to facilitate accepting physician’s development of rapport with the patient and family. 5. Introductory Visit to Accepting Physician Should be arranged as soon as practical after effective date of new plan. The current treating physician should make a recommendation to the patient regarding the timeliness of scheduling the first appointment. The purpose is to begin development of relationship, ensure pertinent records are available, prescriptions are transferred if necessary and consideration of ancillary needs (durable medical equipment, etc.). 6. Physician-to-Physician Consultation It may be appropriate for former and accepting physicians to formally consult regarding patient’s unique needs. 7. Compensation 24 CMS Policy Manual September 2013 Fair and appropriate compensation should be paid promptly for each of these services by the plan in effect at the time of service. The following recommendations should also apply when a physician is separating from a health plan: 1. Physician Initiated When the physician is voluntarily leaving the plan, the physician should initiate the transition process. 2. Plan Initiated When the plan initiated disaffiliation; the health plan should initiate the transition process. (Motion of the Board, July 1996) 180.997 School-Based Health Centers The Colorado Medical Society (CMS) recognizes school-based health centers as an effective approach to reaching previously inaccessible children and adolescents with medical and mental health care needs. The CMS encourages physicians to participate in the community planning process of school-based health centers. The CMS believes that school-based health centers should, when possible, refer and coordinate care with community-based practitioners. (RES-50, AM 1994) 180.998 Encouragement of Physician Participation in Project USA The Colorado Medical Society encourages physician participation in Project USA, administered by the American Medical Association, which recruits physicians and other health care providers for short-term service at National Health Service Corps and Indian Health Service hospitals and clinics. (RES-67, AM 1994) 180.999 Vertical Divestiture in the Health Care System The Colorado Medical Society (CMS) believes that physicians and physician groups are full and equal partners in policy development in vertically integrated structures for health care delivery. The CMS believes that these structures should in no way compromise physician judgment in the provision of health care. (Revised RES-15, IM 1994) 185 Health Care System Reform 185.988 Integration of Physical and Behavioral Health Care CMS supports policy measures to facilitate the integration of physical and behavioral health care, including: • Collaboration among the departments and divisions responsible for the licensing and regulation of providers and facilities; • To ease data sharing between care providers, and with researchers, while also protecting patient privacy. CMS supports payment systems that integrate coverage of physical and behavioral health. (RES 6-P, AM 2013) 185.989 Practice Evolution Recommendations Rapid health care system evolution continues to pressure physicians as they face a myriad of connected and often conflicting issues that affect their ability to care for patients and transform their practices. Some of the more important issues include payment reform, HIT/HIE and performance assessment data 25 CMS Policy Manual September 2013 reporting programs by public and private payers. The Committee on Physician Practice Evolution (CPPE) has focused efforts over the last year on: • Ensuring that physicians thrive personally and professionally throughout their careers in an evolving health care system; • Driving health care system innovation that results in access to high quality, cost-effective care for patients and their communities; and • Improving care and demonstrating value through physician ownership, use and sharing of data. The following report of the Committee on Physician Practice Evolution (CPPE) reviews outcomes from work to date and makes the following recommendations for action: • Payment reform and performance measures/transparency programs Many physicians are struggling to care for their patients, their practices and themselves as the health care system continues to rapidly evolve. Demands to demonstrate value and control health care costs are challenging the status quo, straining relationships and opening new opportunities. Payers are increasingly utilizing physician designation programs to ascertain provider quality and efficiency. Programs are not always aligned, lack a high degree of transparency and are difficult for physicians and other stakeholders to interpret and take action. Moreover, health plans are using these programs to tier out their networks and/or experiment with alternative payment methodologies. Physicians are not well equipped to respond to these programs and position their practices for alternative and/or enhanced payments and new delivery models. Continue to execute a broad-based, outreach and education campaign that emphasizes core competencies and capabilities necessary for physician practices to survive and thrive under new payment models, delivery systems, transparency initiatives and administrative simplification. Help doctors to understand what they can expect from the health care system in the future and provide practical tools and advice to concentrate their preparation and transformation efforts. Aggressively advocate for transparency of payment and performance measure program methodologies and processes. Advocate for standardization of methodologies and measures across payer programs. • Reporting of physician data Public and private payers utilize physicians’ claims data in their profiling and transparency programs, which, as noted above, can have a direct impact on their continued participation with the payer or how they will be reimbursed. Currently physicians are prevented from effectively using the data in these reports as they are complex, difficult to understand and the format and analytic methodologies used to create them vary from one payer to the next. Additionally, the usefulness of the data contained in these reports is also limited by the lack of aggregated claims data from all sources, including Medicare and Medicaid. CMS recognizes the importance of providing performance information to physicians so that they can verify the accuracy of profiling results, especially given how the payers are utilizing this data. If there were greater standardization of the reporting format and increased transparency of the methodology used to create them, then reports could be valuable sources of information to support physicians in their decision-making. Continue to work with CIVHC to ensure that the reports developed from the All Payer Claims Database (APCD) are methodologically sound, easy to understand and use, and are datadriven tools for quality and practice improvement. CMS should also continue to work with health plans and CIVHC to determine the feasibility of using the APCD to merge the claims 26 CMS Policy Manual September 2013 history used by each of the payers and health plans into a single all-payer report, rather than the limited payer-specific data currently in use. • New Medicare Part B Contractor Many physicians experienced extensive delays in payment for Medicare claims during the last transition of Medicare Administrative Contractors (MAC). Such a disruption in cash flow can be a significant hardship on some practices. Any number of factors can contribute to processing delays when delaying with such a large conversion, Colorado is just one of the seven new states that will be under the new MAC. It is important to establish direct, open communication channels with the contractor well in advance of the effective date, and maintain an ongoing working relationship on behalf of CMS members. Monitor the transition of the Medicare Administrative Contractor for Colorado from TrailBlazer Health Enterprises to Novitas Solutions (which becomes effective November 19, 2012) and advocate for members as needed. (CPPE-1, AM 2012) 185.990 Interference in Patient Counseling CMS vigorously and actively defends the physician-patient-family relationship and actively opposes all state and/or federal efforts to interfere in the content of communication in clinical care delivery between clinicians and patients (new HOD policy CMS supports litigation that may be necessary to block the implementation of newly enacted state and/or federal laws that restrict the privacy of physician-patient-family relationships and/or that violate the First Amendment rights of physicians in their practice of the art and science of medicine (new HOD policy) CMS continues to strongly condemn any interference by government or other third parties that compromise a physician’s ability to use his or her medical judgment as to the information or treatment that is in the best interest of their patients. (RES 2-P, AM 2011) 185.991 Physician Practice Evolution Report by the Committee on Physician Practice Evolution (CPPE) - HOD 2011 Changing the way that care is reimbursed poses a number of challenges and opportunities that physicians are uniquely positioned to address. Over the last year Colorado physicians have been engaged in a broad strategy to understand, define and initiate meaningful payment and delivery system reform. While it is clear that at this time there is no one preferred payment reform by Colorado physicians, many other opportunities exist. The following report by the Committee on Physician Practice Evolution (CPPE) reviews outcomes from work to date makes the following recommendations for action: 1. Payment and delivery system reform outreach and education campaign: With or without federal health care reform, change is inevitable based on market forces and financing strategies. Colorado physicians must evolve to meet those demands. Change is going to be based on value rather than volume. CMS believes and is pursuing win/win opportunities for physicians and the patients they serve. Continue to execute a broad-based, outreach and education campaign that helps physicians understand the evolution of payment systems from those that reward volume to those that reimburse for value. Emphasize the urgency for change and specifically target education around the competencies and capabilities that physicians will need in the future in order to provide quality, safe and cost-effective care within alternative payment methodologies. 2. Physician leadership: Future payment initiates are likely to consider population health and a strong commitment to quality improvement as important aspects of payment reform. Physicians need to help guide that work. 27 CMS Policy Manual September 2013 Payment and delivery system reforms must stem from the bedside up, given the unique needs of communities across the state and the strident demands to drive down health care costs while maintaining quality. Encourage participation and drive physician leadership, both within individual practices and broader communities of care, as essential to the implementation of new payment reform models. Patients must be the focus of improved systems. Colorado Medical Society reaffirms policy 185.994 - Health Care Reform Systems of Care - as the definition of a high performing delivery system as one in which: • Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic information systems. • Patient care is coordinated among multiple providers and transitions across care settings are actively managed. • There is clear, shared accountability across the spectrum of patient care. • Providers both within and across settings have accountability to each other, review each others’ work and collaborate to reliably deliver high-quality, high-value care. • Patients have easy access to appropriate care and information; there are multiple points of entry to the system; and patients are treated with dignity, respect and responsiveness to their needs. • The system is continuously innovating and learning in order to improve the safety, quality, value and patients’ experiences of health care delivery. • Patients are supported in their ability to carry out the care plan, including actively participating in the management of their health information. 3. Target win/win opportunities: Payment reform is a complex, extremely important issue that deserves thoughtful physician participation because it is predicated on finding savings within the system. Efforts to realign the system should be taken in stages beginning with things that physicians and their care teams can control and provide benefit to other stakeholders throughout the system. Start first by focusing on payment reforms that present win/win opportunities for patients, physicians and payers. 4. All-payer approaches: Meaningful change will not occur if only one or a few payers adopt payment reforms. If payers adopt different reforms then the benefits will be lost as physicians spend their time, resources and talent on administration rather than care improvement. 5. Advocate for all-payer reforms that utilize consistent and transparent standards and methodologies to support revised payment systems. Transitional approaches and proper risk-adjustment: • Successfully realigning new systems requires time, resources and appropriate risk-adjustment. • Advocate for transitional approaches to payment reform in order to build skills and manage change. Ensure that there is appropriate risk adjustment for Colorado patient populations. 6. Seek pilots: Colorado communities are not the same and there is no one right way to implement payment reform. Seek out and support public and private pilot programs to test these system changes in multiple settings across Colorado. Encourage physicians to make necessary individual practice changes to participate in these pilots and engage with other stakeholders to build trust and affect broader payment and delivery system reforms. 7. Local, state and federal policy development: Private initiatives and public policies will continue to shape the evolving health care system. Ongoing engagement and participation by physicians in these activities is essential. 28 CMS Policy Manual September 2013 Continue work to shape local, state and federal policies on payment and delivery system reform. Remain actively engaged in the work of the Center for Improving Value in Health Care to promote payment reform that appropriately aligns compensation with both individual and system performance. 8. Leverage other work: Payment reform is necessary but not sufficient to affect the changes that must occur to the health care system. Other barriers and issues must also be addressed or else the success of potential reforms will be threatened. Advocate for changes in other areas that support payment and delivery system reform, including: • Advancing health information technology and health information exchange adoption; • Exploring value-based benefit design; • Partnering with patients and others realign incentives and expectations about costs, benefits and risks; • Pursuing anti-trust reforms; • Enhancing administrative simplification; and • Reducing defensive medicine by ensuring a stable liability climate that ensures safety and maintains appropriate accountability and transparency. (CPPE-1, AM 2011) 185.992 Joint Principles of the Patient-Centered Medical Home The Colorado Medical Society endorses the 2007 Joint Principles of the Patient-Centered Medical Home as noted below: Joint Principles of the Patient-Centered Medical Home March 2007 Introduction The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. The AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians, have developed the following joint principles to describe the characteristics of the PC-MH. Principles Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. Quality and safety are hallmarks of the medical home: • Practices advocate for their patients to support the attainment of optimal, patientcentered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the 29 CMS Policy Manual September 2013 patient’s family. • Evidence-based medicine and clinical decision-support tools guide decision making. • Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement. • Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met. • Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication. • Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model. • Patients and families participate in quality improvement activities at the practice level. Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff. Payment appropriately recognizes the added value provided to patients who have a patientcentered medical home. The payment structure should be based on the following framework: • It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit. • It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources. • It should support adoption and use of health information technology for quality improvement; • It should support provision of enhanced communication access such as secure email and telephone consultation; • It should recognize the value of physician work associated with remote monitoring of clinical data using technology. • It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits). • It should recognize case mix differences in the patient population being treated within the practice. • It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting. • It should allow for additional payments for achieving measurable and continuous quality improvements. (RES-9, AM 2010; Reaffirmed, CPPE-1, AM 2011) 185.993 Matrix Reform Plan Colorado Medical Society supports the following as an outline of a basic, universal health plan that could provide medical, mental and dental care for all Coloradans that could be implemented in the event that other reform efforts fail to achieve CMS’ strategic objectives for health care reform. The proposed plan for Colorado would: 1. Universal health care a. Include tiered public support for individuals based upon sliding scale income levels. 30 CMS Policy Manual September 2013 2. 3. 4. 5. 6. 7. 8. 9. 10. b. Provide universal access to a community rated basic benefit package, provided on a guaranteed issue basis. c. Require all individuals to have basic health insurance coverage. d. Allow consumers to purchase additional benefits above the basic package if they choose to, but everyone would have access to the basic package that is affordable. e. Allow and incentivize employers to participate voluntarily by providing coverage for employees, with discounts for health maintenance and risk reduction programs. f. Provide a basic benefit plan that would be uniform and uniformly administered across all beneficiaries and payment sources. Cost containment and improved outcomes a. Ensure open and transparent access to all data so that unwarranted variation in overuse, underuse and misuse of health care services can be identified and addressed. b. Provide physicians with actionable, relevant and trustworthy data to improve outcomes in quality and costs. c. Decrease the administrative costs associated with utilization quality management. d. Explicitly monitor and evaluate conflict of interest issues related to unwarranted variation in care. Payment reform a. Utilize incentives to encourage the provision of primary care and the delivery of care in underserved areas. b. Utilize alternative payment models to maximize transparency and value in the system. Interoperable exchange of data that is patient-centric Establish a mechanism for all stakeholders to fund and participate in the development and usage of interoperable health information systems that facilitate the delivery of patients’ care. System for addressing adverse events, accountability and compensation Utilize non-tort based system that separates compensation for medical injury from a finding of medical negligence, thus facilitating system changes to enhance patient safety. Medical education reform and financial support for students choosing health careers Place greater emphasis on primary care and training principles that highlight patient safety, comparative effectiveness, chronic care management, end of life care and outcomes improvement. Shared accountability and personal responsibility Align accountability with responsibility of all stakeholders and provide incentives for healthy behaviors. Systems of care and patient-centered medical home Support the development of systems of care, specifically patient-centered medical homes, and encourage the development of organizations that are accountable to local communities for the continuum of patient care, including outcomes, quality, service and costs. End of life guidelines a. Ensure sufficient resources are allocated for clear education on the importance of an unambiguous direction for care (advance directive, living will, provider orders for lifesustaining treatment) under a variety of scenarios. b. Enable the use of hospice care, comfort measures, and palliative care with sufficient resources supplied for guided patient / responsible party decision-making. Oversight and Governance Utilize an independent governing board, appointed by the Governor and the legislature, to oversee all aspects of the universal health care plan including: a. Creating a uniform, robust basic plan that is available to everyone and ensuring that additional coverage for non-covered benefits would be sold on a competitive basis. b. Establishing mechanism to address adverse risk selection by plan administrators. c. Requiring all data holders to provide cost and quality information to permit the delivery systems to measure and improve performance. d. Designing incentives to encourage and enforce community collaboration. e. Overseeing the mechanism to reinvest proceeds into the communities. 31 CMS Policy Manual September 2013 f. Monitoring and regulating the utilization of self-owned facilities. g. Encouraging and incentivizing the development of community-based, not-for-profit accountable care organizations. (CONG-1, AM 2009) 185.994 Health Care Reform Systems of Care Colorado Medical Society supports the following integrated set of recommendations to improve health outcomes and value in health care. The recommendations also provide an opportunity to advance health system reform efforts already underway in Colorado and provide direction for long-term change. 1. Professionalism and the care covenant CMS urges all physicians to adopt or reaffirm the following day-to-day operating philosophy relating to patient care: The patient’s needs come first and as a physician I am a member of a care team committed to meet those needs. 2. Triple Aim The Physicians’ Congress recognizes the Triple Aim, developed by of the Institute for Health Care Improvement, as a conceptual framework to integrate and reinforce the principles and criteria within the Evaluation Matrix. The Triple Aim seeks to: a. Improve the individual experience of care; b. Improve the health of the population; and c. Reduce per capita costs of care for populations. Optimizing performance on these three dimensions requires sustained, strategic effort and movement beyond individual self interest because the current system is structured to meet perhaps one or possibly two of the aims, but not all three. 3. Attributes of Systemness a. The Physicians’ Congress believes that the following list of system attributes…(is) a succinct, starting point to define success for a better performing the delivery system: b. Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic information systems. c. Patient care is coordinated among multiple providers and transitions across care settings are actively managed. d. There is clear, shared accountability across the spectrum of patient care. e. Providers both within and across settings have accountability to each other, review each others’ work and collaborate to reliably deliver high-quality, high-value care. f. Patients have easy access to appropriate care and information; there are multiple points of entry to the system; and patients are treated with dignity, respect and responsiveness to their needs. g. The system is continuously innovating and learning in order to improve the safety, quality, value and patients’ experiences of health care delivery. h. Patients are supported in their ability to carry out the care plan, including actively participating in the management of their health information. 4. Integration, coordination and organization Sustainable health care reform must be anchored at every level in the delivery system. The Physicians’ Congress believes that physicians must focus their individual and collective leadership at the microsystem level to improve health outcomes and lower costs by driving better integration, coordination and organization. Reform at this level can be divided into three categories: 1) structural changes, 2) enabling tools and 3) payment changes. 32 CMS Policy Manual September 2013 5. Reduce unwarranted variations in care - Strive to provide appropriate care for every patient every time by reducing extraneous services or treatments including: unwarranted or unnecessary procedures and consultations; inappropriate medication use; unnecessary lab and diagnostic tests; inappropriate end of life care; and potentially harmful preventive services with no plausible benefit. 6. Strong primary care-based system - Promote the development and maintenance of a strong primary care base in the health care system to provide appropriate access to quality, safe and coordinated patient care. 7. Improve coordination of care and teamwork - Develop, promote and utilize physician-to-physician and physician-to-other provider agreements (compacts), and patient activation techniques that establish minimum guidelines for communication and coaching regarding optimal patient care transitions. 8. Patient engagement a. Facilitate shared-decision making with patients by utilizing patient decision aids and advocating for policy changes to utilize informed patient decision-making models. b. Incorporate patients within the administrative and management functions throughout the care system. c. Facilitate patient management of their health information. d. Facilitate health literacy. e. Facilitate healthy behaviors. 9. Redesigned approach to end of life – a. Facilitate close coordination and partnerships between palliative care and hospice programs from diagnosis to the end stages of an illness across the continuum of care settings and living situations. b. Ensure that palliative care is provided in a culturally sensitive, appropriate, and understandable manner to facilitate the comprehension of the condition and realistic potential of treatment options. c. Ensure that palliative care is available at the same time as disease-modifying therapy in acute care, ambulatory care and community-based settings. d. Support legislative efforts that will provide adequate protections for providers for following patient wishes. (MOLST – Medical Orders for Life-Sustaining Treatment) e. Ensure that health care providers throughout the state have adequate generalist-level palliative care knowledge and have access to specialist-level palliative care expertise. 10. Accountable care organizations - Actively work to develop organizations that are accountable to local communities for the continuum of patient care, including outcomes, quality, service and costs. Key attributes of such organizations should include: a. Improving care delivery by spreading and integrating systems of care models; b. Aligning payment incentives; c. Coordinating ancillary supportive services; d. Using data to improve performance; and e. Collaborating among multiple stakeholders (payers, purchasers, patients, providers and government). 11. Outcome measurement and public reporting – a. Support the development and use of appropriate measures to document progress on patient health goals. b. Support policies that aggregate data across all payers with a sufficient level of detail to be actionable for outcomes improvement. c. Support public reporting that drives accountability and continuous improvement. 33 CMS Policy Manual September 2013 12. Health information technology/health information exchange - Use health information technology (HIT) and health information exchange (HIE) to improve health outcomes and reduce costs by: a. Presenting best evidence, consensus recommendations and prompts for both physicians and patients at the point of care; b. Collecting data on treatments, practices, outcomes, diseases, needs and performance across the spectrum of care; c. Conducting quality improvement projects; d. Improving the performance of HIT and HIE designs and processes; and e. Fostering the adoption of HIE tools in the community, as well as agreements among providers regarding appropriate data exchange. 13. Comparative effectiveness research a. Advocate for benefit design changes that use clinical information to show whether new health technologies/services are reasonable and necessary; b. Support efforts to advance the evidence base and facilitate rapid diffusion of appropriate new services, while curbing the use of unwarranted services; and c. Maintain an awareness of warranted variation to protect patients with atypical conditions or needs. 14. Value not volume - Support policies that disconnect physician incomes from volume and intensity; align physician compensation with appropriate measures and goals. 