Doris C. Gundersen MD Medical Director CPHP FSPHP 2011 Annual Meeting April 28, 2011 © Colorado Physician Health Program 2011 All Rights Reserved Please

Colorado Physician Health Program

Medical Practice Act Sunset

Doris C. Gundersen MDMedical Director

CPHPFSPHP 2011 Annual Meeting

April 28, 2011© Colorado Physician Health Program 2011 All Rights Reserved

Please do not reproduce or use without written permission of CPHP

Disclosure Statement

NOTHING TO DISCLOSE

© Colorado Physician Health Program 2011 All Rights Reserved Please do not reproduce or use without written permission of CPHP

Objectives Understand a Medical Practice Act (MPA) sunset

process and the potential effects on one physician health program

Analyze the potential benefits and challenges that may arise during the involvement of a legislative process, including building an awareness of potential resources at a PHP’s disposal

Strategize for future physician health program development - succession planning

Learn ways to strengthen medical community and regulatory relationships

© Colorado Physician Health Program 2011 All Rights ReservedPlease do not reproduce or use without written permission of CPHP

Relationship To The Colorado Medical Board

(CMB)• Contractual Agent of the CMB

• CPHP is an independent 501(c)3• CPHP does not have immunity

• CMB Makes Referrals to CPHP • Applications for licensure• Renewal applications• Complaints

• CPHP Provides “Treatment Monitoring” for individuals with license stipulations

• Approximately 20% of CPHP cases are known to the CMB

• “Safe Haven”© Colorado Physician Health Program 2011 All Rights ReservedPlease do not reproduce or use without written permission of CPHP

CPHP’s OrganizationAl Structure

• Board of Directors• Executive Director & Medical Director• Clinical Team:

• 6 Associate Medical Directors – Psychiatrists with additional expertise in Addiction and/or Forensic Psychiatry. (Independent Contractors)

• Director of Clinical Services • 4 Masters level Licensed Clinicians • Compliance Coordinator• Receptionist/Program Assistant• Part-time Research Assistant

• Administrative Team:• Finance Manager• Development Specialist• Executive Assistant• Administrative Assistant


COLORADO PHYSICIAN HEALTH PROGRAM

CPHP’s Mission is to Assist Physicians, Residents, Medical Students, Physician

Assistants, and Physician Assistant Students, Who May Have Health Problems That if Left

Untreated, Could Adversely Affect Their Ability to Practice Medicine Safely

Serving the Medical Community Since 1986


Annual Number of New Referrals Program History

1986 - 2010

* = BME License Renewal Years© Colorado Physician Health Program 2011 All Rights Reserved

Please do not reproduce or use without written permission of CPHP

0

50

100

150

200

250

300

350

85*-86 86-87 87*-88 88-89 89*-90 90-91 91*-92 92-93 93*-94 94-95 95*-96 96-97 97*-98 98-99 99*-00 00-01 01*-02 02-03 03*-04 04-05 05*-06 06-07 07*-08 08-09 09*-10

Types /Sources of New Referrals 2009-2010

• Voluntary (64%)

• Mandatory (36%)


N=271

9%17%

2%7%

8.5%2%

43%5.5%

1%3%1%1%

0 50 100 150

Administration CMB

Family Hospital Proactive

Medical SchoolSelf

Residency ProgramPA Program

PeerTreatment Provider

Other

Problem Areas Served 2009-2010


N=185

3%

14.5%

2%

8%

8.5%

26%

8%

7%

13%

1.5%

4%

1%

2%

1%

.5%

0 10 20 30 40 50 60

Stress

Behavioral

Family

DUI/DWAI

Physical/Medical

Psychiatric

Legal

Work Stress

Substance Abuse

Psychiatric/Substance

Professional Boundaries

Domestic Violence

Career

Emotional

Other

CPHP Services

• CPHP’s direct services (evaluation, treatment referral and monitoring) are free to Colorado licensed physicians and physician assistants.

• Participants are responsible for costs of any additional evaluations and treatment if those services are necessary.

• Peer Assistance Funds are not used for applicants or re-applicants.

• CPHP has contracts to serve many Colorado residents, medical students and physician assistant students. (12 Training Programs Served)


Program Services Client Services:

Clinical Assessment Treatment referral (CPHP does not provide

treatment in house) Monitoring and support Family support Documentation

Workplace and Referral Source Services: Consultation on identifying physicians who need

assistance Consultation on making effective referrals Workplace consultations Consultation on back-to-work issues Educational presentations Critical Incident Debriefing


CPHP Educational Activities

Education/Presentations CPHP Services (Orientation) Physician Stress and Stress Management Physicians in Relationships and Families Women in Medicine Substance Abuse and Addiction Professional Boundaries Self-care and Physician Health Issues Disruptive Behavior Management Medical Marijuana


