Michigan Medicine®, Volume 120, No. 4 by Michigan State Medical Society

THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 120 / NO. 4

July / August 2021

… AND

JUSTICE FOR ALL

Advancing healthy equity in Michigan

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p resident 's We need to talk As physicians, it is our goal to improve outcomes for all patients. We work continually to pursue new scientific research and better treatment options for all our patients. But there is one area of improvement that still needs much more attention. A growing body of research shows that different populations of patients experience disparate health outcomes based on race, age, ability, gender, or other socio-economic factors. While the causes of these disparities are myriad and deep, we have not done our job as a thoughtful society of practitioners if we haven’t examined them thoroughly with an eye toward correcting them.

PINO D. COLONE, MD (GENESSEE COUNTY) MSMS PRESIDENT

That is why MSMS has developed a task force to leverage an important statewide dialogue about health equity across Michigan. It is important for us to have the conversations, as challenging as they may be, if we are to do our duty to the millions of Michigan patients who look to us for their care. We need to understand the root causes of the inequities they are experiencing and address them in ways that are meaningful and effective. Will it be easy? Absolutely not. Nobody expects a group of individuals to sit around a table and have a comfortable conversation about some of the most profound issues that divide us as a society. However, there are few discussions that are more essential at this time in our state’s history. We know we need to make our future better than our past. We need to end the issues that result in health outcomes that are different between various

“We need to understand the root causes of the inequities [millions of Michigan patients] are experiencing and address them in ways that are meaningful and effective.”

populations of Americans. And it begins with a willingness to start the conversation.

PINO D. COLONE, MD, MSMS PRESIDENT

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FEATURES & CONTENTS July / August 2021

12 … and Justice for All

Health equity is a challenging topic for many physicians. Issues related to race, gender, income, age and ability are tough conversations for our society today, with dialogue that can be loaded with generational trauma, acrimony, fear and guilt. But, as the events of the past year have shown, they are among the most important discussions we can have. (Story begins on page 12.)

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BCBSM Settlement Notice DANIEL J. SCHULTE, JD

Meet the MSMS Government Relations Team

MICHIGAN MEDICINE® VOL. 120 / NO. 4

MICHIGAN STATE MEDICAL SOCIETY

Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org Publication Design STACIA LOVE, REZÜBERANT! INC. rezudesign.com Printing FORESIGHT GROUP staceyt@foresightgroup.net Publication Office Michigan Medicine® 120 West Saginaw Street East Lansing, MI 48823 517-337-1351 www.msms.org

The Power of Stay Interviews JODI SCHAFER, SPHR, SHRM-SCP

All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Trisha Keast.

COVID-19 and Patient Safety in the Medical Office DEBBIE KANE HILL, MBA, RN THE DOCTORS COMPANY

Protect Your Patients Before They Head Back to School! ALYSSA STROUSE, MPH

ALSO INSIDE 27 NEW & REINSTATED MEMBERS 28 EDUCATION

STAY CONNECTED!

Postmaster: Address Changes Michigan Medicine® Trisha Keast 120 West Saginaw Street East Lansing, MI 48823

Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine® and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine® reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine® are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine® (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2021 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2021 Michigan State Medical Society

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ASK OUR LAWYER

BCBSM Settlement Notice By Daniel J. Schulte, JD, MSMS Legal Counsel

I received notice of a class action settlement from BCBSM. It states that it is being sent pursuant to an order of the U.S. District Court in Alabama. What, if anything, do I stand to get from this settlement? Does the settlement contain

any changes to the way the TRUST or other networks are administered?

You received this notice if, according to BCBSM’s records, you are an individual, insured group health plan or self-funded health plan (the “Class Members”) that purchased (or paid a portion of the premiums for) health insurance from BCBSM between February 7, 2008 and October 16, 2020 (the “Claim Period”).

he lawsuit that resulted in this settlement has been pending in an Alabama Federal District Court for several years. The plaintiffs alleged that the Blue Cross Blue Shield Association (BCBSA) and most state Blue Cross Blue Shield plans (including BCBSM) entered into agreements and followed certain business practices that violated the antitrust laws and that these illegal agreements/practices resulted in health insurance premiums being higher than they would have been in their absence. As part of this settlement, $2.67 billion is to be paid into a fund. Part of this fund (estimated to be $1.9 billion) will be used to make refunds to the Class Members who paid the allegedly inflated premiums. The notice you received instructs you to complete a claim form to participate in the settlement and receive a payment. When the

payment will be made and how much it will be are unknown at this time. You must submit a claim form prior to November 5, 2021 to be eligible for any payment from this settlement. The claim form is available at: https://www. bcbssettlement.com/documents. The claim form consists of three sections. Which section you complete depends on the capacity in which you are providing the information. If you are providing the information on behalf of your medical practice which paid the premiums, in whole or in part, for BCBS coverage for your employees during the Claim Period you should complete Section A on behalf of the practice. If you individually paid the premiums for your own BCBS coverage during the Claim Period you should complete Section B. If you were enrolled in a health insurance plan sponsored by your employer and paid a portion of the premiums during

You must submit a claim form prior to November 5, 2021 to be eligible for any payment from this settlement. The claim form is available at: https://www.bcbssettlement.com/documents.

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the Claim Period you should complete Section C. The information requested in each section form the claim form is consistent and fairly straight forward (e.g. your name, employer’s name, addresses, phone number, email address, name of the plan, coverage dates, etc.).

For those individuals who paid part of the premium for coverage provided by an employer sponsored plan, the settlement amount will be allocated between you and your employer. For those individuals who paid part of the premium for coverage provided by an employer sponsored plan, the settlement amount will be allocated

between you and your employer. The settlement agreement provides that 15% (if a fully insured plan) or 18% (for administrative plans) of the settlement amount will be allocated to employees who had single coverage and employees who had family coverage will be allocated 34% (if a fully insured plan) or 25% (if an administrative plan). These are default allocations. If you believe another allocation should be applied, you must complete section D of the claim form. Only if you do not want to follow the default allocations and are completing section D of the claim form will you have to specify the premium amounts you have paid. Section D requires you to include an alternate percentage and

documentation supporting it. This documentation should include proof you paid premiums more than the default percentage. The Settlement Agreement contains other requirements that BCBSA, BCBSM and the other settling Blue Plans no longer enforce certain provisions in their licensing and other agreements and cease certain other business practices. However, none of these requirements directly affect the enforcement or administration of network participation agreements with physicians or other providers of health care services. DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL.

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ASK HUMAN RESOURCES

The Power of Stay Interviews By Jodi Schafer, SPHR, SHRM-SCP, Human Resources Management Services, LLC www. WorkWithHRM.com

I am trying to fill a clinical position and am not having a lot of luck. When I talk to my colleagues, it seems I am not alone in my recruiting struggle. There are several factors at play – inadequate numbers to meet current hiring demands, inflated unemployment payments due to the federal subsidy and ongoing fears and/or family demands due to COVID. While I’m trying to work every angle, the clock is ticking. My team is doing more with less and I can see the signs of burnout all around me. The worst thing that could happen is for me to lose one of my existing staff at this stressful point in time. What can I do to retain my current team in this challenging environment?