15. Develop and adopt new payment models - Promote payment reform that appropriately aligns compensation with both individual and system performance. (CONG-1, AM 2009; Reaffirmed, LATE CPPE-1, AM 2011) 185.995 A Matrix Based Reform Plan Using A Non-Profit Approach The Colorado Medical Society, through the Physicians’ Congress for Health Care Reform, shall explore and consider advocating for reform legislation using the Matrix as a template with one important addition which represents a compromise between the market based advocates and the single payer advocates – that the proposal be based on a private non-profit payer system. (Late RES-23, 2008) 185.996 Health Systems Reform Evaluation Matrix Principle I: Coverage - Health care coverage for Coloradans should be universal, continuous portable and mandatory. Principle I Section A: Universal health care coverage The new system will: • Cover all Colorado residents • Include a process to address non-residents that become ill in Colorado so that providers are fairly reimbursed for care that they are professionally obligated to provide. • Ensure the viability of the providers of care within the delivery system so that patients have access to care Principle I Section B: Continuous/portable coverage The new system will provide coverage that continues without regard to circumstance, including but not limited to, employment, health status, age, family member coverage and marital status Principle I Section C: Mandatory coverage The new system will include a mechanism to ensure that all Colorado residents participate, with the option to obtain additional benefits 34 CMS Policy Manual September 2013 Principle II: Benefits: An essential benefits package should be uniform, with the option to obtain additional benefits. Principle II Section A: Essential benefits The new system will provide comprehensive, essential health care benefits, emphasizing wellness Principle II Section B: Benefit design The new system will utilize a benefit design process that is: • Transparent – Detailing who is covered, what is covered, what is not covered, who decides what is covered, and how they decide • Participatory – Continually involving stakeholders in the design, evaluation and revision of benefits • Equitable and consistent - Reliably detailing medical benefits, the values that guide the prioritization of those benefits, and providing those benefits to all beneficiaries in a dependable and fair manner • Sensitive to value - Balancing benefits and costs in the design and ongoing assessment of covered benefits • Compassionate – Measuring and considering the health effects of benefit design decisions on vulnerable populations and those with exceptional needs Principle II Section C: Administration of benefits The new system will utilize a process to administer benefits that is: • Transparent – Providing a clear process for appeals and grievances • Participatory – Involving stakeholders in the administration of the plan • Equitable and consistent – Using standard and consistent methodologies to clinically evaluate and administer benefits • Sensitive to value – Balancing benefits and costs in administering benefits • Compassionate – Ensuring that benefits administration is patient-centered and considers the unique needs of individuals Principle III: Delivery System – The system must ensure choice of physician and preserve patient/physician relationships. The system must focus on providing care that is safe, timely, efficient, effective, patient-centered and equitable. Principle III Section A: Cost effectiveness 1. Physician performance measurement: o The new system will include data systems that permit physicians to compare their performance: o Against best research evidence and cost effectiveness o With their peers o The new system will provide an accurate mechanism for physicians to measure their performance on: o Quality o Cost o The new system will utilize standards for performance measurement that promote continuous quality improvement o The new system will include interoperable data systems 2. Data systems accuracy 35 CMS Policy Manual September 2013 o The new system will utilize: o Data systems that include transparency of all clinical guidelines o Data system performance measurement methodologies o Processes for physicians that include reasonable notice of performance measurement, appeals processes and chart reviews o Legal protections against misrepresentation of a physician’s practice 3. Public reporting of provider performance: o The new system will utilize a system for measurement and public access to accurate, meaningful and constructive measures of provider performance o The new system will specify that the systems for determining what will be measured and reported will be: o Collaboratively designed (i.e, involve providers, consumers and purchasers) o Publicly accountable o Use a multidimensional approach to quality reporting o Require disclaimers regarding limitations on performance measures 4. Acute and long-term care services and support: o The new system will utilize active care management principles and clinical strategies to meet the needs of high risk/high cost populations 5. End of life care o The new system will utilize a process to develop consensus decisions, based upon best scientific evidence, about clinically, ethically and culturally appropriate end of life care 6. Price transparency o The new system will utilize price transparency provisions that make pricing information meaningful and relevant to patients and purchasers, to enable more informed decision-making Principle III Section B: Quality improvement 1. Guidelines and quality measures a. The new system will require use of nationally-based, clinical care guidelines and quality measures, that are vetted and uniformly adopted through a Colorado-based process when possible 2. Information exchange a. The new system will: o Utilize an interoperable electronic health information network that will enable Colorado’s physicians, hospitals, patients and public health professionals to share and have secure access to vital health information when and where they need it o Permit its aggregated claims, clinical and quality data to be transferred into an aggregated data system for purposes of performance measurement and quality improvement 3. Medical home a. The new system will establish a personal medical home for patients that can provide organized, coordinated and continuous care that can be integrated across specialties and delivery systems 4. Practice redesign and health information technology (HIT) a. The new system will: o Enable Colorado physicians to utilize health information technology o Encourage technology and practice redesign support programs 36 CMS Policy Manual September 2013 Principle III Section C: Patient safety 1. “Blame-free” reporting a. The new system will authorize a mechanism for “blame-free” reporting of medical errors that fosters continued improvement of error reduction b. If a mechanism for “blame-free” reporting is created, then the new system will still protect the rights of patients 2. Patient safety a. The new system will address systems of patient safety across all patient care venues including physician practices by promoting strategies that address: o Medication monitoring and risk assessment o Patient transitions and handoffs o Procedure safety o Training of personnel o Workflow design o Patient education and communication 3. Liability climate a. The new system will preserve and promote stability in Colorado’s professional liability climate Principle III Section D: Regulatory oversight 1. Adequacy of regulatory powers a. The new system will establish adequate legal frameworks and enforcement tools that are uniformly applied 2. Adequacy of regulatory tools a. The new system will establish adequate regulatory infrastructures that maintains balance and fairness among stakeholders Principle IV: Governance and Administration - The system must be simple, transparent, accountable, efficient and effective in order to reduce administrative costs and maximize funding for patient care. The system should be overseen by a governing body that includes regulatory agencies, payers, consumers, and caregivers and is accountable to the citizens. Principle IV Section A: Administration 1. Structure a. The new system will be: o Simple – Utilizing systems that are easy to navigate and that clearly specify how conflicts will be resolved o Transparent – Enabling easily accessible participation in policy development and public reporting of change, administrative actions and financial matters o Accountable to citizens – Utilizing systems to evaluate its performance and instituting meaningful consequences for system inadequacies 2. Reducing administrative costs a. The new system will focus on cost effective administrative management by: o Providing mechanisms for stakeholder input to improve administrative efficiencies 37 CMS Policy Manual September 2013 o Demonstrating reduction of costs associated with implementing and maintaining the administrative structure 3. Public reporting of expenses a. The new system will monitor and publicly report administrative expenses using generally acceptable accounting principles with defined timelines and budgets 4. Patient care outcomes a. The new system will utilize an administrative system that monitors and reports on the effectiveness of patient care outcomes by: o Measuring and reporting on achievable health improvement goals o Establishing timelines for statewide electronic interoperability o Establishing a process that allows the system to responsibly address medical advances in biotechnology o Establishing a process that identifies and addresses gaps in access, delivery and quality in a timely fashion o Supporting a mechanism of aggregating data for quality improvement that is sensitive to vulnerable populations o Demonstrating achievement of best practice standards at the individual and system level Principle IV Section B: Governance 1. Governance a. The new system will be overseen by a single governing body that is accountable to citizens with regionally/stakeholder appropriate representation that has specified methods to manage conflicts of interest Principle V: Financing – Health care coverage should be equitable, affordable and sustainable. The financing strategy should strive for simplicity, transparency and efficiency. It should emphasize personal responsibility as well as societal obligations, due to the limited nature and resources available for health care. Principle V Section A: Financing 1. Equitable, affordable and sustainable financing a. The new system will be: o Equitable – Providing all Coloradans with access to the essential benefits package and ensuring that definable subpopulations of Coloradans are not disadvantaged in their ability to access those benefits o Affordable– Constantly balancing the needs of individuals with the resources of the community o Sustainable – Sustaining and improving current and emerging physician practice types 2. Simple, transparent and efficient financing a. The new system will utilize a simple and transparent financing mechanism that drives down administrative expenses and reinvests savings back into the system 3. Emphasizes personal and societal responsibility and encourages sound stewardship a. The new system will establish a fair and equitable mechanism for shared accountability of health care resources by: o Establishing funding and payment that aligns incentives to achieve a healthy community o Preserving and promoting the provision of quality of health care 38 CMS Policy Manual September 2013 o Demonstrating a commitment to sustaining the health care workforce (CONG-1, AM 2007) 185.997 Individually Selected and Individually Owned Health Insurance As was originally envisioned by the Colorado Medical Society (CMS) (see original concept paper approved September 1996), the CMS supports the following American Medical Association (AMA) policies on individual health insurance (AMA H-165.920, excerpted portions). The CMS supports the principle of the individual’s right to select his/her health insurance plan and actively supports the concept of individually selected and individually owned health insurance. The CMS supports individually selected and individually owned health insurance as the preferred method of people to obtain health insurance coverage. The CMS advocates a system where individually purchased and owned health expense coverage is the preferred option, but employer-provided coverage is still available to the extent the market demands it. The CMS supports the individual’s right to select his/her health insurance plan and to receive the same tax treatment for individually purchased coverage, for contributions toward employer-provided coverage, and for completely employer provided coverage; equal tax treatment for the costs of health insurance is necessary, whether that coverage is purchased fully by individuals, partially by employers or fully by employers. The CMS supports and promotes efforts to establish and use medical savings accounts (MSAs). The tax-free use of such accounts for health care expenses, including health and longterm care insurance premiums and other costs of long-term care, are an integral component of CMS efforts to achieve universal coverage and universal access. The CMS continues to place a high priority on enactment of federal legislation to expand opportunities for employees and others to individually own health insurance through vehicles such as medical savings accounts. Additional Information: Individually Selected and Individually Owned Health Insurance System (Motion of the Board, September 1996 • Amended March 2004) 185.998 Health System Reform The Colorado Medical Society (CMS) believes that a universal health insurance proposal is needed that would provide coverage for all Coloradans. The goal of health system reform must be to allow Coloradans access to the most appropriate site of care. The CMS recognizes the complexity of developing and implementing such a proposal. It is imperative that the medical profession participates in the health system reform process as it evolves. The CMS views the following issues as the top priorities within health system reform: • Providing universal coverage and universal access; • Basic benefit package; • Preserving patient and physician relationships and choice; • Stewardship of health care resources and funding; • Administration; • Protecting and improving quality of care; and • Cost containment. 1. Universal Coverage and Universal Access The CMS supports the concepts of universal health insurance coverage and universal access. All Colorado residents must have health insurance coverage of their appropriate health care costs regardless of their health or employment status. Ensuring universal coverage advances the goal of universal access to affordable, quality health care for all Coloradans. The CMS believes that a universal coverage system should fairly spread risk across all populations. Any universal coverage system must necessarily define the term resident. Once a precise definition is created then coverage should be extended to all residents, regardless of whether they seek the benefit or not. The CMS supports policies regarding residency requirements that discourage people from moving to Colorado specifically to obtain health care coverage. A combination of public and 39 CMS Policy Manual September 2013 private cost sharing should be used to cover people ineligible for coverage due to residency requirements. 2. Portability of Health Insurance Coverage The CMS supports portability of health insurance coverage as an individual’s life situation changes. Continuity of coverage enables continuity of care. 3. Elimination of Pre-existing Condition Limitations The CMS supports the elimination of pre-existing condition limitations. Individuals with chronic or other medical conditions must be able to secure and keep private coverage. The elimination of pre-existing limitations must be done cautiously to maintain the affordability of health insurance coverage. 4. Community Rating The CMS supports the intent of community rating which is to spread the cost of illness or injury evenly over all subscribers to an insurance plan, rather than charging the sick or injured more than the healthy for insurance. The CMS opposes experience rating and rate banding. 5. Basic Benefit Package The CMS believes that all Coloradans should have a basic health insurance benefit package. The CMS believes that a common set of mandated minimum health insurance benefits is necessary for all self-funded and fully insured plans. This basic benefit package requirement should be applied nationally in order to prevent the administrative inefficiencies that result from various state and federal mandated benefits. The CMS supports physician and citizen involvement in the development of a basic set of minimum benefits. Coverage for preventive medicine should be emphasized and included in a basic set of minimum benefits. Among other covered services, a basic benefit package should also include access to inpatient and outpatient care, emergency care and prescription drugs. 6. Multi-Tier Health Insurance System The CMS supports the concept of a multi-tier health insurance system. Such a system should provide for a basic benefit package for all Coloradans, with an option for individuals to purchase, with their own funds, additional benefits and health care services. 7. Preserving Patient and Physician Relationships and Choice The CMS supports the individual patient’s freedom of choice to select his or her own physician and to pursue services that meet his or her health care needs. A patient’s freedom to choose their physician through their health plan should include the ability of patients to select both primary care and specialty physicians. If the physician is not in that specific health plan, access to that physician should be permitted through a point of service option. The CMS supports a physician’s ability to choose to apply to any managed care plan. The CMS recognizes a health plan’s right to set standards for entry into or continuation in their provider panels. Based on those standards, they are entitled to select with whom they will or will not contract. The CMS believes that these standards must be made public and available to physicians prior to applying for membership on a panel. Physicians who are denied access into a panel or terminated from it must have the right to an appeal process. 8. Pluralistic Delivery System The CMS supports a pluralistic delivery system. Decision-making for type of health care delivery system and selection of personal physician must rest in the hands of the patient. Accordingly, the patient should be allowed to choose the financing arrangements for payment of health services, including levels of insurance beyond the basic benefit package, that best meet their personal needs. The CMS promotes competition within such a system and encourages government action to apply the same rules of competition to all competitors, including self insured and fully insured carriers. 9. Health Care Budgets 40 CMS Policy Manual September 2013 The CMS supports a budgeting system for health care that promotes fiscal responsibility. The CMS supports research into health care expenditures to better define where money is spent, by whom and why. The CMS also believes that input from the medical profession is essential in the development of an adequate budget. 10. Stewardship of Health Care Resources The CMS recognizes the finite nature of health care resources; adherence to a health care budget may require the limitation of certain kinds of health care. True cost effective care must be emphasized. The CMS supports dialogue amongst all segments of society regarding the complex and controversial bioethical and socioeconomic issue that must be addressed in any health system reform plan. The CMS believes that it is society’s role to make choices regarding the limitation of certain kinds of health care. The CMS encourages the prioritization of health care services. The CMS encourages physicians to continue to treat their patients as individuals and to use their best professional judgment in every case, and to practice in accordance with the highest ethical standards. The CMS believes that the primary role of an individual physician must be to advocate for the health and well being of his or her patients. In addition, physicians and physician groups must advocate for the public’s health and well being, while being conscientious stewards of health care resources. 11. Funding Universal Health Insurance The CMS believes that funding for a universal coverage plan should be provided through a public sector/private sector partnership that builds upon the strengths of the existing system. While the CMS supports moving away from an employment based health care system toward increased patient responsibility for the cost of health care services, the CMS also promotes compromise and flexibility to achieve universal coverage. The CMS supports the shared responsibility of employers, individuals and government in paying for health care coverage. Sufficient assistance must be provided to low-income or unemployed individuals and families to ensure a basic level of coverage. The CMS believes that it is necessary to conduct research on both the intended and unintended costs of a universal health insurance proposal in order to ensure adequate and appropriate funding. The CMS believes that evaluation of the taxes necessary to fund a universal coverage proposal must be conducted at the time the proposal is developed. Issues to consider when assessing the merits of a proposal include kind of tax, level of tax and implementation timelines for a tax. The CMS supports placing extra taxes on alcohol and tobacco to help offset the cost of a universal coverage program. The CMS opposes the use of provider taxes to fund a universal health insurance plan. 12. Reimbursement and Multi-Payer System The CMS supports equitable and uniform resource-based relative value fee schedules for reimbursement by all payers. The CMS supports comprehensive health care reform that may include consideration of a multi-payer system, a single payer system and all other options. 13. Administration of Universal Coverage The CMS supports proposals that make the health care system simpler, less costly and more efficient. The CMS maintains that it is imperative to maximize administrative cost efficiencies and to simplify administrative functions within any health system reform or universal coverage proposal in order to allow more time and resources to be devoted to patient care. The CMS believes that administrative costs must be made reasonable. The CMS supports the implementation of a universal claim form. The CMS supports the implementation of a single procedural coding system by all third-party payers. The CMS believes that utilization controls should be uniform and periodically evaluated for demonstrated effectiveness and disclosed to patients and physicians. The CMS encourages the purchase of optional, supplemental coverage from the same insurance company that the basic package (see section on basic benefits) was purchased from in order to increase administrative simplification. 14. Protecting and Improving Quality of Care 41 CMS Policy Manual September 2013 The CMS believes that the assurance and improvement of health care quality are essential components of any potential health care system reform or universal coverage plan. The CMS supports quality medical care that is based upon the best evidence or clinical consensus at the time. The CMS believes that health care quality programs should be fair, objective and based upon the principles of continuous quality improvement and outcomes research. The CMS encourages the use of educational feedback as the primary motivating force driving the improvement process. This education should be directed to providers, consumers, health plans and policymakers as each will require access to objective data in order to improve performance and make wise decisions. The CMS encourages rigorous assessment of the accuracy and meaningfulness of data that is used to measure quality. Provider utilization and quality data must be properly interpreted so as not to present inaccurate or misleading information. The CMS maintains that quality programs should measure and compare the effectiveness and efficiency not only of physicians, but also of all providers of care and of health plans. The CMS supports the concept of health plans sharing information on physician performance with practitioners in order to enhance and modify practice patterns through education. The CMS believes that quality programs should have the direct involvement and guidance of practicing physicians in their communities and should not be controlled solely from a regional perspective. The CMS supports the use of clinical performance guidelines that are comprehensive, thoughtful and accepted by the practicing physician community to help guide the improvement process. The CMS believes that practicing physicians must be instrumental in their development. Guidelines must be strong enough to be evidence of appropriate practice in defense of threatened professional liability, yet flexible enough to allow for variations that are appropriate in caring for patients with individual needs. 15. Cost Containment The CMS supports and encourages the use of preventive care as a primary means of containing costs. The CMS believes that physician and patient education is an important component of cost containment. The CMS supports and encourages education of patients, providers and payers regarding appropriate and adequate health care cost containment strategies; individuals must become more sensitive to the actual cost of health care. The CMS believes that in order to contain costs it is essential to simplify the health care delivery system through reduction of paperwork and government regulation, and standardization of third party payer requirements, claims procedures, review practices and disclosure policies. The CMS believes that the costs of health care services should be made as transparent as possible in order to enable more informed decision-making. The CMS encourages both physicians and patients to make cost-conscious decisions. The CMS supports health care cost containment through free market competition and voluntary efforts. The CMS opposes the use of administrative delay or other inconvenience of the patient or physician as an appropriate cost containment technique. The CMS recognizes the impact that medical malpractice liability insurance has on the rising cost of health care. The CMS supports current Colorado malpractice tort laws. Furthermore, the CMS supports the prevention of costly, inappropriate defensive medicine by exploring other dispute resolution procedures in order to avoid the tort system. The CMS believes that appropriate incentives must be built into any health care system that encourage physicians to provide appropriate care and patients to seek appropriate care. The CMS believes that cost savings can be realized by educating physicians on appropriate choice of procedures, prescribing habits for pharmaceuticals, durable medical equipment and like issues. The CMS similarly believes that education of patients regarding healthy lifestyle choices can also generate savings. The CMS encourages health education of the public that includes information on the hazards of substances known to be harmful to public health. The CMS promotes programs to eliminate smoking, discourage alcohol and drug abuse, reduce cholesterol, encourage better adolescent health, and other similar programs that are all aimed at improving health and reducing costs of health care. The CMS encourages collaboration and cooperation among health care providers in order to contain costs by addressing excess capacity within the health care system. (Motion of the Board, March 2004, Amended, AM 2005) 42 CMS Policy Manual September 2013 185.999 Principles for Care of the Medically Indigent The Colorado Medical Society (CMS) acknowledges the important, active leadership role it must play in partnership with other public and private providers, employers, health insurers, community leaders and the residents of Colorado to meet the health needs of indigent Coloradans. The CMS believes that Colorado can reach its full potential only if the residents of the state are healthy. In seeking solutions to the problems of the underserved CMS is guided by the following core values: 1. Coverage for all Coloradans; 2. Choice of physicians, other providers and health insurance plans; 3. Decrease administrative costs; 4. Continuous quality improvement; 5. Emphasis on prevention; 6. Portability of coverage; 7. Cost containment; and 8. Personal responsibility. The CMS supports both comprehensive and incremental efforts that will reduce the number of uninsured in Colorado and ultimately provide access to affordable, quality health care and preventive programs for all Coloradans. The following general principles guide CMS action: 1. Develop a Colorado-specific solution that takes into account Coloradans’ core values and preferences; 2. Develop a plan for all Coloradans that ensures that everyone has access to quality, affordable coverage; 3. Push for substantial incremental reforms that further the vision of health care for all rather than trying to reform the whole system all at once or making marginal reforms only; 4. Develop plans that cross partisan and ideological boundaries; 5. Put priority on getting coverage for low-income uninsured, especially pregnant women and children, who don’t have access to affordable coverage; 6. Build on and improve existing insurance programs, but do not disrupt arrangements that are working well; 7. Maximize cost-effective use of limited dollars and leverage new and existing funds to the extent possible; 8. The public health sector, including community health centers and county health departments, as well as the private sector, have a role in meeting the needs of the medically indigent population in Colorado. The private sector, if not directly involved in care giving, should indirectly provide services through the funding of medically indigent programs; and 9. Financing for programs to reduce the number of uninsured should include but not be limited to taxes on cigarettes and alcohol, tax credits for businesses and general fund revenue. (Motion of the Board, March 2004) 190 Health Education 190.997 Character-based Sex Education in Schools The Colorado Medical Society supports the current Colorado Statute on comprehensive health education, which states that “any curriculum and materials developed and used in teaching sexuality and human reproduction shall include values and responsibility and shall emphasize abstinence to school aged children,” as well as teaching “safe sex.” (Substitute RES-28, IM 1996) 43 CMS Policy Manual September 2013 190.998 Journal Exchange The Colorado Medical Society (CMS) will keep the journal exchange, with journals mailed to CMS and then reposited with Denver Medical Library. (Motion of the Board, April 1982) 190.999 Medical Library The Colorado Medical Society (CMS) will use the Denver Medical Library as now structured and not establish a CMS library. (Motion of the Board, April 1982) 195 Health Insurance 195.999 Informed Consent for Insurance Subscribers The Colorado Medical Society supports the requirement that insurance companies and agents obtain informed consent from each subscriber detailing how their insurance plan is likely to impact or restrict their health care needs. (RES-22, IM 2004) 200 Health Insurance Benefits and Coverage 200.997 Consumer Comparative Data The Colorado Medical Society supports the development of state and federal legislation to require disclosure in a clear and concise standard format by health benefit plans to prospective enrollees of information on: 1. Coverage provisions, benefits and exclusions. 2. Prior authorization or other review requirements, including claims review, which may affect the provision or coverage of services. 3. Plan financial arrangements or contractual provisions that would limit the services offered, restrict referral or treatment options, or negatively affect the physician’s fiduciary responsibility to his or her patient. 4. Medical expense ratios. 5. Cost of health insurance policy premiums. (RES-62, AM 1996) 200.998 Insurance Aspects of Comprehensive Pediatric Care The Colorado Medical Society believes that all third party plans for delivery of medical services to infants and children should be comprehensive in nature. (RES-39, AM 1987) 200.999 Reimbursement for Voluntary Home Treatment of Terminally Ill The Colorado Medical Society believes that all medical charges and costs incurred by individuals electing to remain at home for the period of medical treatment required in the case of a terminal illness be designated as reimbursable by third party insurers, including Medicare, to encourage alternative, less costly treatment settings. (RES-15, AM 1980) 205 Health Planning 205.995 Physician Signature on Cardiopulmonary Resuscitation (CPR) Directives Colorado Medical Society supports informed patient autonomy and supports the removal of the statutory mandate of the physician’s signature on the CPR directive; 44 CMS Policy Manual September 2013 • CMS supports using an appropriate document that is properly and legally executed by the patient in order to carry out patient CPR Directives. (RES-7-A, AM 2007) 205.996 Withholding or Withdrawing Life Sustaining Medical Treatment The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the preferences of the patient should prevail. The principle of patient autonomy requires that physicians respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity. Life-sustaining treatment is any treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment may include, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration. There is no ethical distinction between withdrawing and withholding life-sustaining treatment. A competent, adult patient may, in advance, formulate and provide a valid consent to the withholding or withdrawal of life-support systems in the event that injury or illness renders that individual incompetent to make such a decision. A patient may also appoint a surrogate decision maker in accordance with state law. If the patient receiving life-sustaining treatment is incompetent, a surrogate decision maker should be identified. Without an advance directive that designates a proxy, the patient’s family should become the surrogate decision maker. Family includes persons with whom the patient is closely associated. In the case when there is no person closely associated with the patient, but there are persons who both care about the patient and have sufficient relevant knowledge of the patient, such persons may be appropriate surrogates. Physicians should provide all relevant medical information and explain to surrogate decision makers that decisions regarding withholding or withdrawing life-sustaining treatment should be based on substituted judgment (what the patient would have decided) when there is evidence of the patient’s preferences and values. In making a substituted judgment, decision makers may consider the patient’s advance directive (if any); the patient’s values about life and the way it should be lived; and the patient’s attitudes towards sickness, suffering, medical procedures, and death. If there is not adequate evidence of the incompetent patient’s preferences and values, the decision should be based on the best interests of the patient (what outcome would most likely promote the patient’s well-being). Though the surrogate’s decision for the incompetent patient should almost always be accepted by the physician, there are four situations that may require either institutional or judicial review and/or intervention in the decision-making process: 1. There is no available family member willing to be the patient’s surrogate decision maker; 2. There is a dispute among family members and there is no decision maker designated in an advance directive; 3. A health care provider believes that the family’s decision is clearly not what the patient would have decided if competent; and 4. A health care provider believes that the decision is not a decision that could reasonably be judged to be in the patient’s best interests. When there are disputes among family members or between family and health care providers, the use of ethics committees specifically designed to facilitate sound decision-making is recommended before resorting to the courts. When a permanently unconscious patient was never competent or had not left any evidence of previous preferences or values, since there is no objective way to ascertain the best interests of the patient, the surrogate’s decision should not be challenged as long as the decision is based on the decision maker’s true concern for what would be best for the patient. Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment even though it may foreseeably hasten death. Even if the patient is not terminally ill or permanently unconscious, it is not unethical to discontinue all means of lifesustaining medical treatment in accordance with a proper substituted judgment or best interests analysis. (CEJA Progress Report, AM 2007) 45 CMS Policy Manual September 2013 205.997 Care of Dying Patients Definitions • People are considered dying patients when they have a progressive illness that is expected to 1 end in death and for which there is no treatment that can substantially alter the outcome. • Comfort care includes relief of pain, relief of other symptoms, attention to psychological and spiritual needs, and support for the dying patient and his/her family. Patient Care Issues • Physicians should respect the autonomous decision making of the dying patient. • The dying patient and the family may benefit from other support personnel • Dying patients may need relief of symptoms with pharmacological and non-pharmacological means. Health Care Delivery Issues • Dying patients should have access to comfort care at home. • Reimbursement policies should not favor life-prolonging interventions (e.g., ventilators, dialysis, etc.) over comfort care. • Administrative rules need to encourage and not bar comfort care for dying patients. Education Issues • Research should be funded to improve comfort care for dying patients. • Health professionals need regular education in the optimum care of dying patients. • Health professionals need to develop guidelines for care of the dying patient. • The public needs education about the availability of comfort care as an alternative for the dying patient. Advanced Directives • The public needs to understand advanced directives. • Advanced directives need to be adequate. • It would be appropriate for all physicians to encourage patients to execute advanced directives. 1 The Care of Dying Patients: A Position Statement from the American Geriatrics Society JAGS 43:577578. (RES-12, IM 1996) 205.998 Nursing Home Resident Destination Issues The Colorado Medical Society believes that nursing home residents’ rights and autonomy regarding transport to their designated hospital ought to be honored as often as possible, when specified as part of an advanced medical directive. (RES-40, AM 1993) 205.999 Patient Wishes Regarding Medical Treatment The Colorado Medical Society supports and encourages frequent and forthright discussions between the patient, the family, the physician, and others providing medical care, concerning the patient’s wishes regarding the goal and extent of medical treatment. These discussions are particularly encouraged prior to occurrences which mark a potentially significant change in social or medical circumstances, such as admission to a hospital or long term care facility, the recognition of a significant health condition, the use of general anesthesia, pregnancy, as well as on a regular basis. (RES-14, AM 1986) 46 CMS Policy Manual September 2013 210 Hospital Medical Staff 210.990 Privileges Colorado Medical Society (CMS) supports the granting of privileges to physicians by Colorado hospitals and managed care organizations as stated below: The CMS believes that: 1. Individual character, training, competence, experience and judgment should be the criteria for granting privileges in hospitals. 2. Physicians representing several specialties can and should be permitted to perform the same procedures if they meet these criteria. (RES-31, AM 1996) 210.991 Standardization of Credentialing Forms The Colorado Medical Society supports the development of a statewide standard credentialing form to be used by entities that credential physicians such as managed care organizations, hospitals, medical malpractice carriers, etc. (RES-56, AM 1994) 210.992 Physician Profile and the Prospective Payment System Colorado Medical Society supports ensuring that hospital evaluation of physician performance resulting from Diagnostic Related Group physician profiling will be through an appropriate committee of the hospital medical staff which will have access to the raw data and will participate in the development of the data system. (RES-HMS-5, AM 1984) 210.993 Bylaws The Colorado Medical Society supports the following: 1. The medical staff bylaws, rules and regulations shall be initiated and adopted by the medical staff and shall establish a framework for self-government; 2. The medical staff shall govern itself by these bylaws, rules and regulations which shall: a. be reviewed and revised as necessary to reflect current medical staff practices; b. define the Executive Committee of the medical staff whose members are selected in accordance with criteria and standards established by the medical staff; and 3. The medical staff shall have authority to approve or disapprove all amendments to medical staff bylaws, rules and regulations. (RES-HMS-9, AM 1984) 210.994 Self-Government The Colorado Medical Society supports hospital governing board bylaws that do not contain provisions whereby the hospital corporate board or administration could unilaterally amend the medical staff bylaws, or its rules and regulations. (RES-HMS-7, AM 1984) 210.995 Definition The Colorado Medical Society (CMS) supports the Colorado Department of Health definition of Medical Staff as “...those physicians and dentists granted the privilege by the governing authority of a licensed facility to practice medicine or dentistry therein...” and the definition of physician in Colorado statute as “...a doctor of medicine or doctor of osteopathy duly licensed in the State of Colorado...”. The CMS opposes any attempts to include other care practitioners in these definitions. (AM 1984) 47 CMS Policy Manual September 2013 210.996 Legal Counsel The Colorado Medical Society encourages hospital medical staffs to secure their own legal counsel separate and apart from the hospital administration. (RES-22, IM 1984) 210.997 Self-Governing Medical Staff Hospital medical staff shall have sole authority to select and remove their own officers, set standards for medical staff/patient care and recommend clinical privileges. These principles should be incorporated into model hospital medical staff bylaws. (RES-21, IM 1984) 210.998 Renewal of Staff Reappointments Utilization of hospital resources by members of the hospital medical staff should not be the sole consideration in staff reappointment and renewal of staff privileges, but rather be considered in conjunction with professional performance and in performance of their role as patient advocate, and hospital medical staff bylaws should include these criteria. (RES-20, IM 1984) 210.999 Participation in Decision Making Hospital administrations should seek medical staff participation in hospital decisions regarding marketing and advertising. Additionally, the medical staff should actively seek participation in hospital decisions regarding marketing. The intent of this bilateral involvement is to prevent presentation to the public of medical misinformation. (RES-19, IM 1984) 215 Hospitals 215.999 Status and Disbursement of Profits The Colorado Medical Society supports the concept that all health plans and hospitals be required to be not-for-profit and provide adequate and sensible remuneration to their administrative personnel and their capital requirements. All assets over and above the mentioned monetary requirements be actuarially returned to the patients (payers of premiums) and providers both in lower or sensible premiums and adequate and sensible provider reimbursements. Monetary consideration should always be secondary to excellent and sensible patient care. (RES-22, AM 1999) 220 Legal Medicine 220.998 Position Paper: Expert Witness The Colorado Medical Society considers the tactics by some attorneys in demanding production of information not related to the independent medical examination (IME) itself, as inappropriate, burdensome and harassing. Following is a list of items considered inappropriate and may be considered a violation of Health Insurance Portability and Accountability Act (HIPAA) if releases are not obtained: • Tax records • Patient claim or chart information not related to this specific case • Specific names of previous IME patients • Specific names of businesses and insurance companies with whom the physician has formed a business relationship Note: The Physician has an ethical responsibility to disclose relationships that may result in a conflict of interest. The Colorado Bar Association, the Plaintiff’s Bar and others should condemn these tactics. 48 CMS Policy Manual September 2013 Following is a list of information that may be requested and is considered appropriate for disclosure. Law does not mandate the information in bold print. • Amount of compensation for the study and testimony • Percent of physician’s practice devoted to IMEs • Qualifications (curriculum vitae) • A list of any other cases the witness has testified as an expert at trial or by deposition within the preceding four years • A list of all publications authored by the witness within the preceding ten years (Motion of the Board, February 1995) 220.999 Expert Testimony and Fees A physician’s legal testimony regarding patient care including office and administrative issues should be considered expert witness testimony. This policy is written in accordance with section 9.6 of the Interprofessional Code Second Edition. The Colorado Medical Society position on expert witness fees is the same as that discussed in the Interprofessional Code, Second Edition, and in Article 9.07 of the American Medical Association Current Opinions. In addition, each medical office should develop a policy relevant to Expert Witness matters, which includes a statement that the fee for expert witness testimony must be negotiated prior to the need and that an itemized statement is desirable. Additional Information: Interprofessional Code and AMA Current Opinions Article 9.07 (Motion of the Board, February 1990, Motion of the Board, March 2000) 225 Licensure and Discipline 225.995 • • • Maintenance of Licensure Direct CMS to develop a Colorado-specific maintenance of licensure framework. Direct Maintenance of Licensure Subcommittee to partner with Colorado Medical Board to make this a national pilot. Direct Maintenance of Licensure Subcommittee to phase in MOL requirements. (BOD-1, AM 2011) 225.996 Voluntary License for Retired Physicians In recognition of volunteer services provided by retired physicians and to encourage further volunteer participation in the area of indigent medical care, the Colorado Medical Society will work with the Colorado State Board of Medical Examiners, and if necessary develop legislation, to waive the fee for renewal of license of retired Colorado physicians who can provide confirmation that their only professional practice involves volunteer medical services for recognized charitable 501(c)(3) organizations or government agencies. If the aforementioned is unsuccessful, an alternative source of funding shall be explored. (RES-29, AM 1997) 225.997 Medical License Fees The Colorado Medical Society believes that medical license fees and any associated fees and taxes should only be used to support the quality practice of medicine by doctors of medicine and doctors of osteopathy. (RES-17, IM 1996) 225.998 Support of Colorado Physician Health Program The Colorado Medical Society (CMS) reaffirms its support for the goals of the Colorado Physician Health Program and conveys to the Colorado Board of Medical Examiners CMS’ concerns with regard to the possibility of taking funding from the Colorado Physician Health Program. (RES-69, AM 1990) 49 CMS Policy Manual September 2013 225.999 Support of Board of Medical Examiners The Board of Medical Examiners will be encouraged to enlist the resources of the Colorado Physician Health Program when physicians can reasonably benefit from the program’s resources. (RES-76, AM 1987) 230 Long-Term Care 230.997 Clinical Knowledge of Long Term Care for the Elderly The Colorado Medical Society (CMS) will encourage all Colorado physicians caring for frail, elderly residents in long term care settings as medical directors and/or primary care physicians to maintain appropriate clinical knowledge in the practice of geriatrics, including appropriate use of medications, restraint reduction, hydration, pain control and palliation, appropriate vaccinations, fall prevention, pressure sore prevention and treatment, advanced directives, and neglect/abuse recognition. The CMS will encourage all Colorado physicians acting as Medical Directors and/or primary care physicians caring for the frail, elderly residents in long term care settings, to become acquainted with and participate in some of the geriatric educational programs throughout the state, including those sponsored by the Colorado Medical Directors Association and the American Medical Directors Association, American Geriatric Society, university sponsored programs, and continuing medical education (CME) programs. This will provide access to current knowledge and CME as well as the opportunity to meet and become acquainted with their peers. (RES-5, AM 2003) 230.998 Case Management The Colorado Medical Society (CMS) endorses the utilization of qualified geriatric case managers for the coordination of screening and assessment of long-term care applicants, and for the subsequent development, implementation, monitoring and reassessment of a plan of care. The CMS support legislation to assure the qualification of case managers, to include licensure by an appropriate regulatory agency. (RES-41, AM 1989) 230.999 Standards and Credentialing for Case Managers The Colorado Medical Society supports the development of guidelines for case management to insure the safety and well being of the patient. Special attention should be paid to the role of family case managers and other caring non-professional case managers, recognizing their functions in cost containment. Physician case management time should be considered an appropriate activity worthy of reimbursement. (RES-46, AM 1988) 235 Managed Care 235.976 Prior Authorization CMS accepted the report of the CMS-CAHP Work Group on Prior Authorization (PA) and will continue the process of working with Colorado Association of Health Plans (CAHP). Action steps 1. Develop improved, ongoing PA communications between physicians and the health plans, with emphasis on secure electronic communications where feasible. a. Design a Portal/web page to be hosted by CAHP to allow a single point of entry for physicians, with links to all plans’ websites, and “drop-downs” to protocol-driven criteria for approval; 50 CMS Policy Manual September 2013 b. Convene “expert” committee made up from physician and staff representatives and health plan staff, including medical directors, IT, legal, and utilization management staff, to develop detailed plan, format, content; c. Explore standardized “format” for PA entry pages; d. Ensure that all needed PA information is readily available on plans’ websites – list of medications requiring PA, patient data required, understandable criteria for approval, appeal process, correct form to be submitted, etc. Goal is to make sure physicians and their staff have clear knowledge of what information is required for approval before the first submission. 2. Improve timeliness of PA consideration, submission of needed patient data, and approval/denial of requests. There is consensus that the principal reason for delay in decisions is the lack of complete patient data [given there is no existing incentive for plans to delay a determination once they have complete information] and the inefficient back-and-forth between prescribing physicians and health plans. a. Explore better systems to speed communication directly between health plans and physicians when more information is needed. Focus on asynchronous forms of communication to avoid wait times in both directions. b. Review current federal mandates and NCQA and URAC guidelines for timing of urgent and non-urgent PA requests; consider applying the Medicare Part D standards, i.e. 24 hours for urgent requests and 72 hours for non-urgent requests [timeframes run from receipt of complete information]. c. Monitor timing of PA actions as the improved system for communications outlined above is implemented. 3. Confirm that ordering physicians receive timely, direct notice when a PA is rejected or requires additional patient data/information. Work toward expanding secure electronic notices and option to transmit the data electronically [in addition to the notice to the patient, which is an accreditation and regulatory requirement]. See 2.a above. 4. Contact PBM’s to bring them up to date on progress of the Work Group and include them in future meetings. Consider adding other organizations/stakeholders. SECOND PHASE ACTION STEPS 5. CMS and CAHP will develop an ongoing education program to enhance the knowledge of prescribing physicians and their staff on the PA process, content of plans’ websites, criteria for approval, drugs that require PA, etc. 6. CMS and CAHP should stay informed on the work being done nationally to develop a standardized electronic transaction set for prior authorization. If agreement is reached at the national level, this group should evaluate how the electronic transaction can be utilized to facilitate better electronic communication and more timely processing of requests. 7. After solving the prescriptive PA problems, consider expanding the scope of the Work Group to include the other procedures requiring PA’s. (BOD-1, AM 2012) 235.977 Physician Profiling Following are recommendations for CMS advocacy regarding the profiling of physicians. As such, the Board of Directors may amend or add to these principles as they deem necessary. 1. If the physician prevails during the investigation or appeal process and a proposed “negative” profile is changed/upgraded to a higher-level designation, THEN: That physician should be entitled to recover compensation for professional time and actual incurred expenses. Such recovery should be paid by the health plan/insurer upon receipt of an invoice from the physician. The physician need not litigate to receive such recovery. (If the physician is uncertain as a reasonable charge for his/her 51 CMS Policy Manual September 2013 professional time we would refer them to the Colorado Workers’ Compensation fee schedule as a guideline.) 2. If a test or procedure must be done in order for a physician to comply with profiling criteria, THEN: The plan/insurer should actually pay for the cost involved. Such payment should be “first-dollar coverage,” e.g. it cannot be a “non-covered service” and it cannot be assigned to “patient responsibility” under a “deductible” provision. 3. If a test or procedure must be done in order for a physician to comply with profiling criteria, and such test/procedure requires compliance to a physician recommendation or order on the part of the patient, THEN: The physician need only to establish that the patient’s medical record documents the physician’s recommendation or order for such test or procedure. The plan/insurer should then be required to give the physician full “credit” in the profiling analysis for such test or procedure, whether or not the test or procedure was actually performed. 4. Since physician advisors are involved in the selection of profiling criteria, the majority of such physicians should be based, actively practicing, and licensed in Colorado. The names and professional qualifications of such physicians should be available upon request. The names and professional qualifications of non-Colorado physician advisors should also be available upon request. COPE further recommends that CMS leadership and staff shall engage in dialogue about physician profiling with the Colorado Association of Health Plans, and with individual plans as needed. The goal of such dialogue shall be to attempt to secure adoption of as many of the above guiding principles as possible. A report on these efforts shall be given to the Board of Directors prior to AM’11. (COPE-1, AM 2010) 235.978 National Care Project Physician Input The Colorado delegation to the American Medical Association (AMA) shall direct the AMA to provide education via established means to providers at acute and post acute levels in the Post Acute CARE (Continuity Assessment Record and Evaluation) demonstration project currently underway. The Colorado delegation to the AMA shall direct the AMA to urge the Centers for Medicare and Medicaid Services (CMMS) to solicit local, state, and national physician input during the CMMS CARE demonstration period (2008-2011). (RES-10, AM 2008) 235.979 Physician Networks Colorado Medical Society supports physician networks based on the full complement of quality aspects, as described by the Institute of Medicine: safe, effective, efficient, patient-centered, timely and equitable. CMS opposes physician networks that fail to include all of the Institute of Medicine’s quality aspects. (RES-17, AM 2007) 235.980 Request for Ongoing Reporting from the UnitedHealthcare Physician Advisory Committee (PAC) The Colorado Medical Society (CMS) continue to provide detailed updates on PAC meetings in Colorado Medicine and in written reports with minutes to the Council on Practice Environment (COPE) and CMS Board of Directors. The lack of progression on physicians’ concerns raised at the merger hearing be brought to the attention of both UnitedHealthcare and the Commissioner of Insurance and/or the American Medical Association. (RES-15, AM 2006) 235.981 Drug Formularies The Colorado Medical Society (CMS) supports legislation or other remedies to require all insurers in Colorado using drug formularies to fully disclose the basis for the decision to put a medication in the 52 CMS Policy Manual September 2013 preferred position on the formulary, e.g., cite the studies demonstrating safety and/or efficacy, and disclose any financial and/or business arrangements between the health plan and pharmaceutical companies related to formulary choices. The CMS supports formularies that are evidence based and costeffective for the patient. The CMS supports the use of less restrictive formularies by all insurers and supports the concept that senior health plan formularies for any insurance company licensed in Colorado cannot be more restrictive than the least restrictive commercial plan marketed by that company. The CMS supports the concept that pharmaceuticals that are “non-formulary” be made available at a higher co pay. The CMS supports the development of a uniform and state wide prior authorization and appeal process for non-formulary medications with no more than two appeal steps required prior to review by the plan physician medical director. The CMS encourages all insurers to standardize the format used in their formulary publication. The formulary publication should also include an informational page containing such information as: • Names of formulary committee members and meeting schedules • Appeals mechanism • Names and telephone numbers of contact people for problems requiring immediate attention, and • Administrative prescription drug polices. The CMS encourages all insurers to limit the amount of updates to the formularies to no more often than quarterly, and that updates be published in a uniform format. (RES-57, AM 1996, RES-25, AM 1997, Revised RES-6, AM 2002) 235.982 Admitting Officer and Hospitalist Programs 1. Managed care plan enrollees and prospective enrollees should receive prior notification regarding the implementation and use of “admitting officer” or “hospitalist” programs; 2. Participation in “admitting officer” or “hospitalist programs” developed and implemented by managed care or other health care organizations should be at the voluntary discretion of the patient and the patient’s physician; 3. Hospitalists systems when initiated by a hospital or managed care organization should be developed consistent with American Medical Association policy on medical staff bylaws and implemented with approval of the organized medical staff to assure that the principles and structure of the autonomous and self-governing medical staff are retained; 4. Hospitals and other health care organizations should not compel physicians by contractual obligation to assign their patients to “Hospitalists” and that no punitive measure should be imposed on physicians or patients who decline participation in “hospitalist programs.” 5. Colorado Medical Society opposes any hospitalist model that disrupts the patient/physician relationship or the continuity of patient care and jeopardizes the integrity of inpatient privileges of attending physicians and physician consultants. (RES-7, AM 2002) 235.983 Health Plan Opt Out At the time of enrollment in a health plan, all lists of network providers contracted with a health plan shall be correct and up to date. The Colorado Medical Society shall support legislation or seek other means which would allow a person to opt out and change a health plan before that person’s policy expires if his/her physician’s participation is incorrectly represented in the insurance company provider list at the time the patient contracted with that health insurance plan. (RES-9, AM 2002) 235.984 All-Products Clauses The Colorado Medical Society opposes the inclusion of “all-products clauses” in managed care contracts. (Revised RES-7, AM 2000) 53 CMS Policy Manual September 2013 235.985 Managed Care Contract Participation Listing Deadline The Colorado Medical Society shall pursue legislation stating that health plans cannot market physicians as members of their network without the written consent of the physician unless the physician is under signed contract 120 days prior to the effective date of the contract year of the health benefit plan. (RES-8, AM 2000) 235.986 Accurate Reporting of Health Plan Expenditures for Patient Care HMOs and health care insurers shall include in their calculation of plan expenditures only payments for patient care. The health plan shall exclude from the calculation of health care expense data, any funds retained by “carve out” or “carve in” managed care companies under contract with the insurer for administration and profit. (RES-21, AM 1999) 235.987 Ethical Implications of Capitation Physicians have an obligation to evaluate a health plan’s capitation payments prior to contracting with that plan to ensure that the quality of patient care is not threatened by inadequate rates of capitation. Capitation payments should be calculated primarily on relevant medical factors, available outcomes data, the costs associated with involved providers, and consensus-oriented standards of necessary care. Furthermore, the predictable costs resulting from existing conditions of enrolled patients should be considered when determining the rate of capitation. Different populations of patients have different medical needs and the costs associated with those needs should be reflected in the per member per month payment. Physicians should seek agreements with plans that provide sufficient financial resources for all necessary care and should refuse to sign agreements that fail in this regard. Physicians must not assume inordinate levels of financial risk and should therefore consider a number of factors when deciding whether or not to sign a provider agreement. The size of the plan and the time period over which the rate is figured should be considered by physicians evaluating a plan as well as in determinations of the per member per month payment. The capitation rate for large plans can be calculated more accurately than for smaller plans because of the mitigating influence of probability and the behavior of large systems. Similarly, length of time will influence the predictability of patient expenditures and should be considered accordingly. Capitation rates calculated for large plans over an extended period of time are able to be more accurate and are therefore preferable to those calculated for small groups over a short time period. Stop-loss plans should be in effect to prevent the potential of catastrophic expenses from influencing physician behavior. Physicians should ensure that such arrangements are finalized prior to signing an agreement to provide services in a health plan. Physicians must be prepared to discuss with patients any financial arrangements that could impact patient care. Physicians should avoid reimbursement systems that cannot be disclosed to patients without negatively affecting the patient-physician relationship. (RES-24, AM 1997) 235.988 Managed Care Utilization Review and “Hold Harmless” Clauses Based upon a complaint by a policyholder or participating provider, the Colorado Division of Insurance shall review any prospective utilization review requirement such as prior authorization, etc., for a denial rate. Any utilization review requirement, which does not result in a denial rate of at least five percent, shall be eliminated by the health plan. The Colorado Medical Society shall support legislation to prohibit “hold harmless” clauses in managed care contracts that hold physicians liable for harm to patients as a result of any utilization review decisions made by the payer. (RES-17, AM 1997) 54 CMS Policy Manual September 2013 235.989 Position Paper: Prior Authorizations The Colorado Medical Society (CMS) objects to any prior authorization process that is implemented solely for the purpose of creating a barrier to care. Prior authorization mechanisms created as barriers to care increase overall health care expenses by adding an unnecessary administrative burden. The CMS encourages all managed care organizations with a prior authorization process, to have the process contain at least the following elements: • Authorization of enough visits to complete a course of treatment for the specified condition; • There are circumstances when a health plan wants to know of the existence of a clinical condition. In these circumstances, notification is preferred to prior authorization unless there is a valid clinical rationale for prior authorization; • The criteria used for adjudication of prior authorization should be available to physicians in advance, and the process should be as streamlined as possible. Aids for the physician’s office such as worksheets are desired; • Admissions, referrals, and procedures that meet nationally or regionally accepted guidelines should be exempt from prior authorization; and • Compliance with time limit and written notification standards set forth in Colorado Regulation 4-217 “Prompt Investigation of Health Plan claims Involving Utilization Review”. (RES-24, IM 1997) 235.990 Managed Care Policy Definition Use of a planned and coordinated approach to providing health care with the goal of quality care at a lower cost. Managed care techniques most often include one or more of the following: • Prior, concurrent, and retrospective review of the medical necessity and appropriateness of services and/or site of services; • Contracts with selected health care professionals or providers; • Financial incentives or disincentives related to the use of specific providers, services or service sites; • Controlled access to and coordination of services by a case manager; and • Payer efforts to identify treatment alternatives and modify benefit restrictions for high-cost patients (i.e., high-cost case management). Disclosure Provisions • It should be the legal responsibility of both health insurance companies and benefit managers of businesses to make full disclosure to participants regarding the restrictions in access to health services that occur within managed health plans. • It is the patient’s responsibility to know pertinent details of his/her program. These may include (but not be limited to) insurance benefits under the plan, as well as requirements for: 1. Pre-admission or pre-procedure certification 2. Second surgical opinions 3. Mandatory out-patient surgery for certain procedures 4. Co-payments/payments 5. Pre-existing condition exclusions 6. Limits on Access to Specialty Care 7. Utilization Management Policies 8. Excluded Procedures 55 CMS Policy Manual September 2013 Selective Contracting Participation Criteria • Physicians should have the right to apply to any health plan or network in which they desire to participate if that network needs additional physicians. Applications should be approved if they meet physician-developed and approved objective criteria and are based on professional qualifications, competence, and quality of care as well as cost efficiency of care. • Health care plans or networks should develop and use criteria to determine the number, geographic distribution and specialties of physicians needed. • Managed care organizations and third party payers should be required to disclose to physicians applying to the plan as well as to enrollees, the selection criteria used to select, retain or exclude a physician from a managed care plan, including the criteria used to determine the number, geographic distribution and specialties of physicians needed. • Health care plans or networks that limit the number, geographic distribution and specialties of participating physicians should be required to report to the public, annually, the impact that the limitation has on the access, cost and choice of health care services provided to patients enrolled in such plans or networks. • Managed care plans should not require physicians to contract exclusively with a single plan. Disaffiliation Criteria • In those cases in which economic issues may be used for consideration of sanction or dismissal, participating physicians should have the right to receive profile information (including interpretation of that information) and education. They should have an opportunity to defend and/or modify practice patterns before action of any kind is taken. • All managed care contracts should include formal mediation or meaningful due process protections to prevent wrongful and arbitrary contract terminations that leave the physician without means of redress. Financial Incentives • Managed care plans should provide incentives for cost effective decision making by consumers. 