Medical Record Summer 2013 by Hoffmann Publishing Group

Medical Record SUMMER 2013

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FREE Clinics in Berks County Free Clinics in Berks County........................................ 8 Birding Goes Digital.................................................. 11

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Helping Patients Enhance Their Recovery

Medical Record

OF THE BERKS COUNTY MEDICAL SOCIETY

A Quarterly Publication

To provide news and opinion to support professional growth and personal connections within the Berks County Medical Society community.

THE BERKS COUNTY MEDICAL RECORD

By E

Lucy J. Cairns, MD, Editor EDITORIAL BOARD

The Image Recovery Center at the McGlinn Family Regional Cancer Center is a place of hope and healing, where patients receive personalized counseling and services to help them adjust to the physical and emotional changes they may experience due to chemotherapy, radiation therapy, or surgery. In a relaxed and private setting, patients can receive a one-on-one consultation with a Certified Breast Fitter, Licensed Cosmotologist, or Licensed Massage Therapist.

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• Post-surgical bras and camisoles, pocketed bras, and swimwear

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No referrals required. Hours: Monday – Friday, 8:30 a.m. to 5 p.m.

D. Michael Baxter, MD Emma Singh, RPh, MD Betsy Ostermiller Bruce Weidman

BERKS COUNTY MEDICAL SOCIETY OFFICERS

Pamela Q. Taffera, DO, MBA, President Kristen Sandel, MD , President-Elect

D. Michael Baxter, MD, Chair, Executive Council Michael Haas, MD, Treasurer Andrew Waxler, MD, Secretary William C. Finneran III, MD, Immediate Past President Bruce R. Weidman, Executive Director

PUBLISHER: HOFFMANN PUBLISHING GROUP, INC. Reading, Pa | 610.685.0914 | hoffmannpublishing.com For advertising information contact MedAds@nhgi.net or visit hoffmannpublishing.com/media

Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610 Phone: 610.375.6555 | Fax: 610.375.6535 | Email: info@berkscms.org The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Berks County Medical Society. Manuscripts offered for publication and other correspondence should be sent to 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. The editorial board reserves the right to reject and/or alter submitted material before publication. All manuscripts and letters should be typed double-spaced on standard 8 1/2"x11" stationery. The Berks County Medical Record (ISSN #0736-7333) is published four times a year in March, June, September, and December by the Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices. POSTMASTER: Please send address changes to the Berks County Medical Record, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610.

readinghealth.org | N-Building | Ground Floor | 484-628-4898

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Fiv

BECOME A MEMBER TODAY!

SUMMER 2013

Go to our website at

www.berkscms.org

and click on “Join Now” Cover Photo by Elizabeth Kann, MD

President’s Message A message from Pamela Q. Taffera, D.O., M.B.A.

Free Clinics In Berks County By Emma Singh, RPh, MD

8 11

Birding Goes Digital By Matt Wlasniewski

Five Places In Berks to Study Nature By Matthew J. Spence

Foundation Report Deb Monko

Departments: Editor’s Comments................................................................................................................................................................ 4 Legislative and Regulatory Updates..................................................................................................................................... 16 Foundation Report.............................................................................................................................................................. 22 Members in the News......................................................................................................................................................... 23 Meet a Member.................................................................................................................................................................. 24 Pennsylvania Medical Society Press Release....................................................................................................................... 25 Alliance Updates................................................................................................................................................................. 26 TMJ Sleep Disorders........................................................................................................................................................... 30 Legislative Breakfast............................................................................................................................................................ 32 Calendar of Events.............................................................................................................................................................. 33 Resident’s Day Recap......................................................................................................................................................... M E D I C A L R E C O R D | S U M M E R 2 0 1 3 34 | Medical Record_Summer2013.indd 3

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EDITOR’S COMMENTS

Lucy J. Cairns, MD, Editor

growing number of our Berks County neighbors have no health insurance, which usually means they do not have access to routine preventive care or to regular care for chronic conditions. The percentage of adult county residents without insurance grew from 8.7 percent to 13.3 percent in the four years preceding the latest “Berks County Health Needs Assessment Report,” whose findings were summarized by Dr. Michael Baxter in the Winter 2013 Medical Record. In the city of Reading itself the situation is even worse, with 25 percent uninsured.

The consequences of inadequate access to preventive and chronic care are no mystery: people with no or sub-optimal care for chronic illnesses are prone to suffer more severe disease and need treatment for acute complications, and our emergency rooms become the provider of last resort for both serious and minor ailments. It is a scenario in which everyone loses. The Affordable Care Act (ACA) represents an effort to make health insurance affordable for most Americans, but even with implementation of the ACA some people will remain uninsured because they will find the penalty more affordable than purchasing insurance. There will also be a large number of low-income people who will not gain insurance unless Governor Corbett decides to accept the expansion of Medicaid.

Although the challenge of providing care to the uninsured of Berks County has been growing recently, there are some in the medical community who have been quietly contributing their time and expertise to this vulnerable population. I refer, of course, to those who volunteer at the Western Berks Free Clinic and Lamplight Family Healthcare. Read Dr. Emma Singh’s article to learn more about these faith-based primary care clinics and the physicians, nurses, 4 | MEDICAL RECORD Medical Record_Summer2013.indd 4

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clerical workers, and others who make them possible. Both facilities would like to increase the number of people they serve, but need additional physicians in order to do so. If you are a primary care physician willing to volunteer a few hours a month, please consider joining your colleagues who serve at one of these clinics. Your neighbors will thank you. In this edition of the Record, we would also like to introduce two physicians who have arrived in Berks County over the last year to take similar positions at St. Joseph Health System and Reading Health System. Howard Z. Davis, MD, MBA, is the current Chief Medical Officer and Vice President of Medical Affairs at St. Joe’s, and Gregory K. Sorensen, MD has joined RHS as Chief Medical Officer and Vice President. Both have already accomplished much in their careers and are now making important contributions to the quality of health care in Berks County. We welcome them.

As promised, this edition of the Record includes an article describing a few of the best bird-watching sites in Berks County. If you have guessed that I am a confirmed birder, you are correct. The outdoors has always been where I prefer to go for exercise and relaxation, but it was only after I took a look through my sister’s fancy binoculars about a decade ago that I really tuned in to birds. I’m sure the birds were always there, but I rarely noticed them until I started to learn their names and songs and habits. Have you had the experience of coming across an intriguing word you have never seen before, so you look up the definition, and then you see the word over and over? Once you know a word or a flower or a bird, it comes into focus as part of the foreground of life and enriches your experience going forward. If you have an enthusiasm you would like to share by writing about it for the Record, the birds will gladly move over. n

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PRESIDENT’S MESSAGE

Pamela Q. Taffera, D.O., MBA Summer Greetings! I hope this issue of the Medical Record finds you well. Most often, the idea of a new year is associated with a cold winter evening in January, resolutions, confetti, and champagne, and flipping to a new calendar year. Sometimes, it is associated with the stress of calculations, budgets and ledgers for fiscal planning. But, in academic hospital systems, the New Year starts July 1, after the pomp and circumstance of medical school and residency graduations has passed and our youngest and brightest new doctors are donning their white coats with sudden extensions in length. This is a time filled with excitement, anxiety, enthusiasm, and true opportunity—especially in Berks County!

raise a family. We must never allow the challenges of our healthcare system to cloud the blessing that is our profession.

The Berks County Medical Society is an outstanding avenue for our healthcare professionals and their families to spend time together enjoying Berks County. Thanks to Dr. Kristen Sandel (BCMS President Elect and PAMED Young Physician Section Trustee), we have some wonderful upcoming events planned for Berks County physicians and their families. And, many thanks to Dr. Lucy Cairns and the Medical Record staff for another amazing issue of the Medical Record, this one dedicated to sharing the beauty of Berks County with its readers.

It is a joy to show new physicians what a wonderful place Berks County is to practice medicine, live, explore, and raise a family Berks County is blessed by the St. Joseph Regional Health Network and Reading Health System and their graduate medical education programs. Our residency programs are a gold mine for the future of healthcare in Berks County. Residency training is a complicated life cycle, whereby understanding the pathophysiology of disease is only one key component to raising fine physicians. Graduate medical education must offer residents training in the transforming business of healthcare and healthcare policy, experience in empathetic and compassionate patient care, competence based training in treatment of complicated diseases and procedures, and balance in their careers and personal lives. One of the most important challenges we must embrace in training young physicians is maintaining the passion and gusto that arrives with them to Berks County. It is so important to share our journey with them and demonstrate ongoing passion for our careers in medicine and in Berks County. It is a joy to show new physicians what a wonderful place Berks County is to practice medicine, live, explore, and 6 | MEDICAL RECORD Medical Record_Summer2013.indd 6

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To the new residents of the Reading Health System–I look forward to meeting each and every one of you at our upcoming resident events and Young Physicians’ Social! And, to the new St. Joseph Regional Health Network Family Medicine Residents: Sean, Kathy, Bobbie, Meredith, Anthony, Florence, and Jared–welcome to Berks County and the St. Joe’s family. Buckle up, it’s going to be quite a ride! I assure you that the Berks County Medical Society, physicians, and community of Berks County are very excited to join you and support you through your journey. And maybe, just maybe, Berks County will be a great place for you to settle down and call home. Happy New Year!

