Michigan Medicine®, Volume 121, No. 4

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July / August 2022



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p resident 's Dear friends and colleagues, When people think about health disparities, the lines they often draw in their minds exist along racial lines. After all, the COVID-19 pandemic firmly underscored the racial inequities that exist for people of color, and it’s important for us to attend to those. Unfortunately, these racial disparities represent only a fraction of the equity gaps that exist in Michigan and elsewhere. From gender identity and sexuality to weight, age, and ability—and even language barriers, addiction, and the tendency to frequent emergency rooms—all of these factors present important decision points for physicians to consider when providing care. The work of MSMS’ Task Force on Advancing Health Equity has been underway for some months, and a wealth of important research and engagement has already occurred. What’s been uncovered is a need to expand our conversations beyond race and include many more aspects of equity than most of us have historically considered. With this new lens, the work of the task force now continues to unfold. We are exploring strategies related to education, policy development, advocacy, infrastructure, and funding. While our recommendations are still taking shape, we know the scope of our work is correct, and that the solutions will be both realistic and attainable. Of course, the task force isn’t operating in a vacuum. It is our sincere hope that Michigan physicians are working to assess their own thinking and listen with open hearts and minds to the patients in their care. After all, the greatest changes are those that happen within us. So let’s keep talking, broadening our understanding, and learning more about how we can make a truly lasting, positive impact on the communities we’ve promised to serve.


“The work of MSMS’ Task Force on Advancing Health Equity has been underway for some months, and a wealth of important research and engagement has already occurred.”


Thomas J. Veverka, MD, FACS MSMS President

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FEATURES & CONTENTS July / August 2022



12 Increasing Equity in Michigan Health Care For millions of people in our society, the mind-body relationship is complicated by the social constructs into which they were born. For these individuals, a visit to the doctor feels like a trip to the principal’s office. As physicians, it is our job to render care that is free of judgment. To ensure safe spaces for our patients to heal. (Story begins on page 12.)

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Is it Legal to Offer Discounts and Waive Patient Copayment and Deductible Obligations

MICHIGAN MEDICINE® VOL. 121 / NO. 4 Chief Executive Officer JULIE L. NOVAK


Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org


As Corporate Entities Enter Health Care, Practices Can Respond via Patient-Centered Care RICHARD E. ANDERSON, MD, FACP


Developing Leadership Skills JODI SCHAFER, SPHR, SHRM-SCP

Back to School Immunizations and Vaccine Equity: The Key Role of the Primary Care Physician JENNIFER CROOKER, BSPH, CHES

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Postmaster: Address Changes Michigan Medicine® Kevin McFatridge PO BOX 950 East Lansing, MI 48826

Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine® and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine® reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine® are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine® (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2022 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2022 Michigan State Medical Society

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Is it Legal to Offer Discounts and Waive Patient Copayments Deductible Obligations? By Daniel J. Schulte, J.D., MSMS Legal Counsel


I am planning to build my private practice by

offering patients discounts and/or to waive their copayment or deductible obligations. Is this


nlike other businesses physicians and others providing health care services are subject to constraints on their ability to determine the amount of the fees for their services and when waivers of copayments and deductibles is permissible.

legal? Must it be done on an “across the board” basis or can I instead be selective in deciding which patients to offer the waivers?

First, the terms and conditions of your contracts with third party payers must be considered. These contracts typically restrict your ability to discount your fee and waive copayment and deductible obligations. You must carefully review all these agreements prior to doing so.

Second, Michigan’s Health Care False Claim Act (the “False Claim Act”) makes it illegal to submit a claim for payment to a third party payer that contains a statement of fact or that fails to reveal a material fact that is misleading. Discounting a fee for a patient

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covered under a policy issued by a health care corporation or health care insurer or waiving such patient’s copay or deductible obligation without disclosing this fact could constitute the submission of a claim which fails to reveal a material fact. In the absence of the disclosure it will appear to the health care corporation or health care insurer that your fee for the service provided was more than what was actually charged. Therefore, the claim may be deemed “deceptive” and “false”

under the False Claim Act. The False Claim Act also prohibits the “rebate” all or any portion of your fee if the rebate is given to a patient in consideration of that patient providing you a referral(s) of other patients.

Third, the Federal Department of Health and Human Services (“HHS”) has taken the position that the routine (i.e. “across the board”) waiver

of Medicare copayments and deductibles by health care providers could be a violation of the Federal False Claims Act and the Federal Anti-Kickback statute. HHS’ theory is that if the waiver of the patient’s copayment and/ or deductible was based upon any reason other than the patient’s financial hardship (e.g. referrals of patients by the patient whose deductible or copayment had been waived) violations of these Federal statutes would likely be deemed to have occurred. In guidance issued by HHS, it has been made clear that only the “routine” Medicare and/ or Medicaid copayments and deductibles would subject the health care provider to HHS scrutiny for violation of these Federal statutes. To the contrary, waivers of Medicare and/or Medicaid copayments and deductibles made on a case-by-case basis due to a finding of patient’s financial hardship would not subject the health care provider to such scrutiny. To protect yourself the best practice is to have a written policy in effect in your practice setting forth the criteria that is used to determine when copayment and deductible obligations will be waived and to limit those waivers to only those cases where a financial hardship combined with a documented need for care is present.