56 • Managed health care plans should have limitations on the financial risk transferred to patients and physicians so that conflicts between utilization and quality issues require a burden of proof from the health plan. • Patient advocacy is a fundamental element of the physician-patient relationship that should not be altered by the health care system in which physicians practice, or the methods by which they are compensated. • Physicians should have the right to enter into whatever contractual arrangements with health care systems they deem desirable and necessary, but they should be aware of the potential for some types of systems to create conflicts of interest, due to the use of financial incentives in the management of medical care. • Financial incentives should enhance the provision of high quality, cost-effective medical care. • Financial incentives should not result in the withholding of appropriate medical services or in the denial of patient access to such services. • Any financial incentives that may induce a limitation of the medical services offered to patients, as well as treatment or referral options, should be fully disclosed by health plans to enrollees and prospective enrollees. • Physicians should disclose any financial incentives that may induce a limitation of the diagnostic and therapeutic alternatives that are offered to patients, or restrict treatment or referral options. Physicians may satisfy their disclosure obligations by assuring that the health plans with which they contract provide such disclosure to enrollees and prospective enrollees. CMS Policy Manual September 2013 • Financial incentives should not be based on the performance of physicians over short periods of time, nor should they be linked with individual treatment decisions over periods of time insufficient to identify patterns of care. • Financial incentives generally should be based on the performance of groups of physicians rather than individual physicians. However, within a physician group, individual physician financial incentives may be related to quality of care, productivity, utilization of services, and overall performance of the physician group. • The appropriateness and structure of a specific financial incentive should take into account a variety of factors such as the use and level of “stop-loss” insurance, and the adequacy of the base payments (not at-risk payments) to physicians and physician groups. The purpose of assessing the appropriateness of financial incentives is to avoid placing a physician or physician group at excessive risk, which may induce the rationing of care. • Physicians should consult with legal counsel prior to agreeing to any health plan contract that contains financial incentives, to assure that such incentives will not inappropriately influence their clinical judgment. • Physicians agreeing to health plan contracts that contain financial incentives should seek the inclusion of provisions allowing for an independent annual audit to assure that the distribution of incentive payments is in keeping with the terms of the contract. • Physicians should consider obtaining their own accountants when financial incentives are included in health plan contracts, to assure proper auditing and distribution of incentive payments. • Physicians, other health care professionals, and third party payers through their payment policies should continue to encourage use of the most cost-effective care setting in which medical services can be provided safely with no detriment to quality. Case Management/Coordination of Care • Managed care plans should recognize the physician as the expert in selecting health care for the patient, allowing the physician to select a cost effective treatment plan consistent with quality of patient care. The physician should not be placed between the appropriate needs of the patient and the financial interests of the health plan. • Managed care plans should support continuity of care between physician and patient. Utilization Management • Managed care plans should provide participating physicians access to detailed information concerning their own practice profile and comparisons with physicians with similar practices. • Utilization management under managed care shall be based on open and consistent review criteria developed from valid outcome studies that are acceptable to and have been created in concert with the medical profession. For reviews being appealed, managed care programs shall use actively practicing, Colorado licensed physicians engaged in direct patient care at least 20 hours per week in the same specialty as that of the physicians under review in any decision to deny or reduce coverage for services based on medical necessity or quality of care determinations. Doctor to doctor communication should be encouraged. Administrative Issues • After a managed care company has communicated a decision to a physician’s office, the physician or his representative may request confirmation by printed document. This confirmation will be sent the same day, will contain decisions made in regard to benefits, authorization, preauthorization, acceptance and/or denial of services, the reason for denial, and any other administrative decisions made in regard to the patient’s proposed treatment. This confirmation shall contain the name, phone number, extension, and signature of the person responsible for rendering the decision. 57 CMS Policy Manual September 2013 • All managed care plans and medical delivery systems must include significant physician involvement in their health care delivery policies similar to those of self-governing medical staffs in hospitals. Participating physicians should nominate and elect physician members of the plan’s policymaking board. • Any physicians participating in these plans must be able, without threat of punitive action, to comment on and present their positions on the plan’s policies and procedures for medical review, quality assurance, grievance procedures, credentialing criteria and other financial and administrative matters, including physician representation on the governing board and key committees of the plan. Exclusive Contracting • Managed care organizations and health plans that have exclusive contracts with outside entities to perform their diagnostic services such as laboratory, radiology, etc., should be required to allow physicians to do stat procedures in their offices for clinical decision making. Physicians should be provided reasonable reimbursement for these services. There should be no financial disincentive for physicians to provide such services. Freedom of Choice • The public should be educated on the various types of health care delivery systems and afforded freedom of choice of delivery systems and physicians. • Employers should offer employees a choice of health plans. • The freedom of patients to select and to change their physician or medical care plan should extend to those patients whose care is financed through Medicaid or other tax-supported programs, recognizing that in the choice of some plans the patient is accepting limitations in the free choice of medical services. • Each plan that restricts access by enrollees or members to health care providers shall offer enrollees or members coverage for health care services provided by out-of-network providers through an alternative “Point of Service Option” coverage. In the case of an enrollee who elects this “Point of Service Option” coverage, the plan may charge an alternative premium to the enrollee or member to take into account the actuarial value of such coverage. The managed care plan should incorporate reasonable out-of-pocket patient expenses for choosing out-of-plan providers so as to preserve a measure of free choice of provider by the patient. (RES-40, AM 1994, RES-7, IM 1997) 235.991 Managed Care Network Adequacy The Colorado Medical Society (CMS) shall encourage managed care plans to have provider networks sufficient to not require patients to travel more than 25 miles to receive appropriate primary care services and consulting specialty services. Managed care plans shall be restricted from marketing or enrolling patients who reside in areas poorly served by such plans. The CMS shall support such requirements through legislation or regulation as may be appropriate. (RES-52, AM 1996) 235.992 Access to Care (Gatekeeper Systems) The Colorado Medical Society believes that managed care organizations should provide patients, as well as physicians, with a clear and concise explanation of the type of gatekeeper model their plan utilizes. This explanation should be written in easily understood language and include the procedures for referrals, as well as any physician reimbursement mechanism that may be construed to limit access to care. (RES-56, AM 1996) 58 CMS Policy Manual September 2013 235.993 Ethical Issues in Managed Care Guidelines 1. The duty of patient advocacy is a fundamental element of the physician-patient relationship that should not be altered by the system of health care delivery in which physicians practice. Physicians must continue to place the interests of their patients first. 2. When managed care plans place restrictions on the care that physicians in the plan may provide to their patients, the following principles should be followed: a. Any broad allocation guidelines that restrict care and choices-which go beyond the costbenefit judgments made by physicians as a part of their normal professional responsibilities-should be established at a policy making level so that individual physicians are not asked to engage in ad hoc bedside rationing. b. Regardless of any allocation guidelines or gatekeeper directives, physicians must advocate for any care they believe will materially benefit their patients. c. Physicians should be given an active role in contributing their expertise to any allocation process and should advocate for guidelines that are sensitive to differences among patients. Managed care plans should create structures similar to hospital medical staffs that allow physicians to have meaningful input into the pan’s development of allocation guidelines. Guidelines for allocating health care should be reviewed on a regular basis and updated to reflect advances in medical knowledge and changes in relative costs. d. Adequate appellate mechanisms for both patients and physicians should be in place to address disputes regarding medically necessary care. In some circumstances, physicians have an obligation to initiate appeals on behalf of their patients. Cases may arise in which a health plan has an allocation guideline that is generally fair but in particular circumstances results in unfair denials of care, i.e., denial of care that, in the physician’s judgment, would materially benefit the patient. In such cases, the physician’s duty as patient advocate requires that the physician challenge the denial and argue for the provision of treatment in the specific case. Cases may also arise in which a health plan has an allocation guideline that is generally unfair in its operation. In such cases, the physician’s duty as patient advocate requires not only a challenge to any denials of treatment from the guideline but also advocacy at the health plan’s policy making level to seek an elimination or modification of the guideline. Physicians should assist patients who wish to seek additional appropriate care outside the plan when the physician believes the care is in the patient’s best interests. e. Managed care plans should adhere to the requirement of informed consent that patients be given full disclosure of material information. Full disclosure requires that managed care plans inform potential subscribers of limitations or restrictions on the benefits package when they are considering entering the plan. f. Physicians also should continue to promote full disclosure to patients enrolled in managed care organizations. The physician’s obligation to disclose treatment alternatives to patients is not altered by any limitations in the coverage provided by the patient’s managed care plan. Full disclosure includes informing patients of all their treatment options, even those that may not be covered under the terms of the managed care plan. Patients may then determine whether an appeal is appropriate or whether they wish to seek care outside the plan for treatment alternatives that are not covered. g. Physicians should not participate in any plan that encourages or requires care at or below minimum professional standards. 3. When physicians are employed or reimbursed by managed care plans that offer financial incentives to limit care, serious potential conflicts are created between the physicians’ personal financial interests and the needs of their patients. Efforts to contain health care costs should not place patient welfare at risk. Thus, financial incentives are permissible only if they promote the cost-effective delivery of health care and not the withholding of medically necessary care. 59 CMS Policy Manual September 2013 a. Any incentives to limit care should be disclosed fully to patients by plan administrators on enrollment and at least annually thereafter. b. Limits should be placed on the magnitude of fee withholds, bonuses, and other financial incentives to limit care. Calculating incentive payments according to the performance of a sizable group of physicians rather than on an individual basis should be encouraged. c. Health plans or other groups should develop financial incentives based on quality of care. Such incentives should complement financial incentives based on the quantity of services used. 4. Patients have an individual responsibility to be aware of the benefits and limitations of their health care coverage. Patients should exercise their autonomy by public participation in the formulation of benefits packages and by prudent selection of health care coverage that best suits their needs. (RES-8, IM 1996) 235.994 Quality of Care in Managed Care Plans The Colorado Medical Society (CMS) urges physicians practicing in managed care plans and systems to take the initiative in developing and implementing criteria and peer review oriented processes to access and assure the quality of care provided in these plans. The CMS urges managed care plans, hospitals, review entities, third party administrators and any other organizations that are compiling information on physician performance to share that information with the practitioners concerned in order to enhance and modify practice patterns through education where needed. (RES-41, AM 1994) 235.995 Managed Care and Antitrust The Colorado Medical Society (CMS) shall support the following statements regarding changes to relevant antitrust laws: 1. The CMS supports appropriate changes in relevant antitrust laws to allow physicians and physician organizations to engage in group negotiations with managed care plans. 2. The CMS, through the American Medical Association, shall pursue enhanced roles for physicians in private sector health plans, including lobbying for appropriate modification of the antitrust laws to facilitate physician negotiation with managed care plans and for legislation requiring managed care plans to allow participating physicians to organize for the purpose of commenting on medical review criteria. 3. The CMS shall advocate strongly to the Congress, the Colorado General Assembly, and other appropriate entities, the need for changes in relevant antitrust laws to allow physicians and physician organizations to engage in group negotiations with collective purchasers, managed care plans, insurers and other payers. (RES-43, AM 1994) 235.996 Position Paper: Physician Affiliation/Disaffiliation The Colorado Medical Society (CMS) supports in concept, the following position paper on the Affiliation/Disaffiliation from Managed Care Entities, developed to provide CMS a policy basis from which to continue deliberations with members of the Colorado Association of Health Plans (CAHP) on issues of concern to physicians: COLORADO MEDICAL SOCIETY COLORADO ASSOCIATION OF HEALTH PLANS WHITE PAPER ON PHYSICIAN AFFILIATION/DISAFFILIATION Introduction A number of factors have resulted in expansion or contraction of panels of physicians which contract with HMOs. Such factors include, but are not limited to the following: growth in HMO enrollment; intense 60 CMS Policy Manual September 2013 competition among HMOs and insurance carriers; PPO development; development of Physician-Hospital organizations; and Employer Report Card (Health Plan Employer Data Information Set (HEDIS). Purpose and Scope The purpose of this White Paper is to address issues of mutual concern arising in the affiliation/disaffiliation process among physicians and HMOs. The Colorado Medical Society (CMS) and the Colorado Association of Health Plans (CAHP) recognize that the relationship between a physician and an HMO is voluntary and contractual in nature. It is not the intent of this White Paper to alter current contracting practices between HMOs and physicians. This White Paper should not be construed as endorsing physician disaffiliation solely “for cause” or an adversary hearing process for disaffiliation. The CMS and the CAHP believe that issues arising among physicians and HMOs could be ameliorated by enhanced communication between physicians and HMOs. They wish to develop an alternative to the expensive and time consuming adversary hearing process, while emphasizing mechanisms for dispute prevention. Affiliation/disaffiliation issues involving quality of care or professional competence of physicians that lead to termination “for cause” are outside the scope of this White Paper. Such matters have implications under both state and federal law. This White Paper contains the view and commitments of CMS and the CAHP. However, each organization is comprised of individuals whose adherence to views stated herein may differ. Some HMOs contract with groups of physicians (e.g., IPAs) that have primary responsibility for affiliation/disaffiliation actions. The recommendations of this White Paper are applicable to such groups of physicians as appropriate. The actions contemplated by this White Paper are recommendations that may or may not be adopted by an individual physician, groups of physicians or each HMO. Recommendations HMOs and physicians recognize that two-way communication is a critical part of maintaining an effective working relationship in the provision of quality, cost effective health care to HMO members. The following recommendations are intended to enhance the communication process. 1. Contracting Standards Contracting standards should be developed for primary care physicians and each physician specialty. Such standards should be utilized in determining physician selection, retention and disaffiliation. The standards may include, but not be limited to the following: medical education; post-graduate medical training; board certification and eligibility; geographic location; office hours; hospital staff privileges; needs of HMO members for accessible and available medical care; number of members receiving care from the physician; results of patient satisfaction surveys; medical utilization factors based as much as practicable on objective data collection and interpretation; and the HMO’s perception of a physician’s ability to work collaboratively in a managed care environment. An HMO or physician group may change such standards from time to time. 2. Disclosure of Standards Contracting standards should be disclosed to current and prospective participating physicians and CMS. Amendments to contracting standards should be communicated to participating physicians in a timely manner. Disclosure is subject to reasonable limitations to protect trade secret information. 3. Contracting Standards for Specialty Physicians 61 CMS Policy Manual September 2013 Contracting standards for specialty physicians should be developed by an HMO in consultation with physicians within that specialty and primary care physicians. At the request of an HMO or physician group, CMS will identify specialist physicians from the community, academic institutions or specialty societies who will be available to consult in the development of contracting standards for specialist physicians. 4. Data Collection and Analysis Specialty specific credentialing and contracting methodologies for data collection and analysis should be developed in consultation with physicians within that specialty and primary care physicians. Data systems for credentialing and contracting with primary care physicians should be developed in consultation with primary care physicians and appropriate specialist physicians. 5. Evaluation of Physicians Each physician should be provided periodically (as appropriate for the nature and amount of data and the volume and scope of services provided by the physician for the HMO or physician group) with data regarding his/her performance within the HMO relative to stated criteria and to an appropriate group of comparable physicians. Upon presentation of such data, each physician should work cooperatively with the HMO or physician group to improve performance. 6. Specialist Department Chair HMOs should consider utilizing a “department chair” or specialty consultant for each physician specialty. As determined appropriate by Medical Director of the HMO or physician group, the department chair or specialty consultant would act as an intermediary with specialty physicians to enhance communication and resolve issues relating to that specialty. The department chair or specialty consultant may also assist in the development of methodology for data collection and analysis and the interpretation of data regarding that specialty. 7. Disaffiliation When making a decision to disaffiliate a physician, the most recent data available should be utilized and consideration given to such physician’s response over time to data presented to him/her. When disaffiliation occurs because of change in network size or composition, the disaffiliated physician should be provided with the reason, including the criteria and methodology utilized for disaffiliation decision. When a physician chooses to disaffiliate, the physician should provide the HMO or physician group with the reason for such action. Joint Actions The CMS and the CAHP will work collaboratively to undertake actions, which will foster communication between physicians and HMOs and provide for non-adversarial dispute resolution. 1. Colorado Medical Society Physician Consultant HMO representatives will work with a physician “consultant” employed by CMS to develop “Physician Report Cards” and evaluate existing “Report Cards”. Such consultant should have expertise in managed care and statistical analysis. Such “Report Cards” will consist of a set of criteria utilizing data whereby physician performance is evaluated. The “Report Card” development will include, but not be limited to the following: a. Review of data collection and interpretation methodology; b. Review of data interpretation techniques to ensure that it is understandable and usable for guiding change in physician behavior; and c. Identify issues that are based on data. 62 CMS Policy Manual September 2013 The CMS and the CAHP will work towards identifying and developing data collection and analysis methodologies to be utilized in connection with affiliation/disaffiliation of physicians. A physician consultant or other representative of CMS will be available to advise its member physicians regarding physician “Report Cards” and disaffiliation actions. The CMS and the CAHP will jointly establish a program to review and endorse data collection and interpretation methodologies established for evaluation of physicians. 2. Mediation Process The CMS and the CAHP under the auspices of the Colorado Bar Association shall develop and jointly adopt a procedure for implementing a mediation program for physicians involved in the affiliation/disaffiliation process. Such procedure shall be voluntary on the part of each physician and each HMO or physician group and invoked only after exhaustion of any internal appeal process available to a physician. The CMS and the CAHP will identify and arrange for training of a panel of mediators who will be available to participate in the mediation process. The CMS and the CAHP will annually review the mediation process and jointly implement any needed changes to it. ADOPTED: Colorado Medical Society Colorado Association of Health Plans By: By: Title: Title: CMS/CAHP WHITE PAPER MEDIATION PROCESS The Colorado Medical Society/Colorado Association of Health Plans Joint Committee have agreed to the following mediation process as provided for in the “White Paper on Physician Affiliation/Disaffiliation”. This is a voluntary process on the part of each physician and each HMO or physician group and invoked only after exhaustion of any internal appeal process available to a physician. The steps involved in mediation usually include: (1) application or agreement to mediate, (2) selection of a mediator, (3) preparation for the mediation session, (4) conducting the mediation session, and (5) settlement. There are also separate fees for the services of the mediator. Based on our needs, the American Arbitration Association (AAA) seems to be our best option. AAA has an outstanding reputation and is known as the oldest, wisest and best organization of its kind. It has been around for 69 years. It is also one of the most reasonably priced organizations. AAA charges a $300.00* administrative fee per mediation and $175.00* per hour for the mediator. The length of the mediations will obviously depend on the individual case, but could be anywhere from a half day to a few days. All expenses would be shared equally between both parties. As mentioned above, AAA maintains a panel of mediators from which the physician and the plan would mutually select an individual mediator for each mediation. 