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HEALTH CARE REFORM UPDATE

Reporting PCORI Fees on Form 720 On May 28, 2013, the IRS released an updated Form 720 that includes a section where issuers and plan sponsors will report and pay the PCORI fee. The IRS also released updated instructions along with the revised form.

JESSICA DEAN, E M P L O Y E E B E N E F I T S C O N S U LTA N T

Overview of PCORI Fees The Affordable Care Act (ACA) created the Patient-Centered Outcomes Research Institute (PCORI) to help patients, clinicians, payers and the public make informed health decisions by advancing comparative effectiveness research. The Instituteâ&#x20AC;&#x2122;s research is to be funded, in part, by fees paid by health insurance issuers and sponsors of self-insured health plans. These fees are widely known as PatientCentered Outcomes Research Institute fees (PCORI fees). Issuers and plan sponsors will be required to pay the PCORI fees once a year on IRS Form 720 (Quarterly Federal Excise Tax Return). Form 720 and full payment of the research fees will be due by July 31 of each year. It will generally cover plan years that end during the preceding calendar year. Thus, the first possible deadline for filing Form 720 is July 31, 2013. The PCORI fees apply for plan years ending on or after Oct. 1, 2012, but do not apply for plan years ending on or after Oct. 1, 2019. For calendar year plans, the fees will be effective for the 2012 through 2018 plan years. Who Pays PCORI Fees?

Using Part II, Number 133 of Form 720, issuers and plan sponsors will be required to report the average number of lives covered under the plan separately for specified health insurance policies and applicable self-insured health plans. That number is then multiplied by the applicable rate for that tax year, as follows: $1 for plan years ending before Oct. 1, 2013 (that is, 2012 for calendar year plans).

$2 for plan years ending on or after Oct. 1, 2013 and before Oct. 1, 2014.

For plan years ending on or after Oct. 1, 2014, the rate will increase for inflation.

The fees for specified health insurance policies and applicable self-insured health plans are then combined to equal the total tax owed. When preparing for the payment of the PCORI fee first consult your Tax or Accounting Advisors for further guidance.

For additional information, please feel free to contact Power Kunkle Benefits Consulting at 610-685-1790 and reference this article. Source: Internal Revenue Service

Type of Plan

Who Pays Fee

Fully- Insured Group Accident & Health or Major Medical Insurance Plan

Plan Insurer

Self- Insured Group Accident & Health or Major Medical Insurance Plan

Plan Sponsor

COBRA coverage

Fully Insured: Plan Issuer Self-Insured: Plan Sponsor

Health Reimbursement Arrangement (HRA)

Flexible Spending Arrangement (FSA) Applies if Employer Contributes more than $500 towards FSA plan or applies only to Excepted Benefits (i.e. benefits that are limited to vision or dental benefits and health insurance policies or self-insured plans that are limited to employee assistance programs, disease management programs or wellness programs)

If Combined with Fully-Insured Plan: Plan Sponsor will pay the fee for each covered subscriber (does not apply to dependents) under the HRA. The health insurer will pay the fee for each covered life under the health insurance policy. If Combined with a Self-Insured Plan: Plan Sponsor will pay fee, but will not pay twice for the same lives insured under the Self Insured Plan and the HRA or FSA.

If Combined with Fully-Insured Plan: Plan Sponsor will pay the fee for each covered subscriber (does not apply to dependents) under the FSA. The health insurer will pay the fee for each covered life under the health insurance policy. If Combined with a Self-Insured Plan: Plan Sponsor will pay fee, but will not pay twice for the same lives insured under the Self Insured Plan and the HRA or FSA.

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Free Clinics In Berks County By Emma Singh, RPh, MD

54 year-old-man, employed but uninsured, walks into an Urgent Care Clinic on a Saturday morning to get refills for his daily medications. Due to a lack of health insurance, he has been unable to follow up with his primary care provider regularly and therefore is running out of medication. He hasn’t had any bloodwork or other medical tests in over a year. The few doctor visits he has made have been at an urgent care clinic or emergency room; simply to get refills. Consequently, he has incurred the high cost of making emergency visits for chronic problems. To an uninsured citizen, these accrued costs are scary. Recently he had a $600 emergency room bill. This has placed a tremendous burden on him and his family. Ironically, he is employed, but uninsured, and unfortunately not even a candidate for Medicaid. Like many other men in his shoes, he wants to follow the right guidelines, but is unsure what step to take next. Last year at least 37,000 residents of Berks County did not get health care they needed due to cost according to a survey done as part of the Berks County Health Needs Assessment. As uninsured patients face this dilemma, what can they do to avoid using the emergency room as a primary care provider? One option is to seek out a free healthcare clinic, such as the Western Berks Free Medical Clinic or Lamplight Family Health Care in Berks County.

The Western Berks Free Medical Clinic provides Wednesday evening hours at St. Daniel’s Lutheran Church in Heidelberg Township. It is a faith-based organization

whose mission is to provide stop-gap care to people who are temporarily without medical insurance. Recently, the clinic celebrated its 10th year of service. Treatment is by appointment only, and there is currently a 2-month backlog. Volunteer physicians saw over 600 patients at this clinic last year. Its annual budget has been supplemented over the years by grants from the Lutheran Brotherhood and Aid Association, GlaxoSmithKline, and Highmark Blue Shield. Much of the credit for bringing this clinic into existence goes to Pastor Wayne Heintzelman, the congregation of St. Daniel’s, and Dr. David Brock (who led the original medical team). “It’s a great opportunity to give back to the community,” said Dr. Bigos, who volunteers at Western Berks after retiring from a 30-year private practice career.

Loreen Small, a retired R.N., was one of the founders of this clinic and currently serves as President. She told the Medical Record that the clinic hopes to expand its hours, but that additional physician volunteers are needed before this can be achieved. In a survey completed last year, they found that 46 percent of their patients would not seek further care and 35 percent would start going to ERs if the clinic were not around.

Another free healthcare clinic is Lamplight Family Health Care that provides care to the uninsured of Berks County and surrounding areas. It is a faith-based, primary care center offering no-charge visits to uninsured patients. According to Cheryl Goff, Director, most of their patients find Lamplight by word-of-mouth. Little advertising is done. Many of those seeking care have full- or part-time jobs that either did not come with health benefits or required them to contribute so much that they were priced out of coverage.

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Dr. Leif Christiansen explained that serving as a volunteer physician is “very challenging at times, but it is amazing

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the number of people out there to help. The need is definitely there for the services.” He is a long-time Internal Medicine physician in Berks County who makes time to volunteer despite his busy schedule. Volunteer physicians, nurse practitioners, nurses, and clerical staff operate both facilities. Some of the services provided by the healthcare providers include chronic disease management, women’s health, preventative health, routine physicals, and health education. The clinics were initially intended for colds and physical exams, but they routinely see patients afflicted with diabetes, thyroid disease and hypertension. Many were unaware of their serious illnesses until diagnosed and treated at

these clinics. In addition to free medical care, clinic staff help arrange ancillary services such as X-rays, labs, and prescriptions at discounted rates or at no cost from local healthcare facilities. They have found a few local facilities that are willing to help the uninsured patients with lab work and X-rays.

Both of these Berks County clinics are looking for volunteers to enable expanded hours. The health care providers can obtain a volunteer license from the PA Dept. of State. This is offered without charge under the Volunteer Health Services Act. The Act helps hospitals, health systems, and community organizations establish primary care treatment centers for the poor and in areas

with shortages of medical personnel.

An application for such a license must state that the volunteer will provide professional services without remuneration. A letter from the free clinic is also necessary, stating that the licensee has been approved to volunteer. The volunteer must comply with all continuing education requirements of their respective board. Volunteers may obtain medical liability coverage from the Health Insurance Portability and Accountabilty Act (HIPAA) through the Federal Tort Claims Act (FTCA). The Patient Protection and Affordable Care Act has extended this coverage to free clinic board members, officers, employees and individual contractors. In conclusion, as the healthcare industry is going through major changes, these free clinics provide an avenue to help our fellow citizens. Essentially, they provide medical attention to patients who lack insurance before routine health problems escalate into emergency room situations. n

Physician Volunteers at Western Berks Free Clinic: D. Michael Baxter, MD Edward T. Bigos, MD Nipa Doshi, MD J. Michael Eager, MD (Women’s Clinic) Roger N. Longenecker, MD Claire Murphy, MD Guy Piegari, MD A list of the volunteer Thomas A. Stewart, MD physicians for the Jane A. Weida, MD Lamplighter Clinic was Jennifer Stevens, CNM not available at press time.

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Birding Goes Digital By Matt Wlasniewski

n the winter of 1977–78, a winter finch invasion brought excitement to the Northeast as Common Redpolls, both crossbills and Pine Siskins fled their northern forests in search of food. That year, I was living in Montgomery County, Maryland and had just been introduced to the birding world.

One February afternoon, I received a phone call from a neighbor who was my mentor in my new hobby. He spoke of a Hoary Redpoll coming to his feeders and suggested I hurry over to see this rarity. My wife and I arrived to a living room of birders from Maryland and nearby Virginia who had been notified of this bird via the Rare Bird Phone Tree—a service of the local Audubon club. The word had spread from birder to birder in a process that took hours. 35 years later, the same rare bird alert would have taken less than a minute to reach hundreds of birders in the same area.

