Michigan Medicine, Volume 116, No. 2

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THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 116 / NO. 2

March/April 2017

The Opioid Epidemic:

Michigan Doctors Seeking Solutions Cara Poland, MD, of Spectrum Health in Grand Rapids, is working to find solutions.

www.msms.org


Michigan’s Electronic Death Registration System The Michigan Electronic Death Registration System (EDRS) is an online application that allows coordination between funeral homes, medical certifiers, and county clerks to quickly and conveniently process death certificates – 24 hours a day, 7 days a week.

WHY

WHAT

EDRS creates greater efficiency when participants interact electronically. With higher quality data, built-in edits, increased security, and improved timeliness, EDRS speeds turnaround time for families to obtain certified copies of death certificates.

Free online and in-person training is available. The system is free to use, and the required biometric fingerprint scanner is provided at no cost by the State of Michigan Vital Records!

HOW

To learn more, go the EDRS resource website at:

https://public.mphi.org/sites/edrs/ Find supporting resources, explore the online training, and/or request free in-person training.

EDRS

Electronic Death Registration System


FEATURES & CONTENTS March/April 2017

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HIT Alert: Electronic Prescriptions for Controlled Substances PATRICK J. HADDAD, JD, MSMS LEGAL COUNSEL

14

Prescribing Opioids Safely: How to Facilitate Difficult Patient Conversations BY RONEET LEV, MD Contributed by The Doctors Company

COLUMNS 04 President's Perspective

BY DAVID M. KRHOVSKY, MD

07 Ask Our Lawyer

BY DANIEL J. SCHULTE, JD

08 MDHHS Update

BY JACKLYN CHANDLER, M.S.

12 Ask Human Resources

BY JODI SCHAFER, SPHR, SHRM-SCP

26 WealthCare Advisors

COVER STORY

16

The Opioid Epidemic: Michigan Doctors Seeking Solutions

BY NATHAN MERSEREAU, CFP®

DEPARTMENTS 20 Welcome New Members 20 In Memoriam 21 MSMS Medical Opportunities 24 MSMS Educational Courses

STAY CONNECTED!

Michigan physicians, including Cara Poland, MD, (pictured) are leading the battle for transformative change. See page 16 for story.

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perspective

MICHIGAN MEDICINE Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org Graphic Design STACIA LOVE, REZÜBERANT! INC. rezuberantdesign@gmail.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 All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Trisha Keast. Postmaster: Address Changes Michigan Medicine Hannah Dingwell 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 2017 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. ©2017 Michigan State Medical Society

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The state of Michigan is battling an opioid abuse crisis, and physicians are leading the charge to find solutions, and help patients.

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n this edition of Michigan Medicine you’ll learn about the battle for transformative change in the way providers and regulators think and monitor opioid prescriptions, and the way Michigan physicians and the Michigan State Medical Society are rewriting professional education and accountability standards – to save lives.

The public – and the policymakers with the power to address physicians’ concerns – are finally beginning to grasp the breadth of a crisis that is claiming thousands of Michigan lives annually. 2015 was the deadliest year on record for Michigan opioid users. According to the Centers for Disease Control, overdose deaths in Michigan rose 13.3 percent over the previous year, and 1,980 Michigan residents lost their lives. Not surprisingly, the most common drugs fueling the crisis were prescription painkillers and heroin, the illicit drug individuals often turn to when pills were no longer available or effective. More than 21 million prescriptions for controlled substances were written in Michigan in 2014, according to tracking data compiled by a bipartisan Michigan Prescription Drug and Opioid Abuse Task Force assembled by Governor Rick Snyder. The United States Department of Health and Human Services reports that every single day in America, more than 650,000 opioid prescriptions are dispensed, 3,900 Americans first initiate nonmedical use of prescription opioids, 580 try heroin for the first time, and 78 people die.


By David M. Krhovsky, MD, Michigan State Medical Society President

In this issue, you’ll learn how the Michigan State Medical Society, our internal Opioid Task Force, and physicians statewide are leading the charge to find the solutions that matter. You’ll learn how we’ve worked with elected officials and department staff in Lansing to update an old, out-of-date prescription reporting system – MAPS – and how we’ve worked to bring a new system online in 2017 with the speeds, interoperability, and capabilities to make a difference. In many respects, MAPS is the lynchpin of state policy as it relates to reducing drug diversion, and a highly functioning prescription drug monitoring program provides physicians, pharmacists, and other professionals with valuable clinical information that can be used to detect and deter drug diversion.

“2015 was the deadliest year on record for Michigan opioid users. According to the Centers for Disease Control, overdose deaths in Michigan rose 13.3 percent over the previous year, and 1,980 Michigan residents lost their lives.”

®

We’re making these changes happen. You’ll also learn about the critical work MSMS staff and physician leaders have done to identify numerous other priorities in the battle against addiction, from enhancing data sharing capabilities, fighting to ensure that patients with pain and opioid use disorders have coverage for the treatments and services they need to kick the habit, working with law enforcement agencies, and advocating for increased overdose prevention strategies.

DAVID M. KRHOVSKY, MD, MSMS PRESIDENT

I am proud to report that physicians have been champions in legislative victories that led Lansing to embrace and promote life-saving “Good Samaritan” protections, to reject dangerous bills that would have expanded the number of opioid prescribers in the state, giving full prescribing authority to 3,000 certified registered nurse anesthetists, without requiring any additional training, and in expanding access to naloxone for schools, first responders and others across the state. As the article notes, “a little bit of computer code and a lot of physician leadership have Michigan on the precipice of the kind of transformative change that for thousands of residents a day, may very well mean the difference between life and death.” Thank you for everything you are doing to protect and defend your patients. Your work matters, and, as you’ll read, it’s making a difference.

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M-LINE provides you with access to more than 3,500 doctors and 20 clinical departments at the world-renowned University of Michigan Health System. From scheduling an appointment or coordinating a patient transfer, to conducting a consultation with one of our physicians, you’ll win every time with M-LINE on your team. • One phone number

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ASK OUR LAWYER By Daniel J. Schulte, JD, Michigan State Medical Society Legal Counsel

“Can Unknown Investigations Be Reported to the Data Bank?” Q I retired from practice last year. Because I retired I did not renew my medical staff privileges at the hospital I have worked at for the last twenty years as I normally would have. It was recently brought to my attention that (for the first time in my career) a report was filed by the hospital on me with the National Practitioner Data Bank (“NPDB”). The report indicates that I “surrendered” my privileges while under investigation by the hospital. Supposedly, this was required to be reported. In my thirty years of practice I have never had a claim made against me for malpractice or such a report made. How can this be?

Contact Kim Burley, Director of Recruitment, at 517-827-3149 or kim.burley@corizonhealth.com.

Revisions to the NPDB Guidebook in 2015 are what make this scenario possible. These revisions expanded the definition of “investigation” and “surrender” as they are used in the NPDB reporting requirements. The goal of these revisions was to end “plea bargaining” in the peer review process. It was thought that hospitals and other reporting entities were allowing physicians who were under investigation to surrender their privileges in exchange for no report being made and/or the surrender of privileges was being used as a bargaining chip in the peer review process. The NPDB Guidebook now makes clear that a report must be made when a surrender of privileges takes place “while the physician is under investigation” by the reporting entity “relating to possible incompetence or improper professional conduct” or “in return for not conducting such an investigation or proceeding . . . ”. For purposes of NPDB reporting, the definition of “investigation” is not controlled by your medical staff bylaws. Instead it means any process “focused” on a matter involving a physician’s professional competence and or professional conduct, even a review of a single record following a patient complaint. Such an investigation continues until formally closed by the reviewing entity. Most importantly, it does not matter that the physician has no knowledge that the investigation is occurring. What it means to “surrender” your medical staff privileges has also been expanded by the 2015 revisions to the NPDB Guidebook. Included are some things most may not consider

a surrender of medical staff privileges. For example, the following if they occur while an investigation is under way constitute a surrender of medical staff privileges that must be reported by the hospital to the NPDB: a failure to renew due to age based retirement, infirmity, moving out of town, joining the medical staff of and beginning to practice at another hospital, personal or other reasons. As you have found, a failure to renew your medical staff privileges or voluntarily surrendering your privileges has become a trap for the unwary. The best practice is to insist that your medical staff disclose to you whether or not an investigation involving you is underway prior to deciding to not renew. If an investigation is underway then you should renew your privileges until the investigation and any peer review matter that results from the investigation is resolved. It would also be very helpful to physicians if their medical staff bylaws required that the existence of an investigation be disclosed to physicians involved anytime one is pending. At the very least the bylaws should require the hospital to disclose an investigation is in process at the time for renewal so that physicians like you do not end an otherwise spotless career with a NPDB report.

DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL.

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MDHHS UPDATE By Stefanie Cole, RN, BSN, MPH, Pediatric Immunization Nurse Educator, Michigan Department of Health and Human Services (MDHHS), Division of Immunization

Protecting Children in Michigan from Disease When the Centers for Disease Control and Prevention (CDC) released the 2015 National Immunization Survey (NIS) data last year, Michigan was ranked 44th in the nation for pediatric immunization coverage. Only 67.6 percent of Michigan children aged 19-35 months-old are fully immunized with the 4313314 series, compared to 72.2 percent nationally.1 While this represents a modest improvement from the previous year (ranked 47th in the nation with 65.0 percent series coverage), it is unacceptable that 32.4 percent of our young children are not protected from vaccine preventable diseases.

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he Michigan Department of Health and Human Services (MDHHS) and immunization advocates from the public and private sectors are focusing on a number of initiatives to increase the state’s immunization rates. These include new media campaigns targeting parents, using the Michigan Care Improvement Registry (MCIR) to remind parents their child is overdue for vaccinations, and creating new immunization educational materials.

Media Campaigns The MDHHS Division of Immunization recently partnered with the Women, Infants, and Children (WIC) program to encourage WIC mothers to get their children vaccinated. A media campaign ran from November 2016 to February 2017 targeting specific geographic areas in Michigan. The campaign included radio public service announcements (PSAs), digital advertisements, bus ads, and an immunization message on Dollar General and Family Dollar receipts.

Another media campaign, IVaccinate, launched in 2017 to target messages to parents who are vaccine-hesitant. The IVaccinate campaign is a collaborative effort between the Franny Strong Foundation and MDHHS. This is a statewide media campaign with a heightened focus on selected areas of the state with high immunization waiver rates. IVaccinate includes television and radio PSAs, social media, print ads in parent magazines, and billboards. Later this year, the campaign will also launch its own website. In April 2016, MDHHS began sending immunization reminder letters statewide to parents and guardians of children aged 6-18 months who were overdue for any recommended immunization, including flu vaccine. More than 68,000 letters were sent during the first three rounds (April-December 2016). A fourth round of reminder letters will be sent in March 2017.


Educational Materials The Division of Immunization continues to create new educational materials and posters to promote immunizations and educate parents about why vaccines are so important for their children and why they should be administered following the Advisory Committee on Immunization Practices’ (ACIP) schedule. Along with providing vaccine education, our goal is to assure vaccine-hesitant parents that despite what they may see on social media, over 90 percent of parents in the U.S. immunize their children.2

Provider Focus MDHHS is asking all immunizing healthcare providers in Michigan to focus on getting children vaccinated with all the recommended vaccines, following the recommended schedule. Use MCIR to review your patients’ immunization status at every visit and assess which immunizations are needed. Vaccinate with all ACIP-recommended vaccines and according to the ACIP schedule. ACIP determines when and at what intervals vaccines should be administered based on when the immune system best responds to the vaccine. We need to protect children as early as we can

within the recommended age indications so they are not left vulnerable to diseases. The 2017 Childhood Immunization schedule was released in February and can be found at www.cdc.gov/vaccines.

National Infant Immunization Week National Infant Immunization Week (NIIW) is an annual observance to highlight the importance of protecting infants from vaccine-preventable diseases. This year, NIIW is April 22-29. To learn more about NIIW, visit www.cdc.gov/vaccines/events/ niiw/index.html. Use NIIW within your practice to kick off pediatric immunization efforts. Use MCIR profile reports to determine what areas in your practice you need to work on (e.g., influenza, hepatitis A), and set attainable goals to work towards. Healthcare providers are recommended to meet the Standards for Pediatric Immunization Practice (www.hhs.gov/nvpo/nvac/reports-and-recommendations/the-standards-for-pediatric-immunization-practice/index.html). If your office staff needs a refresher on pediatric immunizations, MDHHS offers infant and early childhood immunization modules. For more about these programs or to request an

H E A LT H

C A R E

in-service, visit www.michigan.gov/immunize, click on Health Care Professionals/Providers, and look under Provider Education Resources for Immunization Education Opportunities for Health Care Personnel. Make sure you and your staff are doing everything you can to immunize Michigan children on time, get children who have fallen behind on vaccines caught back up, and follow the ACIP schedule. Parents who bring their children to your office are putting their trust in you. Protect their children by giving them all the recommended vaccines at the recommended ages. Explain to parents why vaccines are recommended at the ages and intervals they are – to provide the best possible protection to their child.

References 1 The combined 7-vaccine series (4:3:1:3:3:1:4) includes ≥4 doses of DTaP, ≥3 doses of Polio, ≥1 dose of measlescontaining vaccine, Hib full series, ≥3 HepB, ≥1 Var, and ≥4 PCV. 2 Kennedy, A., Basket, M., & Sheedy, K. (2011). Vaccine attitudes, concerns, and information sources reported by parents of young children: Results from the 2009 HealthStyles survey. Pediatrics, 127(Supplement 1), S92-S99. doi:10.1542/ peds.2010-1722N

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Wachler & Associates represents healthcare providers, suppliers, and other individuals in Michigan and across the country in virtually all areas of healthcare law, including but not limited to:

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HEALTH INFORMATION TECHNOLOGY (HIT) ALERT Patrick J. Haddad, JD, Kerr, Russell and Weber, PLC, MSMS Legal Counsel

Electronic Prescriptions for Controlled Substances The Drug Enforcement Administration’s rule (the Rule) permitting physicians to electronically prescribe controlled substances was issued on March 31, 2010 as an interim final rule with request for comment and became effective June 1, 2010. Since then, the Rule still has not been declared final and remains subject to change by Congress and/or the DEA.

T

he Rule allows physicians (and other DEA registrants) to transmit electronic prescriptions to pharmacies for Schedule II-V controlled substances, if the physician uses a compliant electronic prescribing application.1 Electronic prescribing applications that do not comply with the Rule may be used to prescribe drugs other than Schedule II V controlled substances. A physician may also print the form from a non-compliant application and manually sign/deliver the form to prescribe for drugs that are not controlled substances. Physicians are not required to electronically prescribe controlled substances in Michigan. Instead, the Rule gives physicians this option. Before the Rule became effective, this option was not available to physicians, as the only way to legally prescribe controlled substances was with the use of a written prescription. Once a physician has obtained an electronic prescribing application that complies with the Rule, a physician must accomplish the following steps prior to using it to electronically prescribe for controlled substances.

Step 1 Identity proofing must occur (in person or remotely), so that an authorization and authentication credential can be obtained. The Rule requires that the authorization and authentication credential be obtained from federally approved credential service provider (CSP) or certification authority (CA).

Step 2 At each location where an electronic prescribing for controlled substance application will be used for controlled substances, at least two individuals must be designated to manage access to the application. At least one must be a DEA registrant (a DEA authorized prescriber). These two individuals will identify for the electronic prescribing application who may access and use the application s prescribing functions.

Step 3 Each prescriber who has been given access must set a two-factor authentication prior to issuing electronic prescriptions for controlled substances. The authentication is how the application will verify that the person using the application is someone who has been given access.