63 CMS Policy Manual September 2013 In summary, we recommend selecting AAA to provide for our mediation needs. The white paper states that CMS and CHMOA “shall develop and jointly adopt a procedure for implementing a mediation program for physicians involved in the affiliation/disaffiliation process”. By using AAA services, we have met that requirement while expending minimal effort and resources of our organizations. * These charges were in effect in June 1995 when this document was developed. (Motion of the Board, July 1994) 235.997 Discrimination Against Physicians by Health Care Plans The Colorado Medical Society (CMS) opposes policies related to discrimination against physicians and other health care professionals with a history of physical or mental health issues. The CMS supports physicians who are being discriminated against based on any physical or mental health issue. The CMS supports providing appropriate assistance to physicians at the local level who believe they may be treated unfairly by managed care plans, particularly with respect to selective contracting and credentialing decisions that may be due, in part, to a physician’s history of physical or mental health issues. The CMS urges managed care plans and third party payers to refer questions of physician physical or mental health issues to state medical associations and/or county medical societies for review and recommendation as appropriate. (RES-29, IM 1994) 235.998 Punitive Protections for Physicians Participating in Health Care Plans All managed care plans and medical delivery systems must include significant physician involvement in their health care delivery policies similar to those of self-governing medical staffs in hospitals Any physicians participating in these plans must be able without threat of punitive action to comment on and present their positions on the plan’s policies and procedures for medical review, quality assurance, grievance procedures, credentialing criteria and other financial and administrative matters, including physician representation on the governing board and key committees of the plan. (RES-16, IM 1994) 235.999 Point of Service Option for Managed Care Enrollees The Colorado Medical Society encourages all health plans that restrict access by enrollees or members to health care providers to offer coverage for health care services provided by out-of-network providers through an alternative “Point of Service Option”. The benefit level of such plans shall not be set so low as to act as a prohibitive deterrent to patient utilization of this option. (RES-30, IM 1994) 240 Medicaid 240.993 Medicaid Expansion The Colorado Medical Society (CMS) supports the expansion of Medicaid under the terms of the 2010 Patient Protection and Affordable Care Act (ACA). To facilitate successful expansion of access to health care under Medicaid and the ACA, we recommend that the following reforms be addressed urgently. We stand ready to work with the state and other stakeholders on these changes to enhance the value of the Medicaid program to patients and taxpayers. Improving Medicaid CMS has championed the longstanding goal of achieving health care coverage for all Coloradans. We have argued that efforts to redesign Medicaid and the larger health care system have to be about more than just improving coverage. They have to be about providing cost-effective, quality and safe medical care. That is one of the reasons we strongly support the Accountable Care Collaborative and it’s focus on cost-effectively improving the health of Medicaid patients through the use of local, patient-centered systems of care. Improving upon the ACC by developing and following a clearly defined, transparent pathway addressing the following high priority areas will accelerate the already promising cost, quality 64 CMS Policy Manual September 2013 and patient satisfaction trends within the program. CMS strongly encourages efforts to address these systemic issues: Access to care – Ensure appropriate access to care by enhancing reimbursement rates for all physicians to equitable levels that are at least at parity with Medicare. o Utilize the HB1281 pilots and other initiatives to test and accelerate the adoption of alternatives to fee-for-service payment, including bundled payments and other methodologies. o Support 12-month continuous eligibility for children in Medicaid, per existing law. • Preserve and innovate liability protection – Maintain Colorado’s relatively stable medical liability climate and provide enhanced protections for the use of evidence-based approaches to care management, including, but not limited to, shared decision making models. • Patient engagement – Maximize clear, shared accountability between patients and physicians across the spectrum of care. o Explore and promote other options to facilitate patient engagement, health literacy, healthy behaviors and reduce avoidable use of high cost services. o Provide incentives for patients and physicians to use patient decision aids and shared decision-making tools. • Administrative simplification – Eliminate unnecessary administrative complexity, increase efficiency and standardization of Medicaid administrative processes. o Streamline provider enrollment procedures, standardize use of nationally recognized transaction codes (CAHQ/CORE), maximize efficiency of prior authorization using electronic procedures, improve eligibility determination timeliness and transition to Medicare 1500 electronic claims submission. Develop and document a well-defined, fair administrative process for cases of suspected fraud and abuse that includes due process for providers. • (Motion of the Board, January 2013) 240.994 Medicaid/Medicare Parity in Reimbursement Rates If the state of Colorado elects to receive federal dollars to expand its Medicaid program under the Affordable Care Act, the Colorado Medical Society supports the rapid enactment of parity between Medicare and Medicaid physician reimbursement that encourages physician participation. (LATE RES 8-P, AM 2012) 240.995 Remove Exemptions from Medicaid Prescribing The Colorado Medical Society support if proposed legislative relief to remove from 25.5-5-501 1(a) the exemption for generic substitution for medications to treat biologically based mental illness, cancer, epilepsy and HIV. (RES 4, AM 2010) 240.996 Medicaid Guiding Principles Goal of the “Medicaid Reform Task Force: To improve the quality of care for Medicaid recipients and increase the efficiency of the program which would create cost savings and enhance provider participation. Improve access to care o Ensure access and coverage for all eligible persons o Primary care centered; patient-family centered to promote continuity of care o Ensure local control and local networks to enable availability and sustainability of the medical home o Establish a personal medical home for all Medicaid clients • Organized, coordinated, and continuous care that integrates dental, specialty, and mental health services for any patient 65 CMS Policy Manual September 2013 • Team-based care o Establish a well-coordinated care management system for specific high risk, high cost conditions and disease states • Emphasis on prevention and wellness programs • Utilize incentives to leverage more provider participation o Ensure an adequate network of local providers with broad specialty facilitated referral network o Improve reimbursement rates that are adequate and equitable • Medicare parity or “not for loss” • Does not diminish access or quality of care Improve quality of care and health outcomes o Ensure cultural competency by providing care appropriate to patient beliefs and values; respectful o Promote evidence-based medicine with appropriate individualization of care o Emphasize collaborative team-based care with physician and health care professional direction o Establish best practice guidelines o Utilize performance measurements that enable continuous quality improvement o Create shared accountability for all parties o Facilitate transparency of data to providers o Educate and improve patient health literacy o Encourage patient responsibility • Achieve cost savings o Create a shared accountability amongst all parties, including health care professionals, care managers, local networks and administrators, for the overall improvement of the program o Utilize limited resources in the most cost efficient manner • Savings reinvested back into the Medicaid health care system o Reduce inappropriate, ineffective services and cost o Seek and leverage all potential state and federal dollars to improve the infrastructure Enable informed decision-making Enabling more informed decision-making by physicians and patients at the point of care is essential to improving the quality and efficiency of care. The Medicaid Reform Task Force supports a Medicaid care management delivery system that encourages and supports the interoperable exchange of health information using secure health information technology applications. Functions should include: o Functional data systems for tracking and reporting o Share data at all levels (i.e. state, local provider) o Use of immunization and disease registries, as appropriate Promote culture of collaboration among all stakeholders o Create an atmosphere of open dialogue to share information at all levels o Promote continuous consensus building among all health care stakeholders o Establish a meaningful relationship between medical professionals and stakeholders to achieve consensus policy input and development (BOD-1, Progress Report, Attachment 1, AM 2007) 240.997 Medicaid Pharmacy Benefits The Colorado Medical Society (CMS) endorses the concept that the Medicaid program may establish a list of preferred drugs that should be used for treatment of Medicaid beneficiaries, provided that such list should include drugs of every class of clinically useful medication, selected so as to establish cost savings and yet preserve professional choice in selecting agents of expected clinical effectiveness without inefficient and time wasting approval procedures. The CMS supports the development of a preferred drug list as developed by a committee including practicing physicians of multiple specialties for Medicaid in order to encourage cost-effective, quality 66 CMS Policy Manual September 2013 health care. The Board of Directors is encouraged to identify physicians within CMS who could serve as advisors to Medicaid administrators in developing a preferred drug list. (Late RES-36, AM 2003) 240.998 Medicaid Reimbursement and Patient Access to Physicians The Colorado Medical Society shall continue to work with legislators, other appropriate individuals and private/state organizations to educate them regarding: 1. The economic pressures on physicians in private practice that prevent them from providing the access to Medicaid patients they would prefer, 2. The lack of availability of physicians to care for Medicaid patients, 3. The need to increase levels of Medicaid reimbursement to at least Medicare levels, and 4. That any Medicaid fee schedule must recognize the value and cost-effectiveness of physician cognitive services and patient care management, without losing sight of the need for fair reimbursement to physicians rendering procedural services. (Late RES-31, AM 2002, RES-12, AM 1985) 240.999 Medicaid Position Paper The Colorado Medical Society (CMS) supports efforts to create a streamlined Medicaid program that will promote state innovation and efficient use of funds, while maintaining the program’s role as a safety net for the state’s poorest and most vulnerable populations. This Policy is detailed in the CMS Position Paper on Medicaid. Additional Information: Medicaid White Paper (Motion of the Board, March 1996) 245 Medical Education 245.988 Unified Graduate Medical Education The Colorado Medical Society supports a unified accreditation system for allopathic and osteopathic physicians which: a. Grants equal access to application to all residency positions for both osteopathic and allopathic medical students, and b. Grants equal access to application to all postdoctoral fellowships for graduates of both osteopathic and allopathic residency programs. (RES 18-P, AM 2013) 245.989 Discrepancies in Clerkship Cost The Colorado Medical Society supports and encourages continued dialogue between the University of Colorado School of Medicine and Rocky Vista University College of Osteopathic Medicine regarding clerkship costs to arrive at a resolution that satisfied both parties. (RES 17-P, AM 2013) 245.990 Workforce-Centered Education Funding The Colorado Medical Society supports a funding structure for student education at the University of Colorado Anschutz medical campus determined by the workforce and medical needs of Colorado. (RES 7-P, AM 2013) 245.991 Adolescent and Young Adult Cancer in Medical Education The Colorado Medical Society recognizes the importance of Adolescent and Young Adult Cancers and supports the work of AAMC, AACOM, ACGME, AOA, and other relevant organizations in developing core competencies to ensure that medical students and residents are familiar with the unique medical, social and psychological issues posed by AYA cancer. (LATE RES-7-A, AM 2011) 67 CMS Policy Manual September 2013 245.992 Health Policy Education in Medical School The Colorado Medical Society (CMS) supports improving medical student education on health policy. The CMS shall help the Medical Student Component educate its members on the creation of a health policy forum. (RES-3, AM 2008) 245.993 Medical Student Tuition and Debt Medical student tuition and debt be a legislative priority of CMS. (RES-8, AM 2006) 245.994 “All Payer” Funding for Medical Education The Colorado Medical Society supports the American Medical Association’s efforts to achieve “all payer” funding for medical education. (RES-10, IM 1996) 245.995 Training or Retraining Physicians for Rural Practice The Colorado Medical Society encourages and supports broad-based, cross-specialty training and retraining for primary care physicians wishing to practice in rural areas and for physicians wishing to improve and increase their skills. (RES-5, AM 1995) 245.996 Specialty Choice Requirements for Student Financial Aid The Colorado Medical Society (CMS) supports efforts to increase medical student interest in primary care. The CMS supports incentives that enhance the practice of primary care as a means of encouraging selection of primary care specialties by medical students. (RES-8, IM 1994) 245.997 Topics and Responsibility for the Annual Meeting Educational Program Contemporary issues affecting medicine should be the main thrust of the Education Program at the Colorado Medical Society Annual Meeting. (RES-1, AM 1991) 245.998 Resident Working Hours The Colorado Medical Society supports safe working hours and conditions for resident physicians. (RES-54, AM 1990) 245.999 Maternity Leave for Residents The Colorado Medical Society encourages all Residency program directors to review maternity leave policies so as to allow pregnant residents the same leave and benefits as designated for residents who are ill or disabled as defined in Federal law, and the Colorado Medical Society encourages written maternity leave policies which allow residents to return to their training program after said maternity leave without loss of eligibility to complete their training program. (RES-54, AM 1988) 250 Medical Records 250.998 Medical Record Fees-Guidelines Physicians may charge a reasonable cost-based fee for the copying of medical records. The reasonable cost-based fee may include the costs of supplies for and the labor of copying the medical records, as well as postage. (RES-2, AM 2002) 68 CMS Policy Manual September 2013 250.999 Access to Physicians’ Individual Medical Records The Colorado Medical Society opposes the request and use of medical record releases for physicians’ individual medical records by hospitals, other credentialing and privileging entities, and other similar entities. (RES-25, AM 2000) 255 Medical Societies 255.999 Unified Voice for Physicians Colorado Medical Society (CMS) supports the American Medical Association’s (AMA) goal to be the unified voice of the medical profession speaking for all physicians; and the CMS supports the AMA to act as a catalyst to encourage and assist specialty societies to meet and discuss differences and to resolve problems where possible in a specialty society forum. (RES-34, IM 1992) 260 Medicare 260.994 Medicaid/Medicare Parity in Reimbursement Rates If the state of Colorado elects to receive federal dollars to expand its Medicaid program under the Affordable Care Act, the Colorado Medical Society supports the rapid enactment of parity between Medicare and Medicaid physician reimbursement that encourages physician participation. (LATE RES 8-P, AM 2012) 260.995 Analysis of Individual Procedures for Payment Reduction The Colorado Medical Society (CMS) encourages the Centers for Medicare and Medicaid Services to conduct a thorough analysis of data prior to the implementation of any multiple procedure percentage reduction (MPPR) into the Medicare program to determine what efficiencies actually exist. CMS believes that the best avenue for this analysis and recommendation is done at the individual procedure/service level through the existing AMA RUC process. NEEDS CITATION 260.996 Correction of Medicare Under-reimbursement to Colorado Physicians The Colorado Medical Society (CMS) continues to encourage our congressional delegation to introduce and support legislation that would remedy the Medicare’s Geographic Practice Cost Indices (GPCI) adjustment for Colorado, so that Medicare reimbursement to Colorado physicians becomes comparable to the reimbursement in regions with similar costs of living. The CMS shall continue to work with the Governor and other state officials to document the impact of low Medicare reimbursement on Colorado and encourage the Centers for Medicare and Medicaid Services to support legislation to remedy the current inequities. (Revised Late RES-28, AM 2002) 260.997 Terminating Participation in Medicare - Managed Care Plans’ Responsibility to Patients While the Colorado Medical Society (CMS) recognizes the managed care plan’s right to make business decisions, they are responsible for assuring their enrollees receive the health care needed with a minimal amount of disruption. It is ultimately the responsibility of the HMO to help minimize the financial impact to the patient and to assist in the transition of care. The CMS encourages any managed care organization terminating a particular line of business or terminating a particular group of insureds to: • Establish education sessions for enrollees outlining options available to them and steps to be taken to review those options; 69 CMS Policy Manual September 2013 • Develop a list of resources available to assist patients, such as government agencies, consultants etc.; and • Implement the CMS/Colorado Association of Health Plan’s “Recommended Elements of Transition of Care”. Additional Information: Recommendations for Transition of Care (RES-15, AM 1999) 260.998 Medicare Changes to Ensure Patients’ Access to Physicians The Colorado Medical Society encourages the federal Congressional Delegation and their health advisors, to affect changes that would encourage doctors to continue to see Medicare patients. Some suggested changes are: reduction of the massive paperwork, difficulty in obtaining ancillary services, and hassles inherent in the threat of fraud charges. (RES-23, AM 1999) 260.999 Control of Medicare Spending Growth The Colorado Medical Society opposes the use of Expenditure Targets/Sustained Growth Rate to control the volume of services rendered to Medicare beneficiaries and supports a more appropriate approach through funding research on the effectiveness of medical interventions to determine the effect on their outcomes, or the use of accountable focused peer review to examine the variant utilization patterns of Medicare Part B providers. These recommendations take into account the variables of new technologies and other factors that contribute to increased volume. (RES-50, AM 1989, and RES-22, AM 1988) 265 Mental Health 265.998 Nondiscrimination in Mental Health and Substance Abuse Insurance Benefits Similar to American Medical Association policy 185.986, the Colorado Medical Society (CMS) opposes discriminatory benefit limitations, referral mechanisms, co-payments or deductibles for the treatment of psychiatric illness and substance abuse under existing care plans, and opposes discrimination in any proposed plans for national health care coverage or universal access for the people who are uninsured. The CMS affirms its opposition to discriminatory benefit limitations, co-payments or deductibles for the treatment of psychiatric illness and substance abuse under any health care plan. The CMS supports parity of medical coverage for mental illnesses and substance abuse. (Motion of the Board, March 2004) 265.999 Parity for Mental Health in Medical Benefits Programs The Colorado Medical Society supports parity of medical coverage for mental illness and substance abuse and opposes discrimination in benefit limitations, referral mechanisms, co-payments or deductibles for the treatment of mental illness and substance abuse. (RES-19, AM 2002) 270 Non-Physician Providers 270.992 CMS and Specialty Society Principles Regarding APN Scope of Practice Physician-Led Health Care Teams 1. Health care that is effective, efficient, and safe results from the work of patient-centered provider teams – networks of individual providers acting in well-integrated and well-defined relationships. This has always been so for in-patient hospital care, and is increasingly a hallmark of high-quality health care in every medical setting. 2. Provider teams may work in a number of forms, varying with the needs of the patient, the environment in which the care is being provided, and the skills and training of the members of the 70 CMS Policy Manual September 2013 team. In all cases each provider’s work is integrated with the work of others for the betterment of the patient. 3. All effective health care teams respect the specialized skills and knowledge of each participating member; and each member contributes in a defined and coordinated way to achieving optimal care and optimal patient outcomes. 4. The duties, responsibilities, supervisory relationships and boundaries for each member of the team should be explicitly delineated by protocols, medical staff rules, or other similar means. 5. Leadership and overall responsibility for patient care are essential requirements for all effective, efficient and safe medical care. While every provider working in a team contributes a specialized capability, leadership is necessary to integrate the whole to maximize the health benefits to the patient. By the greater depth, length and breadth of their medical education, training, and experience physicians are in most circumstances uniquely qualified for this role. Scope of Practice 1. The optimal degree of interaction among the members of a team is environment-dependent. It may vary with the setting, the facility, and the area of health care. An Advanced Practice Nurse, for example, may have less direct physician contact or supervision in a rural clinic than in a major-city hospital, yet for the same reason require more readily available access to physician expertise. The central criterion is that which provides the best quality and safest care. 2. In no circumstance may Advanced Practice Nurses or other health care professionals practice beyond their license, education, training and experience. 3. Facilities such as hospitals, group practices, out-patient clinics, ACOs and other integrated-care arrangements must establish guidelines or protocols describing the scope of practice for Advanced Practice Nurses and other health care professionals. Such guidelines must be established with participation from physicians having experience and skill in the type of health care being provided. In hospitals the protocols and guidelines should have approval of the medical staff and governing board of the facility. 4. Where facilities establish the scope of practice with guidelines or protocols, the facility must be accountable for the effects of their application. Nurse Anesthetists 1. The practice of Nurse Anesthetists is subject to all of the preceding principles, and to additional considerations reflecting the nature of anesthesiology and its diverse applications. 2. A nurse anesthetist must be supervised either by an anesthesiologist or by the operating physician for the procedure. If not in continuous physical presence, the supervising physician must be immediately available to attend to the patient when needed. 3. In settings without anesthesiologists the supervising physician may be the operating surgeon, obstetrician, or other physician performing the procedure if the facility’s medical staff and governing board determine that the supervising physician has the necessary skill and training to provide such supervision. 4. If in any case the supervising physician or the nurse anesthetist determines that there is not the necessary expertise within the team to perform a procedure safely, that procedure should not be performed. (BOD-1, AM 2012) 270.993 Scope of Practice The Colorado Medical Society (CMS) advocates for patient safety and quality care in an integrated health care model including, without limitation, maintaining: 71 CMS Policy Manual September 2013 1. Statutory requirements for collaborative agreements between advanced practice nurses and physicians; 2. Defined prescriptive practice for advanced practice nurses; and, 3. The requirement for medical direction and supervision of CRNAs (certified registered nurse anesthetists). Furthermore, CMS believes that advanced practice nurses should only function in an integrated practice arrangement with physician backup. The Colorado Medical Society will advance efforts to expand the supply of health care providers in rural areas, either by its own models of rural health care delivery or by supporting the efforts of rural health care delivery experts. (BOD-1, AM 2009) 270.994 Naturopaths The Colorado Medical Society opposes the licensing of naturopaths and supports enforcing the Medical Practice Act, which prohibits the unlicensed practice of medicine and the use of the term physician by any person other than an MD or DO. (RES-4, AM 2005) 270.995 Physical Examinations The Colorado Medical Society will seek legislation defining the physical examination of athletes for sports participation, or of driver candidates for operation of commercial vehicles within the State of Colorado, as being the practice of medicine legally restricted to either a person possessing a license to practice medicine or a person performing a delegated medical function. (RES-14, AM 2003) 270.996 Opposition to Psychologists Prescribing Medication The Colorado Medical Society opposes prescriptive authority for psychologists. (Late RES-29, AM 2002) 270.997 Non-Physician Providers The Colorado Medical Society (CMS) defines non-physician providers (NPPs) as physician assistants (PAs) and advanced practice nurses (APNs). The CMS defines APNs as professional nurses with additional education and clinical experience beyond traditional nursing education. APNs include clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, and nurse practitioners. The CMS encourages the profession of medicine to study the roles, education, scope of practice, potential for autonomy and accountability, and quality issues regarding NPPs to create a basis for informed recommendations and ongoing dialogue with public policy makers and other health professionals. 1. Role The CMS supports incentives to facilitate the education and practice of NPPs that focus on the need for (medical) primary care skills. 2. Education The CMS supports minimum education requirements and minimum clinical experience requirements for all NPPs. The CMS supports the requirement for a master’s level of education in order to be eligible for the title of APN. The CMS supports the definition of APN in Colorado statute to assure title protection and appropriate educational preparation. In addition to specific education requirements the CMS supports a clinical experience criterion, such as a formal internship. The CMS believes that the PA programs, which include minimum education requirements, clinical experience and certification, provide an excellent model for NPP licensure. 72 CMS Policy Manual September 2013 The CMS recommends that physicians have input into the education and clinical requirements of NPPs in Colorado, specifically with regard to that content which is in the domain of medicine. 3. Scope of Practice The CMS supports the development and implementation of uniform regulations for both APNs and PAs. Any functions that are traditional to the practice of medicine must be accompanied by specific education, certification, clinical experience, and require physician review and approval. a. Independent Medical Functions: The CMS believes that independent medical functions should be limited to those practitioners who are licensed to practice medicine as defined in the Medical Practice Act. NPPs do not have the minimum education, clinical experience and certification tests required by the Medical Practice Act. b. Collaborative Practice: The CMS supports the concept of collaborative practice between physicians and NPPs. Collaborative practice includes those medical functions that relate to self-limited and stable chronic conditions, as well as preventive services, provided by an NPP, which do not require the physical presence of the participating physician. The CMS supports mechanisms to facilitate collaborative practice plans. c. NPP Practice with Delegated Medical Functions: The CMS recognizes that currently NPPs perform delegated medical functions under existing statutes. The CMS recommends no modifications of this practice with the following exceptions: I. On-site physician supervision shall not be limited to a specific number of NPPs, provided the physician supervisor can document adequate supervision. II. Specific protocols are not required with on-site supervision. III. Physician sign off on charts is required weekly. 4. Representation of NPPs in the CMS The CMS supports dialogue between organized medicine and NPPs in order to promote the role of NPPs as members of the health care team. Additional Information: Collaborative Practice Plan Guidelines (RES-44, AM 1994) 270.998 Collaboration Among Physicians, Physician Assistants, Nurses and Pharmacists The Colorado Medical Society supports the collaboration of advanced practice nurses, clinical pharmacists, physician assistants and physicians which would define and clarify educational standards and expand the role of this team especially in medically underserved areas and populations. (RES-54, AM 1993) 270.999 Regulation of Allied Health Professionals The Colorado Medical Society supports the following position on regulation of allied health professionals: 1. Regulation should be imposed upon a profession only for purposes of protecting the public. 2. If regulation is needed, the form of regulation should be that which is least restrictive necessary to protect the public interest. 3. If regulation is imposed, the regulation should be subject to periodic review by the legislature to insure its continuing necessity and appropriateness. 4. Definitions: Certification (also called Title Protection): granted to an individual who has met certain prerequisite qualifications. Includes the right to use the “title” of the profession or occupation or to assume of use the term ‘‘certified’’ in conjunction with the title. Licensure: a process by which a statutory regulatory entity grants to an individual who has met certain prerequisite qualifications, the right to perform prescribed professional and occupational tasks and to use the title of the profession or occupation. Registration: a process which requires that, prior to rendering services, all practitioners formally notify a regulatory entity of their intent to engage in the profession or occupation. 73 CMS Policy Manual September 2013 5. Standards: A profession or occupation shall be regulated by the state only when: • It can be demonstrated that the unregulated practice of the profession or occupation can clearly harm or endanger the health, safety, or welfare of the public, and the potential for the harm is recognizable and not remote or speculative; • The public can reasonably be expected to benefit from an assurance of initial and continuing professional ability; and • The public cannot be effectively protected by other means in a cost effective manner. The least restrictive method of regulation shall be imposed, consistent with the public interest: a. If existing common law and statutory civil remedies and criminal sanctions are insufficient to reduce or eliminate existing harm, regulation should occur through enactment of stronger civil or criminal sanctions; b. If a professional or occupational service is performed primarily through business entities that are not regulated, the business entity or facility should be regulated rather than the employee practitioners; c. If the threat to public health, safety, or welfare is relatively small, regulation should be through a system of registration; d. If the consumer may have a substantial interest in relying on the qualifications of the practitioner, regulation should be through a system of certification; or e. If it is apparent that the public cannot be adequately protected by any other means, a system of licensure should be imposed. 6. Criteria for consideration (Regulation): • How does the profession or occupation relate to the practice of medicine? • What is the nature of the potential harm to the public? • Are there specific examples of such harm? • How will the practice of quality medicine be affected? • Extent to which consumers will benefit from a method of regulation for this profession or occupation? • Extent to which physician practice will be affected? • Extent to which practitioners are autonomous, as indicated by: a. Degree to which practice requires independent judgment b. Degree to which practitioners are supervised c. Efforts previously made to address the concerns giving rise to the current need for regulation d. Why alternatives to regulation would not be adequate to protect the public interest e. Benefit to the public if regulation is granted f. Extent to which the public interest might be harmed by regulation of the profession or occupation, including the effect that the registration, certification, or licensure will have on the costs of the services to the public g. How the standards of the profession or occupation will be maintained h. Profile of the Practitioners in the state, including a list of associations representing the practitioners, and an estimate of the number of such practitioners in each association. (RES-21, IM 1990) 74 CMS Policy Manual September 2013 275 Nurses and Nursing 275.999 Aid to Nursing Profession The Colorado Medical Society will pursue an active liaison with the nursing profession, offer active support to the nursing profession in terms of non-financial help and work in conjunction with the nursing profession to address the shortage of nurses in Colorado with the legislature as well as concerned medical institutions. (Late RES-36, AM 2002) 280 Occupational Health 280.991 Workers’ Compensation Benefit Caps The Colorado Medical Society supports legislative efforts to increase the total amount of disability benefits payable under the “Workers’ Compensation Act of Colorado.” (RES-5, AM 2002) 280.992 Workers’ Compensation Utilization Review The Colorado Medical Society supports a policy for provider disciplinary actions under Workers’ Compensation utilization review that includes peer review of all clinical issues, an opportunity for providers to present their case, present additional information and answer questions. The provider will be afforded at least two (2) levels of appeal. (Late RES-13, IM 1998) 280.993 Division of Workers’ Compensation Peer Review Activities Any peer review activities by the Division of Workers’ Compensation shall be implemented in compliance with state and federal regulations governing peer review activities and confidentiality. (RES-64, AM 1996) 280.994 Workers’ Compensation-Level 1 Accreditation The Colorado Medical Society opposes mandatory Level 1 accreditation for physicians treating Workers’ Compensation injuries. (Motion of the Board, January 1996) 280.995 Independent Medical Examination Colorado Medical Society supports the integrity of the “Independent Medical Examination” by assuring that a physician can determine who will be present during examination. If the physician’s integrity is abridged by judicial action, the physician has the right to refuse to perform the examination. (RES-14, IM 1993) 280.996 Patient Solicitation The Council on Ethical and Judicial Affairs considers the practice of soliciting patients through the “Independent Medical Examination” process to be unethical and constitutes a violation of the Colorado Medical Society’s Code of Ethics. (Motion of the Board, January 1993) 280.997 Workers’ Compensation and Health System Reform The following aspects of Workers’ Compensation health care are critical and must be considered when developing an overall health care reform plan: 1. Medical decision-making must continue to be a physician responsibility. 