Birding has gone from land lines and hard-backed field guides to iPhones, iPads, bird identification apps and “ebirding.” Many birders cling to handwritten field notes and life lists consisting of dates noted next to the bird in the color plates of their favorite field guide. However, there is no escaping this technology. Digital photography has eclipsed the Kodachrome slides used for documenting rare species. Photographic equipment quality has improved to where every birder with a digital camera has a chance of taking the photo that graces the cover of BirdWatching Magazine. Satellite images courtesy of weather services show birders colorful clouds of birds by the millions in migration.

Red-tailed Hawk - Wyomissing Park, PA (left) & Northern Flicker Wyomissing, PA (right). Photos taken by Lucy Cairns, MD.

The Internet and the software that personifies it has given birth to tools for birders akin to the gadgets Dick Tracy used in his heyday. A whole new vocabulary has emerged that describes the tools and the instruments that support them. Briefly, a birder in the field can see a rare bird, confirm its identity, document it for the rare bird committee, add it to his life list and notify his birding buddies with a few strokes on a keypad. The new generation of cell phones and tablets have a huge catalog of resources available to them. Apps commonly used for identification are: iBird Pro, Bird Tunes and Audubon Birds. Peterson and Sibley have both created app’s that showcase their field guides. The books replaced by an instrument small enough to fit in a shirt pocket now remain on the back seat of their vehicles.

A website for bird records, eBird.org, was created by The Cornell Lab of Ornithology and National Audubon. Birders now enter their daily bird check list in eBird and within minutes millions of birders around the world will now know where to find the birds. Local bird societies, such as Pennsylvania Birds, use their own computer discussion list to report bird sightings. Every popular birding publication offers an online edition that saves the reader postage as well as using less paper. Birding, gaining in popularity every day, still needs a bird to watch, the elements that influence avian movement and the time to observe nature. All of the recent inventions in birding technology have helped birders get the most out of a dwindling resource for many of us—time. I believe this was all inevitable. Perhaps it is a good thing. For, how much time do some of our favorite birds have left? n

Matt Wlasnieswki is President of the Baird Ornithological Club

White Ibis - Kaercher Creek Park, Hamburg, PA (left) & two Purple Martins Shartlesville, PA (right top and bottom). Photos taken by Matt Wlasniewski. MEDICAL RECORD

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Five Places In Berks to Study Nature By Matthew J. Spence

t is not necessary to travel to Trinidad, New Guinea, or the Gambia to find a varied flora and fauna; indeed, it is possible to discover an interesting variety right here in Berks County. Granted, our wildlife may not be quite as spectacular and complex as that found in tropical climates, but it can be every bit as interesting. What is intriguing to the local naturalist is the dearth of information about the distribution and life histories of many of our plants and animals. Local naturalists have a golden opportunity to make significant contributions to our knowledge of these organisms. As to variety, there are almost 1600 species of plants found in Berks (Hans Wilkens has identified 145 species of mosses, 43 species of ferns, and 29 species of orchids)all within the boundaries of our county). Additionally, 46 species of reptiles and amphibians, 315 species of birds, and 48 species of mammals have been recorded. We have been blessed with many excellent areas for the study of Nature. I will discuss the five localities with which I am most familiar. Nonetheless, there are some other regions that, demand to be mentioned: the Earl Poole Nature Preserve, Nolde State Park, Northkill Gap, Mount Neversink, and South Mountain. A visit to any one of these localities should be most rewarding.

1. The Blue Marsh

In 1979, the US Army Corps of Engineers created Blue Marsh Lake and Recreation area by constructing a dam across the Tulpehocken Creek. Since that time, Blue Marsh has become a favorite locale of hikers, boaters, and birders. To reach Blue Marsh, go North on Rt. 183, then turn left at the traffic light to Palisades Road, which will take you near the Visitor’s Center. Palisades will also lead to the entrance of the Dry Brooks Day Use area. This location has a beach area which is the best place in Berks County to see a variety of gull species. This is also a good place to see Canada Geese, Bald Eagles, and Merlins (a small falcon). Another spot which can be quite productive is the State Hill Boat Launch area. It can be accessed from Brownsville Road. A splendid hawk watch area is just inside the Blue Marsh boundary. Further on is the boating

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area which can produce woodcock in March and April. The entrance to the Squirrel Run Nature Trail is nearby. On the trail, one can find Redstarts, Ovenbirds, and Scarlet Tanagers. It is prudent to check yourself for ticks!

2. Hay Creek and French Creek State Park

This area is located south and east of Birdsboro between Rt. 82 and the southeastern boundary of our county. Triassic rocks (sandstone, conglomerate, trap, etc.) form the substrate for this region. One of the choice sublocations is the Birdsboro reservoir and the small stream which flows from the reservoir to Hay Creek. This spot has been home to Cerulean and Wormeating Warblers, Acadian Flycatchers, and Blue-gray Gnatcatchers. Flowers seen here include Trailing Arbutus (April), Pink Lady’s Slipper (May), and Cardinal Flower (August). Hopewell Lake in French Creek State Park often provides an opportunity to view and feed Mallards and Canada Geese; a number of other waterfowl species have been known to visit the lake. At nearby Scott’s Run Dam there is a good location to hear and see the mating flights of the American Woodcock in March and April. The Scott’s Run area is one of the few places in Berks County where one can reasonably expect to find poison sumac! Hopewell National Park, adjacent to French Creek State Park, is host to a small colony of Cliff Swallows and a large roost of Black and Turkey Vultures; on occasion, Wild Turkeys have been seen displaying and heard gobbling near the National Park headquarters.

3. Mount Penn and Lake Antietam

Solan Parks should be given credit for saving Mount Penn from being denuded by logging and quarrying interests; he referred to Mount Penn as “Reading’s background curtain.” Mount Penn is composed of Cambrian and Precambrian rocks – the oldest rocks in our county. Some experts believe that the mica schist outcropping along Hill Road near Egelman’s Park is our oldest known rock formation. On the eastern slope of the mountain is found Lake Antietam, formed by the damming of Antietam Creek. Special note should be taken of the dam breast, part of which imitates a natural waterfall; I believe this to be the most beautiful human-made spot in southeastern Pennsylvania. Nearby is the Reading Nature Center (formerly known as the Ferndale Nature Trail and Museum) with a number of nature trails which meander over eastern Mount Penn. Plants common here include the Red Trillium, Nodding Trillium, Wild Ginger (all these species may be found in May), and the brilliant red berries of Jack-in-the-Pulpit MEDICAL RECORD

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(in late summer and fall). Screech Owls, Carolina Wrens, Louisiana Waterthrushes, and Scarlet Tanagers nest near the Nature Center. I have recorded more that 120 bird species near the center; of course, my total includes a number of migrants and winter residents.

4. Lake Ontelaunee

Constructed in the late 1920s for the water supply of the city of Reading, the Ontelaunee Dam allows one to observe water birds on a reasonably regular schedule – Mallards, Gadwalls, Black Ducks, and resident Canada Geese during December and January; Pintails in February and March; migrant Canada Geese in March and April; Blue-winged Teal in April and May. In years of drought, the shorebirding may be quite spectacular. Unfortunately, in years of normal rainfall, few if any shorebirds can be found. Gulls, mostly Ring-billed and Herring (often called “Seagulls” by the uninitiated) can be found throughout the year. In spring, Bonaparte’s Gulls can be sighted near the dam breast, which is located on State Rt. 73. It is here that a large colony of Cliff Swallows make their mud nests; this is the same swallow species that returns to Capistrano, and they are almost as regular here at Ontelaunee. Tropical storms have provided the finest ornithological shows, with such exotics as Sooty Terns, Hudsonian Godwits, and Leach’s Storm Petrels noted by competent observers. Any type of storm from March through May, and August through November, will likely provide the birder with a number of interesting waterfowl, including loons, grebes, swans, coots, gulls, terns, and a variety of pond and diving ducks. A short but severe rainstorm on November 2, 1971 yielded a total of 31 waterbird species.

At present, the original pines are being removed; hopefully, the replacement plantings will provide adequate cover so necessary for the abundance of wildlife. The pines formerly hosted a winter roost of American Crows; estimates of the population reached 125,000 individuals. Sadly, this phenomenon is but a memory, for the roost relocated and/or dispersed after the winter of 1975. The lake is truly an evergreen location for those interested in nature. There are many surprises yet in store for those willing to visit the dammed-up Maiden Creek, or as the Lenni Lenape called it, “Ontelaunee.”

I have saved the most famous place for last. While the Pagoda, the Reading Outlet Stores, and the Reading Railroad (not to mention beer and pretzels) have brought a measure of regional fame to Berks County, Hawk Mountain Sanctuary has received resounding acclaim by conservationists on six continents! The Sanctuary was founded in 1934 by feisty and tireless Rosalie Edge; she hired the first curator, Maurice Broun (1906–1979), whose job it was, along with his wife Irma, to stop the slaughter of migrating hawks which passed over the lookout while on their southerly migration during the months of September, October, and November. After a number of unpleasant and even dangerous confrontations with the hawk shooters, the Brouns succeded. Thus the first Sanctuary for birds of prey had survived its birth pangs. Hawks Aloft, the story of the early days at Hawk Mountain by Maurice Broun, is required reading for anyone interested in raptors or conservation. Today, the mountain is a joy to visit. Hawks and other birds can be observed throughout the year; thus far, 243 bird species have been recorded. For hawks and eagles, the best time to visit is autumn, with September providing the greatest numbers (on September 14, 1978, a record 21,447 Broad-winged Hawks were counted), and October producing the greatest variety. An advancing cold front, a low over New England, and a northwest wind usually produced the largest hawk flights.