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Developing Leadership Skills By Jodi Schafer, SPHR, SHRM-SCP HRM Services | www.WorkWithHRM.com


We are having such a hard time hiring staff for our practice. Not only are we struggling to find employees who are the right “fit” for our culture, but we are really struggling to find an office/practice manager. It seems like we have tried everything as far as recruiting goes. Do you have any other ideas to help us?


ou are not alone in this struggle. Employers everywhere are having a hard time finding employees to fill positions, at all levels. Since the pandemic began,

more people have retired or left the workforce for a variety of reasons. With birth rates declining, the challenge of having enough employees to fill positions is not going away anytime soon. Practices must be more creative in recruitment, including developing partnerships with high schools, community colleges, and training programs. They also need to pay attention to their work culture to ensure that they don’t lose the people they have. Opportunities for continuous learning are key for retaining employees, so let’s take a deeper look at how you can create those opportunities within your practice.

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Think about the key skills you need each role to have to be successful in your practice. Ideally, you have these key skills included in the job descriptions for each position. Things like communication, organization, conflict resolution, and working on teams are all skill areas that practices need. You may have others. What do these look like when they are happening effectively? What resources do you have in place to help build and enhance these skills? If you don’t have clear expectations of employees, this would be a great place to start. What are your processes for communication, organizing the work, and conflict resolution? Do you have policies and procedures in your employee handbook and/or additional training protocols for each position? Who is responsible for administering this training and how is comprehension and proficiency measured? Creating an internal training process for these critical areas of interpersonal and teambuilding skills goes a long way

toward building shared awareness and understanding for what is expected. Without these structures, employees guess at what they should do, actions are inconsistent, and sometimes their habits do not fit well with your team and practice, creating conflict.

“In addition to clarifying your internal systems, policies, and procedures, you should also begin building your training and professional development offerings.” In addition to clarifying your internal systems, policies, and procedures, you should also begin building your training and professional development offerings. Now more than ever, practices need to look within to see if there

are employees who can “grow into” new positions, as well as potentially be promoted into leadership roles. You may have someone in the practice who has some natural leadership abilities but needs additional support to take on an office or practice manager role. There are many trainings out there on supervision, communication, conflict resolution, etc. HRM is launching our own online training platform at www. HRhazmat.com to support our clients with these needs. We also provide onsite training, tailored to the needs of each client. This is just one of many external resources/vendors available to assist you with leadership development. Regardless of the training you use, make sure that the learning objectives align with your goals and that it is delivered in a way that is engaging for your staff.

creates real change; helping employees refine their skills as they build new habits. This requires synchronization and ongoing effort on your part to ensure that your investments in training and development bear fruit. Whether you are focused on growing leaders or building a talent pipeline, you will need to be heavily involved in the process. This is going to be the way of the future when it comes to talent acquisition. While we may long for the days of “post and pick”, the truth is that this new path forward (while more time and cost-intensive) is also more flexible, more predictable and more likely pay off in the long run.

Training is one step in building new skills, but it is not sufficient by itself. Training plus ongoing coaching and mentoring at the practice level is what

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Back to School Immunizations and Vaccine Equity: The Key Role of the Primary Care Physician By Jennifer Crooker, BSPH, CHES, Communications Analyst, Michigan Department of Health and Human Services, Division of Immunization and Tyler Logan, MA, Health Equity Project Manager & Vaccine Equity Official, CDC Foundation


ummer is for fun, sun, and routine childhood immunizations! Looking ahead to the 2022-2023 academic year, we know that keeping children up to date on their routine immunizations is an important part of a successful school year. However, rates of routine childhood immunizations have declined during

the COVID-19 pandemic and disparities in vaccination rates have been exacerbated. Summertime presents a great opportunity to engage in outreach and dialogue to help bring protection levels back up.