Other CPHP Activities

Research• Comparing CPHP success rates of monitoring substance

use disorders to other Physician Health Programs • Success of substance abuse recovery in relation to relapse

rates and type of treatment • Tobacco use by physicians • Physician professional boundary issues• Physician prescribing personal medical care • Gender differences among physicians seen at CPHP • Understanding clients who reactivate with CPHP • Evaluating “Art of Medicine” ratings in healthy vs ill MDs• Evaluating if there is a greater risk for malpractice in

CPHP clients© Colorado Physician Health Program 2011 All Rights ReservedPlease do not reproduce or use without written permission of CPHP

Background: CPHP History

Developed in collaboration with Denver County Medical Society/Colorado Medical Society

Inception: 1986 Peer assistance program created through

statute - Medical Practice Act (MPA) Surcharge RFP (every 5 years)

Importance of separate holding of funds with 3rd party (COPIC)



1999 to 2010: Each applicant pays a surcharge not to exceed

$50/yr

Amount adjusted by CMB annually to reflect changes in US bureau of labor statistics, CPI, etc.

Fee shall be used to support designated providers selected by the CMB to provide peer assistance

Cost of living adjustments available to $50 surcharge



Peer Assistance fund grew excessively without equivalent provision to CPHP

CPHP would request increases in funding as needed


Programmatic Funding Increases

DATE

ACTUAL ALLOTMENTS NOT TO EXCEED

2000 to 2001 $696,528.00 $696,530.00

2001 to 2002 $774, 996.00 $775,000.00

2002 to 2003 $840,000.00 $840,000.00

2003 to 2004 $840,000.00 $900,000.00

2004 to 2005 $900,000.00 $900,000.00

2005 to 2006 $1,020,000.00 $1,100,000.00

2006 to 2007 $1,200,000.00 $1,500,000.00

2007 to 2008 $1,200,000.00 $1,500,000.00

2008 to 2009 $1,200,000.00 $1,500,000.00

2009 to 2010 $1,200,000.00 $1,500,000.00

2010 to 2011 $1,200,000.00 $1,500,000.00

Programmatic Funding Increases

• CMB realized excess of peer assistance funds• CMB offered solution of various proposals to utilize

excess funds.• CPHP requested and accepted one of the proposals• Problem! Calculations were not conducted for longer

term and fund was depleted.• CPHP “covered” 3 months in 2009 which were paid back

upon licensure renewal and replenishment of peer assistance fund

• The fund will again be depleted approximately 1-2 months shy this cycle due to COLA increases implemented in 2009 which reduced some of this deficit



Sunset process – MPA is open for revision by legislation

Last sunset process was 1995

2010 sunset occurred with new CPHP leadership (MD and ED)


Sunset 2010

No current CPHP staff members previously participated in sunset process of 1999

CPHP Board Director versant in legislation advised use of CPHP Advisory Committee which includes individuals with significant medical community connections and who were active in legislation

Long Term Planning Committee Established Medical Director Medical Director Emeritus Executive Director Board Directors Advisory Committee


CPHP Recommendations for MPA Sunset:

Preserve statute language to maintain a peer assistance program for Colorado

Surcharge amount not to exceed $61/year Surcharge may be adjusted annually by CMB

Revise funding mechanism: To accommodate for growth of program To allow different surcharge for MD vs PA Allow CMB to determine when surcharge changes are warranted

(to remove it from MPA sunset process) Changes in US Bureau of Labor statistics and CPI Overall utilization of the program and Differences in program utilization by MDs vs PAs


CPHP Recommendations forMPA Sunset (continued)

Fee imposed shall be used to support designated providers selected by the board to provide assistance to physicians and PAs

Administering Entity: All funds collected by the CMB are custodial funds NOT

subject to appropriations by the General Assembly The distribution of payments to the administering entity

does not constitute state fiscal year spending for purposes of Section 20 of Article X of the state constitution


MPA Sunset Strategy

What CPHP wanted to avoid- Unnecessary attention/negative PR- Hostility with other medical community entities (ex. CPEP, CMB)

What CPHP wanted to gain- Maintain language allowing for a peer assistance

program - Develop language to create a better funding stream


Development of Strategy

Meet with other medical community stakeholdersIdentify supporters of our goals

Educate other stakeholders

Find medical community lobbyists to support CPHP:CPHP limitations due to nonprofit status/limited budgetCMS and CPS have strong lobbyists

Awareness of DORA’s role in Sunset Process:Policy Analyst reports to Legislative Committee

Legislative Committee traditionally accepts 80-90% of Analyst’s recommendationsPrimary mission of DORA: Patient Safety


Development of Strategy(continued)

*Created Patient Safety Committee as CPHP BOD advisors

Patty Skolnick Ed Dauer Judy Ham

Legislative Strategy: Highlight and explain the connection between patient safety and CPHP’s work

*Some risk with this!© Colorado Physician Health Program 2011 All Rights ReservedPlease do not reproduce or use without written permission of CPHP

Long Term Planning CommitteeRecommended Course of Action LTP Committee encouraged development of a

presentation highlighting “Public Protection through Physician Wellness”