As you know from talking with other practice owners and administrators, hiring for certain positions has become incredibly difficult and very expensive. The drop in applicant numbers has led to a supply/demand dilemma and starting wages are rising drastically as a result. Some practices have grown so desperate that they have started poaching employees from colleagues in the community. You are right to worry about hanging on to the staff you have. Losing them to burnout or to the practice down the street is a very real threat.

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o ward off unwanted departures, you need to find out how your staff perceive their job responsibilities, their workload, your management style, the practice policies and protocols, their wages and benefits, etc. before it’s too late. Talking to your current team members, one at a time, for the purposes of retaining them is referred to as a ‘stay interview’. These conversations provide insight into why an employee chooses to stay with your practice and what might cause them to leave. While pay may be one factor that needs adjusting as a result of the current job market, it is probably not the only change, nor the most meaningful change, you could make to improve overall job satisfaction. “In calmer times we might be tempted to distribute a survey. Most of us have learned, though, that surveys provide data but rarely take us to effective solutions. This is why Gallup reports employee engagement has barely budged in 20 years and that just one third of employees remain engaged, no matter which ‘solutions’ we try,” according to Richard P. Finnegan, CEO of C-Suite Analytics, a consultancy specializing in engagement and retention. So, this needs to be a conversation, not an impersonal survey tool. If you’ve never conducted a stay interview before, it can be a little nerve-wracking. You may be anxious to hear what employees will say and employees may be hesitant to tell you the truth. It’s best to set the stage for a stay interview in advance of the actual meeting. Let your staff know that you recognize the stress and added demands that have been placed up on them over the last 16+ months and that you want to do what you can to support them and make your practice a great place to work. Then, introduce that you’ll be having an informal talk

5 CLASSIC STAY INTERVIEW QUESTIONS 1 What do you look forward to each day when you come to work? 2 What are you learning here, and what do you want to learn? 3 Why do you stay here? 4 When is the last time you thought about leaving us, and what prompted it? 5 What can I do to make your job better for you?

with each of them to find out how they are doing, what like about their job and the work environment and what you could do to make things even better. When the time comes to speak with your employees, follow the 80/20 rule. Spend 80% of the time listening and 20% of the time probing further and taking notes.

When the time comes to speak with your employees, follow the 80/20 rule. Spend 80% of the time listening and 20% of the time probing further and taking notes. This is about them and their perspectives, so they should do most of the talking. This is about them and their perspectives, so they should do most of the talking. Use the stay interview questions above to get you started, but feel free to dive deeper based on the responses provided. To close the stay interview, thank your employee for their honesty, summarize the key points you heard and let them know what you plan to do with the information. Remember, not acting on the feedback you receive is worse than never having asked for their perspective in the first place. Consider communicating the results of your interviews in aggregate along with any planned changes so that your staff know that their efforts and vulnerability weren’t in vain. The time you invest in this process will pay dividends in retaining key staff and boosting moral during a difficult time.

Visit MSMS.org/AskHR for exclusive member access to a variety of human resources services.

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MDHHS UPDATE

Protect Your Patients Before They Head Back to School! By Alyssa Strouse, MPH, Adult and Adolescent Immunization Coordinator, MDHHS Division of Immunization

Summer months are the perfect time for fun, family, and friends, and for catching back up on vaccines. While busy parents make lists and stock up on back-to-school essentials, take the time to reach out and remind them that vaccines are important back-to-school items too.

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ccording to the American Academy of Pediatrics (AAP), since the onset of the COVID-19 pandemic, a significant drop in well-child visits has resulted in delays in vaccinations. While outpatient visits to adult primary care physicians have rebounded to near pre-pandemic levels, pediatric visits and immunization rates have been slower to rebound.1 According to the Michigan Care Improvement Registry (MCIR) and as of May 2021, the coverage rate for Michigan adolescents 13 through 17 years of age for the 1323213* vaccine series was 42.3% and has been declining in recent months. Concern exists that delays in vaccinations, and decreasing vaccination rates, may result in secondary outbreaks with vaccine-preventable diseases. Adolescents require several vaccines to keep them healthy and fully protected throughout the upcoming school year. According to the Centers for Disease Control and Prevention (CDC), adolescents aged 11-12 years should receive one dose of meningococcal (MenACWY) vaccine, two doses of human papillomavirus (HPV) vaccine 6 to 12 months apart, one dose of tetanus, diphtheria, and pertussis (Tdap) vaccine, and an influenza vaccine every year. (2) This back-to-school season includes another important vaccine for adolescents as well, the COVID-19 vaccine. On May 12, 2021, the Advisory Committee on Immunization Practices’ (ACIP) issued an interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine in adolescents ages 12 through 15 years under the Food and Drug Administration’s Emergency Use Authorization. (3) The Michigan Department of Health and Human Services (MDHHS) urges you to vaccinate your adolescent patients with all recommended vaccines, including COVID-19 vaccine, prior to them returning to school in the fall.

*1 3 2 3 2 1 3

THE RECOMMENDED ADOLESCENT VACCINE SERIES: 1 TDAP, 3 POLIO, 2 MMR, 3 HEPB, 2 VAR, 1 MENACWY, 2 OR 3 HPV DOSES

According to CDC, COVID-19 vaccines and other vaccines may now be administered without regard to timing. This includes simultaneous administration of COVID-19 vaccine and other vaccines on the same day, as well as coadministration within 14 days. Although data are not available for COVID-19 vaccines administered simultaneously with other vaccines, extensive experience with nonCOVID-19 vaccines has demonstrated

When deciding whether to co-administer other vaccine(s) with COVID-19 vaccine, providers should consider whether the patient is behind or at risk of becoming behind on recommended vaccines, their risk of vaccinepreventable disease, and the reactogenicity profile of the vaccines. that immunogenicity and adverse event profiles are generally similar when vaccines are administered simultaneously as when they are administered alone. When deciding whether to co-administer other vaccine(s) with COVID-19 vaccine, providers should consider whether the patient is behind or at risk of becoming behind on recommended vaccines, their risk of vaccine-preventable disease (e.g., during an outbreak or occupational exposures), and the reactogenicity profile of the vaccines. If multiple vaccines are administered at a

single visit, administer each injection in a different injection site. For adolescents and adults, the deltoid muscle can be used for more than one intramuscular injection. (3) Providers are encouraged to utilize the MCIR to conduct reminders and recalls to ensure their patients are up-to-date on all vaccines. Recall letters should be generated from the MCIR and can identify cohorts of patients overdue for specific vaccines. Providers also have the option to change verbiage on the letters to illustrate specific messages that their practice may want to share. For more information on how to run reminders or recalls, visit www.mcir. org or contact your MCIR regional staff. Now is the time to assess the vaccination status for your patients and ensure that they are caught up on all their recommended vaccines. As we continue to combat the COVID-19 pandemic, it is crucial that we protect Michigan residents from diseases that we have vaccines to protect against. Make sure your patients are equipped with everything they need, including their vaccines, for a safe, happy, and healthy 20212022 school year. REFERENCES 1 AAP (2021). Guidance on Providing Pediatric Well-Care During COVID-19. Retrieved from https://services.aap.org/ en/pages/2019-novel-coronavirus-covid-19-infections/ clinical-guidance/guidance-on-providing-pediatric-wellcare-during-covid-19/ 2 CDC (2021). Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger, United States, 2021. Retrieved from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html 3 CDC (2021). Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. Retrieved from https://www.cdc.gov/vaccines/ covid-19/clinical-considerations/covid-19-vaccines-us.html

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… AND

JUSTICE FOR ALL

Advancing healthy equity in Michigan

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“We are living through an unparalleled time that has laid bare significant gaps in health equity in many communities across the state. [These communities] are much less healthy, less safe, have fewer opportunities for jobs, are more likely to be food deserts, and have poorer access to health care than many other communities in the state.” THEODORE JONES, MD, WAYNE COUNTY, CHAIR, MSMS TASK FORCE TO ADVANCE HEALTH EQUITY

or S. Bobby Mukkamala, MD, Genesee County, a simple drive home from the office was all it took.