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During the pandemic, many families became distanced from their communities, including their pediatric offices. Primary care providers are encouraged to make extra efforts to reconnect with patients through reminder/recall outreach, conversations with caregivers about the importance of immunization, creating a “culture of vaccination” in their practices, and expanding clinic hours to accommodate caregivers’ schedules. According to the May 2022 COVID19 impact report from the Michigan Department of Health and Human Services (MDHHS), the COVID-19 pandemic has negatively impacted childhood immunization rates globally, including in Michigan, and exacerbated the vaccination rate disparity between Medicaid and non-Medicaid recipients (1). Data from the Michigan Care Improvement Registry (MCIR) show that childhood immunization coverage for Michigan children under age 2 years has decreased since December 2021 for most milestones. (2) Disparities in routine immunization coverage by Medicaid status continue to increase, with the greatest disparity among 3-month-olds; the rate is 16 percentage points lower for non-Medicaid-enrolled children compared to Medicaid-enrolled children. (2) Disparities that existed prior to the pandemic need extra attention. A 2016 study utilizing the National Immunization Survey (NIS) also found that income below the poverty line, Medicaid recipient status, and uninsured status were associated with lower immunization rates. Black children tended to have lower immunization coverage than white children on most routine childhood immunizations. (3)

. . . the COVID-19 pandemic has negatively impacted childhood immunization rates globally, including in Michigan, and exacerbated the vaccination rate disparity between Medicaid and non-Medicaid recipients). Primary care physicians are key to helping families get caught up on routine immunizations. Research has shown that physicians are one of the most trusted sources of vaccination information and it has been well-established in multiple studies that vaccine uptake increases when patients are able to connect with their trusted primary care provider. A study published in October 2021 by the American Academy of Pediatrics found that 72% of caregivers said that they “completely” or “mostly” trust their child’s pediatrician. (4) Recent studies have also shown that members of underserved communities prefer to receive vaccinations from their primary care physician. One 2021 study found that when considering COVID-19 vaccination, “44 percent of Latino and 53 percent of Black respondents would prefer to get vaccinated in their doctor’s office than elsewhere, and more than half of Latino and Black respondents considered their personal doctor as the most trusted source of information on the [COVID-19] vaccine.” (5) Another 2021 study found that over two thirds of black patients “unsure” about COVID19 vaccination said they would prefer to take the vaccine at their primary care provider’s office. (6) A third 2021 study

found that 30% of adults, and half of those who want to “wait and see” about COVID-19 vaccination would be likely to take it if offered at a routine medical appointment (37% of black and 36% of Hispanic participants vs. 25% of white participants). (7) MDHHS has been working with community-based organizations (CBOs) and local health departments all over the state, and have repeatedly heard the importance of healthy patient-provider relationships for supporting successful outcomes for families. Physicians can take advantage of this high level of trust and help parents access the tools that help keep their families and communities safe including childhood immunizations, COVID-19 vaccines, and influenza vaccines. REFERENCES (1) Malosh, et., al. (2022) COVID-19 Impact Report. Michigan Department of Health and Human Services (MDHHS) Division of Immunization. https://content.govdelivery.com/attachments/MIDHHS/2022/05/20/file_attachments/2164858/ MCIR%20COVID%20Impact%20Report_20220520.pdf (2) Michigan COVID-19 Vaccine Dashboard. https://www. michigan.gov/coronavirus/resources/covid-19-vaccine/ covid-19-dashboard. Accessed May 28, 2022 (3) Hill HA, Elam-Evans LD, Yankey D, Singleton JA, Kang Y. Vaccination Coverage Among Children Aged 19–35 Months — United States, 2016. MMWR Morb Mortal Wkly Rep 2017;66:1171–1177. DOI: http://dx.doi.org/10.15585/mmwr. mm6643a3 (4) Wyckoff Sulaski, A. (August 3, 2021) Survey: Less than half of parents likely to have children receive COVID vaccine. AAP News. https://publications.aap.org/aapnews/news/16357 (5) Klein, S. & Hostetter, M. (July 7, 2021) The Room Where It Happens: The Role of Primary Care in the Next Phase of the COVID-19 Vaccination Campaign. https://www.commonwealthfund.org/publications/2021/jul/room-where-it-happens (6) Fisher, K. A., Nguyen, N., Crawford, S., Fouayzi, H., Singh, S., & Mazor, K. M. (2021). Preferences for COVID-19 vaccination information and location: Associations with vaccine hesitancy, race and ethnicity. Vaccine, 39(45), 6591–6594. https://doi. org/10.1016/j.vaccine.2021.09.058 (7) Hamel, L., et. Al. (March 4, 2022) KFF COVID-19 Vaccine Monitor: March 2021. https://www.kff.org/coronavirus-covid-19/ poll-finding/kff-covid-19-vaccine-monitor-march-2021/

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For most people, the mind-body relationship is a complicated one. Age, weight, illness, injury—few of us make it through life without trying to process our own identities through the lenses of what our bodies look like, or how they perform.


ut for millions in our society, the mind-body relationship is complicated by the social constructs into which they were born. Perhaps they are stymied by a culture that struggles to see past skin color. Maybe they feel trapped inside a physical gender that feels different than who they truly are. Or their obesity makes them feel judged and ashamed. For these individuals, a visit to the doctor feels like a trip to the principal’s office. They worry they’ll be judged and found wanting, so they opt not to visit at all—compounding any existing health challenges they might be experiencing. As physicians, it is our job to render care that is free of judgment. To ensure safe spaces for our patients to heal.