The headquarters building contains a small museum a bookstore, and an extensive birdfeeding area at which one can often see Pine Siskins and other northern finches, as well as the usual variety of feeder birds. If your visit is in May or June, you may be able to find a nice variety of migrating and/or nesting warblers. But you are certain to see the gorgeous display of Mountain Laurel and the less-common Sheep Laurel. To reach the Sanctuary, drive north on Route 61, then turn right onto Route 895. When you reach the village of Drehersville, turn right and follow the road of the Little Schuylkill River and proceed up the mountain to the public parking area. n

Solicited by Barton Smith, MD from Matthew Spence. Matt spent his career as an educator in the Reading Public School system, serving as Superintendent of Science Education before his retirement.

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LEGISLATIVE AND REGULATORY UPDATES FROM: J. SCOT CHADWICK, V I C E P R E S I D E N T, G O V E R N M E N TA L A F FA I R S ———————— AMY C. GREEN, A S S O C IAT E D I R E C T O R , G O V E R N M E N TA L A F FA I R S P E N N S Y L VA N I A M E D I C A L S O C I E T Y

The budget proposal also calls for the state to partner with primary care residency programs in Pennsylvania to expand the number of residency slots throughout Pennsylvania.

In addressing the controversial topic of Medicaid expansion, Corbett said that without serious reform, Medicaid expansion would be financially unsustainable for Pennsylvania taxpayers. However, negotiations between Corbett and the federal government on the issue are ongoing.

Other highlights of the state budget proposal include: LEGISLATIVE AND REGULATORY UPDATE

egislative activity is in full swing, and it will only get busier as we approach the June 30 state budget deadline and subsequent summer recess. As usual in recent years, post-recession financial challenges will take center stage, as the governor and legislature struggle to deal with flat revenues, increased demand for social services, a huge state pension funding deficit and the transportation infrastructure funding shortfall. Those financial challenges will also factor into Governor Corbett’s ultimate decision regarding expansion of the state’s Medicaid program. Following is a status report on key legislative and regulatory activities in Harrisburg.

LEGISLATIVE UPDATE 2013-2014 State Budget

In his February budget address, Governor Corbett proposed more funding to increase access to health care in rural and underserved areas and turned down Medicaid expansion as too costly to Pennsylvania taxpayers.

The proposal expands the Primary Health Practitioner Loan Repayment Program to incentivize physicians and other health care providers to work in rural and underserved areas. To further improve access to care in these areas, the budget dedicates $4 million to the creation of the Community-Based Health Care Subsidy Program to provide grants to health care clinics for preventative primary care services.

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• T he desire to modernize and consolidate the state’s health centers, with a focus on how the staff can see people outside of the health care center rather than requiring patients to come to them.

•$ 8 million to expand the Children’s Health Insurance Program (CHIP)

•$ 40 million to provide critical services to an additional 3,000 adults and children with physical and intellectual disabilities

•A s a result of HealthChoices expansion, to be completed in March 2013, the outpatient services budget will decrease by $194 million, and inpatient services by $175 million. The capitation program, which funds managed care providers, will increase by $252 million. •L evel funding ($1.58 billion) for state and state-related universities. In exchange, university leaders promised to work to keep tuition increases as low as possible.

Apology

As most are aware, sooner or later all tort reform initiatives eventually make their way to the Senate Judiciary Committee, where chairman Stewart Greenleaf (R-Montgomery) buries them. That problem has been solved this session, at least for PAMED’s apology bill. Senator Pat Vance (R-Cumberland) shrewdly attached the measure to a bill (SB 379) extending the life of the CHIP program, which was referred instead to the Senate Banking and Insurance Committee, chaired by tort reform champion Don White (R-Indiana). Senator White’s committee promptly approved the measure, and Senator Vance is now working to secure a vote by the full Senate. If enacted, the bill would prohibit the use of provider apologies and other benevolent gestures after a poor outcome in any subsequent medical liability action.

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Mcare Pursuant to Act 13 of 2002, this spring Insurance Commissioner Michael Consedine will examine the financial health of the state’s primary liability insurance carriers this spring to determine their capacity to begin selling physicians and hospitals $750,000 in coverage, rather than today’s coverage level of $500,000. Previously, on July 29, 2011, Commissioner Consedine ruled that the primary insurance limits would NOT be increased for the next two years. Now it is time to repeat the exercise. A positive finding will cause the primary limits to rise to $750,000 next January, with a corresponding reduction in Mcare coverage from its current $500,000 level to $250,000. A negative finding will keep primary and Mcare insurance at current levels for another two years, when the process would again be repeated. An increase in the primary limits would result in a significant rise in out-of-pocket liability insurance costs for physicians unless accompanied by transition relief. PAMED supports the phase-out of the Mcare Fund, but only in a manner that does not impose the cost of retiring the Fund’s $1.3 billion unfunded liability on the state’s physicians, and has so notified state officials. Some in the Corbett administration have strongly suggested that Commissioner Consedine will order the primary limits raised. Others have suggested that may not happen.

HAP, which wants to eliminate the Fund at any cost, has advocated legislation to raise the primary limits by $100,000 to $600,000, using the current Mcare “surplus,” estimated at $130 million, to offset the increased out-ofpocket costs for providers. The HAP proposal would then freeze the limits at this new, higher level and use future surpluses to reduce the following year’s assessment. In the event that a single year surplus of $75 million or more is realized, the primary limits would be raised by another $100,000, with the large surplus again helping to offset increased out-of-pocket costs for physicians. PAMED has been studying this proposal. The Insurance Department retained Price Waterhouse to run numbers on what this proposal and other possible phase-out scenarios might look like, and Representative Glen Grell (R-Cumberland) is drafting legislation to move the proposal forward if stakeholders approve. However, HAP has now disavowed its own proposal because of the likelihood that it would never result in the ultimate elimination of the Mcare Fund. Rather, HAP is now working with the Mcare Fund to get numbers from Price Waterhouse on different scenarios that would ultimately end the Fund. None of these scenarios provide for any state funding to offset the increased cost, and would

result in providers paying off the entire unfunded liability. PAMED opposes any such arrangement, and continues to work toward a satisfactory solution. PAMED is coordinating its examination of this issue with the Pennsylvania Orthopaedic Society and other stakeholders.

Prompt Credentialing

In the last session, Representative Bryan Cutler (R-Lancaster) introduced House Bill 1551, PAMED’s prompt credentialing legislation. A similar bill, Senate Bill 1224, was introduced by Senator Gene Yaw (R-Lycoming) on October 18, 2011. These bills were intended to eliminate the unnecessary delays that frequently occur when physicians apply to be credentialed by various health insurers. Under the bills, insurers would have to notify applicants of the status of their application for credentialing within five business days after receipt, including their intention to continue the process and an itemization of any missing items. Insurers would have 60 days to act on a completed application, and physicians would be eligible for reimbursement within 15 calendar days from the postmarked date on the application.

From that point until the credentialing process is complete, health insurers would reimburse physicians based on their fee schedule rates applicable to nonparticipating physicians. If the physician applicant is a member of a medical group practice currently contracted with the health insurer he or she will be reimbursed at the group’s contracted rate. A health insurer would be required to accept the CAQH’s Provider Credentialing Application when submitted by a physician for participation in the health insurer’s provider panel. On November 30, 2011, the House Insurance Committee held a public hearing on the bill, at which PAMED testified. Committee members and staff expressed considerable interest in the proposal, and PAMED spent much of the last year responding to members’ questions and objections raised by payers. As a result of input received last year, we have redrafted the legislation to address outstanding issues, and will be reintroducing the House and Senate bills shortly.

Continued on page 17

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Regulation of Tanning Salons Last session Senate Bill 349, which would regulate the state’s tanning facilities and set age limits for who can use them, was approved by the Senate by a vote of 48-1. The bill subsequently cleared the House Health Committee on December 5, 2011, and was poised for final House passage.

However, SB 349 was a middle-of-the-road proposal that ultimately died in the tug of war between those who wanted a stronger bill and smaller government advocates who opposed any bill at all. PAMED will attempt to reconcile the two sides and get the strongest possible bill that can actually pass to the governor’s desk. New House and Senate measures have been drafted, and that process is under way.

Fair Contracting

Once again PAMED is seeking enactment of legislation to level the playing field between physicians and payers. Last session PAMED supported House Bill 1763, legislation intended to closely track expired court settlements known as the Love settlements. However, the bill received harsh treatment during a November 2011 House Insurance Committee public hearing, which, as expected, generated considerable opposition from the Blues. This session, PAMED will draft new legislation focusing on our core concerns and addressing payer objections.

Deemed Status

In an effort to jumpstart a long overdue update of Pennsylvania’s hospital regulations, the Hospital and Healthsystem Association of Pennsylvania (HAP) is attempting to bypass the lack of regulatory action via the legislative route.

Last session House Bill 1570, introduced by Representative Doug Reichley (R-Lehigh), provided that facilities or specialized health care services accredited by a national accrediting organization approved by the Centers for Medicare and Medicaid Services (CMS) would be deemed to meet state licensure requirements and would be be entitled to a license issued by the Department of Health (DOH). This would allow them to ignore inconsistent state licensing requirements. PAMED was, and remains, sympathetic to HAP’s desire to modernize the state hospital regulations, and indeed, supports such an endeavor. However, the blanket erasure of some significant state patient and physician protections

through deemed status, is a major concern. Importantly, the bill as introduced would have eliminated state regulations that ensure the protection of physician-led hospital medical staffs.