The Rule requires physicians to use two of the following three authentication factors: Something only the physician KNOWS (e.g. a password or a response to a challenge question); Something the physician IS (e.g. biometric data such as a fingerprint or iris scan); Something the physician HAS (e.g. a PDA, cell phone, smartcard, USB drive or other hard token or device separate from the computer to which the physician is gaining access). The Rule imposes additional technical requirements if either a hard token or biometric factor is selected.

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Step 4 Each electronic prescription for a controlled substance must be electronically signed by the physician. The electronic signing of the prescription by the physician and its transmission are not required to occur at the same time. Physicians may fill in drug and dosage information, electronically sign the prescription and then leave it to office staff to transmit after completing pharmacy, insurance and other necessary information.

Additional requirements and restrictions of the Rule: Printed Copies of Prescriptions Following Transmission. Once an electronic prescription for a controlled substance has been transmitted, the application can print the prescription only if copy only-not valid for dispensing is printed on the form. In addition, the form must state the pharmacy that the electronic prescription was sent to and the date and time it was transmitted. Physicians are prohibited by the Rule from signing printed copies of electronically transmit-

ted prescriptions. When a physician is certain that the electronic transmission to the pharmacy has failed, the Rule allows the physician to print a prescription for signing and dispensing if the manual prescription includes a statement that an electronic prescription was transmitted and to which pharmacy it was attempted to be transmitted.

vision of the Rule does not preempt any Michigan law requiring the retention of medical records for a longer period (i.e., the minimum required retention period in Michigan is seven years if the prescription is a part of a patient s medical record), as well as other federal and Michigan law regulating the prescribing of controlled substances.

Notification.

More information on the DEA’s requirements for electronic prescriptions for controlled substances is available on the DEA’s website: https://www.deadiversion.usdoj.gov/ ecomm/e_rx/.

The Rule requires physicians to notify the two individuals designated to grant access to the electronic prescribing application any time a hard token has been lost, stolen or compromised or that the authorization or authentication credential protocol has been compromised. The same is true upon a physician’s discovery that a prescription has been electronically signed and/ or transmitted by someone other than the physician who has properly been granted access.

Recordkeeping. The Rule requires physicians to maintain records related to electronic prescriptions for controlled substances for two years from the date of their creation. This pro-

References 1 Such an electronic prescribing application may be stand along software or a part of electronic health record software. In order to electronically prescribe for controlled substances, the software used must comply with the requirements of the Rule. This includes having the software audited by someone the physician engages to certify compliance or obtaining this certification from a DEA-approved certifying organization. The receiving pharmacy must similarly be equipped with a compliant receiving application.

Patients trust you. You can trust Kerr Russell. A successful practice requires more than talented individuals and a desire to heal. Let Kerr Russell provide the legal insight needed to manage and grow your business. ENTITY FORMATION • BUSINESS MATTERS • EMPLOYMENT CONTRACTS • PURCHASE / SALE OF OWNERSHIP INTERESTS • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • APPEALS • MEDICAL STAFF PRIVILEGE DISPUTES HOSPITAL RELATIONS MATTERS • HEALTHCARE FRAUD DEFENSE •• LICENSING AND AND OTHER OTHER REGULATORY REGULATORY MATTERS MATTERS

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ASK HUMAN RESOURCES By Jodi Schafer, SPHR, SHRM-SCP

“How Do I Address An Employee’s Suspected Substance Abuse?” Q

I have an employee who I suspect may be under the influence while at work. I’m not saying she is necessarily drinking on the job, but I think she comes in still hung-over from the night before. It doesn’t happen all the time, but since going through her divorce I have started to notice it more and more. She becomes short with people and has difficulty concentrating on her work. I want to address the issue, but am not sure if I should bring up my suspicions about her alcohol use or not. What should I do?

Issues regarding suspected substance abuse among employees (and doctors) come up more often than I care to mention. You are right to be cautious about how you address these concerns with your employee because you don’t want to alienate or falsely accuse someone. However, despite knowing that this will be a difficult conversation to have, it’s one that you MUST have. For starters, this employee could pose a hazard to herself or others if she is providing clinical care while under the influence. She is also an ambassador for your practice and if you are thinking she is intoxicated then chances are that other employees and patients have come to the same conclusion. That doesn’t bode well for your practice’s reputation or for your personal reputation as a leader. So the million dollar question is how to approach it. The answer is, “It depends.”

If you have a substance abuse policy that allows you to test employees (either randomly or with reasonable suspicion) then you could choose to go this route and base your future course of action on the results of the test. However, if you don’t have pretty strong evidence that her behavior is the result of being under the influence then I would advise against this; at least in the very beginning. You mentioned that your employee is going through a divorce. It is possible that the behaviors she is exhibiting are the result of that and not alcohol use. Perhaps she is depressed or maybe the stress of her situation is interfering with her ability to sleep well at night. Both of these things could lead to being irritable and unfocused at work. These behaviors could also be side-effects of prescription medication. So, unless you have more than

How you handle this situation depends on several factors. 1. How sure are you that the rudeness and difficulty concentrating are the result of your employee being under the influence of drugs or alcohol? 2. Have you witnessed any additional symptoms like the smell of alcohol on her breath, tremors, vomiting, complaining of headaches, or a pattern of absences/tardiness? 3. Have other people expressed similar concerns to you about this employee? 4. Is this employee in any sort of protected classification and could your actions be construed as retaliatory or discriminatory? 5. Do you have a substance abuse policy?

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basic suspicion to support your concern of substance abuse, you should hold off on sending your employee for drug testing. Instead, I would recommend that your first conversation with her be focused on the behaviors themselves. You would start by discussing the kinds of things you’ve been seeing and hearing in regards to her conduct at work. Keep the focus on the behavior rather than what you think might be causing it. Be as specific as possible and let her know that you are concerned about this and wanted to bring it to her attention. Then wait to see how she responds. She might be surprised or she could break down and start crying or she might just stare at you with a blank look on her face. Based on how she reacts and what she tells you, you can determine if you want to make any accommodations to assist your employee during this difficult time. Regardless of the reason she gives you, your employee will need to know what your expectations are going forward and that if she is not able to correct these issues you’ve brought to her attention that you may be forced to take disciplinary action. Be sure to document your conversation for her file and then monitor the situation very closely. If you don’t see improvement then your next conversation with her will be more disciplinary in nature. If you gather more evidence to support your initial suspicions of alcohol use then you may decide to opt for the drug test (in accordance with your policy) and let the results of that inform your next move.


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THE DOCTORS COMPANY

Prescribing Opioids Safely: How to Facilitate Difficult Patient Conversations By Roneet Lev, MD, Chief of Scripps Mercy Emergency Department, Chair of Prescription Drug Abuse Medical Task Force, and President of Independent Emergency Physicians Consortium

These tips can help when dealing with opioid requests and prescriptions:

Drug overdose is the leading cause of accidental death in the U.S., and opioids account for over 60 percent of those deaths.1

W

hile opioids are effective pain medications when used in the proper setting, concerns arise when the patient’s condition lasts longer than three months, and prescribing more medication does not necessarily result in better pain control. Building a strong doctor-patient rapport can help facilitate tough conversations with patients about opioid prescriptions and reduce risks. Communication issues appear in 40 percent of malpractice claims, according to a study by The Doctors Company.2 Incomplete or unclear communication can compromise patients’ ability to understand the doctor’s instructions and, especially in the case of pain medications, also make them feel as if the doctor doesn’t care about their issues or concerns.