“I saw a billboard on I-75,” he says. “It showed the average life expectancy for a person living in the city of Flint compared to the next zip code over, in Grand Blanc. The billboard pointed out that people in Grand Blanc live, on average, 20 years longer than people living in Flint. That’s two decades, just based on adjacent zip codes—and it really hit home. It was at that point I really started digging into what was going on in my community from a health equity perspective.”

Doctor Mukkamala’s investigation quickly led him to one inescapable conclusion: there are cracks in Michigan’s health care system, and those fault lines center around unequal outcomes among various patient populations. “Despite our best intentions, there are significant health disparities here in Michigan,” Doctor Mukkamala says. “It is a high priority for us as a community of physicians to consider and address very carefully, so each patient receives the best care possible, no matter who they are or where they come from. We saw the issue brought suddenly and sharply to light during the COVID-19 pandemic, which was in many ways the biggest wake-up call yet for physicians, health care systems, and policy leaders alike.”

Health equity is a challenging topic for many physicians as professionals— and, indeed, as Americans—living in the year 2021. Issues related to race, gender, income, age and ability are tough conversations for our society today, with dialogue that can be loaded with generational trauma, acrimony, fear and guilt. But, as the events of the past year have shown, they are among the most important discussions we can have. That is why the Michigan State Medical Society has launched a new task force to Advance Health Equity to conduct extensive, thoughtful statewide conversations on the topic.

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The goal of the Advance Health Equity task force is to “eliminate health disparities by pursuing health equity throughout society by direct engagement with policymakers, medical schools, health care leaders, members and other stakeholders and to advance policies that lead to a more diverse physician workforce, greater cultural awareness, mitigation of social determinants of health, and transparent and equitable organizational structures.”

“MSMS and its members recognize that they are in a position to be active change agents that encourage an honest examination of the systems of government and culture and health care that reinforce a legacy of exclusion and structured oppression that impedes racial justic and equity. The task force will take on the work of

Specific strategies to be pursued within the Strategic Plan’s structure include: The development of strategic partnerships, Education and resource development, Legislative, regulatory and payer advocacy, and Health equity prioritization This new task force, chaired by Theodore Jones, MD, is dedicated to exploring strategies for eliminating health disparities among populations across Michigan. “As a medical society, we need to really be concerned about the health status and care experiences of all state residents,” says Stacey Hettiger, senior director of medical and regulatory policy at MSMS, who is providing staff support for the task force. “As we think of the current inequities that exist, it’s

about more than implicit bias, though that’s certainly a piece of it. It’s also about social determinants of health and the larger institutional factors that create adverse outcomes for people.” It’s also challenging territory. Conversations about health equity are uncomfortable under the most positive of conditions, for they reflect shortcomings in a system from which our society expects a great deal. “These discussions are going to require a lot of self-examination,” says Lawrence Reynolds, MD, Genesee County, a pediatrician from Flint. “Some people, when they realize they’ve been doing something that is perpetuating an inequity, are overwhelmed by guilt. And people respond to guilt differently, particularly when it comes to their own biases. Some seek to make amends, some will try but then quit early, and others will just say, ‘it’s your fault, not mine.’ And then there are other folks who say, ‘Why don’t you all get over it’? We have to be ready to address all of these reactions in ways that make sense and lead to better outcomes.” Doctor Mukkamala concurs. “This is an important topic, and we need to handle it the right way,” he says. “We need to use approaches that are deep, respectful and strategic, so we don’t have unproductive conversations that feel defensive or divisive. Our dialogue needs to meet people where they are so we can change the aspects of our system that aren’t working to ensure equitable results for all patient populations.”

devising a robust response to this very real need.” THEODORE JONES, MD

“These discussions are going to require a lot of self-examination. Some people, when they realize they’ve been doing something that is perpetuating an inequity, are overwhelmed by guilt. And people respond to guilt differently, particularly when it comes to their own biases.” LAWRENCE REYNOLDS, MD

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The Challenge

ealth disparities have been a topic of concern since the mid-19th century, when social and medical experts first began to recognize the different experiences and outcomes of different population groups. After World War II, both the World Health Organization and the United Nations’ Universal Declaration of Human Rights enshrined the health equity concept as an ideal to be pursued. For many years, however, the issue has been simmering beneath the surface of a global conversation that’s been more focused on emergent situations. In fact, health equity has seemed to be such a distant ideal that most felt it probably could not be achieved in anyone’s lifetime.

Here in Michigan, for example, COVID-19 cases among Black and African American populations were, on a cumulative basis, 40 percent higher than among white populations.

“COVID-19 showed us the scope of the problem in ways that were vivid and urgent. If you were going to get sick or—God forbid—die from COVID, it would happen in days or weeks rather than 10, 20 or 30 years, as in other chronic diseases like diabetes or hypertension.” M. ROY WILSON, MD

“COVID-19 showed us the scope of the problem in ways that were vivid and urgent,” says M. Roy Wilson, MD, president of Wayne State University and appointee to the Michigan Coronavirus Racial Disparities Task Force. “If you were going to get sick or—God forbid—die from COVID, it would happen in days or weeks rather than 10, 20 or 30 years, as in other chronic diseases like diabetes or hypertension. And so it really focused attention on this immediate problem, while giving us an opportunity to think deeply about how we can address our state’s health inequities more broadly in the future.” From maternal and fetal loss at the beginning to life to sickle cell disease, HIV/ AIDS, cancer, diabetes, lung disease and stroke, adverse health outcomes are more common among Michigan residents who are Black. Given that these illnesses and conditions take so much time to manifest, however, there was little urgency around addressing them in all populations. The health equity challenge is even evident in today’s medical research.

With the advent of COVID-19, however, the need for more equitable health outcomes was cast into stark, immediate relief. Here in Michigan, for example, COVID-19 cases among Black and African American populations were, on a cumulative basis, 40 percent higher than among white populations. Similarly, Black and African American deaths due to COVID were more than three times the rate among their white counterparts.

“I was just reading that almost nine times more is being spent on cystic fibrosis research than is spent on sickle cell disease, even though sickle cell disease is three times more prevalent,” Doctor Reynolds says. “So it’s a history of decisions, practices and allocations of resources that contribute to health disparities and move us away from a place of equity.” Doctor Reynolds says these kinds of disparate outcomes have their roots in institutional racism.