The Data Tells the Story There are countless anecdotal examples of instances in which physicians’ offices have felt unsafe in the minds of patients. There are tales of physicians informing transgendered teens and adults they are mentally ill—full stop—rather than taking time to address both their physical and emotional needs effectively. Other stories tell of obese patients whose physicians tell them all the need to do is lose weight without probing deeper into other serious medical issues. Even more alarming, people of color still experience a lesser quality of care than their white counterparts. Of course, no physician is committing errors purposefully. Michigan physicians are known for their integrity, their skill, and—most important of all—their desire to do good for others. So how do we reconcile these stories with what we know? We begin with the data. Here’s what we know: Time and again, research shows people of color experience lower life expectancies and vaccination rates, higher blood pressure, and sharply reduced access to pain management tools than white people do. In fact, a 2016 study of U.S. medical students showed that 73 percent held at least one false belief about biological differences between races, some of which are dangerous (e.g., black people have less sensitive nerve endings or stronger immune systems). A June 2022 survey conducted by the National LGBTQ Task Force showed that 28 percent of transgender people in the U.S. have been subjected to harassment in medical settings. Nearly one in five reported being refused care outright because they were transgender or gender non-conforming. Weight bias has become far more prevalent in U.S. health care, increasing by

66 percent during the past decade or so. Around 53 percent of women with obesity report hearing inappropriate comments about their weight from health care professionals, and roughly 40 percent of health care professionals admit to having negative reactions to patients with obesity. Given these data, what are we to think about physicians’ attitudes toward people whose bodies and minds are not slim, young, white and cisgendered? It seems clear, given the weight of the evidence, that many physicians may be demonstrating unconscious biases. While many acknowledge these biases and are working to correct their own thinking, others may require more support as their personal evolution occurs alongside that of our society.

The MSMS Task Force on Advancing Health Equity Last year, the Michigan State Medical Society convened a new task force whose focus would be on the need for greater equity in the state’s health care community. Funded, in part, by a grant from the W.K. Kellogg Foundation, the task force is working to devise solutions that address health disparities in the short, medium and long term. This work was responsive to the greater issues facing our patients, but it also was prompted by the many surprising health disparities revealed during the COVID-19 pandemic. During that period, Michigan was brutally awaked from its slumber with respect to health equity. African Americans represent nearly 14 percent of the state's population, yet they represented around 40 percent of the deaths from coronavirus. CONTINUED ON PAGE 14

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Since the formation of the MSMS Task Force on Advancing Health Equity, its members have been working to understand the issues and strategies at play more fully. To put their arms entirely around such a broad, insidious issue as implicit bias is deeply challenging, but the task force has been effective in beginning their research and gathering the data they’ll need to make future decisions. “The pandemic, really, was such a disruptor,” says Kate Redinger, MD, FACEP, who is a member of the MSMS Task Force on Advancing Health Equity, an assistant professor in the department of emergency medicine at Western Michigan University, and an emergency medicine provider in Kalamazoo. “It really challenged the way we had traditionally thought about different care delivery, barriers, and outcomes. And for me personally, COVID-19 caused a major shift in my own professional development and pushed me to a better understanding of how these disparities are impacting people in my own community.” Doctor Redinger says the task force hopes to support all physicians in Michigan through education, community outreach, and best practice recommendations. Under the leadership

“We are all cognizant of the investment of time over the long term to make intentional forward progress toward our goal of achieving health equity in Michigan.” KATE REDINGER, MD, FACEP

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of Theodore Jones, MD, FACOG, the task force has met several times to hear from experts and engage in preliminary conversations about the challenges and solutions associated with eliminating health care disparities. They will actively continue their work in the year ahead.

to understand,’” Doctor Shajahan says. “Once we got a translator on the line, we found the patient had several advanced degrees. He is a very smart person who fell victim to some ethnocentric behavior. It was as simple as being in this country and not speaking English.”

“We are all cognizant of the investment of time over the long term to make intentional forward progress toward our goal of achieving health equity in Michigan,” Doctor Redinger says.

Weight-based implicit biases are of particular concern.

The Role of Implicit Bias While many implicit biases are changing over time, others are becoming more entrenched. A 2019 study drew on data from over four million tests of various attitude regarding race, sexual orientation and skin tone, finding that negative implicit biases in these categories have decreased meaningfully in just 10 years.

“Often, patients with back or chest pain are told they need to lose weight and not examined for other health conditions,” Doctor Shajahan says. “While some things may be attributable to weight, a slim patient complaining of back pain would get an x-ray, whereas an obese person might not.”

When it comes to other factors, however, the news is not so good.