Create list of individuals from Medical Community supportive of CPHP. This info was available as a “supporter list” drafted as apart

of our proposal in the RFP process for the Peer Assistance Contract every five years

Create a list of individuals who need to know about CPHP We did not identify local “enemies” of CPHP Concern about national detractors of PHPs


Regarding Lobbying Activities

CPHP did not hire a lobbyist: Our nonprofit status Budgetary limitations Our strategy was to align with DORA/CMS/CMB

recommendations so their lobbyists could carry our revisions to sunset

CMS has a strong lobbyist presence Dilemma:

CMB disallowed from directly having any position on legislative matters

CMB could not publically speak to the benefits of CPHP


Regarding Lobbying Activities(Continued)

*DORA Analyst

Highly Competent Thoughtful Analysis of the MPA Several interviews/meetings with knowledgeable

stakeholders Initially was opposed to recommended changes in how

peer assistance program would be funded

*CPHP’s Patient Safety Committee Member DU Law School Professor (Ed Dauer) DORA Analyst was previously his student Convinced DORA Analyst to support CPHP’s funding recs

© Colorado Physician Health Program 2011 All Rights Reserved Please do not reproduce or use without written permission of CPHP

Actual Sunset Process

CPHP Board Director attended legislative proceedings.

No comments on the peer assistance program revisions.

Passed without incident in June 2010!


Statute Revisions

In CPHP’s favor:

Creation (continuance) of a peer assistance program

An unanticipated Surprise:Creation of “Confidential Agreements”

One disappointment: • SUDs excluded from confidential agreements


Changes to CPHP Funding as of 2011

Per statute revisions, CPHP created a report summarizing:

CPHP Growth Projected Growth (and need for increased

funding) Budget proposal


Changes to CPHP Funding as of 2011 (continued)

CPHP met with CMB in November 2010

Previous deficit from peer assistance fund was included to vote upon with CPHP budget proposal

Deficit was due to a CMB miscalculation (CPHP did not want to “out” the CMB for this mistake)

Both funding requests require the CMB to authorize a peer assistance surcharge increase under the statute language “utilization of program”

The funding request to account for the deficit was more than CPHP budget proposal request

Concern that the funding request to make up for the deficit would jeopardize overall CPHP budget request


CPHP provided organizational growth indices of:

-New referrals -Average active case load -CMB referrals -Safe haven cases (exceed CMB referrals) -Cost per program participant

-Salary costs for staff/contract MDs -Funds from other contracts (i.e. medical school) -Reports generated

-Community outreach activities (education/crisis interventions, etc)

CMB members complained that they did not have enough information – they wanted more “metrics”


Difficulty:

Growth indices used could not be compared directly to program funding increases as CPHP previously made requests for budget increases on an as needed basis

Budget Proposal was approved:

8 CMB members approved our budget proposal 2 voted no (wanting additional data) 2 voted no (believed budget proposed was inadequate)

Budget requests will now correspond directly to license renewal cycle so that growth rate comparisons are more realistic

Lessons for the Future

Preparation time – one year in advance

Maintain awareness of political climate

Maintain Community Relationships


Lessons for the Future Regarding Statute Know your states legislative process and key players Importance of historical memory – requires succession

planning Develop program advocates active in the legislative

process Medical Boards Important to know what data MB wants to review Design budget proposals which correspond

directly to license renewal cycles/program utilization so that growth rate comparisons are more realistic

Keep budget issues outside of statute for easier modifications

Medical Boards are political entities that change Work to maintain relationships Consider routine task force/liaison meetings

Protect funding with 3rd party administrator

PHP Succession Planning

Requires constant identification and recruitment of skill: Medical Director Executive Director/Program Administrator Board of Directors

Cross Pollination with medical board ideal Clinical Staff – diversity is good Relationships with the community

Team Consultation Model (Unique to Colorado)

Six Psychiatrists with Varying Expertise and Age

General PsychiatryForensic PsychiatryAddiction PsychiatryPsychoanalytic Psychiatry

Four Experienced Masters Level Clinicians

Executive Director

Executive Committee (Anonymously)


Team Consultation ModelClinical Staff Meetings

Weekly full team meetingsReview/discussion of new casesReview/discussion of difficult casesDetermination of:

• Diagnostic clarity• Additional Assessment Needs• Treatment Plan Development/Modification• Treatment Referral

AMD/Clinicians Weekly Meetings


Final Lesson for the Future

Physician Health Programs are dynamic – not static

Consider “flux” the status quo

Maintain Vigilance

Contacting CPHP

Phone• 303-860-0122 or 800-927-0122

Office Hours: • 8:30 a.m.- 4:30 p.m. • Monday – Friday

After Hours Clinical Emergencies: • Pager: 303-437-2138

For additional information visit the CPHP website: • www.CPHP.org


Documents

Doris C. Gundersen MD Medical Director CPHP FSPHP 2011 Annual Meeting April 28, 2011 © Colorado Physician Health Program 2011 All Rights Reserved Please