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; Reaffirmed, BOD-1, AM 2014)

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 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 data-driven 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 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.

(CPPE-1, AM 2012; Revised, BOD-1, AM 2014)

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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:

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.
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. 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:
1. Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic information systems.
2. Patient care is coordinated among multiple providers and transitions across care settings are actively managed.
3. There is clear, shared accountability across the spectrum of patient care.
4. 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.
5. 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.
6. The system is continuously innovating and learning in order to improve the safety, quality, value and patients’ experiences of health care delivery.
7. Patients are supported in their ability to carry out the care plan, including actively participating in the management of their health information.
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.
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.
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.
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.
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.
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.
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; Reaffirmed, BOD-1, AM 2014)

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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, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the 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 non-governmental 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 patient-centered 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 e-mail 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; Reaffirmed, BOD-1, AM 2014)

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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:

Universal health care

Include tiered public support for individuals based upon sliding scale income levels.
Provide universal access to a community rated basic benefit package, provided on a guaranteed issue basis.
Require all individuals to have basic health insurance coverage.
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.
Allow and incentivize employers to participate voluntarily by providing coverage for employees, with discounts for health maintenance and risk reduction programs.
Provide a basic benefit plan that would be uniform and uniformly administered across all beneficiaries and payment sources.

Cost containment and improved outcomes

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.
Provide physicians with actionable, relevant and trustworthy data to improve outcomes in quality and costs.
Decrease the administrative costs associated with utilization quality management.
Explicitly monitor and evaluate conflict of interest issues related to unwarranted variation in care.

Payment reform

Utilize incentives to encourage the provision of primary care and the delivery of care in underserved areas.
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

Ensure sufficient resources are allocated for clear education on the importance of an unambiguous direction for care (advance directive, living will, provider orders for life-sustaining treatment) under a variety of scenarios.
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:

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.
Establishing mechanism to address adverse risk selection by plan administrators.
Requiring all data holders to provide cost and quality information to permit the delivery systems to measure and improve performance.
Designing incentives to encourage and enforce community collaboration.
Overseeing the mechanism to reinvest proceeds into the communities.
Monitoring and regulating the utilization of self-owned facilities.
Encouraging and incentivizing the development of community-based, not-for-profit accountable care organizations.

(CONG-1, AM 2009; Reaffirmed, BOD-1, AM 2014)

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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.

Professionalism and the care covenant
Triple Aim

Improve the individual experience of care;
Improve the health of the population; and
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.

Attributes of Systemness

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:

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.

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:

structural changes,
enabling tools and
payment changes.

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.

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.

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.

Patient engagement -

Facilitate shared-decision making with patients by utilizing patient decision aids and advocating for policy changes to utilize informed patient decision-making models.
Incorporate patients within the administrative and management functions throughout the care system.
Facilitate patient management of their health information.
Facilitate health literacy.
Facilitate healthy behaviors.

Redesigned approach to end of life -

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.
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.
Ensure that palliative care is available at the same time as disease-modifying therapy in acute care, ambulatory care and community-based settings.
Support legislative efforts that will provide adequate protections for providers for following patient wishes. (MOLST – Medical Orders for Life-Sustaining Treatment)
Ensure that health care providers throughout the state have adequate generalist-level palliative care knowledge and have access to specialist-level palliative care expertise.

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:

Improving care delivery by spreading and integrating systems of care models;
Aligning payment incentives;
Coordinating ancillary supportive services;
Using data to improve performance; and
Collaborating among multiple stakeholders (payers, purchasers, patients, providers and government).

Outcome measurement and public reporting –

Support the development and use of appropriate measures to document progress on patient health goals.
Support policies that aggregate data across all payers with a sufficient level of detail to be actionable for outcomes improvement.
Support public reporting that drives accountability and continuous improvement.

Health information technology/health information exchange - Use health information technology (HIT) and health information exchange (HIE) to improve health outcomes and reduce costs by:

Presenting best evidence, consensus recommendations and prompts for both physicians and patients at the point of care;
Collecting data on treatments, practices, outcomes, diseases, needs and performance across the spectrum of care;
Conducting quality improvement projects;
Improving the performance of HIT and HIE designs and processes; and
Fostering the adoption of HIE tools in the community, as well as agreements among providers regarding appropriate data exchange.

Comparative effectiveness research

Advocate for benefit design changes that use clinical information to show whether new health technologies/services are reasonable and necessary;
Support efforts to advance the evidence base and facilitate rapid diffusion of appropriate new services, while curbing the use of unwarranted services; and
Maintain an awareness of warranted variation to protect patients with atypical conditions or needs.

Value not volume - Support policies that disconnect physician incomes from volume and intensity; align physician compensation with appropriate measures and goals.