“If you start with the premise that one group of people is not entitled to the same protections as others, it quickly becomes a practice,” he says. “And although its roots may not be apparent to later practitioners, it’s the assumption, ‘Oh, well, we’re doing all this research in, let’s say, cystic fibrosis and so I’ll do some more.’ Your mentor will have you go into that area. The dollars will follow the more experienced researchers. So it’s one step after another, to the point where the researchers, the practitioners, the funders become blind to this inequity and just don’t see it anymore.” Of course, these disparities and implicit biases are not confined to issues of race. “There are biases related to weight, age, income, and more,” Hettiger says. “For example, a physician might assume that because a person is obese, he might not be interested in learning about a particular fitness program. Or when it comes to gender, research shows there are differences sometimes in how men and women are cared for or the options they’re offered.” Moreover, there are structural inequities present in health care systems, from research and policy to affordability and access. There are widespread differences in the social determinants of health that also foster outcomes that are less than optimal for everyone. “We’ve barely begun to scratch the surface of all the interconnected systems that result in disparities among Michigan residents,” Doctor Reynolds says.

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The Opportunity

or Brian Stork, MD, Muskegon County, the journey toward health equity in Michigan is paved with awareness.

“Everyday, before I begin surgery or clinic, I make an effort to ‘get my mind right’ by reflecting on my own biases, thinking about where they came from, and making an attempt to filter them out,” he says.

“We’ve gained a lot of knowledge from the Flint water crisis and from the COVID-19 experience. The topic is right in front of us, right now.

front of us, right now. The challenge will be to keep it right there in front of us when these crises have passed.” According to Doctor Reynolds, that day is still a long way off. “Many people think it’s over,” he says. “But I am a Flint resident, who drank the Flint water, who worked in Flint during that year when no one would listen. I’ve been on the work groups and coordinating committees and task forces—and we’re still a long way from achieving justice. It’s a crisis that keeps on cursing us to this day.”

Doctor Stork grew in his own awareness through past work with a Muskegon organization that helps young adults aging out of the foster care system.

The challenge will be to keep it

“Working with this population of young adults, we quickly began to see differences. We went on to learn about how exposure to childhood trauma can lead to dramatic changes in behavior as well as physical, and mental health,” Doctor Stork says. “Over time we began to understand, more and more, that when people don’t have their basic needs met, there’s a domino effect in terms of their health. As physicians, each one of our interactions with these vulnerable adults is

BRIAN STORK, MD

The same was said of Michigan’s COVID-19 experience during the early days of the pandemic.

a potential game changer. We can’t afford to let any personal biases get in the way.” The key, Doctor Stork says, is ensuring we don’t lose focus and urgency around the need for health equity in Michigan.

“Our state had its residents who were Black going to the emergency rooms and being turned away, so they would go back home and die,” Doctor Wilson said. “They were dying at four times what the expected rate would have been. And the other part of it was a reduced access to testing, because you needed to have a car to get to many testing areas. Mobile testing was needed to get to the populations that were most vulnerable.”

right there in front of us when these crises have passed.”

“We’ve gained a lot of knowledge from the Flint water crisis and from the COVID-19 experience,” he notes. “The topic is right in

These issues were addressed though the concrete actions taken by the Michigan Coronavirus Racial Disparities Task Force. Doctor Wilson says the work made an enormous difference, and gives him hope for MSMS’s future task force discussions.

Theodore Jones, MD, task force chair, being inducted by Pino Colone, MD, as the Speaker of the MSMS House of Delegates.

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“Our work wasn’t just theoretical,” Doctor Wilson says. “I am convinced our efforts actually helped eliminate the gaps among populations who were contracting and dying from COVID-19 in significant ways. There was a measurable outcome at the end of all that, which makes me think that having a task force for eliminating health disparities more broadly can lead to some major improvements.”

The Future

hen it comes to having a productive, positive conversation of health equity issues, the road ahead is murky. Health care professionals are, by virtue of the careers they have chosen, caring individuals who want to help people remain healthy and disease-free. They are well-educated and thoughtful, so the implication that their work (and the systems that have been built to support it) can often result in adverse outcomes for some groups of patients—well, it stings. A lot.

Add the ever-changing complexity of modern American language, the turbulent 21st-century political environment, social media and the possibility of reputational harm, and the prospect of a deep statewide discussion of health equity can seem worrisome at best, frightening at worst. What if I choose the wrong word and offend someone? What if someone suggests I’m racist, ageist or anti-feminist? And, most of all, how can we move forward productively in ways that are specific and concrete enough to generate the results we hope for? “First of all, I think we need to go slowly,” Doctor Mukkamala says. “People need to feel safe in order to be honest, and that

requires a high level of trust. We need to gather input from people who are more ‘woke,’ and from others who think this entire exercise is a waste of time. Both perspectives have value, and both need to be accommodated in ways that make it more comfortable for them to talk to one another.” Hettiger also makes it clear implicit bias isn’t the only topic on the table. “There are so many other aspects to health equity, and those factors need to be discussed as well,” she says. “We have to look at the social determinants of health across Michigan, and how we can work together to make a difference in these areas. We have to think about medical deserts, where people can’t access the care they need in a timely way, and are suffering adverse outcomes as a result. We must consider the policies—from payers to statewide policy—that impact public health. There are so many levers we can press to improve health equity in Michigan and, through this work, we’re putting them all on the table.” Some physicians, like Doctor Reynolds, are eagerly anticipating the work ahead. “I can’t wait for things to change,” he says. “Is it better than it was before? Yes, but

“People need to feel safe in order to be honest, and that requires a high level of trust. We need to gather input from people who are more ‘woke,’ and from others who think this entire exercise is a waste of time. Both perspectives have value, and both need to be accommodated in ways that make it more comfortable for them to talk to one another.”

we still have a very long way to go. We need to listen when someone says, ‘Hold up, this doesn’t look right, sound right, or smell right.’ We have to change the power dynamics, broaden our perspectives.” Doctor Mukkamala agrees.

“I’m really excited about the fact that we’re moving in this direction,” he says. “It’s a turn in the conversation that has needed to happen for a long time, for our state and for our entire nation. The most important thing I can say to my colleagues in the medical profession is that this is not something that any single one of us is to be blamed for. We are all human beings, and this system wasn’t built by any person or group in isolation. Together, we all have an opportunity to grow and to change the system for the better.” As the MSMS task force comes together throughout the rest of 2021 and beyond, it is important for all society members to find ways to add their voices. Whether it’s participating in a stakeholder meeting, providing advocacy locally or at the state level, or collaborating to increase access, there are important roles for all those working in Michigan health care to play. Of course, it all begins with a personal commitment to being part of the process. If you are interested in becoming involved in MSMS’ work on health equity, contact Stacey Hettiger at SHettiger@msms.org or call MSMS at (800) 352-1351. “We all rise and fall together,” Doctor Stork says. “As health care professionals, as hospitals, as governments and payers— we want everybody to do well. With that as our goal, how can we go wrong?”

S. BOBBY MUKKAMALA, MD

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ADVOCACY CORNER

Meet the MSMS Government Relations Team

ne of the most effective ways of letting elected officials know an organization’s views on issues is through personal meetings. In political terms, this is called lobbying. The MSMS Government Relations team provides elected officials with the information they need to make the best decisions for their constituencies. The team also works to connect legislators directly with their constituents. Elected officials pay attention to mass numbers. When a group of people from a lawmaker’s district request a meeting, email, or call about a particular issue, the lawmaker wants to hear their point of view. As experts in their field, physicians in mass numbers can truly help officials understand the benefits or pitfalls of a piece of legislation.