Don’t make the mistake of jumping to conclusions that the patient is a drug seeker because the patient is there repeatedly for the same pain complaint. It could instead be a situation of missed diagnosis. Treat this patient like any other patient. Take a good history, including a very detailed medication history. Do a thorough physical examination. See if something was missed on previous visits. The prescription drug monitoring program (PDMP) is a valuable tool; use it to learn about your patient’s prescription patterns, not just to check for doctor shopping. Medication refills for chronic conditions should have a medication agreement. ONE doctor and ONE pharmacy should prescribe controlled medication given for three months or more. This is true for dental pain, fractures, fibromyalgia, cancer, anxiety, and ADHD. If you see a patient for the third month of a controlled medication, start a medication agreement if you plan on continuing this therapy. Opioid withdrawal is uncomfortable but not life-threatening. New patients who present to a new pain specialist should not immediately be given the pain medications they state they need. A pain specialist typically completes thorough research before making medication recommendations and it could be two weeks before the patient is placed on a regular regimen. You may find it necessary to send a patient home without a pain prescription if that patient has already received one in the past month from a different provider. When patients say that their medication is not working, ask the patient, “How are you taking the medication?” You’ll be surprised how many patients used 400mg of ibuprofen twice a day and it was not enough. Taking a detailed medication history and providing patient education about the right dosage, right timing, and side effects to be aware of is essential to medication safety. When you hand a patient a prescription for a controlled medication, add a few words to let the patient know that these are serious medications: “I will give you a prescription for Norco. Please realize that this is a medication that can be abused. Keep it secure, take it only as prescribed, and do not drive if not fully alert.” Be aware of the level of health literacy of the individual patient, and adjust your language appropriately. Ask patients to repeat back the information you gave to ensure they properly understand. Communicate the risk of medication theft to patients. Patients who are on a chronic treatment plan should know to watch their medication as closely as they would their money.

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The chart below shows some helpful answers for specific patient questions and situations: PATIENT

DOCTOR ANSWER

“Can I have something for pain?”

“Yes, let me check your medical record for the best choice.”

“The medicines don’t work.”

“Can you please tell me how you take the prescription?”

“My prescription was stolen.”

“Did you file a police report?”

“I have chronic pain.”

“For your safety, you need your medications coordinated by one doctor and one pharmacy.”

“I received extra pain medications elsewhere.”

“Let’s do a drug specimen today.”

“I see you received 20 pills from the emergency department, what happened?”

“OK, to stay on the same schedule, this month I will write 100 tablets (120 minus 20).”

A case of clear doctor shopping

“I am concerned because your medications can be addicting. I am going to refer you to someone who can help with this.”

A case of need to stop an opioid prescription

“The medication no longer appears to be as beneficial as it once was. As the benefits of the opioids no longer outweigh the risks, we need to discontinue this approach and together find a safer and more effective means of dealing with your pain.”

Get more safe prescribing resources at www.SanDiegoSafePrescribing.org and learn more about effective doctor-patient communication at www.thedoctors.com/askme3. References 1 Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. Centers for Disease Control and Prevention. December 30, 2016. https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm. Accessed January 26, 2017. 2 Patient-centered communications: Building patient rapport. The Doctors Company. http://www.thedoctors.com/KnowledgeCenter/ PatientSafety/articles/Patient-Centered-Communications-Building-Patient-Rapport. Accessed January 9, 2017. CONTRIBUTED BY THE DOCTORS COMPANY (WWW.THEDOCTORS.COM)

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THE

OPIOID EPIDEMIC: MICHIGAN DOCTORS SEEKING SOLUTIONS

A pill. Then a needle. Soon a full-blown national crisis with intensely personal consequences. The United States finds itself in the middle of an opioid abuse epidemic, but Michigan physicians aren’t taking the crisis lying down. They’re leading the battle for transformative change in the way providers and regulators think and monitor opioid prescriptions, and rewriting professional education and accountability standards to save lives. A little bit of computer code and a lot of physician leadership have Michigan on the precipice of the kind of transformative change that for thousands of residents a day, may very well mean the difference between life and death.

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A Crisis Decades in the Making It was a cool August day in 2015, with a breeze pushing through the Motor City that evoked visions of an early autumn. United States Attorney Barbara McQuade, flanked by nearly a dozen law enforcement leaders from the federal government and neighboring states convened an urgent summit in Detroit, and dropped a bombshell on the assembled press, chilling the air and rewriting policymakers’ understanding of opioid abuse in Michigan. Michigan didn’t just have an opioid problem. Michigan had become a “drug pipeline,” exporting opioid and heroin abuse east to Pennsylvania, and south through Ohio into Kentucky, Tennessee and West Virginia. If the announcement was a wakeup call for the general public, it was merely confirmation for the state’s physician community, which had observed and sounded the alarm about a growing crisis for years. The public – and the policymakers with the power to address physicians concerns’ – were finally beginning to grasp the breadth of a crisis that was claiming thousands of Michigan lives each year, and was only getting worse. Opioid abuse had already reached epidemic proportions the year before, with overdose and other opioid related deaths skyrocketing across the nation, and closer to home here in Michigan. According to data compiled by the U.S. Department of Health and Human Services (HHS), it was the deadliest year on record for overdose-related deaths in the United States.

Not surprisingly, the most common drugs fueling the crisis were prescription painkillers like Vicodin and Oxycontin, and heroin, the illicit drug individuals often turned to when pills were no longer available or effective. The numbers are staggering. HHS reports that every single day in America, more than 650,000 opioid prescriptions are dispensed, 3,900 Americans first initiate nonmedical use of prescription opioids, 580 try heroin for the first time, and 78 people die. Here in Michigan, a report from Trust for America’s Health found that youth overdoses almost quadrupled in the state between 1999 and 2013. Deaths related to heroin doubled between 2009 and 2012.

AND THE WORST WAS YET TO COME. 2015 was more deadly for opioid users and abusers than any year before. According to the Centers for Disease Control, overdose deaths in Michigan shot up 13.3 percent over the previous year, and 1,980 Michigan residents lost their lives. The Great Lakes State now had the 7th highest number of fatalities in the nation, and was one of 19 states to see a statistically significant increase in opioid-related deaths over the previous year. Among the others were five identified by McQuade, the United States Attorney, as all being part of the pipeline of pain meds flowing illicitly out of Michigan. Cara Poland, MD, is a practicing physician at Spectrum Health in Grand Rapids, and the President of the Michigan Society of Addiction Management. She’s battled the crisis as it unfolded from the frontlines, and says the more physicians have learned about opioids, the more aware they’ve become of the dangers of addiction.

“The information physicians had 15 or 20 years ago was that if we were treating someone with opioids for chronic pain, they would not develop addiction. Now we know that wasn’t true. In fact, 82.3 percent of people who inject heroin started with prescription opioids.” —Cara Poland, MD

Pain and Addiction - A Swinging Pendulum Awareness of the crisis among state policymakers may have seemingly happened overnight, but the problem had been brewing for years. Whether Michigan was properly equipped to see the warning signs is another question altogether. Michigan’s skyrocketing opioid abuse rate corresponds with increasing state and national awareness over the effects of pain. Fred Davis, MD, is a clinical associate professor at Michigan State University’s College of Human Medicine, and likens the interwoven battles against pain and addiction to a swinging pendulum.

“There was a great awakening to the problems associated with pain beginning in the 1980s and it led to a sea change in the way physicians worked to combat it.” —Fred Davis, MD “There was a great awakening to the problems associated with pain beginning in the 1980s and it led to a sea change in the way physicians worked to combat it,” said Dr. Davis, who also serves as the President and Chief Medical Officer of ProCare Pain Solutions, a company of North American Partners in Anesthesia, that manages pain practices at more than a dozen clinics across the state. In 2011, the Institute of Medicine (IOM) published a sweeping report that identified pain as a public health problem, and an expensive one at that. According to the IOM report, preventable chronic pain affected at least 116 million adult Americans, and cost the United States as much as $635 billion annually, covering everything from direct costs like emergency room visits and hospital stays to lost productivity in the workforce. The report recommended policymakers and health care providers increase awareness in the patient population about pain Continued on page 18

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OPIOIDS: A CRISIS (continued)

and its health consequences, while emphasizing comprehensive pain management and prevention. It was part of a seemingly endless drumbeat of news, initiatives, and programs heralding a brave new age of pain treatment and awareness. “Physicians were trained that opioids were safe and effective, and reimbursements were even tied to how patients believed their physicians felt their doctor was treating their pain,” said Mark Weiner, MD, a board certified addiction specialist who serves as the Medical Director of Substance Use Disorders at St. Joseph Mercy Hospital in Ann Arbor. Not surprisingly, as agencies, providers, and patients focused on combatting pain, the number of prescriptions skyrocketed. More than 21 million prescriptions for controlled substances were written in Michigan in 2014, according to tracking data compiled by a bipartisan Michigan Prescription Drug and Opioid Abuse Task Force assembled in 2015 by Governor Rick Snyder. “This is roughly four million more prescriptions than were written in 2007, despite the fact that Michigan’s population slightly decreased over the same time period,” noted the report. The startling numbers rank Michigan 10th in the nation, per-capita, for the number of opioid pain killer prescriptions.