HAP and PAMED worked to address those concerns, and that process produced an agreement on all issues, an agreement that was endorsed by DOH and Rep. Matt Baker, who chairs the House Health Committee. However, a number of non-physician provider groups saw the bill as an opportunity to expand their role and scope of practice in a hospital setting. This and other complications resulted in a scuttling of the bill at the end of the session.

In the new session PAMED has worked with DOH and other stakeholders to craft language that reduces the likelihood of an assault on the bill by mid-level provider groups. While the language ultimately settled on by the Corbett administration isn’t as “tight” as we would like, DOH has issued a letter reassuring us that its interpretation of the legislation addresses our concerns. HAP has also sent a letter stating that they accept that interpretation. That language is contained in House Bill 1190, introduced by Representative Bryan Cutler (R-Lancaster), and as of this writing the bill has cleared the House Health Committee with no negative votes. Controlled Substance Database (CSDB)

Last session Representative Gene DiGirolomo (R-Bucks) introduced House Bill 1651, legislation intended to improve the Commonwealth’s ability to enable informed and responsible prescribing and dispensing of controlled substances and to reduce diversion and misuse of such drugs in an efficient and cost-effective manner that will not impede the appropriate medical utilization of licit controlled substances.

PAMED supports the creation of a CSDB, but had a number of concerns with the bill as drafted, including the lack of legal protection for physicians who opt not to use the database, and overly broad language permitting law enforcement personnel to surf the data looking for fraud. PAMED worked with Rep. DiGirolomo and key stakeholders to address these concerns and ultimately a vastly improved version of the bill was approved by the House Human Services Committee. Unfortunately the bill went no farther.

However, PAMED’s “Pills for Ills, Not Thrills” campaign has generated significant support for a CSDB in the governor’s office and legislature, and we are optimistic that a good bill can be enacted this year. MEDICAL RECORD

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CRNP Independent Practice Senator Pat Vance has circulated draft legislation that would entitle CRNPs to practice independently, to be recognized as primary care providers under managed care and other health care plans, and to be reimbursed directly by insurers and other third-party payers. The proposal would also take priority over the authority of DOH and DPW to regulate the types of health care professionals who are eligible for medical staff membership or clinical privileges, along with the authority of a health care facility to determine the scope of practice and supervision or other oversight requirements for health care professionals practicing within the facility. The measure, though not yet introduced, will be discussed at PAMED’s May board meeting.

REGULATORY UPDATE

Department of Health State Budget Proposal Within the Governor’s budget proposal, there is a $1 million increase towards loan repayment programs and $4 million to expand primary care focused on underserved areas. Residency slots will be expanded by 10 this year, and a $50,000 loan forgiveness grant will be given to those who commit to at least 2 years of service—this is a change from previous years showing a 4-year commitment for $65,000. Currently, there is a large discussion regarding the state health center modernization showing that Pennsylvania will go from 60 state health care centers to 36, with the elimination of roughly 50 positions. Deputy Secretary, Marty Raniowski, indicated that approximately 77 percent of their state health center budget was going to leasing costs. Generally speaking, there is low utilization of these centers by the public and buildings were becoming empty spaces. Items such as active patients, population, and proximity to another facility were assessed and determined that community outreach is thought to be more effective rather than maintaining actual physical health centers. This means that while the centers may be closing, services to the public (i.e. education, prevention, testing, and referrals) will continue through a community outreach based approach.

Medical Board Policy Change: Physician Assistant Application

The State Board of Medicine recently changed its policy that allows for temporary authorization for PAs to practice, pending board approval of their application. This was done due to the backlog of applications and lack of 20 | MEDICAL RECORD Medical Record_Summer2013.indd 20

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administrative staff to adequately filter all applications in a timely manner. The notice can be found on the Medical Board’s website under “Special Notices.”

Once an application is received, the physician or physician assistant will receive an acknowledgement letter indicating either a discrepancy with the application, or an authorization letter indicating that the physician assistant can begin employment, with the application to be reviewed within a 120-day time frame. The physician assistant, however, cannot begin work until they receive that authorization letter—meaning there still may be a delay depending on how long it takes the Board to receive the application and send out the authorization letter. More specifically, the 120 days is a temporary authorization that will provide a period during which the physician assistant may practice, under the terms of set forth in the written agreement as submitted to the Board. Within 120 days, the Board will notify the supervising physician of the final approval or disapproval of the application. There will also no longer be a requirement to submit a change form when there is a change in the substitute physician supervisor only. This does not eliminate change forms completely, as they will still need to be submitted when there is any change in medical practice, satellite location, or any other relative information. PAMED is also continuing to work collaboratively with the state Physician Assistant Association to remove some of the onerous requirements with respect to review of patient charts. We expect this legislation to be introduced by Representative Curt Sonney (R-Erie) within the next week or two.

State Board of Medicine Vacancies

At its May 2011 meeting, the PAMED Board of Trustees approved a process to be used to identify PAMEDrecommended candidates to fill future vacancies on the State Board of Medicine (SBOM). That process directs the Executive Committee to utilize specified suggested criteria to identify and ultimately select qualified candidates that PAMED will recommend for consideration by the Governor. The State Board of Medicine will have a total of three physician vacancies in spring 2013. PAMED has been given the opportunity to provide names of nominees they wish to be considered for vacancies on the State Board of Medicine. A total of five names were provided for the Executive Committee to review, and all names were selected for formal submission to the Governor’s office.

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State Board of Pharmacy and Compounding Companies The outbreak of meningitis at the New England Compounding Center has sparked a large initiative among many states and the FDA on the issue of compounding. Staff and members at the Pharmacy Board attended a meeting held by the FDA and discussed what states are seeking to do through regulation and ways in which the FDA can tighten its rules. Many individuals from other states requested for a consistent definition of a compounding pharmacy. A separate meeting was called on behalf of Rep. Matt Baker that brought together staff from the Department of Health, Department of State and several compounding experts. One initiative that the State and DOH will look into is registering out-of-state compounding pharmacies. We expect to see several pieces of legislation that deal specifically with this issue as well.

Lastly, the National Registry of Certified Medical Examiners is a federal program that establishes requirements for healthcare professionals that perform physical exams for truck and bus drivers. Medical examiners that wish to perform or continue exams for interstate commercial motor vehicle drivers must complete training and pass a certification test. This will be effective May 21, 2014. PAMED has information on the website about this, but we anticipate more questions from members as we approach the effective date. n

The State Board of Pharmacy is currently developing draft language within regulation to address issues of compounding. PAMED has participated in all discussions and will continue to monitor this regulation as it progresses.

PennDOT Medical Advisory Board

PennDOT is working on a number of items that may affect physicians and patient drivers. Currently, a new physical exam re-certification form is being developed electronically. Drivers 45 and older are randomly selected to participate in the re-exam program prior to the renewal of their license to determine visual and physical qualifications. Switching from manual to electronic will allow the Department to have the capability to send out more forms to drivers for screening purposes.

Next, the Department is considering adding contrast sensitivity as a screening method and will undergo a pilot project with the expectation to begin this summer. Visual screening of drivers needs to meet the standards outlined in regulation for binocular acuity and visual field testing, but what is not considered in visual impairment is contrast sensitivity. They are hoping to bid on and receive research money to undergo this project but made certain to members at the meeting that they will be moving forward with the pilot project with or without the grant money.

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FOUNDATION REPORT FROM THE DESK OF DEB MONKO D I R E C T O R , S T U D E N T F I N A N C I A L S E RV I C E S

FOUNDATION HELPS TO EASE EDUCATIONAL DEBT

ducational debt for medical students is an increasing burden on today’s students who will become our physicians of tomorrow. On an annual basis, the Association of American Medical Colleges (AAMC) reports on the financial picture of the current year’s medical school graduates. Below is a comparison of the burden of educational debt among the graduating classes of 2003 and 2012, as reported by the AAMC. Class of 2003 Class of 2012

Indebted Graduates, Mean $109,457

$166,750

Percent of All Graduates with Educational Debt

82%

86%

25%

62%

7.5%

36%

Percent of Graduates with Debt >$150,000

Percent of Graduates with Debt > $200,000

On average the amount of educational debt that a student carries upon medical school graduation has increased nearly $60,000 over the last 10 years. Many students utilize the government’s Federal Stafford Loan program to meet the cost of attending medical school. The expenses that students incur on these loans has increased during the last decade due to the changes in loan terms. In 2006, the government increased the interest rate charged on these loans from a variable interest rate to a fixed interest rate of 6.8 percent, which increased the percentage rate by 1.5 percent in the first year the change was introduced. Additionally in 2012, the government no longer allowed

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medical students to receive a subsidized portion of their Stafford loan, which means that the government no longer pays interest that accrues during school. Both of these term changes are one factor that has increased the total amount of a student’s indebtedness reported at the time they graduate from medical school. The Foundation believes in supporting our Pennsylvania residents attending medical school with lower cost alternatives to fund their medical school education. Currently eight scholarships are administered by the Foundation and in 2012 a total of $52,500 was awarded to 22 Pennsylvania residents attending medical school. Individual scholarship awards ranged between $1,000 and $3,000 each. Students also have the opportunity to acquire a low-cost Foundation student loan up to $7,000 annually with an aggregate total not to exceed $21,000. This loan is available to Pennsylvania residents attending a Pennsylvania medical school. The interest rate charged during school and graduate training (i.e., internship, residency, and fellowship training) will not exceed 6 percent. In 2012, a total of $400,000 in low-cost loans was awarded to 76 medical students from Pennsylvania. The interest rate on loans disbursed in 2012 was only 2.09 percent and remains fixed through medical school graduation.