Who We Are The MSMS Government Relations team has well over 20 years of combined bi-partisan and bi-cameral experience. This allows for better relationships with lawmakers and the ability to more effectively advocate for the needs of Michigan’s patients. The team includes:

Josiah Kissling, Senior Director, State and Federal Government Relations Josiah Kissling worked as the Legislative Director for former House Speakers Tom Leonard and Lee Chatfield, was the Budget Director for Speaker Kevin Cotter, and Policy Adviser for the House Republican Caucus.

Kate Dorsey, Manager, State and Federal Government Relations Kate Dorsey worked for former Representative Lisa Brown before joining the Government Relations team for the Oakland County Intermediate School District.

Scott Kempa, Manager, State and Federal Government Relations Prior to serving as the Legislative Director for Representative Mike Mueller, Scott Kempa spent time on staff in both the House and Senate.

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What We Are Working On Scope of Practice Our goal is to protect the health and safety of patients by opposing efforts of health care practitioners to seek licensure or recognition to perform tasks or procedures for which they lack the education, training, or experience. Attention so far this term has been focused on House Bill 4359, which would greatly expand the scope of CRNA practice. Having moved quickly through the House with little chance to engage, MSMS has offered many amendments to help improve the bill, specifically options that would allow for collaborative agreements between physicians and CRNAs. Although some slight improvements were made during the committee process, those changes do not do nearly enough to ensure safe patient care. MSMS has been in negotiations with Senate Leadership and continue our push for amendments to the bill that would allow for collaborative agreements between physicians and CRNAs. These agreements must include, at a minimum: physician sign-off on the anesthetic plan language for CRNA consultation with a physician who is in-person and physically available on-site an outline of the duties and responsibilities of the CRNA and the participating physician,

Prior Authorization As you know, the prior authorization process regularly delays the start or continuation of necessary medical treatment, directs resources away from patient care, and can negatively impact patient health outcomes. On April 29, 2021, the Michigan Senate unanimously passed Senate Bill 247 by a vote of 35 yeas, 0 nays, and one member absent. Senate Bill 247 would reform the prior authorization process to do the following: Require an insurer to make available, by January 1, 2023, a standardized electronic prior authorization request transaction process. Require prior authorization requirements to be based on peer-reviewed clinical review criteria. Require an insurer to post on its website if it implemented a new prior authorization requirement or restriction or amended an existing requirement or restriction, with respect to any benefit under a health benefit plan. Require an insurer or its designee utilization review organization to notify, on issuing a medical benefit denial, the health professional and insured or enrollee of certain information, including the right to appeal the adverse determination, and require an appeal of the denial to be reviewed by a health professional.

specific post-graduate clinical experience, with direct anesthetic patient care.

Prohibit an insurer or its designee utilization review organization from affirming the denial of an appeal unless the appeal was reviewed by a licensed physician.

We are also preparing for potential similar issues with regards to Physician’s Assistants and Nurse Practitioners, as well as others. We continue to proactively promote physician-led, team-based care efforts, including holistic approaches to scope of practice and licensure that meaningfully address care.

Prescribe procedures for granting a prior authorization request that had or had not been certified as urgent by a health care provider. For urgent requests, the prior authorization is considered granted if the insurer fails to act within 72 hours of the original submission.

a required verification of the CRNA’s credentials

For non-urgent requests, the prior authorization is considered granted if the insurer fails to act within 7 business days of the original submission. Require an insurer to adopt a program that promoted the modification of prior authorization requirements of certain prescription drugs, medical care, or related benefits, based on the performance of the health care providers with respect to adherence to nationally recognized evidence-based medical guidelines and other quality criteria. The bill was transmitted to the Senate and referred to the Senate Health Policy and Human Services Committee for action. We continue to advocate for this and other legislation that will promote transparency, appropriate clinical decision-making, and timely processing of requests. Telehealth During the COVID-19 pandemic, physicians of all kinds had to pivot toward telehealth services. This has proven to be an incredibly effective care delivery method that ensures patients can access care in a convenient and timely manner. While payers did temporarily remove some of the regulatory and administrative obstacles during the height of the pandemic, those policies are now reverting to pre-pandemic times. For physicians, the standard of care remains the same, regardless of the care delivery method. For this reason, we are working to achieve parity for payment and services whether in person or virtual. Unfortunately, most relevant bill introduced thus far this term is House Bill 4355, which allows out-of-state practitioners to treat patients without any licensing or regulation. MSMS is opposed to this bill as currently written, but hopeful that improvements and changes to the bill could offer the opportunity to create model legislation for other states to follow.

For updates on tracked legislation and to learn how you can TAKE ACTION visit MSMS Engage site: MSMS.org/Engage JULY / AUGUST 2021 |

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COVID-19 and Patient Safety in the Medical Office Debbie Kane Hill, MBA, RN, Senior Patient Safety Risk Manager UPDATED JUNE 8, 2021 — As a larger segment of the U.S. population has become vaccinated, COVID-19 cases and deaths have substantially declined. According to the Centers for Disease Control and Prevention’s (CDC’s) Vaccine Data Tracker, roughly half of the U.S. population has had at least one dose of the COVID-19 vaccine, with around 41 percent being fully vaccinated (with vaccinated defined as being at least two weeks out from receiving a second dose of the two-part Moderna or Pfizer vaccine, or two weeks after Johnson & Johnson’s single-dose Janssen vaccine). For those over the age of 65, more than 85 percent have received one dose, while around 75 percent of that demographic have completed the series. Accordingly, on May 16, the CDC released new safety guidelines for individuals who have been fully vaccinated; however, medical practices should note that these recent changes do not apply to patients and staff within healthcare settings. Recommendations for use of personal protective equipment (PPE) by healthcare workers remain unchanged.

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Contributed by The Doctors Company

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With some states fully reopening and COVID-19 mandates being lifted, what are the latest considerations for keeping patients and staff safe within the medical office setting? Here are some guidelines.

Managing the Unmasked Some patients have refused to wear masks during the pandemic for various reasons, and now other patients may not understand that the CDC’s lifting of masking protocols for fully vaccinated patients does not apply to healthcare settings. The CDC’s language may have caused confusion, and the reference to healthcare settings was somewhat buried within their public announcement. Thus, when making appointments for in-office visits, practice staff should continue to set expectations prior to patients coming into the office regarding established infection control protocol. Patients should be informed that continued adherence with masking protocol is required. Patients also should be reminded that individuals in healthcare settings are often sick, immunocompromised, and in close proximity to one another, creating the potential for more exposure. Signage on the practice website, on the front door, and at the reception area will help alert patients that infection control protocols are still in effect. If the patient is uncooperative upon arrival, healthcare providers should ask the patient to step aside to a private area and acknowledge the patient’s concerns. If the patient is angry, they should be reminded that you are obligated to follow guidelines from the CDC as well as other government mandates, and that all infection control policies remain in place to ensure everyone’s safety.

If the patient remains emotionally volatile and uncooperative, a healthcare provider can suggest the patient seek care with another healthcare provider. Per the CDC, cloth face coverings should not be used by those who are unable to remove the masks themselves, who have trouble breathing, or who are children under age 2.

Vital Pandemic Recordkeeping Continue to maintain records of staff-patient contact, i.e., who was assigned to work with the patient, either in a log or in the electronic health record. Document so that you can track and notify contacts in case of a COVID-19 diagnosis or probable exposure on either the patient or provider side. Further, to protect your practice, file records of staff screenings and screenings of those entering your facility in your administrative records, as well as maintaining records of all protocols and updated policies your office is following throughout this crisis. Keep records of PPE supplies/shortages, cleaning protocols followed, communications with patients, case incidence, and available medical resources within your community. Documentation that you have taken steps to follow recommended infection control protocol may be your best defense should COVID-19-related litigation occur in the future. For details, see COVID-19 Administrative and Medical Record Documentation: Prepare for Future Lawsuits.