Technology has changed a lot in the last 15 years, but MAPS hasn’t.

Tackling the problem starts, experts agree, with collecting solid data. Unfortunately, Michigan has long lagged behind the rest of the nation when it comes to the usefulness and effectiveness of the state’s prescription drug monitoring system.

MAPS is slow. Trying to utilize the system within the course of a patient examination can be difficult. With lengthy processing times, the current system simply isn’t consistent enough with other technologies to be used efficiently by prescribing physicians.

The old system is one that has confounded physicians almost since the day it came online, and embracing new and effective technology has long been the subject of intense lobbying by the state’s physician community. The Michigan Automated Prescription System (MAPS) is outdated, cumbersome, and ineffective. Physicians have for years demanded a fix to the system, and thanks to their persistence, Lansing is poised later this year, for the first time, to take their concerns seriously. “In many respects, MAPS is the lynchpin of state policy as it relates to reducing drug diversion,” MSMS President David M. Krhovsky, MD, told lawmakers last spring during a hearing before the Michigan Senate Health Policy Committee.

Michigan ranks 10th in the nation, per-capita, for the number of opioid pain killer prescriptions.

Physicians work hard to adequately and effectively treat their patients, including those suffering from chronic pain, but the accumulated effect of these treatments, insufficient training on opioids for both physicians and patients, and the exceedingly rare bad actor, has produced an inescapable reality—there are just plain too many pills on the streets. When Lansing started asking how Michiganders could fix the problem, physicians were already hard at work developing and implementing solutions.

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Physician Leadership When Needed Most

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The committee met to consider an effort to bring Michigan’s prescription drug monitoring program up to speed with the 48 other states in the nation using online monitoring systems.

“A highly functioning prescription drug monitoring program provides physicians, pharmacists, and other professionals with valuable clinical information that can be used to detect and deter drug diversion,” said Doctor Krhovsky. “A highly functioning prescription drug monitoring program can also help regulators, by providing them with the tools necessary to detect and sanction those professionals that are acting criminally and outside the scope of professional standards.” Michigan was an early adopter of electronic drug monitoring, implementing MAPS in 2002, when only a handful of other states even used the technology. The online program was rolled out as an upgrade to the cumbersome, paper-based Michigan Official Prescription Program.

Doctor Krhovsky unpacked the problem during his testimony to lawmakers.

MAPS is not integrated. The program requires physicians to exit out of electronic health records or use multiple computers or terminals just to access the program. In an age when regulators routinely demand and patients expect electronic record keeping and lightning fast prescriptions and referrals, MAPS is the rare interoperability outlier. But those are just the problems on the front end of the system. It’s the back end where MAPS suffers most. The data it produces simply isn’t user-friendly, spitting out raw and sometimes only partial data to physicians. The result is a system that’s hard to use, takes physicians away from their patients, and provides little meaningful benefit to prescribers and providers.

BUT HELP IS ON THE WAY. “Addressing an epidemic of this magnitude requires a comprehensive set of policies,” Doctor Krhovsky testified. “Updating and upgrading MAPS is a crucial first step that will help Michigan better assess what other gaps need to be addressed to curtail prescription drug diversion.” MSMS staff and physicians from across the state have been working night and day with officials at the Michigan Department of Health and Human Services, and the Bureau of Professional Licensing to run the traps on a new reporting system, with the features, interoperability, and usefulness that have benefited physicians and regulators in other states for years. A new system from a top-of-the-field developer called Appriss is on the way, and one that’s on par with the systems being used in 42 other states. According to MSMS staff and physicians, it’s a system with incredible promise as a weapon in the war against abuse and addiction. The new and improved MAPS system provides seamless reporting in real time, features


near-instant upload speeds to help doctors focus on their patients instead of a computer terminal, and allows for the simple production of the mass reports so important to practice management.

tion expert with Spectrum Health Medical Group. “Physicians are leaders and people look to us for best practices. This is a way for us to give back to the community and correct misinformation about pain and addiction.”

Just as importantly in a state that’s working diligently to cut off a drug export pipeline, the system is interoperable with the reporting systems being used in almost every other state in the nation. The new system is a critical and exciting weapon in the state’s anti-addiction arsenal, but physicians insist it’s not a silver bullet.

There are only 134 board certified addiction medicine physicians in the state of Michigan, and just 4 of those are fellowship-trained. According to Doctor Poland, the dearth of addiction specialists illustrates the importance of an anti-addiction focus across the state’s physician community, something the Task Force aims to facilitate.

Even with the Apriss system’s incredible benefits, the physician task force says addressing the opioid crisis means taking additional important steps to educate providers, treat patients, and form strategic alliances.

“We need to partner with primary care doctors, with spine and pain doctors, orthopedic surgeons. Everyone. This isn’t something that can be addressed by only one facet of the medical field,” she says.

Fighting a Crisis on Multiple Fronts Staff and physician leaders from MSMS met routinely with the Governor’s Task Force, driving the discussion and helping produce important recommendations for action at the state and local level to tackle the opioid crisis. At the same time, MSMS launched its own multi-disciplinary Opioid Stewardship Initiative to build on preexisting strategies, including live educational activities, seminars, and free online and printed materials provided by the Physician’s Institute for members unable to attend the live sessions. That same fall, MSMS established its own internal, physician-led Task Force on Opioid Stewardship, to help guide and direct the physician community’s strategic policy on opioid stewardship in the future, while identifying the tools and resources that would prove most useful to physicians and practices. “The Task Force was created, in part, because we need to take ownership finding solutions, as physicians,” says Doctor Poland, an addic-

Apriss: Key Dates and Information AS THE STATE OF MICHIGAN REPLACES THE MICHIGAN AUTOMATED PRESCRIPTION SYSTEM (MAPS) WITH APPRISS, PMP AWARXE SOFTWARE

MSMS staff and physician leaders have identified numerous other priorities in the battle, from enhancing data sharing capabilities, fighting to ensure that patients with pain and opioid use disorders have coverage for the treatments and services they need to kick the habit, and advocating for increased overdose prevention strategies. Physicians have been on the frontline pushing Lansing to embrace and promote so-called “Good Samaritan” protections designed to empower individuals who see a problem – or an overdose in progress – to get the victims the urgent help they need, without fear of prosecution. Physicians also led the fight in 2016 to finally convince lawmakers to reject numerous bills that would have expanded the number of opioid prescribers in the state, for the first time ever giving full prescribing authority to 3,000 certified registered nurse anesthetists, without requiring any additional training. Additionally, MSMS was a key player in the successful end-of-the-year push to convince lawmakers to increase access to naloxone for schools, first responders, members of the law enforcement community, and others.