You too can assist Pennsylvania residents with their medical school education by informing your friends, neighbors, family, and patients about the Foundation’s loan and scholarship opportunities available to them. Further support to these students can be done by making a tax-deductible contribution to support one particular scholarship, all scholarships, or the loan program. Your contribution no matter how large or small will benefit the students by assisting them with less expensive financial resources that will allow them to cover not only educational expenses but also living expenses such as, food, clothing, utilities, and residency interview costs to name just a few. Please consider giving a gift today.

Full details of all scholarships and the loan program administered by the Foundation can be found on our website at www.foundationpamedsoc.org under the student financial services tab. Please contact SFS directly at 717-558-7854 for discussion of financial aid programs or to obtain information on how you may partner with the Foundation to create a scholarship fund for medical students. n

2013 7/17/13 9:46 AM

MEMBERS IN THE NEWS

READING HEALTH SYSTEM ELECTS NEW LEADERS

William J. West Jr., MD

When I went to medical school, I was married and the father of a three-year-old daughter. I not only needed money for my tuition, but also for rent, food and other family needs. The Foundation of the Pennsylvania Medical Society provided me with a loan while I was enrolled. While the loan couldn’t pay for everything, it did help significantly with my expenses and I was able to graduate from Thomas Jefferson University. As a practicing physician, I was able to pay back my loan early so those funds would be available for other students in need. I am grateful to the Foundation for this program and believe it is invaluable to help ease the financial burden of medical school. I have tried to pay back the Foundation for its support of me and feel honored to serve on the Board of the Foundation. Prior to serving on the Board, I started an AMES Scholarship in memory of my grandfather, William B. West MD, past president of the Pennsylvania Medical Society. To date we have provided over $12,500 in grants to deserving students. I strongly encourage my colleagues to join me in supporting this program.

he Reading Health System Board of Directors elected a new chairman, vice chariman, and five directors during its annual meeting. Four members of the Berks County Medical Society were included in that elite group. Dr. Brent J. Wagner of West Reading Radiology Associates was elected the new Vice Chairman. He is immediate past president of the Reading Hospital Medical Staff and Chief of the Health System’s Diagnostic Radiology section. Robert A. Brigham, MD of Reading Health Physician Network and Chairman of the hospital’s Department of Surgery was also elected to the board, as well as Anne M. Flynn, MD of Flynn & Hanley Surgical Specialists and the hospital’s General Surgery section. Dr. Kristen M. Sandel, Associate Director of the hospital’s Department of Emergency Medicine and President-Elect of the Berks County Medical Society also joins the board. We offer our congratulations to these members! n

Dr. Kristen Sandel

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ogress

notes

SEPTEMBER, 2012

MEET A MEMBER DR. CAIRNS

Howard Z. Davis, MD, MBA has been with St. Joe’s since May 2012. He is clinical Integration lead for SJHRN, which involved creating the Saint Joseph Provider Hospital Organization (SJPHO) which eventually will Gregory K. Sorensen, evolve into a formal Clinically MD, has joined Reading Integrated Network. Before Health System as Senior accepting his current position Vice President Chief troduce myself in my new role as Chief Medical Officer and at St. Joseph Dr. Davis was CMO and VP of Officer. Before ast May and I finally feel like I am getting Medical the lay of the land, so to Health Networks at Saint John’s joining RHS, he served as Health Center in Santa Monica, d: I practiced Emergency Medicine in California for almost 30 years Chief Medical Officer and His Jose, dutiesthree there included overseeing peer review, Vice President of three Medical family. After moving into hospital administration, I spent years as a California. CMO in San quality, utilization, risk, and the recently created Saint John’s Affairs for the Marylandtwo years in Los Angeles before moving back to PA, which is where I was born and raised. Except Health Clinic. He was a member of the California Hospital based Bon Secours Health ed to be in Pennsylvania. Association’s Center for Medical Executives and belonged to System. His responsibilities the California Medical Association, in which he once served as ng things going on at St. Joe’s – here arethere someincluded of them:medical a delegate. serving as a board member of the California services, healthand informatics, quality, tice Residency staff is fully subscribed serves asclinical a source of physicians to bolster our While primary Chapter of the American College of Emergency Physicians he laboratory, imaging, and pharmacy. During his tenure »» Bill Stroke»update:» authored The Emergency Physician’s of Rights. While at there (2010 through 2012) he also led the clinical Billion health system, Catholic Health Initiatives, (CHI), we have access to and receive support Saint John’s he also worked to implement a grant from Blue SJMC»receives» transformation team and the implementation and Shield to form an Accountable Care Organization out of the ay of services, particularly Information Technology. optimization of Epic electronic Advanced»Primary» newly formed Saint John’s Health Clinic. health record. with Penn State Hershey which will add an academic expertise ing a cooperative relationship

is assumes role as Chief Medical Joseph Medical Center

What’s in Progress...

Stroke»Center»

re we provide toDr.the community. Dr. Davis grew up in Pennsylvania, attended Amherst Sorensen earned a bachelor’s degree in pharmacy status College undergraduate studies, received his MD from ating and reorganizing our from employed physicianofgroup so that havefor a key role in and his M.D. the University Nebraska. Histhe physicians the University of Pennsylvania, and trained in Emergency postgraduate education included a pediatric residency g. Medicine at Stanford Medical Center. He served as clinical the University of Washington, a fellowship in » » Safe»use»of»opioids» ing a Clinically atIntegrated Network which will include independent physicians, employed phyfaculty in the Department of Surgery at Stanford after pediatric cardiology at Vanderbilt University, and a y providers, andreturn contracted physicians. This will allow us to approach the payers and employcompleting his residency. Dr. Davis then spent 26 years at in»hospitals» to the University of Washington for a fellowship O’Connor Hospital in San Jose, California where he worked grated product in which provides a comprehensive of services. neonatal and respiratory diseases,range followed by a as an Emergency Physician, eventually becoming Emergency in anesthesiology. g on the aboveresidency items, I have been also working with Dr. Santarelli and theDepartment medical executive Medical Director and Chief Medical Officer/ »» Peer»Review ian issues: at its meeting this committee the following changes to theInformatics Rules andOfficer. In 2007, he moved back Chief Medical HisAugust experience includes 11 years as approved Executive Director

to Pennsylvania to serve as Senior Vice President/Chief at Swedish Medical Center in Seattle, Washington. »» Partnership» at Pocono Medical Center. In this position this return time hephone created a pediatric aking call for theDuring ED must calls promptlyhospitaland must personally Medical evaluateOfficer the patient he implemented a hospitalist programwith»physicians» and created a Level a-hospital, established the first pediatric to do so by thewithinED physician. 3 trauma center in partnership with Lehigh Valley Health hospitalist program in the northwest U.S., led a group nts must have their care managed bythe a critical intensivist. System. During this time he received his and»health» MBA from DeSales of 40respiratory pediatric specialists, chaired patientcare safety University in Pennsylvania. created andtransfers. led the Grossman Center or on call mustinitiatives, be notifiedand of all patient organizations» for Medical Simulation. gent or stat consultations must be handled by direct personal communication between Dr, Davis is anthe avid tennis player and rock climber. He has key»to»providing» consulting physicians. climbed in Yosemite, Africa, Mexico, and the Andes. His wife, Dr. Sorensen also served as director of pediatric patients»with»high» Wendy, is a violinist who plays with the Reading Symphony. cardiac anesthesiology at practices. Seattle re consistent with federal regulationsand andcritical currentcare best His son, a graduate is employed by the Children’s while hepeer was review Associate Professorwhich, under es include the creation of Hospital a hospital wide committee theEthan, leadership of of Yale Law,quality»care Department of Justice in the federal programs division and of anesthesiology at the University of Washington. complications and untoward outcomes. This committee is made up of representatives from varied is one of the attorneys defending the constitutionality of the He complication is a diplomaterate, of both the American Boardevents of »» Family»Medicine» t. Joes has a low occasional untoward do occur from time to time. Affordable Care Act. ItDr.isDavis’s daughter, Leah, is currently Pediatrics and the American Board of Anesthesiology, for aprocess residency in EmergencyResidency»Program Medicine, and his sses which may lead to errors so that they can be corrected in the spirit ofapplying continuous and a member of the American College of youngest daughter, Jocelyn, coaches a Women’s Division 1 Physician Executives. n tennis team at California Polytechnic Institute. n

e part of the St. Joes family and to be associated with an excellent medical staff and hard working . As health care reform descends upon us, I believe St. Joes has positioned itself to be successful ess of health care. 24 | MEDICAL RECORD | SUMMER 2013 Medical Record_Summer2013.indd 24

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PENNSYLVANIA MEDICAL SOCIETY PRESS RELEASE PAMED APPOINTS MICHAEL FRASER AS EXECUTIVE VICE PRESIDENT

he Pennsylvania Medical Society (PAMED) today announced the appointment of Michael R. Fraser, PhD, CAE as executive vice president, effective August 19, 2013. Fraser succeeds Denise E. Zimmerman, who will retire from the position at the end of August, after working for the Society for more than 35 years.