Planning for a Vaccine Vaccine Distribution With vaccines now recommended for a broader population and more readily available within most communities (i.e., local pharmacies and grocery chains), practices should evaluate access to the vaccine for their patients and make plans to determine if and how they will handle administering a vaccine, should this be an option. Many medical practices are partnering with state and local governments to provide vaccine clinics within the community, particularly in rural areas.

Informed Decision Making As the COVID-19 vaccine rollout continues across the United States, medical practices should implement plans to educate patients and guide them to an informed decision about the vaccines available within their community. Vaccine information sheets are available through the Food and Drug Administration (FDA) website: Pfizer-BioNTech—Fact Sheet for Recipients and Caregivers, Moderna—Fact Sheet for Recipients and Caregivers, and Janssen (Johnson & Johnson)—Fact Sheet for Recipients and Caregivers. The CDC also provides easy-to-understand fact sheets for patients on its website: Benefits of Getting a COVID-19 Vaccine and Myths and Facts about COVID-19 Vaccines. For additional information, see The Doctors Company Communicating With COVID-19 Vaccine-Hesitant Patients: Top Tips.

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Vaccine Administration Should your practice be designated as a vaccine administration site, policies and procedures should be established for storage and inventory, scheduling and patient screening, patient education, documentation and patient follow-up, and the management of medication errors and emergencies. If you are assigned a state-sponsored vaccination team to administer vaccines within your facility on your behalf, you should review their protocols to ensure practices are safe, and inform patients that the administration is being conducted by the state. The CDC provides guidance on vaccine storage and handling best practices, a training module for healthcare professionals, and reference material in training and education, as does the World Health Organization (WHO) through its online training. The FDA offers fact sheets (Pfizer-BioNTech, Moderna , Janssen) for healthcare providers administering the different vaccines under emergency use authorization and gives information on vaccine administration, safety, storage, informed consent, and reporting adverse events specific to the manufacturer’s vaccine. Other resources include the CDC’s Prevaccination Checklist for COVID-19 Vaccines (patient screening tool) and The Doctors Company’s FAQs About COVID-19 Vaccinations Reimbursement: See the Health Resources and Services Administration’s “What Providers Need to Know About COVID-19 Vaccine Fees and Reimbursements.”

Follow the CDC’s patient screening protocol for early disease detection for patients presenting to your practice. We recommend that you check the CDC website regularly for any updates in screening criteria.

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Staying Diligent The following recommendations will assist in the ongoing screening and management of suspected COVID-19 patients in your practice:

Legislation and Guidance Reference the CDC, your state medical board, professional societies, and federal, state, and local authorities daily for public health guidance and new legislation, as this continues to be a fluid situation. Monitor for outbreaks of COVID-19 cases within your community. Stay on top of current trends to protect your patients and your practice.

Screening Criteria Follow the CDC’s patient screening protocol for early disease detection for patients presenting to your practice. We recommend that you check the CDC website regularly for any updates in screening criteria. Essential visitors to your facility should also be assessed for symptoms and contact exposure and redirected to remain outside if it is suspected that they could have COVID-19.

Comparing COVID-19 and the Flu Both the flu and COVID-19 are respiratory illnesses and can present in similar ways. For further guidance, see Flu or COVID-19? Convergence of Two Viruses Creates Risk of Diagnostic Errors.

Accepting Patients It is strongly recommended that practices do not turn patients away who are not fully vaccinated or simply because a patient calls with acute respiratory symptoms. All patients should be triaged over the phone or via telemedicine and managed according to CDC recommendations. Refusing assessment/care may lead to concerns of patient abandonment.

Designated Triage Location Check with your local public health authorities for locations designated to triage suspected patients, so exposure is limited in general medical offices. Community emergency preparedness plans have been activated so that parties are coordinating efforts to deliver effective public health intervention.

Telehealth Triage The CDC recommends alternatives to face-to-face triage and visits, particularly for high-risk patients, if screening can take place over the phone, via telemedicine, through patient portals or online self-assessment tools, or through a designated external triage station. Licensed staff should be trained in triage protocol to determine which patients can be managed safely at home versus those who need to be seen either at the office or at a designated community facility. See Healthcare Facilities: Managing Operations During the COVID-19 Pandemic. The CDC provides a Clinical Decision Algorithm to Guide Care Advice Messages, which includes a clinical decision-making tree. The Doctors Company offers resources on telemedicine in our COVID-19 Telehealth Resource Center, as does the CDC in Using Telehealth to Expand Access to Essential Health Services During the COVID-19 Pandemic. For a list of telehealth COVID-19 rules by state, visit Federation of State Medical Boards: COVID-19.

Patient Testing Physicians should determine which patients require testing based on presenting symptoms, history, contact exposure, community transmission of disease, and for early identification in special settings (e.g., nursing home admission or elective surgery). See the CDC’s COVID-19 Testing Overview and Overview of Testing for SARS-CoV-2 (COVID-19). The CDC advises, “Healthcare providers should im-

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mediately notify their local or state health department in the event of the identification of a PUI (Person Under Investigation) for COVID-19.” The CDC offers the Clinician Call Center, which is available to healthcare personnel to assist with diagnosis, clinical management, and infection control protocol. Dial (800) CDC-INFO [(800) 232-4636] and ask for the Clinician Call Center.

The CDC still recommends physical distancing within your facility; require that patients and staff sit at least six feet or more apart. Patients should be asked to wait in their car if that option is available.

Elective Services

immediately isolate the patient coming into the office (segregating them from other patients in the facility) in a designated regular exam room with dedicated patient care equipment. A back entrance should be utilized.

Patient Precaution For individuals entering your facility, query all patients about symptoms of coronavirus and document findings on an administrative log. Instruct patients to put on a cloth mask, face mask, or respirator covering the nose and mouth (source control), utilize tissues, practice good hand hygiene, and physically distance from others in the designated waiting area. Educational resources, including posters and print resources for use in the medical office, are available from the CDC (Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings) and the WHO. Reference the CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic and Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) for patient management guidance.

Should cases of COVID-19 trend upward within your community, check with regional health authorities on the provision of nonessential and elective healthcare visits and group-related activities. States and counties vary depending on number of cases, availability of PPE, and availability of hospital beds. For diagnostic and therapeutic interventions, including surgery, the CDC provides the Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic. Also, the American College of Surgeons (ACS) published Clinical Issues and Guidance on triage and management of surgical cases, including specialty guidelines. Some states may reinstate restrictions on the provision of nonurgent, elective surgeries and procedures. (See ACS: COVID-19: Executive Orders by State on Dental, Medical, and Surgical Procedures). In some states, violations may result in physician jail time, fines, or complaints to the medical board. Check with state and local regulatory agencies for any related mandates.

telephone assessment/telemedicine, and visitors. Also, post COVID-19 resources for patients (e.g., the CDC’s Coronavirus (COVID-19) page and COVID-19 Frequently Asked Questions) with a reminder to maintain physical distance, to wear a face mask, and to follow local orders to lessen community spread. If the office is closed, update voicemail messages to address telephone assessment, telemedicine, and how to reach the physician in the event of an emergency.