Naloxone is an emergency medication used to block or reverse the effects of opioid medication, including extreme drowsiness, slowed breathing, or loss of consciousness. Under the laws enacted last December, pharmacists have the ability to dispense the life-saving drug without a prescription, and schools with trained staff members have the ability to keep naloxone on-site in the case of an emergency. “If we want to save lives, we need to get naloxone in our communities,” says Doctor Poland. “It’s a sign that the state is helping the medical community address this epidemic.” The MSMS Task Force late last year even entered into a new partnership with the Michigan Association of Treatment Court Professionals (MATCP), to combine forces when it comes to public awareness, education, and advocacy around drug diversion. According to physicians, the most effective tool for change is improved education for patients and physicians alike. When Mark Weiner, MD, speaks with patients, colleagues, and policymakers, he reminds them that the crisis isn’t really about the drugs – it’s about patients, and physicians remain their best health care interface and advocates. “The most important thing we can do is provide better education and support for primary care physicians on the frontlines of patient care,” said Doctor Weiner. “Solutions aren’t easy, but the answer lies along the path of education and addressing the fears and concerns of patients and physicians alike. The goal is to have compassion for the patients as well as the doctors on the front lines who must handle these difficult cases.” Doctor Davis, the MSU medical school professor, agrees. “Individuals who go into medicine do it for the right reasons. They want to help people. We care about our patients and we are advocates for our patients.” At the end of the day, it’s exactly that kind of advocacy that will turn the tide.

March 9, 2017: PMP AWARxE registration available for new MAPS platform. April 3, 2017: Last day to submit requests and/or file submissions to the existing MAPS. April 4, 2017: All requests and reporting must go through the new system. Current MAPS accounts will no longer be accessible. Accounts from the current MAPS will not be transferred to the new system. All requests and reporting will be made to the current system through April 3, 2017. To request patient reports, please visit https://michigan.pmpaware.net/


Welcome New Members Clinton

Kent

Midland

Ottawa

Brandon Licht, MD

Stephanie Almy, DO

Katia Asali, DO

Robert Genovese, MD, FACC

Thomas Manning, MD

Lisa Markman, MD

Kabet Sterk, MD

Jessie Marshall, MD

Nicole Bibbee, MD

Eaton David Grekin, MD

Genesee Dhiraj (Dee) Bedi, DO Stacy Frye, MD Molly McConachie, MD

Kathryn Born, MD

Muskegon

Arleen Chadha, DO

Gretchen Goltz, DO

Saginaw

Matthew Christy, MD

Archana Patel, MD

Rita Ratani, MD

Oakland

St. Clair

Tom Raisanen, MD

Andrew Banooni, MD

Mohammad Othman, MD

Mitali Roblin, MD

YiJia Chu, MD Christine Gal, MD Jason Griffith, DO Olga Ignatov, MD

Artin Bastani, MD

Tyler Menge, MD Sarah Michelson, MD Fyzah Qureshi, MD

Oren Sagher, MD

Washtenaw

Luke Saski, MD

Anastasia Alex, MD

Aditi Saxena, MD

Alex Argyelan, MD

Kate Szymanski, DO

Syeda Asad, MD

Dalun Tang, MD

Patrick Forrest, MD

Danny Barlev, MD

Ravi Vadlamudi, MD

Vamshi Garlapaty, MD

William Becton, MD

Angie Wang, MD

Chirag Patel, MD

Aaron Glaeser, MD

Jordan Burner, MD

Ellen Webb, MD

Leslie Pelkey, MD

Charlotte Hartzell, MD

Scott Burner, MD

Kiyanna Williams, MD

Houghton/Baraga/

Vernon Proctor, MD

Natalia Hnatiuk, MD

Ying Chen, MD

James Wycoff, DO

Keewenaw

Matthew Reynolds, MD

Brian Kopitzki, DO

Robert Elliott, DO

Lori Vaughan, MD

Daniel Robinson, DO

Kevin Lee, MD

Philip Garza, MD

Michael Ryan, MD

Cindy Lin, MD

Benjamin Gilbert, DO

Ingham

Peter Severson, MD

Peter Littrup, MD

Jessica Gowing, MD

Carla Dudash-Mion, DO

William Wilson, MD

Michael Meininger, MD

Sanjay Pathak, MD

Astrid Wingard, DO

Caroline Meldrum, MD

Victor Hakim, MD

Joel Wood, MD

Francesca Nesi-Eloff, MD

Andrew Zbojniewicz, MD

Diane Paratore, DO

Dori Tamagne, MD

Lisa Walker, MD

Harry Parr, DO, MBA

Kalamazoo

Livingston

Gregory Bibart, MD

Nasir Ali, MD

Zachary Friess, DO

Joseph Skandalaris, DO

Altin Miraka, DO Rasha Nakhleh, MD Daniel Osborn, MD Mohamed Satti, MD Michael Zielinski, DO

Jennifer Johnston, MD Michael Kersjes, MD Ryan Konwinski, MD Daniel Nadeau, MD Jerry O'Brien, DO Molly O'Kane, DO

Gratiot Megan Hoffman, MD

Jackson

Arthur Laurell, MD Earl Norman, MD Jonathan Olsen, MD

Macomb Linda Plizga, DO

Isaac Davidovich, MD Imelda DeVera, DO Michael Farah, MD Maria Forrest, MD

Angela Porter, MD Bruce Ruben, MD Julie Shultz, MD

Jason Haus, MD Stephen Hickner, MD Ahmad Issawi, MD Wisam Khalil, MD Eduardo Kleer, MD Celina Kleer, MD

Donald Siwek, MD

Benjamin Kohnen, MD

Eric Suris, DO

Abhilash Kotte, MD

Basel Taha, MD

Kathryn Lankton, DO

Mandy Trevino, MD

Anna Laucis, MD

Stephen Peck, MD

Mason

Paul Villalba, MD

Yongjin Lee, MD

Matthew Smetts, MD

Darin Gurizzian, DO

Edward Yousif, MD

Emily Levin, MD

Robert Zick, MD

Ann Koss, DO

Mark Ziadeh, MD

Linda Li, MD

In Memoriam

THE MEMBERS OF THE MICHIGAN STATE MEDICAL SOCIETY REMEMBER WITH RESPECT THEIR COLLEAGUES WHO HAVE DIED.

Wayne Munther Alaiwat, MD Eric Biondo-Savin, DO James Coticchia, MD, FACS Peter Dews, III, MD Shauna Diggs, MD Mahir Elder, MD Kamal Gupta, MD Fredrick Junn, MD Paula Kim, MD Gunjan Malhotra, MD Tejpaul Pannu, MD John Roarty, MD Bronwyn Southwell, MD Joanne Wright, MD Danielle Howe, MD

Philip J. Maloney, MD, Wayne County Medical Society, 12/8/16 Michael D. Arsenault, DO, Wayne County Medical Society, 12/20/16 Timothy M. Talbott, MD, Kent County Medical Society, 12/26/16 George B. Pusczak, MD, Mecosta/Lake/Osceola County Medical Society, 1/9/17 John P. Papp, Sr., MD, Kent County Medical Society, 1/13/17

If you would like to recognize a colleague by making a gift or bequest to the MSMS Foundation in their memory, contact: Rebecca Blake, Director, MSMS Foundation, 120 W. Saginaw St., East Lansing, MI 48823 p: 517-336-5729 e: rblake@msms.org

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MSMS Medical Opportunities msms.medopps.org

MSMS Medical Opportunities has been connecting physicians with employers since 1944. It is a nonprofit program through the Michigan Health Council designed to simplify your job search by posting jobs that match your practice preferences. Learn more at msms.medopps.org.

msms.medopps.org

OPPORTUNITY ID: 472

OPPORTUNITY ID: 7496

OPPORTUNITY ID: 11037

OPPORTUNITY ID: 11771

Family Medicine, MD, DO Opportunity in Michigan East Jordan Family Health Center, East Jordan, MI

Family Medicine, MD, DO Opportunity in Michigan Great Lakes Bay Health Centers

Orthopaedic Surgeon Opportunity in Defiance, Ohio Defiance Regional Hospital

Physician-Pediatrics Children’s Care Medical Center

We are currently seeking Physicians to join our team. Successful candidates will provide direct patient care at one of our primary health care centers. We offer a very competitive salary package and an excellent benefits package which includes 403(b) and 457(b), paid vacation and generous continuing education allowances. Malpractice insurance coverage is provided through the Federal Tort Claims Act. Offers of employment may include signing bonuses and relocation assistance. Under NHSC guidelines, Great Lakes Bay Health Center sites qualify for both Scholarship and Loan Repayment candidates.