Fraser comes to PAMED from the Association of Maternal & Child Health Programs (AMCHP), a Washington, D.C.based nonprofit, where he served as chief executive officer since 2007. From 1999 to 2007, he worked for the National Association of County and City Health Officials, ending his career there as deputy executive director and senior advisor. Prior to that, he worked for the US Department of Health and Human Services and for Aspen Systems, Inc. (Rockville, MD). Fraser brings a strong understanding of health care and public health systems, as well as association leadership, to the position.

“Mike brings a strong understanding of the changing dynamics associated with providing medical care and the new paradigm physicians are facing as health care delivery focuses more on quality outcomes and value for the patient. As PAMED’s executive vice president, he will be well-positioned to hit the ground running as these changes occur.” Fraser holds a doctorate in sociology from the University of Massachusetts at Amherst, a master of sociology degree (also from Amherst), and a bachelor of arts in sociology (highest honors) from Oberlin College in Ohio. He also holds a certified association executive designation with the American Society of Association Executives. Fraser currently resides in Cheverly, Maryland but is planning to relocate to the Harrisburg area.

“Coming to Pennsylvania to work with one of its largest and most reputable organizations, the Pennsylvania Medical Society, is truly an honor for me,” Fraser said. “The opportunity to make a difference for Pennsylvania physicians and their patients is one that I take seriously and look forward to with energy and enthusiasm.” n

Mike brings a strong understanding of the changing dynamics associated with providing medical care and the new paradigm physicians are facing as health care delivery focuses more on quality outcomes and value for the patient. “Mike’s passion for and experience in leading organizations through a transformational process is welcomed by the Medical Society, particularly as the practice of medicine and health care overall is undergoing significant change,” said John Pagan, MD, PAMED board chair and general surgeon from Sellersville, Bucks County. As our health care system evolves, more Pennsylvania physicians are affiliating or becoming employed by large groups or health systems, challenging the traditional medical society role as advocate for physicians and their patients.

The patient-doctor relationship has been the priority of the Pennsylvania Medical Society since its founding in 1848. Today, the physician members continue to focus on better health for all Pennsylvanians. To learn more about the Pennsylvania Medical Society, visit the website at www.pamedsoc.org.

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ALLIANCE UPDATE KATHY ROGERS, ALLIANCE PRESIDENT

IT TAKES ALL TYPES “A species in which everyone was General Patton would not succeed, any more than would a race in which everyone was Vincent van Gogh. I prefer to think that the planet needs athletes, philosophers, sex symbols, painters, scientists; it needs the warmhearted, the hardhearted, the coldhearted, and the weakhearted. It needs those who can devote their lives to studying how many droplets of water are secreted by the salivary glands of dogs under which circumstances, and it needs those who can capture the passing impression of cherry blossoms in a fourteen-syllable poem or devote twenty-five pages to the dissection of a small boy’s feelings as he lies in bed in the dark waiting for his mother to kiss him goodnight.” — A llen Shawn: American composer, pianist, educator, and author

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This quotation by Allen Shawn is the opening paragraph of the New York Times best seller, Quiet: The Power of Introverts in a World that Can’t Stop Talking. It is a good reminder that we need both introverts and extroverts to be successful. At a recent meeting, while soliciting volunteers for next year’s board, a member stood up and decided to thank everyone who has never held a board position and may never have interest in doing so. The people who quietly come to everything, are always there to support events and projects and while not offering a lot of opinions, the ones they do venture to share are well thought out. We were so focused on filling the executive positions that we had forgotten that it takes all types for our organization to be successful. That the faithful members are equally as important as the people volunteering their time to lead the organization. You could not have one without the other and hope to be successful. Clearly we are not all good or comfortable at the same things, yet together with each person sharing their strengths, all the gaps were filled. Below are some statistics that show what we accomplished together over the past year.

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Year in review: n n n

n n

6 - the number of new members added this year

13,665 - number of dollars raised by the holiday card 7 ,000 - number of dollars to be distributed as medical scholarships ,600 - number of dollars to be distributed to 5 community organizations

18 - number of trees planted in Doctor’s Grove

4 - number of participants for the morning program 4 of the health project on Autism

Over 60 - number of participants who came out for the evening portion of the health project

101 - number of likes on our Facebook page

,016 - number of people who viewed our posted 1 photos from the Doctor’s Grove ceremony on our Facebook page

Annual Health Project

Philanthropy & Scholarships Thank you for your generous giving last December. With the $13,665 raised, the Alliance was able award seven $1,000 scholarships to students pursuing health related careers that attend schools in Berks County. Additionally, approximately $6,500 was distributed to community organizations that support and improve our area. This year’s recipients include The Children’s Dyslexia Center, Western Berks Free Medical Clinic, Reach Out and Read, Aaron’s Acres, Berks Youth in Action, IMAble Foundation, Girls on the Run, Breast Cancer Support Services, and Berks Women in Crisis.

Doctor’s Grove Ceremony

The Doctor’s Grove Ceremony was held April 26, 2013 at the Berks County Heritage Center. Around 60 people came out in support of the project and to honor and remember those who were having a tree planted in their honor.

This year’s Health in Balance Lecture Series on Autism was well attended. Around 40 people were registered for the daytime program, where participants could receive continuing education credits, nursing CEUs and certificates of participation. According to registration forms the audience consisted of a mix of administrators, hospital and school nurses, educators, paraprofessionals, advocates, preschool coordinators, children’s ministry leaders, medical students, pediatric home care professionals, parents and grandparents of children with Autism. The evening program did not require registration, but there were over 60 people in attendance. The program consisted of three speakers, a question and answer panel session and resource tables with representatives from various related support services available in the community. Attendees repeatedly commented that it was very helpful that the speakers had personal experiences with autism as well as degrees and experience. Evaluation surveys indicated the program met or exceeded participant’s expectations. Topics requested for next year’s program include mental health issues in children and adolescents, down syndrome, ADD, ADHD, learning disabilities, getting children physically active, breast cancer, and Internet safety.

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A total of 18 trees were planted this year. In addition to the 16 names previously listed in the Medical Record, The Reading Health System also purchased 2 trees in honor of Reading Hospital Medical Staff. Thank you to the Medical Society for supporting the project and providing the catering for the event! We could not do any of our projects without the help and support your members provide us with each year. Forms for purchasing a tree are available on our website www.berskcmsa.org and will also be mailed out with our holiday card letter each year. We have not decided if we will hold a ceremony each year yet. More details will follow once the board has decided how to best negotiate this going forward.

Welcome to the Executive Board for 2013-2014

Left to Right: Lisa Geyer, Judith Kraines, Jacquie Fernandez, Kathy Rogers, Lindsay Romeo, Emily Bundy, Gretchen Platt

This yearâ&#x20AC;&#x2122;s installation luncheon was held May 8, 2013 at Reading Art Works. State officer Kathleen Hall, past president of the PA Medical Society Alliance and current Director of Central and South Central Districts, installed the new officers. We are excited to have a great group of ladies taking over next year. President: Kathy Rogers

President Elect: Lindsay Romeo VP Health Project: (open)

VP Membership: Gretchen Platt Treasurer: Lisa Geyer

Assistant Treasurer: Kara DeJohn

Recording Secretary: Meghan White

Corresponding Secretary: Jacqui Fernandez Directors: Emily Bundy and Dee Dee Burke

It has been a pleasure writing the Alliance Updates for the past two years. Starting this fall, this privilege will be turned over to the very capable hands of our new president, Kathy Rogers. n

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Left to Right: Outgoing president-Emily Bundy, State OfficerKathleen Hall, Incoming president-Kathy Rogers

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TMJ SLEEP DISORDERS TAMMY L. BALATGEK, D.D.S., M.S.

DIFFERENTIAL DIAGNOSIS: WHEN SHOULD TEMPOROMANDIBULR JOINT DISORDER AND/OR OBSTRUCTIVE SLEEP APNEA BE CONSIDERED? Current clinical practices recognize and treat Temporomandibular joint dysfunction (TMD) and obstructive sleep apnea (OSA) as two separate and unrelated syndromes, however, there is evidence in the literature that the two conditions overlap. Patients with TMD most commonly present with pain in the jaw or face, limited or asymmetric movement of the lower jaw, and clicking, popping or grating sounds in the temporomandibular (jaw) joint (TMJ). Other common complaints from patients include earache, headache, jaw clenching, and tooth grinding.1 Additional symptoms may include: ear ringing (tinnitus), dizziness, and neck and back pain. 2 Conditions such as fibromyalgia, chronic fatigue syndrome, headache, panic disorder, gastroesophogeal reflux disorder (GERD), irritable bowel syndrome, multiple chemical sensitivity, interstitial cystitis, and post-traumatic stress disorder have been found to coexist with TMD and these patients share many clinical illness symptoms such as myalgia, fatigue, sleep disturbances, and quality of life issues. 3

Brousseau et al. 4 documented that patients with chronic pain (i.e. TMD) have more fragmented sleep, which increase heart rate and muscle tone. When these events occur too frequently, they may result in poor sleep. Certain sleep disorders that have been reported to exist most commonly with orofacial pain include OSA; insomnia, upper airway resistance syndrome, and sleep bruxism.5 OSA is one of the most common sleep disorders, along with insomnia.6 OSA is characterized by repeated episodes 30 | MEDICAL RECORD Medical Record_Summer2013.indd 30

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of upper airway obstruction and defined as a cessation of airflow at the nostrils and mouth lasting at least 10 seconds or more, called “apnea.” Clinically, OSA is defined by the occurrence of daytime tiredness, diminished neurocognitive functioning (feeling in a “fog”), snoring, witnessed breathing interruptions, and/or awakenings due to gasping or choking in the presence of at least five obstructive respiratory events per hour of sleep.7

Predisposing risk factors for OSA have been identified as: narrowing of the upper airway; nasopharyngeal abnormalities; obesity; hypothyroidism; acromegaly; male gender; family history of sleep apnea;8 high body mass index (BMI); history of hypertension; and night-time choking. 9

Conversely, the majority of TMD subjects are females who frequently report insomnia, restless legs, depression, nightmares, and heart palpitations at night.10 Therefore, they are not usually recognized as potential sleep apnea candidates or referred to the sleep lab.