2. We support managed care within the Workers’ Compensation system with employer and employee input into the structure of that system. 3. Maintain recognition of physician case management reimbursement including appropriate reimbursement for impairment ratings. 75 CMS Policy Manual September 2013 4. Provider payments must be commensurate with current prevailing reimbursement levels in the State of Colorado. (Motion of the Board, November 1992) 280.998 Unfair Treatment of Occupationally Injured Patients The Colorado Medical Society (CMS) continues to support fair and equal treatment of occupationally injured patients in the Workers’ Compensation system. The CMS will continue to work with the Governor and Legislature on an on-going basis to ameliorate inequities in the Workers’ Compensation Act. (RES-75, AM 1991) 280.999 Continued Improvements to the Colorado Workers’ Compensation System The Colorado Workers’ Compensation system should provide the highest level of benefits to the worker with proper incentives for the worker to return to productive employment as soon as possible. The Colorado Medical Society shall work directly with the business community, the state legislature, the Department of Labor and Employment, labor organizations and other appropriate groups to improve the Workers’ Compensation System. (RES-28, IM 1990) 285 Peer Review 285.993 Colorado Professional Peer Review Act Sunset Colorado Professional Peer Review Act Sunset Guiding principles for peer review sunset: CMS believes that statutory changes to CPRA should strengthen professional review processes that: Improve patient safety and contribute to ongoing education in the health care system • Improve provider accountability • Are fair • Provide for consistency in data collection • Contain safeguards to minimize the potential for abuse • Minimize adversarial situations • Promote teamwork among stakeholders Recommendations 1. Schedule sunset for five years in order to create momentum for continued work by physicians and hospitals on consistency and predictability of peer review processes. 2. Harmonize CPRA with federal peer review law to minimize conflicts. 3. Clarify the definition of records to eliminate disputes about what is and is not admissible in court. 4. Expand the definition of entities that qualify as professional review committees to reflect new, non-hospital-based models of care. 5. Procedural improvements, including: a. Expand the jurisdiction of the Committee on Anticompetitive Conduct to include any claim of unreasonable conduct related to peer review. b. Require training for service on professional review committees. c. Require all professional review organizations to have, and uniformly apply, written triggers for review and investigation. d. Require that physicians under review have reasonable notice and an opportunity to respond to issues being considered, as well as access to such information and documents as are reasonably necessary to respond to a review or investigation. e. Require all professional review organizations to institute a process for objectively validating the efficacy of its professional review system, e.g., external audits. 76 CMS Policy Manual September 2013 f. Stipulate that CPRA confidentiality protections may not be undermined by technical defects in a review, provided the process itself complies with CPRA and an individual review is in substantial compliance with the process. g. Allow credentialing entities to share peer review data without losing confidentiality protections (this recommendation echoes a bill that CMS and COPIC tried to pass some years ago). (BOD-1, AM 2011) 285.994 Quality of Care and Medical Staff Review The Colorado Medical Society (CMS) believes that all quality of care issues pertaining to inpatient care should be referred to and evaluated by the hospital medical staff to determine whether physician and/or hospital quality assurance problems exist. The CMS maintains that medical staffs must be involved in resolving all hospital quality assurance problems pertaining to patient care and should be encouraged to take the initiative in these matters. The CMS supports the following principles regarding medical staff and quality assurance: 1. The care of the hospitalized patient should be under the direction of a physician (M.D. or D.O.) who is a member of the medical staff; 2. Peer review of medical care should be conducted by physicians on the medical staff; 3. Utilization review and Quality Assurance activities should be conducted under the direction of the medical staff; 4. Nursing and allied health staff should participate in quality assurance activities when appropriate; and 5. Quality assurance activities should not be conducted without medical staff involvement. (Motion of the Board, March 2004) 285.995 Support of Physician Peer Review The Colorado Medical Society (CMS) supports the concept of physician peer review and the direct involvement and participation of Colorado physicians in the peer review process. The CMS believes that the Colorado Foundation for Medical Care is the appropriate body to conduct peer review in the state. (Motion of the Board, March 2004) 285.996 Health Plan External Grievance Review All external grievance review procedures for adverse health plan decisions shall include the following basic components: 1. It should apply to all health carriers in Colorado; 2. Grievances involving adverse determinations can be submitted by the policy holder, their representative or their attending physician; 3. Issues eligible for external grievance review should include, at a minimum, denials for a) medical necessity determinations; and b) determinations by a carrier that such care was not covered because it was experimental or investigational; 4. Internal grievance procedures should generally be exhausted before requesting external review; 5. An expedited review mechanism should be created for urgent medical conditions; 6. Independent reviewers in the same community should be used whenever possible; 7. Patient cost-sharing requirements should not preclude the ability of a policyholder to access such external review; 8. The overall results of external review should be available for public scrutiny with procedures established to safeguard the confidentiality of individual medical information; and 9. External grievance reviewers shall, whenever possible, obtain input from physicians involved in the area of practice being reviewed. If the review involves specialty or sub-specialty practice, the input shall, whenever possible, be obtained from specialists or sub-specialists in that area of medicine. 77 CMS Policy Manual September 2013 (RES-26, AM 1998) 285.997 Peer Review, Corrective Action and Exclusive Contracts Exclusive contracts should never be used as a mechanism to solve quality assurance problems in lieu of appropriate peer review processes. When there are quality assurance issues, exclusive contracting may result but the medical staff should be involved through the application of appropriate peer review processes, bearing in mind due process procedures. (RES-37, AM 1991) 285.998 Center for Personalized Education for Physicians (CPEP) The Colorado Medical Society supports the Center for Personalized Education for Physicians. (RES-1, AM 1991) 285.999 Peer Review Organization (PRO) Data Dissemination The Colorado Medical Society (CMS) discourages the use of any peer review organization (PRO) data by any hospital, medical staff, or other body for credentialing purposes. The CMS strongly urges PROs to discontinue (or refrain from initiating) dissemination of any such utilization review or quality data collected from their work under their scope of practice for credentialing or any other similar purpose. (RES-66, AM 1991) 290 Physician Fees 290.999 Medicare Fees The Colorado Medical Society supports all efforts to minimize all government controls on physicians’ fees. (Substitute Resolution in lieu of RES-15 and RES-25, IM 1987) 295 Physician Payment 295.985 Physician Preparedness for Payment Reform Goal CMS should help physicians to understand, prepare and transition to new and evolving payment system. Objectives 1. Educate physicians about alternative systems of payment and the opportunities and challenges they present for different physician specialties 2. Identify opportunities in each specialty for reducing health care costs that do not harm physicians or patients, and identify the barriers to realizing those opportunities 3. Develop physician consensus on specific recommendations about payment system design that will best enable physicians to help improve value in health care 4. Identify assistance needed to ensure the success of those preferred payment systems 5. Identify roles that the Colorado Medical Society can play to ensure that Colorado implements payment and delivery reforms in the most effective way 6. Help physician practices make the necessary changes to be successful under new payment models Strategies 1. Develop and drive a multi-pronged educational campaign that helps physicians understand the evolution of payment systems from those that reward volume to those that reimburse for value. 2. Contract with nationally-recognized payment reform expert Harold Miller in a three-part engagement to include a multi-specialty summit in the winter, at the 2011 Spring Conference and at the fall 2011 Annual Meeting 3. Utilize the Systems of Care/Patient-centered Medical Home Initiative to connect payment reform to existing work on building out patient-centered medical homes, medical neighborhoods and other systems of care 78 CMS Policy Manual September 2013 4. Create a framework and promote forums for intra- and inter-disciplinary dialogue on payment reform 5. Connect reasons why use of data and clinical/business performance improvement activities can help to position a practice/specialty for alternative payment systems and broader system transformation 6. Closely coordinate physician education campaign with Colorado’s Center for Improving Value in Health Care (CIVHC), the American Medical Association and other physician-driven organizations (BOD-1, AM 2011) 295.986 Payment Reform CMS will actively monitor payment reform initiatives at national and local levels, educate physician members on how new payment models can and will impact their practices and the quality and cost of care, and aggressively seek out opportunities to participate in payment reform initiatives in Colorado to ensure that physicians are well represented in new programs from the start. (COPE-1, AM 2010) 295.987 Budget Neutrality Factor The Colorado Delegation to the American Medical Association (AMA) shall encourage the AMA to oppose the commercial plans’ use of adverse adjustment factors designed for use by government plans. The Colorado Delegation to the AMA shall encourage the AMA to support federal legislation requiring transparent and separate identification of the use of all adjustment factors, including the Budget Neutrality Factor, by commercial plans. (RES-19, AM 2008) 295.988 Delivery of Multiple Services to Patients at a Single Encounter The Colorado Medical Society supports the reform of payment rules amongst all payers that penalize the delivery of more than one service to patients at single encounter or on a single day. The Colorado Delegation to the American Medical Association (AMA) shall bring a similar resolution to the AMA. (RES-13, AM 2008) 295.989 Medical Directors’ Responsibility in Denial of Procedures The Colorado Medical Society take appropriate actions through its quarterly payers meetings and in discussions with the Colorado Insurance Commissioner and the legislature to require insurance companies to have their medical director call the ordering physician during regular office hours if a test or procedure is denied and not just send a denial. (RES-12, AM 2005) 295.990 National Prompt Payment The Colorado Medical Society supports federal legislation that would extend the Colorado Prompt Payment Statute nationwide. (RES-18, AM 2004) 295.991 Reimbursement for Telephonic and Electronic Communications Physicians should be compensated for their professional services based on a uniform policy, at a fair fee of their choosing, for established patients with whom the physician has had previous face to face professional contact, whether the current consultation service is rendered by telephone, fax, electronic mail or other forms of communication. The Colorado Medical Society (CMS), both singularly and jointly through their American Medical Association delegation, press the Centers for Medicare & Medicaid Services and other payers for separate recognition of such supplemental communication work as discrete services, not as bundled into 79 CMS Policy Manual September 2013 existing service codes or, have such services recognized as “not covered by Medicare” and therefore chargeable as a patient convenience outside the benefit package of Medicare. The CMS shall continue to work with employers and insurers to discuss the value of electronic communications to their employees/insureds both from a triage and cost effective basis and is worthy of coverage. In addition, CMS shall prepare a public education initiative to explain the appropriateness and necessity of paying for physicians’ professional time. (RES-25, AM 2002) 295.992 Retroactive Denial of Payment The Colorado Medical Society opposes the unfair practice of retroactively denying payment of claims. (RES-21, AM 2000) 295.993 Physician Charge Audit Procedures The Colorado Medical Society supports the averaging of coding discrepancies with respect to audits of physicians’ charging practices so that both high and low coding is taken into account in arriving at a final audit report. (RES-14, AM 2000) 295.994 Reimbursement for Paperwork Completion The Colorado Medical Society believes physicians should receive reimbursement for completion of mandated forms. (RES-36, AM 1993) 295.995 Fair and Equitable Payment The Colorado Medical Society supports the concept of payment that is fair and equitable across specialty lines and across geographic areas. (RES-48, AM 1993) 295.996 Standardized Eligibility for Health Benefits The Colorado Medical Society supports a standardized system of verifying eligibility for health benefits. Health insurers shall pay physicians for any services rendered to patients whose eligibility for benefits have been verified and approved. (RES-66, AM 1992) 295.997 Reimbursement of Expenses Incurred with Office Procedures Overhead expenses incurred by physicians when rendering office procedures should be reimbursed at actual cost when appropriate documentation is supplied to the third party payer. Actual cost should be inclusive of invoice cost, personnel costs, and all associated costs appropriately applied. This policy applies to all third party payers including Medicare and Medicaid. (RES-34, AM 1991) 295.998 Excessive Requests for Information The Colorado Medical Society opposes excessive and unnecessary requests for additional information and unexplained delays in processing and payment by third party insurance carriers where a completed standard claim form for reimbursement has been submitted. (RES-44, AM 1991) 295.999 Endorsement of Resource-Based Relative Value Scales The Colorado Medical Society supports a resource-based relative value approach as a method of Medicare reimbursement. (RES-2, IM 1989) 80 CMS Policy Manual September 2013 300 Physicians 300.994 Physician Rights Board Action 1: Approved increased due process protections that allow providers to fairly challenge adverse credentialing, quality, or service reviews. Board Action 2: Approved objective review triggers for provider reviews that are written and consistently applied. Board Action 3: Approved change in Pinnacol’s Network Affiliation Committee to a majority of physicians with the power to make binding recommendations. Board Action 4: Approved change in Pinnacol’s “Without Cause Termination” policy to make clear that the guidelines providing due process protections apply when disaffiliation involves any Quality of Care or Quality of Service matter, eliminating use of “without cause” contract provisions to circumvent these processes. Board Action 5: Written notice, investigations, and adverse actions: Approved a change in Pinnacol’s policies to require existing processes provide for written notice and an opportunity for physicians to be heard until Pinnacol has made a determination about taking adverse action. (BOD-1, AM 2011) 300.995 Diversity in Medicine The Colorado Medical Society shall encourage pipeline activities that ready a diverse application pool of qualified students who are prepared to study medicine, encourage diversity-conscious admissions policies and encourage continued research that will help meet the health care needs of vulnerable populations in urban and rural communities that will address persistent disparities in health care. (RES-2, AM 2008) 300.996 Commitment to Physician Rights The Colorado Medical Society reaffirms its commitment to the principles of the physician as a patient advocate, the right of the physician to peer review and medical staff privileges and the right of the physician to work. (Late RES-26, AM 2001) 300.997 Increase in the Numbers of Primary Care Physicians The Colorado Medical Society encourages the identification and funding for incentives to increase the number of primary care physicians in Colorado, especially in rural areas, with emphasis on improving access to quality health care in those rural areas in general. (RES-16, IM 1993) 300.998 Second Opinions The Colorado Medical Society supports the right of the patient to participate in the selection of the physician to provide a second opinion. (RES-37, AM 1987) 300.999 Definition Colorado Medical Society recommends that the term “physician” wherever used continue to be only applied to persons having graduated from a school of medicine or osteopathy and otherwise satisfied the legal requirements to practice medicine as outlined by the Medical Practice Act. (RES-16, IM 1979) 81 CMS Policy Manual September 2013 305 Practice Parameters 305.998 Clinical Practice Guidelines The Colorado Medical Society encourages the development of clinical practice guidelines that conform to the following principles: 1. Clinical practice guidelines state that they are guidelines, not standards; 2. Clinical practice guidelines be developed with the involvement of physicians who use them; 3. Clinical practice guidelines include a rating scheme for strength of evidence, such as that published by the U.S. Preventive Services Task Force; 4. Clinical practice guidelines be periodically reviewed for conformance to best medical practice, based on reasonable medical evidence. Such review will occur no less often than every two years; and 5. Clinical practice guidelines be distributed to those who might use them, and that any organization or individual making use of such a clinical practice guideline will use the guideline only for educational and/or quality improvement purposes. (RES-1, AM 1999) 305.999 Guidelines for Use of Standards in Physician Office Assessment The Colorado Medical Society (CMS) adopts the following guidelines regarding how a physician office assessment is conducted and criteria for development and use of guidelines: 1. The focus of evaluation should be on those processes of care where adherence to a guideline results in improvements in patient outcomes and compliance with state and federal regulations and statutes. 2. Evaluations should include tools to help physicians improve the process of care and should track progress over time. 3. The evaluation should be physician and physician staff specific and valid in reflecting the appropriateness of decisions rendered by the physician and the physician’s staff. 4. Guidelines for evaluations should be: explicit; evidence-based; comparable between insurers; and recommended by national authorities and/or professional medical societies and in compliance with state and federal regulations and statutes. 5. Physicians should not be held responsible for outcomes beyond their control. The measurements used must be explicit, objective methods to ensure consistency and comparability. Measurements shall be adjusted for factors such as patient compliance, plan design, patient case-mix, co morbidity, scope of practice, severity of illness, heredity, lifestyle, and environment. 6. Guidelines and methods of measurement should be presented to the physician prior to the office assessment. 7. Conflicting guidelines should not be adopted. 8. Evaluations should quantify and document the accuracy, consistency, and statistical validity of the findings. 9. Optimal objectivity in the collection and reporting of evaluations should be validated through internal methodology by the health plans, or done by an independent objective organization. 10. The scores from evaluations should provide a reference for physicians and physicians’ staff to compare with the aggregate scores achieved by other physicians and physicians’ staff currently in practice, providing similar services, in a confidential manner, with the goal of enhancing meaningful quality improvement activity. 11. The physicians should have access to their raw data used to compile their scores. 12. An appeals process should be available for physicians who disagree with findings or dispute the evaluations. Evaluations should remain confidential until reviewed by the physician and the physician has had the opportunity to express concerns. The scores from evaluations and the physician’s concerns should be released only to those organizations with whom the physician has a written agreement. 82 CMS Policy Manual September 2013 The CMS makes these guidelines available to physicians and appropriate interested parties upon request; and the CMS assists its members with problems that may arise due to nonconformity of these guidelines by the office assessment companies. The CMS works with the Colorado HMO Association, individual organizations and other organizations or individuals contracted to perform physician office assessments, to encourage voluntary compliance. (RES-58, AM 1996) 310 Pregnancy and Child Birth 310.998 Home Delivery of Newborns The Colorado Medical Society (CMS) believes that in-hospital obstetrical care should be a healthy, family oriented experience. The CMS supports efforts to educate patients about the relative risks of home delivery in order to enable more informed decision-making. The CMS does not support the practice of home deliveries in Colorado because of the increased risk for adverse outcomes for mother and baby. (Motion of the Board, March 2004) 310.999 Length of Hospital Stay Following Obstetric Delivery The Colorado Medical Society believes post-partum stays shall in the opinion of the attending physician be sufficient for the adequate recovery and instructional guidance for mothers and newborns and that appropriate ambulatory services should be provided in the early post-partum period. (RES-18, IM 1996) 315 Prisons 315.998 Executions Physician participation in executions is a personal and moral decision; and physicians should not be required to participate in an execution. (Substitute RES-26, IM 1996) 315.999 Health Care and Corrections The Colorado Medical Society supports sanitary conditions in jails and the humane treatment of inmates during the delivery of health care services in correctional facilities. (RES-18, IM 1981) 320 Professional Liability 320.996 Reporting on Applications The Colorado Medical Society opposes the need for reporting on medical staff and other non-licensing board applications, including insurance company credentialing applications, (except for professional liability insurance applications) any threatened, pending, or closed professional liability claims where the claim did not result in payment on behalf of that physician. Credentialing applications should not contain questions that are subjective and accusatory in nature such as: “Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?” or “Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated, mediated or litigated)? If yes, provide information for each case.” A limitation of not more than five years should be placed on the centralized credentialing collection services to implement this policy. (RES-28, AM 2004) 320.997 Colorado Tort Reform Priority The Colorado Medical Society will make the preservation and expansion of civil liability tort reform by legislation and all other means a top priority. (RES-22, AM 2002) 83 CMS Policy Manual September 2013 320.998 Governmental Immunity The Colorado Medical Society supports the expansion of the Colorado Governmental Immunity Act to cover all state licensed physicians while engaged in the care of the indigent patient. (RES-40, AM 1996) 320.999 Malpractice Liability/Tort Reform The Colorado Medical Society supports both tort reform and innovative solutions to liability insurance problems that affect the citizens of Colorado. (Substitute RES-79, AM 1987) 325 Public Health 325.975 Inquiry of Gun Ownership The Colorado Medical Society encourages physicians to include inquiry of gun ownership and subsequent discussion of gun safety as an element of their practice, as appropriate, and will work with the specialty society community to support development of specialty-appropriate guidelines to encourage and support this activity. (RES 3-P, AM 2013) 325.976 Firearm Safety Policies CMS Firearm Safety Policies adopted by the CMS Board of Directors in 2013 The BOD voted unanimously on March 15, 2013 to support: • Reinstituting universal background checks for buyers • Strengthening mental health checks at purchase (Motion of the Board, March 2013) 325.977 Preventing Violent Crime through Expanding Mental Health Services The BOD voted to support Gov. Hickenlooper’s proposal to strengthen Colorado’s mental health system in response to firearm violence and, in addition to the elements set forth in his proposal, the Board further suggests more mental health workers and patient beds, more emergency mental health workers, more mental health workers that are available to treat dual diagnosis of substance abuse and mental health illness, and more emphasis on pediatric mental health care.” The five key strategies of the Governor’s plan include: 1. Provide the right services to the right people at the right time. o Align three statutes into one new civil commitment law. This alignment protects the civil liberties of people experiencing mental crises or substance abuse emergencies, and clarifies the process and options for providers of mental health and substance abuse services (requires legislative change). o Authorize the Colorado State Judicial System to transfer mental health commitment records electronically and directly to the Colorado Bureau of Investigation in real-time so the information is available for firearm purchase background checks conducted by Colorado InstaCheck (requires legislative change). 2. Enhance Colorado’s crisis response system ($10,272,874 budget request). o Establish a single statewide mental health crisis hotline. o Establish five, 24/7 walk-in crisis stabilization services for urgent mental health care needs. 3. Expand hospital capacity ($2,063,438 budget request). o Develop a 20-bed jailed-based restoration program in the Denver area. 4. Enhance community care ($4,793,824 budget request). 84 CMS Policy Manual September 2013 o Develop community residential services for those transitioning from institutional care. o Expand case management and wrap-around services for seriously mentally ill people in the community. o Develop two 15-bed Residential Facilities for short-term transition from mental health hospitals to the community. o Target housing subsidies to add 107 housing vouchers for individuals with serious mental illness. 5. Build a trauma-informed culture of care ($1,391,865 budget request). o Develop peer support specialist positions in the state’s mental health hospitals. o Provide de-escalation rooms at each of the state’s mental health hospitals. o Develop a consolidated mental health/substance abuse data system. The Governor’s plan would be: • Implemented through the Office of Behavioral Health at the Colorado Department of Human Services. • Coordinated and in partnership with the state’s Behavioral Health Organizations, Community Behavioral Health Centers, state and local law enforcement, the Department of Public Safety, the Department of Health Care Policy and Financing, the Department of Public Health and Environment, the numerous highly-skilled providers and advocates across the state, and many hospitals and psychiatric emergency medical partners. Details of the Governor’s budget request include: • $13 million to provide services to 809 additional people with developmental disabilities, including an increase of 576 funded waiver slots to eliminate the Children’s Extensive Services Waiver Program waiting list. Currently 2,400 individuals are on the wait list to access Developmental Disability services. The Governor’s budget proposal reduces that wait list by 30%. • $1.8 million in continuing funds to provide Early Intervention and Case Management services for children from birth to 2 years of age. • $17.7 million for strengthening Colorado’s Behavioral Health system including $10.3 million for expansions of the behavioral health crisis response system; $4.8 million for improving behavioral health community capacity; and $2.1 million for increasing access to civil beds for those defendants determined incompetent to proceed with their trials. • $6.8 million for County Administration Food Assistance, including $2 million to cover county administrative costs associated with a projected increase in caseload with implementation of health care reform. • $15.5 million for a 1.5% rate increase in provider rates. • $1.3 million to compensate for increasing utility costs. • $3.8 million to provide services for elderly adults in needs, including a 1.7% Cost of Living increase for Old Age Pension recipients. • $860,000 to modernize Departmental data and IT systems. • $5 million as a legislative set aside for the estimated costs of the recommendations of the Elder Abuse Task Force to increase protections for vulnerable seniors. These costs will fund a system of mandatory reporting of instances of exploitation or mistreatment of seniors. (Motion of the Board, January 2013) 325.978 Body Art The Colorado Medical Society requests that the Colorado Board of Health make inspections of body art facilities in accordance with 6CCR 1010-22, basic public health services required of all public health departments, and implement a registration program for body art facilities. 