Doctor Shajahan penned an op-ed last year detailing an experience with an black female who was a known drug user, a regular emergency room visitor, and had been labeled as a drug seeker. She came into the ER screaming in pain and begging for powerful medications, which were denied.

Negative biases toward the elderly or people with disabilities remains relatively fixed. Even worse, implicit weight bias (pro-thin/anti-fat) increased by 40 percent during the same 10-year period.

After several hours, a CT scan was performed and surgery was ordered. “When we opened her up, she was completely necrotic on the inside,” Doctor Shajahan says. “She ended up dying two days later.”

There are other biases physicians must consider, as well, such as language, drug usage, and frequency of emergency room. Asha Shajahan, MD, MHSA, GME director of health equity at Beaumont Health and associate professor at Oakland University William Beaumont School of Medicine, puts some of these less obvious implicit biases into fresh context.

Doctor Shajahan argues the missed diagnosis was caused, in large part, by the labels that had been applied to the patient. She works against these types of issues by coordinating two-week rotations for physician residents, so they can be exposed to different health inequities.

“I had a patient from another country, and when he was being roomed the assistant came out and said something to the effect of, ‘Well, this guy isn’t very smart and he’s sort of difficult

“All of the participants say the most important part of the rotation is actually hearing patients tell their stories,” Doctor Shajahan says. “When an alcoholic is talking about how they didn’t trust doctors because they felt judged for their addictions—well, it helps to

foster a better clinical understanding of how people are feeling and thinking, so we can support them more effectively as physicians.”

The Importance of Education As a fellow physician educator, Doctor Redinger also is well positioned to support the kinds of long-term changes our state needs. “At Western Michigan University’s medical school, I’m involved in the clinical education, clinical skills, and clerkships,” Doctor Redinger says. “In that role, I’m able to look at our curriculum and see where we can infuse health equity principles from the beginning.” In fact, WMU’s new dean, Paula Termuhlen, MD, FACS, has joined with the entire school and community to place health equity at the epicenter of the institution’s work. It’s an approach that resonates. “More med schools are recognizing the importance of early exposure,” says Susanna Wang, a medical student at Michigan State University’s College of Human Medicine. “During my courses, we go through various clinical case scenarios where inequity was a problem in someone’s healthcare, we openly discuss implicit bias, and we focus on recognizing different perspectives.” Wang says MSU initiates a strong awareness of health inequity right away, as they get to know prospective students during the application and interview process. “I think by doing that, they created a really diverse class,” Wang says. “It follows that when we have our conversations, we come to understand different backgrounds, beliefs, and religious systems. It is eye opening and helps foster an open mind.” Wang’s classmate at MSU, Mary Finedore, agrees.

“. . . it helps to foster a better clinical understanding of how people are feeling and thinking, so we can support them more effectively as physicians.” ASHA SHAJAHAN, MD, MHSA

“I’m in a class right now called Patient Vulnerabilities. So it’s literally the goal of the class to talk about healthcare disparities,” Finedore says. “But it’s difficult. There are 5,000 problems in the world, but we have nowhere to go.” Both Finedore and Wang agree the best prescription for change may simply be time. “I hope that my generation would be a lot more open,” Finedore says. “And then we have kids and then that generation would demonstrate less bias than we do. We’re on the right pathway, but it does take time, and a willingness to be fierce in our advocacy for change.” Wang says education also plays an important role. “I think a lot of it comes from a lot earlier than we have believed,” she says. “We learn a lot about health inequities in college or at the grad level, but I think even in elementary school, we can be telling students, ‘Hey, people have different backgrounds, different holidays, eat different foods.’ Building an expectation of differences, rather than an expectation of sameness, can go a long way.” Brian Stork, MD, who also sits on the task force, echoes this notion. “My father-in-law once asked my daughter, a high school student, about pronouns. ‘What's up with all these pronouns and why are people using them on the bottom of their e-mails and at the top of their social media profiles?’ My daughter went on to make several, thoughtful arguments about why

pronouns are important,” Doctor Stork says. “Finally, at the end of the conversation, my daughter finally said, ‘You know, Grandpa, this is a generational issue. These are the kind of issues parents focus on, but it really isn’t an issue for us kids.” As a physician, I found my daughter’s perspective to be really enlightening. “It got me thinking, you know what? I need to get on board and become better educated about this. Because even as a urologist, I still have a lot of questions.”