Suspected Infection

Office Messaging

Provider/Staff Precautions

Evaluate patients on a case-by-case basis. If presenting symptoms and/or contacts are suspicious for COVID-19, and it is determined that the patient must be seen, have the patient call prior to their arrival to make preparation for accommodation. When possible, conduct the patient evaluation outside your facility at a designated triage location. If that is not possible,

Follow Standard Precautions and Transmission-Based Precautions, including gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that follow the Occupational Safety and Health Administration’s (OSHA’s) Temporary Enforcement Guidance—Healthcare Respiratory Protection Annual Fit-Testing for N95 Filtering Facepieces During the

Practices should post front-door signage requiring patients and visitors who are exhibiting COVID-19 symptoms or who have had contact exposure to immediately notify facility personnel via telephone for instructions on accessing care. Include information on the practice website regarding office policies for appointments,

Physical Distancing The CDC still recommends physical distancing within your facility; require that patients and staff sit at least six feet or more apart. Patients should be asked to wait in their car if that option is available. Reconfigure seating as needed. Remove magazines and toys from the waiting room. Routinely disinfect the waiting room throughout the day. Develop a cleaning schedule and checklist for your facility, and document in administrative files that it is followed.

Visitor Precautions Allow only those visitors who are essential for the patient’s well-being and care to enter your healthcare facility, and require screening and source control cloth masks as indicated.

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COVID-19 Outbreak. If there is a shortage of N95 respirators in your facility, access current CDC respirator recommendations and review Optimizing Personal Protective Equipment (PPE) Supplies. Remember that patients will scrutinize your adherence to infection control protocol; ensure that staff follow it precisely. Failure to do so may result in medical board complaints, negative social media coverage, and the patient leaving the practice permanently. Provide updated staff training on infection control protocol as needed. See Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination for more information.

Limit Exposure Limit staff exposure to suspected COVID-19 patients, with the exam room door kept closed. Ideally, the designated exam room should be at the back of the office, far away from other staff and patients.

Surface Disinfection Once the patient exits the room, conduct surface disinfection while staff continues to wear PPE. For general guidance, see Clinical Questions About COVID-19: Questions and Answers. The CDC has updated guidelines for considerations on how long exam rooms should remain vacant between patients. Be mindful that according to the CDC and research published in the New England Journal of Medicine, it is unknown exactly how long the virus remains active once a room is vacated. Follow the CDC for updated guidance on how COVID-19 spreads: “It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes. This is not thought to be the main way the virus spreads . . .”

Patient Education Provide up-to-date, factual information on the virus to suspected COVID-19 patients and their close contacts, including how to follow infection-control practices at home, such as in-home isolation, hand hygiene,

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cough etiquette, waste disposal, and the use of face masks. Remind patients and their families to access information about the virus through reputable sources such as the CDC, not social media.

Provider/Staff Exposure Encourage vaccination among your staff. Screen healthcare personnel daily for symptoms/contacts relevant to COVID-19. Any unprotected occupational exposure by staff members should be assessed, monitored, and documented in administrative files. See Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19. Should providers and/or staff test positive within your facility, conduct and document a risk assessment identifying contacts, type of interaction, and PPE in use, then contact local health authorities for additional instruction. The CDC provides guidance under the section “Infection Control” for management. Disclosure to patients may be necessary depending on the type of exposure that occurred, if any, but always take necessary steps to protect the privacy of the infected employee. Telephone calls directly to the patient are the most efficient method of notification, followed with a letter. Suggested notification may include “We are calling to inform you that someone in our office tested positive for COVID-19 on the day of your visit…” followed by recommendations for assessment and any needed follow-up. The health department may assist with patient notification if determined to be necessary. Contact your patient safety risk manager at The Doctors Company, as needed, for additional guidance. For return-to-work guidance, review the Return to Work Criteria.

Staff Training Assess the need for additional staff training to review screening and triage protocols, patient management, use of PPE, patient communications, and any revision in policies and procedures that have been made to adapt to the evolution of the virus. Document all training provided to staff and maintain records in administrative files.

Team Briefs Conduct daily staff briefs/huddles and end-of-day debriefs. This provides all staff opportunities to discuss anticipated issues during the day and identify concerns, pre- and post-clinic, including COVID-19 updates. (See TeamSTEPPS Fundamentals.) Acknowledge the need to provide emotional support to staff who may be dealing with fear or other stressors through employee assistance programs or other support mechanisms. Communicate resources to employees.

Managing Legal Risks Worldwide, COVID-19 has stricken more than 171.3 million, with global deaths reaching beyond 3.5 million. Within U.S. borders, more than 33 million Americans have been afflicted, with number of deaths surpassing 595,000. While actual case numbers are declining, the potential influx of variants in the U.S. will again present unique challenges. Government authorities in some states will mandate additional restrictions of public activities, while other states, conversely, will likely maintain unrestricted business operations. Medical offices will continue to face multiple challenges, including in-pandemic rules for operation, managing sick employees, and the provision of “catch-up” care for patients who had clinical services postponed while offices were closed, or who have put off contacting their physician because of fears. The bottom line: even with the availability of the vaccine, medical practices must not let their guard down with complacency. Because this continues to be a moving target, physicians and all healthcare facilities must remain well-informed and current on public health guidance for screening protocols and patient management, as well as regulatory requirements impacting their practices. Continued careful screening with a bias for suspicion that a patient might have COVID-19 will serve healthcare providers well in this situation.

thedoctors.com

As we move forward, we emphasize that keeping office policies and procedures current while following recommended guidelines, with documentation of adherence in both administrative files and medical records, is key to litigation defense in the future. The dynamics surrounding the virus will continue to evolve, particularly with the spread of variants and as the population is vaccinated. What must not change is that physicians and care teams should remain vigilant and adapt their practices accordingly. They should remain exceptionally proactive in asking the right questions, documenting interactions, rigorously following protocols, and keeping abreast of emerging insights and data as they become available from the CDC.

RESOURCES: The Doctors Company: COVID-19 Resource Center for Healthcare Professionals The Doctors Company: FAQs About COVID-19 Vaccinations The Doctors Company: Communicating With COVID-19 Vaccine-Hesitant Patients: Top Tips American College of Physicians: COVID-19: An ACP Physician's Guide + Resources (Last Updated May 28, 2021) The Doctors Company: Flu or COVID-19? Convergence of Two Viruses Creates Risk of Diagnostic Errors Equal Employment Opportunity Commission (EEOC): What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws CDC: Healthcare Workers: Information on COVID-19 CDC: Clinical Questions About COVID-19: Questions and Answers American Academy of Family Physicians (AAFP): Checklist to Prepare Physician Offices for COVID-19 The Doctors Company: Burnout During COVID-19: How Healthcare Professionals Can Manage Stress ECRI: COVID-19 Resource Center ACS: Be Prepared: Patient-Surgeon Discussion Guide Johns Hopkins Global Case Map: COVID-19 Dashboard by the Center for Systems Science and Engineering

___________ The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. Reprinted with permission. ©2021 The Doctors Company (www.thedoctors.com).

Driven by results. As counsel to the MSMS community for over 70 years, we know how to help physicians.