85 CMS Policy Manual September 2013 (RES-2, AM 2009) 325.979 Disaster Communication/Preparedness The Colorado Medical Society supports a secure, statewide, noncommercial, disaster preparedness database dedicated to the singular purpose of recording participating physicians’ contact preferences during disasters, with access strictly limited to authorized officials. (RES-9, AM 2008) 325.980 National Immunization Registry The Colorado Medical Society supports a national immunization registry. Any required physician participation and data entry or maintenance shall be appropriately compensated. (RES-7, AM 2008) 325.981 Childhood Vaccinations The Colorado Medical Society (CMS) supports increased efforts to achieve herd immunity in Colorado for childhood vaccine preventable diseases through improved outreach to parents, encouraging the use of on-site school nurses, and through increased provider usage of the Colorado immunization registry. CMS opposes exemptions from childhood immunizations based on personal beliefs while maintaining exemptions for medical reasons and religious beliefs. (RES-6, AM 2008) 325.982 Opposition to Importation of Radioactive and Toxic Waste Materials Colorado Medical Society opposes the importation of nuclear and or toxic waste material from any other state or nation to the State of Colorado. (RES-40, AM 2004) 325.983 Firearm Safety The Colorado Medical Society (CMS) recognizes firearm violence as a public health crisis. The CMS supports educational efforts designed to increase awareness, especially among children, about the dangers of firearms and to reduce firearm violence in our society. The CMS encourages physicians to consider this issue each and every time an opportunity to educate patients and parents presents itself. The CMS also encourages awareness among physicians and school faculty about traits that may indicate an individual could be capable of violence. Although these individuals may never display violent behavior, they still may benefit from professional help. Health care professionals should collaborate with school officials in developing programs to achieve zero tolerance toward school violence. The CMS supports the enactment of reasonable laws that seek to regulate the sale and distribution of firearms in order to protect public health and safety. The CMS supports enforcement of existing firearm safety and firearm control laws. The CMS supports legislative efforts that specifically penalize those who commit crimes with firearms. (Motion of the Board, March 2004; Reaffirmed, RES-6-P, AM 2011) 325.984 Medical and Dental Care for Persons who are Developmentally Disabled The Colorado Medical Society (CMS) entreats healthcare professionals, parents and others participating in decision-making to be guided by the following principles: • All people with developmental disabilities, regardless of the degree of their disability, should have access to appropriate and affordable medical and dental care throughout their lives. • An individual’s medical condition and welfare must be the basis of any medical decision. The CMS American Medical Association (AMA) Delegation will submit a similar resolution to the AMA for consideration. (RES-3, AM 2003) 86 CMS Policy Manual September 2013 325.985 Protective Headgear The Colorado Medical Society (CMS) encourages recreational and competitive sports organizations and facilities to mandate the use of protective headgear during participation in sporting activities with the risk of head injury, including, but not limited to, skiing, snowboarding, bicycling, inline skating, skate boarding, roller skates, scooters, go-peds, horseback riding, hang gliding, and parachuting. The CMS supports legislation to mandate the use of protective helmets for children under the age of 14 who are participating in these activities. (RES-20, AM 2002) 325.986 Support for Colorado Coalition for the Medically Underserved The Colorado Medical Society supports the goals and work of the Colorado Coalition for the Medically Underserved. (RES-22, AM 2001) 325.987 Elimination of Tuberculosis in the United States The Colorado Medical Society supports tuberculosis screening for active and latent infection of all individuals seeking to enter the United States and for high-risk groups in Colorado such as prison inmates, homeless persons, intravenous (IV) drug abusers, and people infected with human immunodeficiency virus (HIV). (RES-11, AM 2000) 325.988 Statewide Immunization Tracking System The Colorado Medical Society supports the creation of an electronic statewide immunization tracking system or registry for all children, birth through age 18, at the earliest possible date. (RES-20, AM 2000) 325.989 Immunization of Children, Adolescents and Adults The Colorado Medical Society supports and encourages the immunization of children, adolescents and adults based on national standards. (Substitute RES-27, IM 1996) 325.990 Rocky Flats Environmental Technology Site The Colorado Medical Society (CMS) recommends that the Colorado Department of Health and Environment (CDPHE) continue its strict and regular sampling of the soil, air and water for plutonium levels and other hazardous waste at the Rocky Flats Environmental Technology Site (RFETS), and that this information should be regularly provided to all interested parties. The CDPHE should not relax its minimum standards regarding soil, air and water contamination. The CMS supports the toxicologic review, dose reconstruction and risk characterization of Plant activities. The CMS supports the need for accurate monitoring of cancer incidence rates and birth defects and, therefore, supports the Central Cancer Registry and the Colorado Registry of Children with Special Needs in the CDPHE for the collection of complete cancer incidence and birth defect data in the RFETS area as well as the State of Colorado. Adequate funding for the Cancer and Birth Defects Registries should be continued by the State Legislature on a yearly basis. The CMS supports responsible reporting of, and access to, all information and data at RFETS, which do not jeopardize the national security or patient confidentiality. The CMS representation on the Rocky Flats Health Advisory Panel is necessary so that CMS may remain current in its review of the operations and studies of the Plant facility, workers and environmental hazards. (RES-9, AM 1991) 325.991 Family Planning The Colorado Medical Society (CMS) recognizes the existing problem of the rapidly proliferating population and supports efforts for voluntary limitation of family size and the dissemination of family 87 CMS Policy Manual September 2013 planning material and information to everyone. The CMS opposes efforts that may potentially interfere with the delivery of needed family planning health services in our communities that have met all requirements of the law. (RES-20-A, IM 1990) 325.992 Health Promotion The Colorado Medical Society (CMS) recognizes the huge socio-economic impacts on the community and individuals of unhealthy lifestyle practices. The CMS supports health promotion and disease prevention by both physicians and patients. (RES-29, IM 1990) 325.993 Routine Screening of Newborn Infants The Colorado Medical Society supports the screening of all newborn infants of Colorado to include those diseases screened by the Colorado Department of Public Health and Environment that is supported by appropriate funding. (RES-53, AM 1986) 325.994 Asbestos Abatement in Public Buildings and Schools In the past asbestos was used in the construction of public places, including schools. If the asbestos is already sealed in and no demolition or remodeling is required, the Colorado Medical Society (CMS) recommends that no action be taken. If remodeling or demolition of buildings containing asbestos is to be done for reasons other than the asbestos content, the CMS recommends that the work be done by a firm approved for such work by the Colorado Department of Public Health and Environment. (Motion of the Board, March 1985) 325.995 Joint Statement Regarding Smoking The Colorado Medical Society (CMS) adopts the statement below prepared jointly by the CMS, the Colorado Hospital Association and the Colorado Department of Public Health and Environment. Because smoking is the single most preventable cause of illness and early death, health care providers have a responsibility to take a leadership role to reduce smoking, to encourage non-smoking, and to protect the rights of the non-smokers. We recognize our role as exemplars in influencing the smoking behavior of the general public, and our responsibility in educating the community at large regarding the health hazards of smoking. We are particularly concerned with the dangers of smoking, and address this subject as a high priority issue. Exposure to cigarette smoke not only adversely affects the health of the smoker but increases the health risk and discomfort of patients who are already at risk for medical complications. Therefore, it is incumbent upon health care professionals to eliminate smoking in all health facilities. Because we, as health care providers, professionals and educators, are in a unique position to support the aims of all smoking-reduction activities, we unite our voices in a joint statement to recommend that smoking ultimately be eliminated from all health facilities in the state of Colorado. (RES-17, AM 1984) 325.996 Indoor and Outdoor Air Pollution In the interest of preserving public health the Colorado Medical Society supports efforts to reduce indoor and outdoor air pollution. (Motion of the Board, March 1984) 325.997 Mandatory Seat Belt Use The Colorado Medical Society (CMS) supports and encourages seat belt usage in automobiles and primary enforcement of the seat belt statutes. Further, CMS supports the increase in fines for a violation of the statute to be commensurate with other traffic violations of a like class. (RES-3, IM 1984) 88 CMS Policy Manual September 2013 325.998 Nuclear Power Generation The Colorado Medical Society (CMS) recognizes and stresses the great differences between nuclear warfare and the generation of nuclear power. The CMS believes that these two issues are essentially unrelated and should be considered independently. The CMS supports the further safe development and use of nuclear energy for electricity generation and energy independence, while pursuing research and development of alternative sources of energy. (Motion of the Board, December 1982) 325.999 Motorcycle Helmet Law The Colorado Medical Society supports requiring helmets for motorcycle riders. (RES-25, AM 1980) 330 Quality of Care 330.999 Restricting Communication Between Physicians and Patients The Colorado Medical Society strongly condemns any interference by the government or other third parties that causes a physician to compromise his or her medical judgment as to what information or treatment is in the best interest of the patient. (RES-43, AM 1991) 335 Research 335.999 Biomedical Research and Animal Activism The Colorado Medical Society (CMS) supports the establishment of a uniform method to assure a prompt, unbiased review by scientific peers of federally funded research projects before grant or contract monies can be withheld from any investigator or institution. The CMS opposes legislation that inappropriately restricts the choice of scientific animal models used in research. The CMS supports the Facilities Protection Act (S-544 and HR-2407), which makes it a federal crime and similar legislation at state levels to make it a felony to trespass and/or destroy laboratory areas where biomedical research is conducted. The CMS supports education of the public and policy makers regarding the need for medical research. (RES-65, AM 1991) 340 Rural Health 340.998 Rural Health The Colorado Medical Society (CMS) supports and encourages rural training track residency programs in order to assist rural physicians and rural medicine and to increase the number of well-trained, broadly skilled rural physicians.. The CMS encourages other primary care specialties, along with Family Practice, to develop similar training programs. The CMS also encourages the improvement of training in traditional residency sites to teach broad-based skills to better qualify residents for rural practice. The CMS encourages the cultivation of an educational environment more supportive of rural primary care by: 1. Promoting changes at the medical school, which include consideration of a rural rotation for all first year residents and students, and encouraging faculty visits to rural areas; 2. Working with the Medical Student Component of CMS to mobilize students to work for a more favorable environment for the training of rural physicians; 3. Promoting the medical students’ mentor program to encourage and facilitate rural physician participation; and 4. Utilizing the CMS network of physicians to develop rural sites for use in conjunction with the medical education in an effort to get students out to rural areas and increase their interest in rural primary care. In an effort to improve the financial situation for rural physicians so as to encourage more physicians to choose rural practice and retain those currently in rural Colorado, the CMS 89 CMS Policy Manual September 2013 encourages public and private payers to eliminate fee differentials, which result in reduced payment in rural fee schedules. (RES-51, AM 1994) 340.999 Support of Colorado Rural Outreach Program The Colorado Medical Society supports its Colorado Rural Outreach Program (CROP) and encourages federal programs and other states to adopt a similar program. (RES-51, AM 1992) 345 Surgery 345.998 Laser Surgery The Colorado Medical Society recognizes the medical community’s concern that the quality of care of patients undergoing laser surgery must be safeguarded in the same tradition as that of patients undergoing other types of surgery. The public should be assured that individuals performing laser surgery are licensed physicians who meet appropriate professional standards as evidenced by training, experience and credentials in both surgical or medical specialties and laser technology. (RES-32, AM 1991) 345.999 Post-Operative Care The Colorado Medical Society believes that patient postoperative medical management is the responsibility of the operating surgeon, and must be provided by the operating surgeon, or with the patient’s knowledge be delegated to another licensed physician. (RES-58, AM 1989) 350 Technology 350.998 Statewide Master Patient Index The Colorado Medical Society supports a statewide secure and accessible network for sharing clinical † data by encouraging adoption of a dedicated, secure, master patient index to improve care and reduce ambiguity during electronic record exchange between dissimilar hospitals. (RES-11, AM 2006) 350.999 Office Automation The Colorado Medical Society (CMS) supports improved physician knowledge about office automation techniques so that: 1. All ambulatory medical practices in the state could have the capability of exchanging messages electronically; 2. All physicians could be able to survey and extract information from encounter data (e.g., list of all patients with a particular diagnosis or on a certain medication); 3. All laboratory data could be electronically retrievable by the physician’s office from the referral lab; and 1† MPI: “Master Patient Index,” is a data retrieval strategy whereby a guarded set of unique patient identifiers allows authenticated queries to securely “point” to the correct hospital and internal identifier (medical record number, account number, etc), thereby generating a probabilistic “match list” for review by a credentialed requestor. Data remains decentralized and does not reside in any single statewide repository. The Internet and banking systems have used this strategy for over a decade. 90 CMS Policy Manual September 2013 4. Every physician’s office could have access to an electronic drug interaction system. The CMS supports a common protocol for use in transmission of data. (RES-1, IM 1995) 355 Tobacco 355.992 Smoking Ban Colorado Medical Society strongly and actively supports both state and local efforts to prohibit smoking in the following places: 1. All enclosed areas of worksites and public places owned, rented, leased or otherwise under the control of the State of Colorado including motor vehicles. 2. Restrooms, lobbies, reception areas, hallways and any other common-use areas. 3. Buses, taxicabs, and other means of public transit under the authority of the State of Colorado, and ticket, boarding, and waiting areas of public transit depots. 4. All restaurants and bars. 5. Service lines. 6. Retail stores. 7. All areas available to and customarily used by the general public in all businesses and non-profit entities patronized by the public, including but not limited to, banks, laundromats, hotels and motels. 8. All areas of galleries, libraries and museums. 9. Any facility which is primarily used for exhibiting any motion picture, stage, drama, lecture, musical recital or other similar performance, except performers when smoking is part of a stage production. 10. Sports arenas. 11. Convention halls. 12. Public and private meeting facilities. 13. Every room, chamber, place of meeting or public assembly, including school buildings under the control of any board, council, commission, committee, including joint committees, or agencies of the State of Colorado or any political subdivision of the State of Colorado, to the extent such location is subject to the jurisdiction of the State of Colorado. 14. Waiting rooms, hallways, wards and semi-private rooms of health facilities, including, but not limited to, hospitals, clinics, physical therapy facilities, doctors’ offices, and dentists’ offices. 15. Lobbies, hallways, and other common areas in hotels, motels, multiple-tenant office buildings and malls, apartment buildings, condominiums, trailer parks, retirement facilities, nursing homes, and other multiple-unit residential facilities. 16. Eighty percent (80%) of hotel and motel rooms rented to guests. 17. Airplanes. (RES-32, AM 2004) 355.993 Display of Tobacco Advertisements The Colorado Medical Society opposes the display in patient areas of periodicals and printed materials containing tobacco advertisements. (RES-24, AM 2000) 355.994 Tobacco Settlement The Colorado Medical Society supports the following positions regarding tobacco settlement money: 1. All money paid to the state of Colorado in the Master Settlement Agreement and other agreements be utilized to increase tobacco cessation and prevention programs including 91 CMS Policy Manual September 2013 research, education, prevention and treatment of nicotine addiction as needed, especially in children and adolescents, and treatment of diseases related to nicotine addiction and tobacco use; 2. All money not directed to other specific tobacco control activities be used to increase patient access to medical services and to improve the general health of Colorado citizens with emphasis on programs and services impacting children, specifically, adequate funding for the children’s basic health plan; 3. All money shall remain within the state and not be reimbursed to the federal government on the basis of Colorado’s federal Medicaid match; 4. Assure any tobacco settlement funds not supplant but augment health program funding; and 5. All money paid to the state of Colorado through the various settlements are TABOR exempt. (RES-13, AM 1999) 355.995 Tobacco Related Research The Colorado Medical Society supports a restriction on tobacco industry funding for tobacco related research in any state-supported institution. (RES-44, AM 1996) 355.996 State Excise Taxes on Tobacco Products The Colorado Medical Society supports and encourages the passage of increased excise taxes on tobacco products and that these proceeds support educational cessation, prevention activities and increase patient access to medical services. (RES-64, AM 1992) 355.997 Smoke-Free Colorado Medical Society Smoking is prohibited at all Colorado Medical Society (CMS) functions. Smoking is prohibited in the offices of the CMS. (Motion of the Board, January 1982, Substitute RES 67, AM 1990) 355.998 Reducing Tobacco Sales to Children The Colorado Medical Society supports strict compliance with and enforcement of laws prohibiting sale of tobacco to children. (RES-41, AM 1990) 355.999 Limitation on Distribution of Tobacco The Colorado Medical Society (CMS) opposes the sale of tobacco products in vending machines. The CMS opposes the free distribution of tobacco products as a promotional tool of the tobacco manufacturers. (RES-31, AM 1988) 360 Violence and Abuse 360.996 Violence in Society CMS urges our community leaders to support the creation of a comprehensive and accessible network of mental health services and crisis intervention capabilities in order to divert emotionally or mentally disturbed individuals from violence to a support system that can identify and address their potentially harmful actions. (RES-6-P, AM 2012) 360.997 Colorado Medical Society Condemns Terrorism The Colorado Medical Society stands with the United States Government, and all concerned people everywhere, to condemn those who commit terrorism and cause loss of human life. 92 CMS Policy Manual September 2013 (Late RES-24, AM 2001) 360.998 Domestic Violence The Colorado Medical Society supports efforts to change existing laws and regulations regarding domestic violence to: 1. Improve immunity for physicians; 2. Mandate that the plaintiff cover legal fees for physicians acting in good faith, 3. Protect physicians from ethical complaints for breaking physician/patient confidentiality when reporting domestic violence; 4. Clarify the duty to report in a manner that recognizes the need for flexibility and protection for reasonable failure to report, and 5. Refine the definition of what is to be reported. (RES-42, AM 1993) 360.999 Domestic Abuse The Colorado Medical Society encourages and supports the education of physicians about proper ways to recognize, report, treat and refer domestic violence victims. (RES-8, IM 1993) 365 War 365.999 Condemning the Use of Children as Soldiers and Weapons of War The Colorado Medical Society condemns the use of children as soldiers or weapons of war. (Late RES-25, AM 2001) 370 Women 370.999 Female Genital Mutilation The Colorado Medical Society (CMS) condemns the practice of female genital mutilation, as defined by the American College of Obstetrics and Gynecology as a medically inappropriate procedure that has no scientific basis. The CMS considers it a form of physical abuse subject to the same criminal sanctions and reporting requirements as any other type of physical abuse. (Late RES-12, IM 1998) 900 Administration and Organization 900.975 Spring Conference Statement of Purpose It shall be the purpose of the CMS Spring Conference to: • • • • Create unity among physicians, a larger voice for the profession, increased involvement and a greater overall impact on the health of Colorado. Attract new faces to CMS, with specific outreach to employed physicians, less active members and non-members so as to achieve greater diversity among the attendees and a welcoming atmosphere. Build new relationships, develop and learn new ideas in order to address the critical issues facing physicians. Place an emphasis on broadening the view of attendees by bringing in outside experts and an equal emphasis on relevant policy matters. (BOD-1, AM 2012) 900.976 Strategic Plan 93 CMS Policy Manual September 2013 The New Road Map (Strategic Plan) Core Purpose To champion the health care issues of critical importance to Colorado physicians and the patients and communities they serve Core Values • Leadership of a diverse population of physicians focused on delivery of accessible, safe, highquality, patient-centered care • A collaborative philosophy for addressing health care challenges and issues facing our members and their patients • A commitment to professionalism and transparency in our operations, demonstrating both individual and organizational integrity and credibility • Innovative approaches that are data-driven, knowledge-based, and grassroots-responsive Vision Colorado Medical Society will be the leader in making Colorado the best state in which to provide and receive safe, high-quality, and cost-effective medical care Goals and Objectives Goal A: Physician Well Being and Success Ensure physicians thrive personally and professionally throughout their careers in an evolving health care system Objectives • Increase physician knowledge about the implications of health care system evolution and how it fits into the evolving system • Help physicians to understand, prepare and comply with federal and state regulatory changes • Aggressively advocate for fair and reasonable reimbursement in current and future payment systems, both public and private • Support physicians in their continuing professional development • Increase CMS capacity to help members enhance their quality of life Goal B: Patient Safety and Professional Accountability New approaches to delivering care and addressing adverse events will enhance safety, learning and accountability while appropriately compensating injured patients Objectives • Increase patient engagement in their own care • Continue to develop and implement robust, evidence-based system improvements that enhance patient safety • Develop and institute meaningful enhancements to existing professional accountability mechanisms • Increase understanding and appreciation of the alternatives to traditional tort litigation • Maintain Colorado’s stable medical liability climate Goal C: Health Care System Evolution Health care system innovation will result in access to high-quality, cost-effective care for patients and their communities. Objectives • Increase physician capacity to adapt to the evolving health care system 94 CMS Policy Manual September 2013 • • • Influence how health care systems evolve, particularly in Colorado Improve physician stewardship of limited health care resources Advance team-based care Goal D: Turning data into intelligence By owning, using and sharing data, physicians will both improve care and demonstrate their ability to provide high-quality and cost-effective care Objectives • Increase physician awareness of the need for and benefits of collecting and using data • Increase the ability of members and their staffs to collect data and use the information gathered to maximum benefit • Reduce barriers, most notably high costs, to sharing and using data Goal E: Organizational Excellence CMS will be a well governed, effectively managed, fiscally sound organization that meets the needs of a diverse membership in a rapidly changing environment Objectives • Increase CMS’s value and attractiveness to members and potential members, and including employed physicians • Increase overall member satisfaction with CMS • Increase efforts to develop and engage physician leaders • Make CMS the most attractive employer in order to recruit and retain the best and brightest • Continue to nurture current and explore additional sources of revenue to support expanded services and initiatives in support of our purpose • Continue to operate in a transparent manner, working collaboratively and sharing insights into not only what decisions are made but also why (BOD-1, AM 2011) 900.977 Policy Manual The Colorado Medical Society Policy Manual will be reviewed every three to five years to determine those policies that are no longer pertinent and incorporate like policies into one policy. Such changes will be brought to the House of Delegates for review and approval. (RES-12, AM 2003) 900.978 Investment Guidelines General Statement of Investment Objectives The Board of Directors, through its Finance Committee, shall establish, implement and monitor investment activities for Colorado Medical Society (CMS) assuring fulfillment of the following guidelines. All investments shall fall within the legal requirements and regulations governing the society structure. Investments shall be consistent with conserving principal and earning the highest return available on short-term liquid investments. Guidelines for Investments • Expected Rate of Return Rate of return is defined as: dividends and interest plus realized and unrealized capital gains and losses. Since it is extremely difficult to predict future interest rates and corresponding returns, the rate of return should be consistent with and appropriate to the relative amount of risk assumed and the investments chosen. 95 CMS Policy Manual September 2013 • Comparison Benchmarks For the evaluation of performance, the Finance Committee will periodically review current rates of return on similar investments. • Risk Tolerance The CMS expects reasonable consistency of returns and the preservation of capital. Investments should reflect both those expectations while avoiding undue exposure in achieving income goals while limiting downside risk. • Investment Limitations The CMS investments will be limited to the following instruments: 1. Bonds or other direct obligations of the United States Government. 2. Obligations of U.S. Federal Agencies. 3. Certificates of Deposit, Banker’s Acceptances or Repurchase Agreements of banks or trust companies subject to approved FDIC guaranteed insurance limitations organized under the laws of the United States of America having combined capital and surplus of at least 20 million dollars. 4. Commercial paper rated “prime” or its equivalent by either the National Credit Office, Inc. or Moody’s (or their successors) and unrated commercial paper of similar quality if issued by companies having an outstanding debt issue rated double AA or single A. 5. Corporate bonds with a quality rating of no less than A rated by Standard & Poor’s. 6. Stocks in the form of Mutual Funds or individually managed stock portfolios not to exceed 40% of entire portfolio with no more than 5% in any one security. 7. Maturities on any individual investment should not exceed 10 years. Any pooled securities or mutual funds should include maturities no longer than 10 years. 8. The total portfolio should be diversified such that no more than 5% may be in any individual security; or 25% in any one industry except for pooled, mutual funds or bond/money market funds or U.S. government obligations. • Investment Discretion Investment recommendations will be made by the Finance Committee and then be ratified by the Board. • Reporting Requirements All transactions will be reported to the Finance Committee and Board of Directors at every scheduled meeting. • Monthly Reports Monthly reports should include a summary of all monthly and year-to-date transactions by investment vehicle. • Annual Reports Annual reports to the Board of Directors shall include at least: 1. A statement of net assets 2. A statement of operations 3. A listing of all securities at cost, market value and the percent of the total portfolio. 4. A listing of acquisitions and dispositions noting book and market value of each. 5. A summary of the future outlook on the economy and market including alternate strategies. 6. A review of the year just completed noting any unusual happenings. 7. Any other recommendations or items of importance. (Motion of the Board, March 1994 • Amended July 2002, May 2003) 96 CMS Policy Manual September 2013 900.979 Mileage Reimbursement Mileage will be reimbursed up to federally approved reimbursement level as yearly budget will permit. (Motion of the Board, March 2000) 900.980 Funding Requests from Outside Entities Any outside entity or group that is related to or affiliated with the Federation of Medicine shall be given due consideration to legitimate requests for funding. The Finance Committee shall first review the request and then make a recommendation to the Board of Directors. (Motion of the Board, March 2000) 900.981 In-State Travel Members of councils and committees and task forces are reimbursed for mileage over 50 miles round trip (beyond 25 mile radius) of Colorado Medical Society (CMS). This means no mileage will be paid for the first 50 miles, e.g., council member travels 200 miles round trip; reimbursement will be for 150 miles. Members of the Board of Directors will be reimbursed for actual round-trip mileage to attend board meetings. If a member travels more than 150 miles and chooses to fly, he/she will be reimbursed airfare. He/she may also be reimbursed one night’s lodging, dinner, and breakfast when CMS business or related circumstances prevent return travel the same day. In accordance with the CMS Bylaws, no member of this Society may be reimbursed for attending any meeting of the whole Society or House of Delegates. (Motion of the Board, July 1998) 900.982 Out-of-State Travel Out of state travel expenses are approved to cover round trip coach air fare, hotel accommodations up to the lowest published room rate, transportation to and from airports, and parking at the airport, plus up to an additional $50.00 per day for validated incidental expenses. Expenses related to rental cars will not be reimbursed without prior approval from the executive office. (Motion of the Board, November 1997) 900.983 Participation in the Provider Coalition The Colorado Medical Society (CMS) may participate in the “Provider Coalition” with the clear understanding that differences will arise and that CMS will not be listed as a member when CMS individually is in opposition to a particular piece of legislation. (Motion of the Board, February 1995) 900.984 Conduct of Representatives of the Colorado Medical Society Any individual who is publicly representing the Colorado Medical Society (CMS) will present only established CMS policy. (RES-32, IM 1994) 900.985 Use of Dues Monies The Colorado Medical Society (CMS) should not, as a standing policy, use its non-profit dues income to support other organizations. The CMS policy is that any organization asking for financial support must have a 501 (c)(3) tax exempt status. The Finance Committee or the Board can make exceptions. Therefore, any organization making such a request would be referred to the Colorado Medical Foundation Trust or the Colorado Medical Society Foundation. Dues monies should not be used for philanthropic purposes. (Motion of the Board, September 1980, Motion of the Board, May 1993) 900.986 Requests for Money, Time or Endorsements All agencies, parties, political entities, lobbying groups and special interest groups not included in the organizational structure of the Colorado Medical Society, who are requesting donations of money, time or other endorsements, will not be allowed to present their requests to the Board of Directors until their requests are referred through the Finance Committee (in the case of monetary requests) or through the 97 CMS Policy Manual September 2013 Executive Committee. All physicians, staff and lay people who have any requests with financial implications will be required to make such requests to the Finance Committee before being presented to the Board of Directors. (Motion of the Board, September 1982, Motion of the Board, November 1992) 900.987 Gender Neutrality All official speakers and presentations by and for the members and general public should be devoid of all references of physicians as being of the male gender only. (RES-44, AM 1992) 900.988 Exhibit Space Discounted table-top space. When space is available outside the exhibit hall, tables may be sold to Colorado Personalized Education for Physicians (CPEP), Colorado Physician Health Program (CPHP) and other non-profit associations on a case-by-case basis at a rate of 50% of the cost per table at the Annual Meeting. (Motion of the Board, May 1992) 900.989 Guidelines for Financial Contributions, Co-Sponsorships and/or Endorsements To carry out the general objectives and purposes of the Colorado Medical Society (CMS), the following criteria and guidelines have been established to assist in determining co-sponsorship, endorsement, financial support, or any in-kind services of any type given to a “program,” “organization” or “business” providing a perpetuating service to the membership: 1. To improve the health of the citizens of the State of Colorado. 