Opportunity Includes: busy solo practice; total joint potential fellowship trained as well as general orthopaedics - knee replacements, hips, scopes & sports med. Call splits with Physician Assistant who receives first call.

Seeking Family Practice Providers looking for adventure in our small but progressive clinics in beautiful North-West Lower Michigan. Who we are: A Federally Qualified Health Center (FQHC) with a strong sense of organization wide mission to serve the community health needs. Who you are: A Family Practioner who wants to be a part of the community, really wanting to feel you make a difference, and willing to be part of a team based care model actively engaged in removing barriers to care and improving health outcomes.

OPPORTUNITY ID: 6892 Neurological Surgery, MD, DO Opportunity in Ohio The Toledo Hospital ProMedica Physicians, located in Toledo, OH, is in the process of developing a compre-hensive neurosurgical program serving northwest Ohio and southeast Michigan. This role will take the Neurosurgery program to a new level. Now is the perfect time to join and help us build our NeuroSciences Institute! Come and see what ProMedica has to offer for a rewarding career and lifestyle.

OPPORTUNITY ID: 7307 Psychiatry - Adult, MD, DO Opportunity in Michigan Tuscola Behavioral Health System • Provides psychiatric care and services to agency consumers including assessments and consultations, medication prescription and medication monitoring. • Recommends referrals for specialized medical services to external sources as appropriate and provides psychiatric documentation to assist in accomplishing the referral. • Ensures coordination of care with consumer’s Primary Care Physician and Medicaid Health Plan. • Evaluates need for psychiatric hospitalization, assists with inpatient referrals when necessary and consults with CMH clinical staff and hospital staff regarding treatment needs and aftercare plans.

OPPORTUNITY ID: 7660 General Surgery, MD, DO Opportunity in Ohio Defiance Regional Hospital We are looking for a motivated, high quality, BE/BC General Surgeon interested in doing bread and butter general surgery cases as well as colonoscopies. Enjoy working in a well established practice on the campus of ProMedica Defiance Regional Hospital. The incoming surgeon will practice as an employee of the ProMedica Physicians.

OPPORTUNITY ID: 9711

OPPORTUNITY ID: 11524

Family Medicine or Internal Medicine Position in Michigan Bixby Hospital Excellent opportunity for a BC/BE FM or IM physician to join a busy, well-established practice in Adrian, Michigan known for providing quality medical care in the community.

OPPORTUNITY ID: 11775

OPPORTUNITY ID: 11633 Excellent Neurotologist Opportunity in Midwest - Toledo, OH Promedica Health and Wellness Center ProMedica Physicians Ear, Nose and Throat is seeking a full time BE / BC Neurotology fellowship-trained individual to join a five-physician ENT group based in Toledo, Ohio. Three partners within the group are fellowship-trained subspecialist.

OPPORTUNITY ID: 11727

Pulmonologist-CCU-Sleep Opportunity Oaklawn Medical Group

Ophthalmologist Promedica Health and Wellness Center

Located in south central Michigan, Oaklawn Hospital is seeking a Pulmonologist/CCU physician to join the Oaklawn Medical Group working alongside another Pulmonologist/ CCU physician providing out-patient Pulmonology care with shared Critical Care inpatient rounds and call (small 12-bed CCU).

ProMedica Physicians Eye Care (PPEC) is a multi-specialty eye practice with retail optical, optometry, and ophthalmolgy. PPEC is the eye department for ProMedica Health System which encompasses 12 acute care hospitals in Northwest Ohio and Southeast Michigan. PPEC’s mission is to deliver state of the art eye care with compassion.

OPPORTUNITY ID: 10509 Child & Adolescent Psychiatrist Tuscola Behavioral Health System Responsible for the provision of outpatient psychiatric services for children, adolescents and families. Provides face-to-face psychiatric evaluation as well as medication management and consultation services in a collaborative work environment focusing on integrated health care. Demonstrates knowledge of and actively supports culturally competent, recovery based practices.

Our pediatric office currently consists of one full time and one part time physician. We are looking to expand the office hours and better accomodate our patients with quicker and more convenient appointments. A full or part time permanent position is available. We have a full, well trained staff and have been using an excellent EMR system for over a year now. Children’s Care Medical Center has 7 exam rooms and a CLIA Waived lab. We are continually updating our tests and technology to keep current for our patients. Please check out our website and facebook page to get a better idea of our office environment.

Psychiatry: Core Faculty / Substance / Geriatrics Henry Ford Allegiance Clinical duties include a combination of inpatient, outpatient, and consult liaison work in psychiatric service and will include participation in research. Core Faculty will model professionalism, collaboration, and teamwork with staff and other health professionals. The faculties are expected to engage in any or all areas of scholarship: discovery, teaching, integration, and application. .

FOR RENT Perfect accommodations for a Medical Professional Office. The site is located on M15. The beautiful office space is 1,300 square feet. The building is a modern, beautiful building. If interested call 248-627-5700.

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You can help reduce the impact of the opioid epidemic by using the CDC’s Guideline for Prescribing Opioids for Chronic Pain. The guideline will help you: 1. Discern when to initiate or continue opioids for chronic pain 2. Determine opioid selection, dosage and duration 3. Assess the risk before a life-threatening addiction can take hold Empower yourself. Improve care. See the full CDC guideline at: https://www.cdc.gov/drugoverdose/prescribing/resources.html

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Prescription guideline to reduce the risk of opioid addiction. • The death rate from opioid and heroin overdose has grown 3x in Michigan sin ce 1999 • 91 Americans die every day from opioid overdose • 3 out of 4 heroin users rep ort having first used opioid s • More than 50% of prescripti on drug abusers get unused pills from friends and family


Practices for Sale 1 MILLION GROSS PER YEAR – Oak Park General Internal Med Practice, Owner/MD wants to retire but N.P. would like to stay and increase hours. 40 patients per day few Walk-in and nearly NO HMOs. Good insurance Mix, Serious Medical Patients, no weekends and ½ day on Friday. This Practice can be Financed with Little out of pocket. Rent the Real Estate. Asking $375K Joe Zrenchik on cell 248-240-2141.

FOR SALE Quakertown Medical Arts Suite 400 32905 W 12 MILE ROAD, FARMINGTON HILLS, MI

Office/Medical Bldg - 1,079 SF available 3 exam rooms, 1 office, lab and lobby Includes suite HVAC control Abundant parking Great visibility Close to area freeways Sale Price $70,000 Contact: Mr. Robert Moon, Vice President, FBC Brokerage Friedman Integrated Real Estate Solutions Ph: 248-848-4122 email: Robert.moon@freg.com

Dearborn – General Practice Semi Retired Physician has a 2-3 day practice 20-30 patients per week, $27,500 or Lease the Building and price is flexible…terms. Jackson – Well Established Practice, Mostly Medicare Nice 2700sq.ft Building, Large Parking Lot, favorable location. Good Insurance Mix, Equipment. Will offer Terms of all kinds on this $425-500K Grossing Business with good Loyal Patients. Conservatively operated for years. $125K Business, $160K Building or Land Contract terms. ENT with mostly Allergy Patients, Westland Hearing Aid Tenant in Building, Small General Medicine Tenant, Buy Practice (asking $40K) and rent on short or long term agreement, very reasonable rates. Plenty of room and parking. Southfield, Retiring Physician, Gynecology Practice Doctor stopped deliveries and has very little infertility practice anymore. What we have is a 3 generation type of Practice where family refer new Gynecology Patients. For you the Ob/Gyn Specialist this could be a spring board for your Career, a profitable part time Practice on a Month to Month rent! $25,000 asking includes equipment and Goodwill. Pediatrics in Westland near Canton 30 years, high volume, yes it does a big Gross. A Pediatrician Physician can work into the practice and take over EARN and Purchase transaction. Only a Boarded Pediatrician, potential to earn substantial income call Joe for details, Cell: 248-240-2141. Southfield Internist, 20 hrs. per week, Good Income Just Listed, Married Physician is going to follow her Husband out of state. General Internist Med. Near Telegraph up for Sale. Month to Month Rent. Take over and Build or move it into Your Practice. Priced right. Sooner the Better, since Owner wants to give the next Person a Transition period.