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; Reaffirmed, BOD-1, AM 2014)

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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; Reaffirmed, BOD-1, AM 2014)

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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

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

Physician performance measurement:

Against best research evidence and cost effectiveness
With their peers

The new system will provide an accurate mechanism for physicians to measure their performance on:

Quality
Cost

The new system will utilize standards for performance measurement that promote continuous quality improvement

The new system will include interoperable data systems

Data systems accuracy

The new system will utilize:

Data systems that include transparency of all clinical guidelines
Data system performance measurement methodologies
Processes for physicians that include reasonable notice of performance measurement, appeals processes and chart reviews
Legal protections against misrepresentation of a physician’s practice

Public reporting of provider performance:

The new system will utilize a system for measurement and public access to accurate, meaningful and constructive measures of provider performance
The new system will specify that the systems for determining what will be measured and reported will be:

Collaboratively designed (i.e, involve providers, consumers and purchasers)
Publicly accountable
Use a multidimensional approach to quality reporting
Require disclaimers regarding limitations on performance measures

Acute and long-term care services and support:

The new system will utilize active care management principles and clinical strategies to meet the needs of high risk/high cost populations

End of life care

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

Price transparency

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

Guidelines and quality measures

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

Information exchange

The new system will:

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
Permit its aggregated claims, clinical and quality data to be transferred into an aggregated data system for purposes of performance measurement and quality improvement

Medical home

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

Practice redesign and health information technology (HIT)

The new system will:

Enable Colorado physicians to utilize health information technology
Encourage technology and practice redesign support programs

Principle III Section C: Patient safety

“Blame-free” reporting

The new system will authorize a mechanism for “blame-free” reporting of medical errors that fosters continued improvement of error reduction
If a mechanism for “blame-free” reporting is created, then the new system will still protect the rights of patients

Patient safety

The new system will address systems of patient safety across all patient care venues including physician practices by promoting strategies that address:

Medication monitoring and risk assessment
Patient transitions and handoffs
Procedure safety
Training of personnel
Workflow design
Patient education and communication

Liability climate

The new system will preserve and promote stability in Colorado’s professional liability climate

Principle III Section D: Regulatory oversight

Adequacy of regulatory powers

The new system will establish adequate legal frameworks and enforcement tools that are uniformly applied

Adequacy of regulatory tools

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

Structure

The new system will be:

Simple – Utilizing systems that are easy to navigate and that clearly specify how conflicts will be resolved
Transparent – Enabling easily accessible participation in policy development and public reporting of change, administrative actions and financial matters
Accountable to citizens – Utilizing systems to evaluate its performance and instituting meaningful consequences for system inadequacies

Reducing administrative costs

The new system will focus on cost effective administrative management by:

Providing mechanisms for stakeholder input to improve administrative efficiencies
Demonstrating reduction of costs associated with implementing and maintaining the administrative structure

Public reporting of expenses

The new system will monitor and publicly report administrative expenses using generally acceptable accounting principles with defined timelines and budgets

Patient care outcomes

The new system will utilize an administrative system that monitors and reports on the effectiveness of patient care outcomes by:

Measuring and reporting on achievable health improvement goals
Establishing timelines for statewide electronic interoperability
Establishing a process that allows the system to responsibly address medical advances in biotechnology
Establishing a process that identifies and addresses gaps in access, delivery and quality in a timely fashion
Supporting a mechanism of aggregating data for quality improvement that is sensitive to vulnerable populations
Demonstrating achievement of best practice standards at the individual and system level

Principle IV Section B: Governance

Governance

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

Equitable, affordable and sustainable financing

The new system will be:

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
Affordable– Constantly balancing the needs of individuals with the resources of the community
Sustainable – Sustaining and improving current and emerging physician practice types

Simple, transparent and efficient financing

The new system will utilize a simple and transparent financing mechanism that drives down administrative expenses and reinvests savings back into the system

Emphasizes personal and societal responsibility and encourages sound stewardship

The new system will establish a fair and equitable mechanism for shared accountability of health care resources by:

Establishing funding and payment that aligns incentives to achieve a healthy community
Preserving and promoting the provision of quality of health care
Demonstrating a commitment to sustaining the health care workforce

(CONG-1, AM 2007; Reaffirmed, BOD-1, AM 2014)

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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 long-term 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 supports 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; Revised, BOD-1, AM 2014)

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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.

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 private cost sharing should be used to cover people ineligible for coverage due to residency requirements.

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.

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.

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.

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.

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.

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.
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.

Health Care Budgets
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.

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.

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.

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.

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.

Protecting and Improving Quality of Care
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.

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; Reaffirmed, BOD-1, AM 2014)

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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:

Coverage for all Coloradans;
Choice of physicians, other providers and health insurance plans;
Decrease administrative costs;
Continuous quality improvement;
Emphasis on prevention;
Portability of coverage;
Cost containment; and
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:

Develop a Colorado-specific solution that takes into account Coloradans’ core values and preferences;
Develop a plan for all Coloradans that ensures that everyone has access to quality, affordable coverage;
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;
Develop plans that cross partisan and ideological boundaries;
Put priority on getting coverage for low-income uninsured, especially pregnant women and children, who don’t have access to affordable coverage;
Build on and improve existing insurance programs, but do not disrupt arrangements that are working well;
Maximize cost-effective use of limited dollars and leverage new and existing funds to the extent possible;
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
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; Reaffirmed, BOD-1, AM 2014)

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