2. To aid in problems of research which directly or indirectly concern the health of the people of the State of Colorado. 3. To aid the education and/or advancement of the ancillary medical professions. 4. To aid any charitable or general social purpose program or activity which is directly or indirectly concerned with the improvement of the health of people of this state. 5. To aid in the welfare, education and/or advancement of the CMS members and the medical profession. If any of the above criteria are satisfied, certain guidelines must be met. The guidelines to be followed are divided into two categories: 1. A “program,” “project,” “organization” or “business” which the CMS provides financial support, cosponsorship, endorsement or in-kind services on a one-time basis; 2. Provide financial support, co-sponsorship, endorsement or in-kind service for a “program,” “project,” “organization,” or “business” that is offering on-going services to the membership. The following guidelines are to be used for both categories: Co-Sponsorship Co-sponsorship implies full use of the Colorado Medical Society’s name and usage of mailing lists gratis. CMS will appoint a physician or staff to the organization controlling the project. If financial support is given directly or indirectly by in-kind services, the “program,” “project” or “business” must provide full financial disclosure of how the money will be spent. Determination must be made by CMS for at least one of the following: 1. An unencumbered cash donation may be given, with no provision for unused funds to revert to CMS. There would also be no obligation to provide funds should the costs overrun the projection. 2. A cash donation, requiring that unused funds revert to CMS, and no obligation to participate in any cost overruns. 98 CMS Policy Manual September 2013 3. A cash donation, requiring any proceeds or unused funds to revert to CMS on a prorated basis, and upon examination of accounting for cost overruns, CMS may elect to subsidize such overruns with an additional donation. 4. Full disclosure must also be made as to the use of the mailing list with the requesting party agreeing not to re-use or sell the list for any other purpose than so stated. Endorsement Endorsement implies full use of Colorado Medical Society’s name and use of mailing lists gratis or at cost. Physician or staff involvement is not required for project completion. If financial support is given directly, or indirectly by in-kind services, the “project,” “program,” “organization,” or “business” must provide full financial disclosure of how the money will be spent. Unencumbered cash donations may be given in such a manner not to obligate CMS to share in any profits or losses. Full disclosure must also be made as to the use of the mailing list with the requesting party agreeing not to re-use or sell the list for any other purpose than so stated. The following financial disclosure may also be required, if the endorsement implies a continuing business relationship: 1. Financial reports showing administrative costs as they pertain to CMS. Show fees received for services rendered by giving the exact percentage that is applied either to the total operating budget, premiums and/or monies received, as well as the exact dollar amount of those administration fees received. 2. Additional information must include the last three (3) prior years of financial reports showing total profit and administrative costs relating to administration and brokerage fees. All the above criteria must be adhered to by a Broker of Record. 3. Any outside organization/institution desiring CMS co-sponsorship or endorsement of an educational activity through use of the CMS name must submit required information to the Director of the Department of Professional Services for preliminary investigation after which the request shall be directed, as efficiently as possible, to the appropriate CMS Committee or Council for further approval or disapproval, then to the Board of Directors for final approval or disapproval. If only the use of the Society’s name is requested, but with American Medical Association (AMA) Category 1 Continuing Medical Education (CME) credit acquired elsewhere, the name of the entity certifying AMA Category 1 CME credit must be clearly indicated within the body of the program brochure. (RES-1, AM 1991) 900.990 Relationship with the University of Colorado School of Medicine The Colorado Medical Society (CMS) and the University of Colorado School of Medicine (UCSM) maintain a close and cooperative working relationship. The CMS reaffirms its strong support for the UCSM and endorses vigorous state financial support for the Health Sciences Center and the School of Medicine. Among items included in the working relationship are the following: 1. When requested, the CMS will provide representation on the UCSM Curriculum and Review Committee, the Admissions Committee, or any other appropriate standing or ad hoc committee, as well as ad hoc advice on specific educational questions. 2. When requested, the CMS will obtain information on the opinions of practicing physicians concerning specific educational questions. 3. CMS encourages its members to make individual contributions to the UCSM through donations to the American Medical Association Foundation (AMAF). 4. Additional support may be provided by the CMS to individual, incoming first-year medical school students through the Colorado Medical Society Education Foundation (CMS/EF). (RES-1, AM 1991) 900.991 Spending from the Reserve Fund Spending of any of the principal and earnings of the reserve fund requires a two-thirds affirmative vote of the Board of Directors. A reserve fund will be built to include a minimum of six months of operating 99 CMS Policy Manual September 2013 expenses. Any monies taken from reserve principal must become a budgeted item for the next three years and be repaid to the reserve fund. (Motion of the Board, August 1989) 900.992 Antitrust Guidelines Statement of Policy It is the policy of the Colorado Medical Society (CMS) and its members to comply strictly with all laws applicable to the Medical Society’s activities. The Board emphasizes the ongoing commitment of the Medical Society and its members to full compliance with federal and state antitrust laws. This statement is being distributed to all officers, Board members, council and committee chairs, and council and committee members as a reminder of that commitment and as a general guide for our activities and meetings. Responsibility for Antitrust Compliance The Medical Society’s programs have been carefully designed and reviewed to insure their conformity with antitrust standards. An equivalent responsibility for antitrust compliance is yours. The Society depends on your good judgment to avoid all discussions and activities which may involve improper subject matter or improper procedures or an appearance of improper activity. Society staff members work conscientiously to avoid subject matter discussion which may have unintended implications, and counsel for the Society will provide guidance with regard to these matters. It is important for you to realize, however, that the competitive significance of a particular conduct or communication probably is most evident to you who are directly involved in medicine. For this reason you have an important and individual responsibility for assisting antitrust compliance in Society activities. Moreover, it must be clearly understood that no officer, director, or any other CMS member, whether acting in his or her individual capacity or as a committee or council member, or in any other way, is authorized to propose or to carry out in behalf of Colorado Medical Society any program, agreement, or any other activity in violation of state or federal antitrust laws. Antitrust Statutes The most important antitrust statutes relating to the activities of a professional association or society are the Sherman Act and the Federal Trade Commission Act. Both of these prohibit contracts, combinations, and conspiracies between two or more persons in restraint of trade. The Supreme Court has ruled that not every contract or combination in restraint of trade is a violation. Only those which unreasonably restrain trade are unlawful. To determine what is “unreasonable”, the courts will look at the surrounding circumstances and the conduct in question, and may consider benefits to the general public from the program as compared with the anti-competitive effect of that activity. This is the “rule of reason”. However, certain types of conduct have been held to be so inherently or nakedly anti-competitive that such activities are “per se” violations of the law, and further proof is unnecessary. Such per se violations include: • Price fixing agreements. • Agreements to refuse to deal with certain third parties (boycotts). • Agreements to allocate markets or to limit production. • Tie-in sales, which require the customer to buy an unwanted product or service in order to obtain the desired item. Since a professional association, by its very nature, brings competitors together to carry out its programs, the potential for collusion exists. Because of that potential, the enforcement agencies are watching professional organizations, especially in the medical profession, very carefully. For antitrust purposes the term “agreement” is very broadly applied. It includes oral or written, formal or informal, express or implied agreements. An unlawful agreement has been inferred from circumstantial evidence, such as the words and conduct of the parties and their course of dealing. 100 CMS Policy Manual September 2013 Section 5 of the Federal Trade Commission Act prohibits “unfair methods of competition in or affecting commerce, and unfair or deceptive acts or practices in or affecting commerce.” Unlike the Sherman Act, the Federal Trade Commission Act reaches anti-competitive acts committed by single persons or companies, whether or not there is any agreement or “combination”; like the Sherman Act, it also covers joint actions. There are Colorado statutes which closely parallel the federal law. Antitrust Problem Areas of Activity • Price Fixing. • Agreements to divide customers (patients or groups of patients). • Membership restrictions. • Standardization or stabilization of fees or charges. • Peer review activity. Avoidance of Antitrust Problems In the absence of specific legal advice on a matter, you should follow the guidelines which are set forth below, which are designed to avoid even the appearance of questionable activity: • Topics of Discussions to be Avoided 1. Do not discuss your own or other physicians’ current or future fees or expenses or any other financial matters which could affect fees. 2. Do not discuss possible increases or decreases in fees. 3. Do not take part in any discussion of what should be considered a fair level of income from practice. 4. Do not make any public statements about your own fees or the fees of competitors, or about any other matters which could affect fees, at Medical Society functions. 5. Do not discuss what you or other physicians plan to do in a particular geographic area or market, or with particular patients or with third party payers. 6. Do not discuss your intention to refuse to deal with an HMO, a PPO, or any other third party payer or with any group or class of patients. 7. Do not encourage any other physicians to refuse to deal. 8. Do not disclose to any other person, at meetings or otherwise, information which may be sensitive competitively. 9. If you are present at any group where any such discussion as mentioned above takes place, and if you are unable to prevent such a discussion taking place, then remove yourself from the meeting. 10. If reasonably possible, avoid performances of peer review of the services of a competitor, and, if not reasonably avoidable, take careful precautions. • Meeting Procedures To avoid the appearance of questionable activity, as well as to guard against any inadvertent illegal conduct, all Society meetings, including committee, council, or section meetings, and including any meetings which are not legally constituted because of absence of a quorum, should be conducted in accordance with the following procedures: 1. Meetings should not be held unless there are proper items of substance to be discussed which justify a proper meeting. 2. In advance of every meeting, a notice of the meeting with an agenda should be sent to each member of the group; and the agenda should be specific. Broad topics, such as “Marketing Practices” which might look suspicious from an antitrust standpoint should be avoided. 101 CMS Policy Manual September 2013 3. The discussion at the meeting should be limited to agenda items. Subjects not included on the agenda should not be considered. 4. If a member brings up for discussion a subject of doubtful legality, that person should be advised that the subject is not a proper one for discussion. This would primarily be the responsibility of legal counsel for the Society. If a member has any reservation concerning the remarks or the nature of discussion at a Society meeting, those reservations should be expressed; and if the discussion is not terminated or satisfactorily resolved, that member should leave the meeting. 5. Accurate minutes of each meeting should be prepared, and if reasonably possible, sent to the chair and the other members of the group prior to the next meeting. 6. Secret or “rump sessions” should be strictly avoided. It is desirable that a CMS staff member attend all meetings. 7. No recommendations or actions should be taken with regard to antitrust sensitive subjects, without the advice of the Society legal counsel. Conclusion Compliance with these guidelines is intended not only to avoid antitrust violations, but also any behavior which could be so construed. However, it should be understood that the antitrust laws are complex and far-reaching, and that this statement is not a complete summary of the law. It is intended only to highlight and emphasize certain basic precautions designed to avoid antitrust problems. You must therefore seek the guidance of either the Society staff, its legal counsel, or your own attorney if antitrust questions arise. If you would like further information concerning the Medical Society’s antitrust compliance procedures, please contact the CMS staff. (Motion of the Board, April 1987) 900.993 Expense Report Submission Expense reports must be submitted within 60 days or they will not be honored. (Motion of the Board, January 1987) 900.994 Registration Fees The Colorado Medical Society (CMS) House of Delegates approved the specific concept of charging registration fees for CMS educational meetings, conferences, scientific workshops and similar meetings of the membership with the exclusion of the Annual Meeting. (RES-10, AM 1983) 900.995 Sources of Non-Dues Revenue The Colorado Medical Society (CMS) endorses the concept of financial support through non-dues income funds as may be produced; and the CMS House of Delegates approves the concept of seeking additional services and sources of revenue through non-dues opportunities. (RES-9, AM 1983) 900.996 Budget Recommendations Final budget recommendations, including any proposed dues increases, will be brought for action to the Board meeting at least one month prior to the Annual Meeting and budgetary information will be received by Board members at least two weeks in advance of this meeting. (Motion of the Board, October 1982) 900.997 Budget Information The Board will receive financial information concerning the budget prior to each Board meeting and the Board will receive each month an assessment of Colorado Medical Society adherence to the budget. (Motion of the Board, October 1982) 102 CMS Policy Manual September 2013 900.998 Member Representatives When openings arise on boards or committees of regulatory agencies and other relevant entities, the Colorado Medical Society will provide the names of interested, qualified members, along with other relevant information, to the appropriate body for consideration. (RES-14, AM 1980) 900.999 Evaluation of Chief Administrative Officer The Executive Committee of the Board of Directors will evaluate the chief administrative officer on an annual basis as outlined in the guidelines presented to the Board -- the evaluation is to be conducted at the time of budget preparation. (Motion of the Board, January 1980) 905 Board of Directors 905.994 Medical Student Representation There shall be four student representatives on the CMS Board of Directors, two from the University of Colorado and two from Rocky Vista University, each with full voting privileges at the Board and House of Delegates. Furthermore, student representation in the House of Delegates shall be no fewer than 20 delegates and may be increased to a ceiling of 12% of the voting seats in attendance at the start of business of the annual meeting of the CMS House of Delegates. The medical student component will make every effort to fill the delegate seats with upper-class students who have attended previous CMS meetings. (RES 5-A, AM 2011) 905.995 Presentations to the Board of Directors Presentations by outside interest groups to the Board of Directors will be limited to one presentation per meeting with time limitations and enforcement, unless an additional presentation is deemed urgent for the good of the Society by the presiding officer of the meeting. (Motion of the Board, September 1996) 905.996 Attendance at Board of Directors Meetings Component societies will be asked to replace a board member who misses three consecutive regularly scheduled meetings in one year. (Motion of the Board, May 1992) 905.997 Proxy Voting by Members of the Board of Directors The use of proxy votes for members of the Board of Directors is denied. (Motion of the Board, May 1992) 905.998 Minutes of Board of Directors Meetings In an effort to expedite information to the Board and Colorado Medical Society (CMS) membership, and as a cost savings, highlights of the Board of Directors meetings are to be posted on the CMS web site immediately following the Board meetings, with full minutes being mailed to Board members with the agenda materials for the next scheduled meeting. (Motion of the Board, March 1980) 905.999 Business of the Board of Directors Unless information is enclosed in agenda packets mailed prior to each Board meeting, no other business will be considered unless of an emergent nature. (Motion of the Board, June 1979) 103 CMS Policy Manual September 2013 910 Councils and Committees 910.997 Meeting Attendance The Presiding Chair of each Board, Council and Committee shall file an attendance report in the Executive Office within one week after each called meeting of the body over which he/she has presided. Each Chair shall have the authority, subject to review by the body concerned, to excuse any member from a meeting for due cause. Unexcused absence from one-third of the called meetings within any six-month period if such called meetings number four or more, or unexcused absence from any two consecutive meetings, may on the recommendation of the Presiding Chair of each Board, Council or Committee, serve as cause for requesting the resignation of the member from the body concerned. (Motion of the Board, February 1980) 910.998 Approval of Council Recommendations 1. The Board of Directors will approve or disapprove all Council recommendations as reported by Council Chairs. 2. In the event the Board of Directors cannot meet, the Council’s recommendations will be approved or disapproved by the Executive Committee. 3. In the event the Executive Committee cannot meet, Colorado Medical Society (CMS) staff will act with concurrence of Council Chair (e.g., Legislative Chair). The Council’s recommendations will be approved or disapproved by the President or President-elect. 4. In the event the President or President-elect is unavailable, CMS staff will act with concurrence of the Council Chair. (Motion of the Board, February 1980) 910.999 Minutes of Council Meetings All Council minutes are to be referred to the Board of Directors for review. (Motion of the Board, April 1979) 915 House of Delegates 915.992 Annual Meeting and House of Delegates Report of the Expert Panel on Annual Meeting and House of Delegates 1. Shorten the Annual Meeting to a full two-day meeting 2. Institute an order of business, as follows: • Convene the Board of Directors on Noon Friday instead of Thursday. • Registration: Open registration on Friday evening associated with a social function. • The House of Delegates: Convene the HOD on Saturday morning for opening business and adjourn immediately to reference committees. • Reference committee(s) will: • Be held online in advance of the Annual Meeting and in-person at the Annual Meeting. • Convene in advance of the Annual Meeting to develop Reference Committee reports that will be available either before or immediately at the start of the Annual Meeting. 3. Socialization and engagement on issues of critical importance to the profession shall be a priority at the Annual Meeting. The Board of Directors should continue to pursue other improvements to streamline the Annual Meeting and functions of the House Of Delegates to provide more time in a two-day format for strategic, interactive programming on issues important to physicians and their patients that are also directly related to CMS goals and objectives, and for socialization. (BOD-1, AM 2012) 915.993 Medical Student Advisory Board (MSAB) Approved “Objectives and Strategies” for the medical student component; 104 CMS Policy Manual September 2013 Approved a resolution addressing medical student representation in the House of Delegates. (BOD-1, AM 2011) 915.994 Establishment of a Residents’ and Fellows’ Section The Colorado Medical Society (CMS) shall immediately establish a Residents’ and Fellows’ Section (RFS). The RFS will serve as the primary body responsible for mediating interactions between CMS and all residents/fellows in the state, working with the Governing Council, Board of Directors, and executive leadership to ensure appropriate involvement and representation of residents at every level within CMS, and to engage in resident recruitment activities in all Colorado resident and fellowship programs. The initial Governing Council of this RFS shall consist of the author and co-authors of this resolution. This Governing Council shall work with the CEO, President, President-Elect, and Immediate PastPresident of CMS, as well as any Council or Committee deemed appropriate by Leadership, to establish bylaws, a budget, and initial appointments to CMS Councils and Committees, with approval/ratification of these items to be accomplished at the next regularly scheduled meeting of the CMS Board of Directors. (RES-4, AM 2008) 915.995 Use of Consent Calendar at House of Delegates Meetings The entire report of the Reference Committee will be placed on the Consent Calendar with items of business grouped together according to the committees’ recommendations. Members of the House of Delegates can extract any item of business from the Consent Calendar for vote by the House. (RES-1, AM 2006) 915.996 Reference Committee Schedules The Speaker will be requested to revise the schedule to avoid overlap of the two reference committees. (RES-6, AM 2001) 915.997 Family Friendly Colorado Medical Society Colorado Medical Society, in its planning for the Annual Meeting, will attempt to assure that the needs of delegates and their families be considered in the criteria when choosing a meeting site for the Annual Meeting. (RES-2, IM 1998) 915.998 Approval of Budget by House of Delegates A summary of the proposed budget will be distributed to each delegate at the first session of the Annual Meeting. The House of Delegates will approve the budget at the second session. The detailed actual budget will be available at the Annual Meeting for review by any Colorado Medical Society member. The Board of Directors will be empowered to alter the budget at its first meeting consistent with an added or deleted fiscal impact of resolutions passed at that session. (Substitute RES-12, IM 1985) 915.999 Annual Meeting Scheduling Religious holidays will be avoided when scheduling Annual Meetings of the Colorado Medical Society. (Motion of the Board, July 1981) 920 Membership and Dues 920.996 Medical Student Support–Rocky Vista University Colorado Medical Society leadership will make contact with the administration of Rocky Vista University, School of Osteopathic Medicine and extend the same membership benefits to its students, specifically free membership in the Colorado Medical Society, and pay out of its operating budget Medical Student Component Society dues and AMA student membership dues for these medical students for all four medical school years, if the students so choose to become AMA members. 105 CMS Policy Manual September 2013 Colorado Medical Society will serve as an administrative resource for the two medical schools’ student bodies in order to facilitate a collaborative relationship between the two campuses. (RES-23, AM 2007) 920.997 Medical Student Support The Colorado Medical Society Board of Directors’ annual budget will include enough funds for four-year student memberships in both the Colorado Medical Society Medical Student Component and American Medical Association for all incoming medical students to the University of Colorado Health Sciences Center each year. (RES-23, AM 2002) 920.998 Processing of Membership Applications Applications for Colorado Medical Society (CMS) membership should not be accepted unless accompanied with the appropriate membership dues. Also, COPIC will not be advised of their pending membership. 1. A physician will be considered “pending” if CMS has received dues from the member, but the component has not yet elected the member. The pending status will remain in effect for no more than 90 days unless extenuating circumstances arise. The Executive Committee or Finance Committee can then decide to pend the member for another 90 days, depending upon the reason for the continuing pending status. COPIC discount will apply for the 90 days. 2. If CMS receives a completed application along with an indication that the component society has elected the physician, with no dues remitted, the physician is considered a non-member. COPIC discount does not apply. 3. Simultaneous receipt by CMS of dues and notice of election will result in full membership in the appropriate classification. COPIC discount applies. 4. Timely communication to all affected component societies, COPIC and “pending” members will occur. (Motion of the Board, May 1996) 920.999 Medical Society Jurisdiction A change of medical society jurisdiction (i.e., component society) should not be granted while the physician is being investigated and the Change of Jurisdiction form should contain a statement indicating whether or not the physician was under investigation. (Motion of the Board, July 1994) 925 Nomination, Election and Tenure 925.996 Campaign Reform Colorado Medical Society assumes the responsibility for arranging a candidates’ reception at the annual meeting. Candidate presentations for elected society offices will be continued at the general membership meeting, and adequate time will be provided for a question and answer period following such presentations. (RES-3, IM 1998) 925.997 American Medical Association Delegation Candidates for the positions of American Medical Association (AMA) Delegate and Alternate Delegate will present their viewpoints during the general membership meeting at the Colorado Medical Society (CMS) Annual Meeting. A forum will be established at the Annual Meeting for the CMS Delegation to the AMA to present issues and obtain input from members. (RES-6, IM 1996) 106 CMS Policy Manual September 2013 925.998 Distribution of President-elect Resumes A copy of the resume of each candidate for President-elect will be distributed to each delegate before the election via the Delegate Handbook. (RES-3, IM 1992) 925.999 Implied Resignation A Delegate or Alternate Delegate to the American Medical Association (AMA) who misses two consecutive meetings of the AMA House of Delegates should be considered to have tendered his/her resignation. (Motion of the Board, March 1988) 930 Political Action 930.996 Unified Position of Colorado Medical Society and its Component Medical Societies Component medical societies should be encouraged to lobby legislators in a manner which is consistent with a position taken by the Colorado Medical Society (CMS), or its Council on Legislation. Individual physicians may lobby legislators on the same issue in any direction, for or against, that they see fit. The CMS will maintain a process by which the leadership of all component societies: 1. May consider, in advance of meeting of the Council on Legislation, any proposed legislation as well as staff recommendations on the issue; 2. Give timely constructive feedback prior to any final decision. (RES-5, AM 2001) 930.997 Colorado Medical Society Leadership The Colorado Medical Society Leadership shall be encouraged to join the Colorado Medical Political Action Committee (COMPAC) and the American Medical Political Action Committee (AMPAC) at any level of membership. (RES-37, AM 1996) 930.998 Political Effectiveness The Colorado Medical Society (CMS) promotes political effectiveness through the utilization of the legislative staff for Colorado Medical Political Action Committee (COMPAC) activities, the encouragement of membership in COMPAC by all CMS and Colorado Medical Society Alliance members, and the use of in kind services provided by the CMS to enhance COMPAC’s support of candidates favorable to medicine. (RES-36, AM 1996) 930.999 Support Priorities The Colorado Medical Political Action Committee (COMPAC) supports candidates for state public office within the limits of its financial capabilities. The relative priority for support shall be as follows: 1. Candidates for the Colorado Senate and House of Representatives; 2. Candidates for state offices which impact medicine such as Governor, Attorney General, Board of Regents, etc., and 3. All other public offices. (Motion of the Board, October 1983) 107