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NEW & REINSTATED MEMBERS BERRIEN COUNTY

LIVINGSTON COUNTY

SAGINAW COUNTY

David Cooke, MD

James Hayner, MD

Dafina Allen, MD

Sharon Deskins, MD

Jean Nelson, DO

Jeffery Carney, MD

Erica Ridley, MD

John Collins, MD

CALHOUN COUNTY Holli Neiman-Hart, MD

CLINTON COUNTY Eugene Choo, MD

GENESEE COUNTY Mohamad Loay Alasbahi, MD Gregory Forstall, MD Mona Hanna-Attisha, MD, MPH Avery Jackson, MD Sunil Kaushal, MD Mousa Mohamed, MD Damayanthi Pandrangi, MD Abdullah Raffee, MD Jawad Shah, MD

GRAND TRAVERSE/BENZIE/ LEELANAU COUNTY Britton Carter, MD

INGHAM COUNTY Anthony Brandau, DO Jed Magen, DO, MS Carol Rapson, MD Amit Sachdev, MD

ISABELLA/CLARE COUNTY Ahmad Hakemi, MD

KALAMAZOO ACADEMY OF MEDICINE Cheryl Dickson, MD Kathryn Redinger, MD

Theophilus Ulinfun, DO

MACOMB COUNTY Maria Ruiz, MD

MARQUETTE/ALGER COUNTY Craig Coccia, MD

CRAWFORD/ GLADWIN/KALKASKA/ MONTMORENCY/OTSEGO/ ROSCOMMON COUNTY Jason Brodkey, MD

Jonathon Deibel, MD Suhasini Gudipati, MD Tareq Kamal, MD Vipin Khetarpal, MD Ruth Licht, DO Veronica Lorenzo, MD Chad Ringley, MD, FACS Asim Yunus, MD Pervez Yusaf, MD

ST CLAIR COUNTY Payam Sadry, DO

WASHTENAW COUNTY

MIDLAND COUNTY

Joshua Burkard, DO

Catherine Bodnar, MD

Brandon Francis, MD

Amelia Morrison, MD

Lisa Glass, MD

MONROE COUNTY

Mustafa Mawih, MD

Azadeh Khaghany, MD William Murdoch, MD, FAAFP

MUSKEGON COUNTY Mark Dunn, MD Steven Dunn, MD

Stephanie Kukora, MD Timothy McGorisk, MD Jeffrey Moyer, MD Karin Muraszko, MD Cheryl Ruble, MD Brett Russell, MD Alon Weizer, MD

Caleb Fleming, MD

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OAKLAND COUNTY Elizabeth Hall, MD

Jeffrey Clark, MD Marc Cullen, MD Emily Draper, MD Hazem Eltahawy, MD, MHCM, FRCS, FACS Joneigh Khaldun, MD, MPH Paul Kilgore, MD, MPH, FACP

KENT COUNTY

Mustafa Hamed, MD

Jeanne Lewandowski, MD

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Thank you for your ongoing support of organized medicine in Michigan.

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MSMS ON-DEMAND WEBINARS The MSMS Foundation has a library of on-demand webinars available, many of which are free, making it easy for physicians to participate at their convenience to meet their educational needs.

Webinars that Meet Board of Medicine Requirements:

A Day of Board of Medicine Renewal Requirements Human Trafficking Medical Ethics – Conscientious Objection among Physicians Medical Ethics – Confidentiality: An Ethical Review Medical Ethics – Decision Making Capability Medical Ethics – Eliminating Disparities in Health Care What Can You Do? Medical Ethics – Just Caring: Physicians and Non-Adherent Patients Medical Ethics – Racial Disparities in Maternal Morbidity and Mortality: A Persisting Crisis Medical Ethics – Reclaiming the Borders of Medicine: Futility, Non-Beneficial Treatment, and Physician Autonomy Pain and Symptom Management Series

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Balancing Pain Treatment and Legal Responsibilities MAPS Update and Opportunities Michigan Automated Prescription System (MAPS) Update Naloxone Prescribing Pain and Symptom Management 2020 Prescribing Legislation Tapering Off Opioids The CDC Guidelines The Current Epidemic and Standards of Care The Role of the Laboratory in Toxicology and Drug Testing Treatment of Opioid Dependence Update on the Opioid Crisis 2019

COVID-19 Webinars:

OTHER WEBINARS:

2020 Fall Symposium on COVID-19 Day One 2020 Fall Symposium on COVID-19 Day Two 24th Annual Conference on Bioethics AMA Advocacy and Physician Resources Best Practices for Implementation of Telemedicine CARES Act Impact CARES Act Impact: Q&A with CPAs CARES Act Impact: Q&A with CPAs Part 2 Leading Through Crises: Financial Guidance and Strategies Medical Practices and Employment/ HR FAQs New Employment Policies for Practices New Waivers and Billing Changes for Telemedicine Race Inequalities and COVID-19: Contagion, Severity, and Social Systems Safe and Innovative Office Procedures for Seeing Patients Telemedicine and Other Technology Codes in a COVID-19 Environment Testing, Tracing and Tracking The Changing Health Care Landscape: Preventing Diabetes During and Beyond the Pandemic What Physicians Need to Know as Employers During the COVID-19 Pandemic

GRAND ROUNDS WEBINAR SERIES: A Review of COVID-19 Variants Coronavirus Relief – Overview and Updates

24th Annual Conference on Bioethics Coding Update for 2021 Evaluation Management Updates for 2021 Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities HEDIS Best Practices In Search of Joy in Practice: Innovations in Patient Centered Care Integrating Pharmacists into Practice: The Missing Link for Comprehensive Medication Therapy Management Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media Medical Marihuana Law Medical Necessity Tips on Documentation to Prove it Non-Pharmacologic Management of Musculoskeletal Pain Syndromes Section 1557: Anti-Discrimination Obligations Sexual Misconduct – Prevention and Reporting Update on Chronic Fatigue Syndrome Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS Update on Chronic Fatigue Syndrome Part 2: Uniting Compassion, Attention and Innovation to treat ME/CFS

To register or to view full course details, visit: MSMS.org/OnDemandWebinars

Once registered, you will receive an email within 15 minutes with links to watch the on-demand webinar and to complete the survey evaluation. Contact: Beth Elliott at 517/336-5789 or belliott@msms.org JULY / AUGUST 2021 |

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2021 CONFERENCE SCHEDULE

2021 Live Virtual Conference Schedule Grand Rounds Dates: July 14, July21, September 8, October 13, November 10, and December 8, 2021 Time: 12:00 – 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Monday Night Medicine Dates: September 7, October 4, and November 1, 2021 Time: 6:30 – 8:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

A Day of Board of Medicine Renewal Requirements Date: September 14, 2021 Time: 8:00 am – 1:15 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

2021 Live In-Person Conference Schedule A Day of Board of Medicine Renewal Requirements Date: November 12, 2021 Time: 9:00 am – 1:15 pm Location: Sheraton, Ann Arbor Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Annual Scientific Meeting

24th Annual Conference on Bioethics

Date: September 15-16, October 20-21, and November 17-18, 2021 Time: 3:00 – 6:00 pm Location: Virtual Conference

Date: November 13, 2021 Time: 8:45 am – 3:00 pm

Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Intended for: Physicians and all other health care professionals

Location: Sheraton, Ann Arbor Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

For more information or to register, contact Beth Elliott: email belliott@msms.org or call 517/336-5789

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