Addressing Social Determinants Doctor Stork goes on to describe the need for physicians to better attend to the many socio-economic issues that lead to health challenges. “As physicians, I think the fact that we really don’t have adequate time to take a trauma history from our patients, or ask them about their social determinants of health, is problematic. Exposure to childhood trauma is a known risk factor for a wide range of physical and mental health conditions. Even on those rare occasions when we do have time, it’s becoming increasingly difficult to help connect patients with appropriate counseling, mental health services, and other supports,” Doctor Stork says. In the face of such challenges, Doctor Stork says there is much more physicians can—and should—be doing. “I personally don’t feel like we as physicians intervene on that enough or have a system to be able to help with that through social services or mental CONTINUED ON PAGE 16

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health counseling or other supports,” Doctor Stork says. “I think the fact that we don’t always patients’ trauma history and address it, is a gap that causes layers of inequity over time.” Finedore agrees and urges action on an economic—as well as a personal—level. “We really do need to just invest in infrastructure,” she says. “We must truly invest in communities; that is the only way we’re going to tackle healthcare disparities. So if we’re going to be proponents for our patients, that means doctors inherently have to get involved on all ground levels of things, from social services to education and opportunity.” In fact, Finedore argues, physicians who truly hope to eradicate health inequities must become far more aggressive in their advocacy efforts to better support economic mobility, as well as housing, education, poverty, and other social determinants.

“There's a really big difference between saying you're for something and then going out and doing something about it,” she says. “And a lot of people just like to yell into the ether and then feel like they've done their due diligence and then walk away to their lives, which is fine, that's their prerogative. But the only way that we get things done is if you show up, so we're going to the Capitol and we're advocating, we're chasing down politicians down the hallway, be like, "Excuse me, sir. Do you have two minutes?"

our community, Michigan policymakers really need to not only be supportive of that mission and vision, but then also be able to supply funding so that those can come to fruition.”

Doctor Redinger suggests Michigan’s policy leaders can better support health equity by allocating funds to support the necessary infrastructure and education.

In the meantime, however, the most meaningful of actions will occur in physicians’ personal contemplation of what patient experiences are like in this time and this place. Perhaps through professional development, private conversations, and other tools for building understanding, we can begin to create the changes we most want to see.

“Ultimately, it comes down to funding,” she says. “When we make our recommendations, whether it be community outreach, educational programs, continuing medical education or other ideas for improving the resources in

Searching for Real Solutions Through the work of the MSMS task force, it is likely that meaningful, shared solutions to the health disparities that plague our society can be found. And through our society’s advocacy, we hope to provide meaningful action on these solutions.

The solutions are there for each of us if we choose to pursue them. Convergence — Detroit From Above by Brian Day

Trusted Advisors to Michigan Physicians

A successful practice requires physicians focused on treating Apatients. successful practiceto requires physicians focused on treating patients. As counsel the MSMS community for over 70 years, As to the MSMS community years, we know how to wecounsel know how to help physicians. Letfor usover help70 you protect, help physicians. Letyour us help you protect, manage, and grow your practice. manage, and grow practice.

kerr-russell.com Daniel J. Schulte, dschulte@kerr-russell.com | Patrick J. Haddad, phaddad@kerr-russell.com | Kathleen A. Westfall, kwestfall@kerr-russell.com

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Dean McFarlane Parrott, MD

Christa Persyn, MD

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

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As Corporate Entities Enter Health Care, Practices Can Respond via Patient-Centered Care Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

Retail medicine and private equity are important drivers of primary care delivery in the U.S., and they are poised to become even more so. Corporate entities have always been involved in healthcare, but now mega corporations—from outside the medical space—are entering the field. The involvement of these large non-legacy corporate entities in healthcare is growing and is challenging—and while this trend brings some benefits, it will also impact how all clinicians provide healthcare.


n a single quarter of 2021, private equity firms acquired $126 billion in medical practices. And these private equity firms, formerly mostly interested in specialty practices, have now set their sights on primary care. Similarly, the expansion of retail medicine into traditional areas of physician practice has been massive. For context, here’s a quick snapshot of the retail medicine landscape: Walgreens is the first national pharmacy chain to offer full-service provider offices co-located at its stores on a large scale. CVS now has around 1,000 HealthHUBs associated with its pharmacies. These will play an important role in managing patients' chronic diseases between primary care visits. Amazon is on a path to offer healthcare across a broad swath of the healthcare spectrum.

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Contributed by The Doctors Company


Microsoft is moving aggressively into healthcare with several partnerships with large healthcare systems. Its key initiatives are to help healthcare move into the Microsoft Azure cloud and to thoughtfully apply AI to medical data. Urgent Care Clinics now number more than 10,000 in the U.S. Let’s focus on several of these.

Amazon Brings Credibility to Claims of Service As Amazon continues their push into the healthcare space, they have several advantages. One is their remarkable reputation for customer service. As they move into healthcare, they will have significant credibility in claims they make about providing better service, better access, better prices, and better convenience. Traditional healthcare will struggle to match them. We clinicians are aware of the distinction between medicine’s definition of “patient-centered care” and retail’s perspective on “customer service.” Yet despite the profession’s emphasis on patient-centered care for several decades, we haven’t fully achieved it. That’s one reason that these new healthcare entities will exert broad downward economic pressure on primary care practices.