Looking for Part time/Full time Work as a Provider? Different locations available. Call Joe Zrenchik.

Joe Zrenchik, Broker 248-240-2141 (cell) • 734-808-0147 (eFax) bestdoctors@yahoo.com 248-919-0037(office) www.michiganmedicalpractices.com Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.

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2017 Educational Courses MSMS ON-DEMAND WEBINARS

BILLING AND CODING COURSES

Physician Executive Development Programs:

MSMS/MMBA billing webinar series at noon on the third Wednesday of each month.

• Health Care Law for Physicians in ACO’s • Medicaid Issues and Trends: Outlook for 2014 and Beyond • In Search of Joy in Practice: Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism: Cultivating Collaboration • Financial Information Analysis, Budget Development, and Monitoring • Choosing Wisely • CDL-Medical Examiner Course Legalities Practicalities, and Compliance including: • Cyber Security: Issues and Liability Coverage

Below are past billing webinars available on-demand: • Compliance • ICD-10 for 2017 & Routine Waiver of Co-pays • ICD-10 • Credentialing • Billing 101 • Managing Accounts Receivable • Understanding the Remittance Advice • Tips and Tricks on Working Rejections • Claim Appeals For a complete list of billing courses, contact Stacie Saylor 336-5722 or ssaylor@msms.org

• Engaging Patients on Their Own Turf: Using Websites and Social Media • Summary of the Affordable Care Act

EDUCATIONAL CONFERENCES

• HIPAA Security Rule • End of Life Concerns and Considerations

Practical Guidance for Health Care Compliance

• What’s New in Labor and Employment Law

Date: Saturday, March 18

• Preparing for the Medicare Physician Value-Based Payment Modifier

Time: 10:00 am – 3:00 pm

• Understanding and Preventing Identity Theft in Your Practice • Stepping Up to Stage 2

Location: Prince Auditorium at Calvin College, Grand Rapids Note: Lunch will be provided.

• Physician On-line Rating and Reviews: Do’s and Don’ts

Intended for: Physicians, PO Administrators, practice consultants, office administrators, students, other health care professionals.

• Patient Portals as a Tool for Patient Engagement

Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

• Health Care Providers’ Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities

Making MACRA Work for You

• Opioids and Michigan Workers’ Compensation

Date: Friday, May 5

• Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction

Time: 9:00 am – 3:45 pm

• Section 1557: Anti-Discrimination Obligations

Note: Lunch will be provided.

Visit www.msms.org/OnDemand for complete listing of MSMS On-Demand Webinars.

Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

Location: Amway Grand Plaza Hotel, Grand Rapids Intended for: Physicians, PO Administrators, practice consultants, office administrators, students, other health care professionals.

Register online at msms.org/EO or call MSMS Registrar at 517-336-7581. 24 michigan MEDICINE

| MAR / APR 2017


Annual Joseph S. Moore, MD, Conference on Maternal and Perinatal Health

Making MACRA Work for You

Date: Thursday, May 18

Time: 9:00 am – 3:45 pm

Time: 9:00 am - 4:15 pm Location: Somerset Inn, Troy Note: Continental breakfast and lunch will be provided

Location: Sheraton Detroit Novi Hotel, Novi

Intended for: Physicians, nurses, residents, students, and all other health care professionals working with women and their infants.

Date: Tuesday, October 24

Note: Lunch will be provided. Intended for: Physicians, PO Administrators, practice consultants, office administrators, students, other health care professionals. Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

Contact: Marianne Ben-Hamza 517-336-7581or mbenhamza@msms.org

152nd MSMS Annual Scientific Meeting Spring Scientific Meeting

Morning, afternoon and evening clinical courses available.

Morning, afternoon and evening clinical courses available

Date: Wednesday, October 25 - Saturday, October 28

Date: Thursday, May 18 and Friday, May 19

Location: Sheraton Detroit Novi Hotel, Novi

Location: Somerset Inn, Troy

Note: Continental breakfast and lunch will be provided.

Note: Continental breakfast and lunch will be provided

Intended for: Physicians and all other health care professionals

Intended for: Physicians and all other health care professionals

Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

Regional Scientific Meeting Date: Saturday, September 16 Time: 8:30 – 11:45 am Location: Prince Auditorium at Calvin College, Grand Rapids Note: Continental breakfast and lunch will be provided Intended for: Physicians and all other health care professionals Contact: Beth Elliott 517-336-5789 or belliott@msms.org

Symposium on Retirement Planning

21st Annual Conference on Bioethics Date: Saturday, November 11 Time: 9:00 am – 4:30 pm Location: Sheraton Detroit Hotel, Ann Arbor Note: Continental breakfast and lunch will be provided Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues Contact: Caryl Markzon at 517-336-5755 or cmarkzon@msms.org.

Practical Guidance for Health Care Compliance Date: Wednesday, December 6

Date: Saturday, September 16

Time: 10:00 am – 3:00 pm

Time: 12:30 – 3:45 pm

Location: MSMS Headquarters, East Lansing

Location: Prince Auditorium at Calvin College, Grand Rapids

Note: Lunch will be provided.

Intended for: Retired physicians, physicians planning for retirement, spouses, and office managers

Intended for: Physicians, PO Administrators, practice consultants, office administrators, students, other health care professionals.

Contact: Caryl Markzon at 517-336-5755 or cmarkzon@msms.org.

Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

Visit msms.org/EO or phone MSMS Registrar at 517-336-7581 for more information. MAR / APR 2017 |

michigan MEDICINE 25


WEALTHCARE ADVISORS By Nathan Mersereau, CFP®

Look Ahead: Potential Tax Reform and Planning Opportunities One thing many of us can agree on is that our current income tax code is confusing. The last significant federal tax reform was in 1986. With President Donald Trump, we are very likely to see some version of his tax proposal—or a GOP proposal—pushed through Congress in 2017. Most experts expect the first year affected by tax reform will be 2018. The following is a look at some proposed changes, plus some viable 2017 tax planning considerations, based on what we know today.

Proposed Tax Reforms CHANGES TO INDIVIDUAL INCOME TAX RATES

President-elect Trump’s plan proposes to consolidate from seven tax brackets (10%, 15%, 25%, 28%, 33%, 35%, 39.6%) to three tax brackets (12%, 25%, 33%). The proposed changes will be beneficial for most married couples (see top chart). Individuals with $112,000 -192,000 of taxable income have a proposed increase in taxes (see bottom chart). For those who are in the “green zone” – where tax rates will potentially be lower next year than this year – tax planning becomes very simple: try to defer any income possible, and push it out to the lower tax rate next year. In addition to deferring income until next year (when rates may be lower), looming tax reform would also make it more valuable to accelerate deductions (“red zone”) into the current year.

Lower tax rates next year?

» Defer Income

Higher tax rates next year?

» Accelerate Income

OTHER PROPOSED TAX REFORMS INCLUDE:

• Elimination of head of household filing status • Changes to capital gains tax rates • Elimination of 3.8% net investment surtax • Elimination or caps on itemized deductions • Higher standard deduction: $15,000 single and $30,000 married filing jointly verses $6,300 single and $12,600 married filing jointly • Elimination of some personal exemptions for each dependent • Elimination of the alternative minimum tax What can you do? It depends on your unique situation. Review the chart below for a few ideas.

Roth conversions: » Consider delaying Roth conversions until next year. Partial conversions to fill the lower Lower tax rates next year? brackets this year (25% marginal and below) may still be a good planning consideration Accelerate deductions:

» If itemized deductions are eliminated or phased out consider accelerating them before year end

Make charitable contributions:

» Gift highly appreciated stock

» Contribute to a donor-advised fund

» Complete a qualified charitable distribution

Contact your tax professional and your WealthCare advisor to determine the best strategy for you. 26 michigan MEDICINE

| MAR / APR 2017



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