There is evidence to suggest that OSA and TMD may be overlapping syndromes. Smith et al. 11 found 28 percent of TMD subjects tested positive for OSA via overnight in-lab sleep study. The subjects reported symptoms of increased daytime sleepiness, fatigue, insomnia, and pain-related interference in daily function. A study published by Cunali et al.12 reported that 52 percent of the 87 subjects with mild to moderate OSA presented with some type of sign and/or symptom of TMD. There are many symptoms that are documented in the literature to co-exist with TMD and/or OSA. Medical and dental colleagues may come across overlapping symptoms that may not respond to conventional therapy due to being a potential symptom of underlying OSA and/or TMD. The following is a list of conditions per specialty that have been documented to be related to OSA and/or TMD: Allergy Specialist –asthma, GERD, nasal disease, use of corticosteroids, chronic cough, allergic rhinitis with sleep disturbance

Cardiology - hypertension, atrial fibrillation, arrhythmias, GERD, heart palpitations at night

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Dentistry – strong gag reflex (guarding of airway), tongue scalloping (imprints of teeth on the tongue is 70 percent specific for abnormal breathing during sleep), pain in the teeth that is referred from clenching muscles, crooked teeth, overbite or underbite, tooth grinding/clenching, TMJ symptoms Endocrinology –insulin resistance, diabetes, polycystic ovary syndrome (PCOS)

ENT (Otolaryngology) –ear pain, pressure, itching, feeling of clogged ears, nasal obstruction, allergic rhinitis or nonallergic rhinitis with sleep disturbance, nasal steroids, tinnitus, reduced hearing ability, deafness, dizziness, recurrent sinus infection, feeling of a foreign body in the throat, persistent throat clearing, sinus headache Gastroenterology – GERD, irritable bowel syndrome

Neurology – migraine, headache, tension type headache, myofascial pain syndrome (MFPS), morning headache, trigeminal neuralgia, numbness or tingling of hands and/or arms, restless legs Obstetrics and Gynecology – insomnia, menopause, pregnancy, PCOS, sexual dysfunction, interstitial cystitis, fibromyalgia, restless legs, depression, nightmares

Ophthalmology – eye pain and fatigue, pain behind and around the eye, blurred vision Orthopedics – neck, shoulder and/or back pain, altered posture, head rotation (compensation mechanisms)

Pain Clinics –insomnia, chronic neck, shoulder, back pain, MFPS, fibromyalgia, chronic fatigue syndrome, headache

Pediatrics – bedwetting, choking or drooling, excessive sweating at night, Attention Deficit / Hyperactivity Disorder (ADD, ADHD), learning and behavioral disorders, poor school performance, snoring, tooth grinding, restlessness in bed, unusual sleeping positions (i.e. sleeping on the hands and knees or with the neck hyperextended), frequent ear infections, headaches Primary Care- any of the conditions mentioned

Podiatry – leg length discrepancy, ankle, foot pain, diabetes

Psychiatry –depression, cognitive impairment, chronic pain, panic disorder, post-traumatic stress disorder, restless legs, nightmares Pulmonology –insomnia, sleep disturbance, coexisting COPD Rheumatology –rheumatoid arthritis (RA), osteoarthritis, joint pain, jaw joint noises and limited or asymmetric mouth opening Urology – chronic kidney disease, sexual dysfunction, erectile dysfunction (ED)

This list is a compilation of possible associated symptoms. It is highly recommended that if a patient is not responding to conventional treatments, then evaluation by a physician or dentist qualified to recognize potential sleep breathing and/or TMJ disorders is prudent. Locally, Dr. Winifred Kao (Berks ENT), Dr. Thomas Kohl and Dr. John Travers (Primary Care Physicians), Dr. Alec Platt (Respiratory Specialists), and Dr. Gary Ginsberg (Urology) are a few the many professional health care providers who are well versed in the overlapping signs and symptoms of TMD and OSA. n

REFERENCES

1. d e Leeuw R. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. Vol Fourth. Hanover Park, IL: Quintessence Publishing Co., Inc.; 2008. 2. S crivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. New England Journal of Medicine. 2008;359(25):2693-2705. 3. Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med. Jan 24 2000;160(2):221-227. 4. B rousseau M, Manzini C, Thie N, Lavigne G. Understanding and managing the interaction between sleep and pain: an update for the dentist. Journal (Canadian Dental Association). 2003;69(7):437-442. 5. B ailey DR. Sleep disorders. Overview and relationship to orofacial pain. Dental clinics of North America. 1997;41(2):189-209. 6. K ryger MH, Roth T, Dement WC. Principles and practice of sleep medicine. Vol 3rd. Philadelphia: Saunders; 2000. 7. S leep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep. 1999;22(5):667-689. 8. A merican Academy of Sleep M. International classification of sleep disorders; Diagnostic and Coding Manual. Vol 2nd edition. Westchester, IL.: American Academy of Sleep Medicine; 2005. 9. R amachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology. 2009;110(4):928-939. 10. V alipour A, Lothaller H, Rauscher H, Zwick H, Burghuber OC, Lavie P. Gender-related differences in symptoms of patients with suspected breathing disorders in sleep: a clinical population study using the sleep disorders questionnaire. Sleep. 2007;30(3):312-319. 11. S mith MT, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep. 2009;32(6):779-790. 12. C unali PA, Almeida FR, Santos CD, et al. Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy. Journal of orofacial pain. 2009;23(4):339-344.

Tammy L. Balatgek, D.D.S., M.S. Center for TMJ & Sleep Disorders, LLC 2433 Morgantown Road, Suite 200 Reading, PA 19607 PHONE: 610-796-2835 E-MAIL: tbalatgek@mac.com Dr. Balatgek obtained her Doctor of Dental Surgery Degree from the Ohio State University and a Master’s Degree in Craniofacial Pain from Tufts University. She maintains a private practice in Reading, PA that is limited to treatment of TMJ Disorders and Sleep Disordered Breathing.

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LEGISLATIVE BREAKFAST RECAP

LEGISLATIVE BREAKFAST WRAP-UP

Presentations were then made by Senator Judith Schwank and Representatives Caltagirone, Gillen, Cox, Mackenzie, and Day. A question and answer period followed the presentations. n

The 22nd Annual Legislative Breakfast was held on Friday, May 17, 2013 at VIVA. Dr. Pam Taffera, BCMS President welcomed all in attendance and introduced Mr. Larry L. light, VP of Political Affairs of the Pennsylvania Medical Society.

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RESIDENT’S DAY RECAP

The Berks County Medical Society held its annual Resident’s Day and the Fourth Annual Memorial Lecture on April 12, 2013.

Seventeen posters were submitted by residents with the following receiving awards and the honor of being selected to present to the group: A Case of Necrotizing Fasciitis without Known Entry Portal Jessica M. Bricker, DO and Damaris S. Wessel, DO St. Joseph Medical Center Acute Abdominal Pain in a Young Female a Month after Diagnostic Laparoscopy Archana Satyal Chaudhary, MD Reading Hospital

Association of Coronary Artery Vitamin D Receptor Expression and Systemic Risk Factors for Coronary Artery Atherosclerosis Ran Xie, MD Reading Hospital Contraceptive Use in Teens in sub-Saharian Africa; Evidence from Demographic & Health Surveys Rebekah J. McCurdy, MD Reading Hospital

Following the presentations, a buffet lunch was enjoyed. Deceased members were honored and Dr. Samie A. Alley, MD received his 50 Year Membership Award. Dr. Rachel Masch then presented a talk entitled “Screening and Prevention in Low-Resource Settings: a Focus on Cervical Cancer.” n

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SUMMER

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The Berks County Medical Society and the Pennsylvania Medical Society invite you to attend our

New Physicians and YPS Event at the

Pagoda Thursday, August 1 6:00 -9:00 p.m. Drinks and hors dâ&#x20AC;&#x2122;oeuvres A casual evening to meet and mingle. Call 610-375-6555 to RSVP or email info@berkscms.org

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Please join the Berks County Medical Society & Berks County Medical Society Alliance at the

Sunday, August 25th - 1:35 p.m. Bunbinoâ&#x20AC;&#x2122;s Tailgate at the Coors Light Deck All you Can Eat Buffet - Price- $10 per adult /$5 per child over 4 years of age Reservations required by July 15th. Call 610-375-6555 to reserve space or email info@berkscms.org This event sponsored by PMSLIC

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