But Amazon’s expanding influence goes beyond drawing patients away from individual small practices. Nobody has more data than Amazon—between Whole Foods, Alexa, and Prime members—and this data can be used to shape healthcare delivery. Moreover, Amazon is in the process of developing nationwide pharmacy availability, a hospital at home partnership with leading healthcare providers, and an accelerator for healthcare startups. Clearly, Amazon plans to develop into a major player in healthcare delivery.

Walmart Brings Experience as an Insurer— Plus Affordable Prescriptions Walmart seems to be one company that is able to compete, at least along some metrics, head to head to head with Amazon. Though Walmart once had a terrible reputation for not providing healthcare insurance for their own employees, they now provide substantial coverage. And they already have

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Today, [Optum owns] the practices of 56,000 physicians in 1,600 clinics, representing $40 billion a year of revenue. By 2028, their expressed goal is to reach $100 billion in revenue. Optum is far from the only player in this space, but it is the BIGGEST.

more than a million people in their own insurance plan. It may not be long before Walmart starts providing a health insurance plan for non-employees.

their expressed goal is to reach $100 billion in revenue. Optum is far from the only player in this space, but it is the biggest.

In addition, Walmart has done some very commendable things in the realm of pharmaceutical pricing. Walmart provides most of the most common generic drugs for a flat $4 per prescription, which is a true blessing for many people. In addition, while the cost of some proprietary insulins runs to thousands of dollars a month, Walmart has its own private-label version of analogue insulin, which it makes available at very nominal cost. That’s not only an important service, but a visionary one.

This is a different model of healthcare delivery, with a real potential for conflicts of interest. As this trend accelerates, it is conceivable that health insurance will come to cover an increasingly limited range of clinical options.

We’ll see how the healthcare competition between Walmart and Amazon shapes up over time, but the outcome is likely to have a major impact on pricing and service in many areas of clinical practice.

Health Insurers Bring Their Ambition to Become Healthcare Providers—At Scale Health insurers are not just financing care. They’re providing care. Optum, working under its parent company, UnitedHealth Group, purchased its first medical practice 15 years ago. Today, they own the practices of 56,000 physicians in 1,600 clinics, representing $40 billion a year of revenue. By 2028,

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Private Equity Brings Ongoing Disruption The model of private equity—invest, disrupt, exit— wouldn’t seem to fit healthcare. Nonetheless, as the first wave of private equity investments matures, we’ll see what those exits look like. Who will buy these companies and practices? They will be sold, presumably, at much higher valuations than before. This means that revenue and operational efficiencies will become more important than ever, and the management agreements that may have been attractive in the initial partnership may or may not be continued into the new partnership. Regardless, when we see that private equity firms acquired $126 billion in medical practices in a single quarter of 2021, we must expect that pressure will increase on physician-owned practices to compete with the challenges presented by private equity investment.

Contributed by The Doctors Company


The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Can Medicine Compete Through Patient-Centered Care? If we want to continue to be the driving force in our healthcare system, when medical professionals say “patient-centered care,” we’re really going to have to mean it. We’re going to have to mean it in the customer-service-forward way practiced by corporations like Amazon or Nordstrom or FedEx. After a decade of talking about “patient-centered care,” although we know what it should mean, it isn’t what we typically offer. We need to stop requiring outpatients to see multiple doctors, labs, and imaging centers in different locations at different times, and then to hope that someone thoughtfully acts on the results. That isn’t how we access

services anywhere else in the economy. Retail medicine is making significant inroads into primary care by providing rapid access at convenient locations at lower cost. We should recognize that some of the disruption in healthcare today is actually healthy, because it is based on the pressing need for improved healthcare access, healthcare equity, and healthcare literacy. That said, as these new forces in healthcare compete to recruit new medical school graduates, they will also disrupt the day-to-day operations of many existing physician practices. Instead of reacting in surprise when these forces reach the door of our practice or our healthcare system—if they haven’t already—we would be wise to think now about how we should respond.

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LIVE, VIRTUAL, ON-DEMAND WEBINARS To register or to view full course details, please visit: https://connect.msms.org/ Education-Events/On-Demand-Webinars Once registered, you will receive an email within 15 minutes with links to watch the on-demand webinar and to complete the survey evaluation.

Webinars that Meet Board of Medicine Requirements: 25th Annual Conference on Bioethics A Day of Board of Medicine Renewal Requirements Human Trafficking Medical Ethics – Conscientious Objection among Physicians Medical Ethics – Confidentiality: An Ethical Review Medical Ethics – Decision Making Capability Medical Ethics – Research Ethics Medical Ethics – Just Caring: Physicians and Non-Adherent Patients Medical Ethics – Reclaiming the Borders of Medicine Pain and Symptom Management – Naloxone Prescribing Pain and Symptom Management – Balancing Pain Treatment and Legal Responsibilities

Monday Night Medicine Series Creating a Manageable Cockpit for Clinicians 100% Virtual Collaborative Care for Behavioral Health Outcomes Practicing Wisely – Save 2 Hours Each Day

Practice Management Embezzlement: How to Protect Your Practice HHS Portal Reporting Navigating the State and Federal Surprise Billing Legislation: 2022 Update Resources to Navigate Surprise Billing Requirements

Grand Rounds Series A Message from Your MAC: Depression Screening Utilization Updates A Review of COVID-19 Variants Changes to Michigan’s Auto No-Fault for Physicians Coronavirus Relief – Overview and Updates CURES Act – What is Information Blocking and How Do I Comply? Cyber Preparedness & Response for Medical Practices Domestic Violence and Sexual Assault (Intimate Partner Violence) Federal Information Blocking Rules Harm Reduction in Practice and Policy Strategies

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Henry Ford Health System COVID-10 Requirement for Employees LGBTQ Health in MI: An Overview of Efforts to Improve Care & Reduce Health Disparities MI Dept of Health and Human Services Update from New Director Elizabeth Hertel Navigating the No Surprises Act Omicron: The Next Variant of Concern and Responses in the COVID Pandemic Efforts Recovery Audit Contractor (RAC) Region 1 Sharing Clinical Notes with Patients: A New Era of Transparency in Medicine State of Michigan Update from Natasha Bagdasarian, MD, Chief Medical Executive Update on COVID-19 from Joneigh Khaldun, MD, Chief Medical Executive Update on the Omicron Variant

Other Webinars: 2021 ASM – Updates in Endocrinology 2021 ASM – Updates in Otolaryngology 2021 ASM – Cardio-Oncology: Enhancing the Cardiac Care of the Cancer Patient 2021 ASM – Update in Infectious Disease 2021 SSM – Contemporary Management of Nephrolithiasis 2021 SSM – Neuroscience: Central Nervous System and Neuromuscular Junction Inflammatory Disorders 2021 SSM – Updates in Allergy, Asthma and Immunology

2021 SSM – Updates in Dermatology A Team Bast Approach Training Modules: Module 1: How to Develop a PharmacistPhysician Collaboration A Team Bast Approach Training Modules: Module 2: Medication Therapy Management Reimbursement and ROI A Team Bast Approach Training Modules: Module 3: Best Practices for Addressing Workflows Resources, and Challenges A Team Bast Approach Training Modules: Module 4: Patient Case Scenarios Connecting Treatment Courts and Health Care Professionals CPT/ICD-10 Updates for 2022 Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities HEDIS Best Practices Improving Health Outcomes for Healthy Michigan Plan Patients: Using the Health Risk Assessment to Help Address Social Determinants of Health In Search of Joy in Practice: Innovations in Patient Centered Care Integrating Pharmacists into Practice: The Missing Link for Comprehensive Medication Therapy Management Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media Medical Marihuana Law Medical Decision Making: Understanding What Counts Medical Necessity Tips on Documentation to Prove it Non-Pharmacologic Management of Musculoskeletal Pain Syndromes Section 1557: Anti-Discrimination Obligations Sexual Misconduct – Prevention and Reporting Update on Chronic Fatigue Syndrome Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS Update on Chronic Fatigue Syndrome Part 2: Uniting Compassion, Attention and Innovation to treat ME/CFS

2022 LIVE VIRTUAL CONFERENCES For more information or to register, please visit: MSMS.org/EO Questions? Email Beth at belliott@msms.org or call 517/336-5789.

Implicit Bias Two Part Series – Reducing Unconscious Bias – an Imperative (RUBI) Part 1 - Recorded Webinar Part 2 – Virtual Dates: August 10, September 21, October 12, November 16 and 30, 2022 Time: 12:00 – 12:30 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

Grand Rounds Date(s): September14, October 5, November 9, and December 14, 2022 Time: 12:00 - 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Practice Management Date(s): September14, October 5, November 9, and December 14, 2022 Time: 1:00 – 2:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Monday Night Medicine Date(s): October 3, and November 7, 2022 Time: 6:30 – 8:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

A Day of Board of Medicine Renewal Requirements

A Day of Board of Medicine Renewal Requirements

Date: September 23, 2022 Time: 9:00 am – 4:00 pm Location: In-Person Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Date: November 4, 2022 Time: 8:30 am – 4:15 pm Location: In-Person, Sheraton Ann Arbor Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Annual Scientific Meeting

26th Annual Conference on Bioethics – Contemporary Challenges in Clinical Bioethics

Date: September 22, October 20-21, and November 17, 2022 Time: September and November 3:00- 6:00 pm, October 8:30 am - 4:30 pm Location: September and November Virtual Conference, October In-Person Conference, Westin Southfield Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

Date: November 5, 2022 Time: 8:45 am – 4:00 pm Location: In Person, Sheraton Ann Arbor Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

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