Spring 2021 PIERCE COUNTY MEDICAL SOCIETY
BULLET N Serving Our Members and Community Since 1888
Inside this Edition
• President’s Message • Executive Director Report • Legislative Update 2021
• TPCHD: Building Bridges • New PA Practice Laws to Take Effect
Visit us at www.pcmswa.or g
Table of Contents
PIERCE COUNTY MEDICAL SOCIETY
BULLET N Serving Our Members and Community Since 1888
PCMS Officers/Trustees
Ann Goetcheus Gehl, MD, President Dina C. Titova, MD, PhD, President-Elect A. Alex Mohit, MD, PhD, Past President C. Blake Perry, MD, Vice President Courtney M. Kennel, DO, Secretary/Tresurer Julian S. Arroyo, MD H. Matt Davis, MD Irene Grias, DO Christine L. Hammer, MD Nicholas Rajacich, MD Camille P. Samujh, DO, MPH
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Hindsight 2020 and Foresight 2021!
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Spring Cleaning
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Why Bullying Happens in Health Care and How to Stop It
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Legislative Update 2021
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TPCHD: Building Bridges to Better Health
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Washington’s New Physician Assistant Practice Laws to Take Effect in July, 2021
The Bulletin
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Liability Insurance Premiums Spike Across the U.S.: AMA Report
The Bulletin
PCMS Foundation
Charles Weatherby, MD, President Lawrence A. Larson, DO, Vice President Mark S. Grubb, MD Mary Eversole, Secretary
Staff
Executive Director: Mary Eversole Membership Coordinator: Tanya McClain is published quarterly by PCMS. Contact Tanya McClain regarding deadlines for submitting articles and advertisements: tanya@pcmswa.org or 253-572-3667. is dedicated to the art, science and delivery of medicine and the betterment of the health and medical welfare of the community. The opinions herein are those of the individual contributors and do not necessarily reflect the official position of PCMS. Acceptance of advertising in no way constitutes professional approval or endorsement of products or services advertised. The Bulletin reserves the right to reject any advertising.
Managing Editor: Mary Eversole Advertising Information: 253-572-3667; tanya@pcmswa.org
Cover photo: “Daffodils and water” by kodakgold (Samuel ROSA) www.rgbstock.com
223 Tacoma Avenue South, Tacoma, WA 98402 Phone (253) 572-3667 Fax (253) 572-2470 Email pcms@pcmswa.org
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PIERCE COUNTY MEDICAL SOCIETY
President ’s Page
Hindsight 2020 and Foresight 2021! Ann Goetcheus Gehl, MD
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am a family physician at a Community Health Care (CHC), a federally qualified health center, working with the most vulnerable populations in Pierce County through a pandemic. I have just come off a busy rounding week at St. Joseph Hospital where our group practices true full spectrum family medicine. Here, I pause to reflect on what a year it has been for me, my family, the residents I teach, my colleagues, and the community that we serve. One of my most memorable and heartbreaking patients was an elderly Latina woman who ultimately died of COVID. Although she was comfortable at the end, she was unable to have visitors; her entire family, including her husband of over fifty years, also had COVID and had to stay home. She only had the structured and sterile visits from myself and the nurses as we dressed up like astronauts, ready to venture into a dark and terrible unknown. It pains me that the end of her life lacked the warmth of a doting family member’s hand, that she heard no whispered reassurance from another in her native tongue. The agony that her family endured by not being present with her during her final moments will be forever ingrained in my mind. I attended deliveries in full PPE, with the constant dull roar of negative pressure ventilation in my ears, threatening to drown my words of encouragement as I coached each mother through labor. My congratulations were coupled with counseling about infection precautions as we weighed the risk of keeping newborns at arm’s reach versus opting for the cold comfort of quarantine. Lactation support dwindled, even for first time moms, in order to limit the number of staff entering the rooms of COVID patients. My work welcoming newborns into a pandemic world was bittersweet. Outpatient clinic was mostly telehealth, and exposed glaring health inequities. Many CHC patients do not
have the luxury of internet, so “virtual” appointments were telephone only, frequently complicated by the use of an interpreter. Children struggled with remote classroom instruction, many unable to access coursework or even adequate food. One longtime patient of mine disappeared for months, only to present for a routine visit with tachypnea and hypoxia of 60%. She told me she had been sick for a week but had not sought care out of fear of catching the virus but felt safe in our clinic. She was taken quickly to the hospital, admitted with a positive COVID test and within 24 hours, was intubated and proned. At that time, I was not sure if I would see her again but happily, she recovered and is doing well. More personally, the early days of the pandemic were also difficult. As my husband and I are working parents, we struggled through the challenges of remote learning with our first grader. I performed a decontamination ritual via our basement entrance prior to hugging my daughters each night. I had hard conversations about end-of-life choices, just in case, with my 80-year-old parents who continue to work with the homeless in Washington, DC. Would they want to be intubated? Would my mother end up like my elderly Latina patient, dying alone? My heart was heavy, but the comradery of my fellow colleagues and the feeling of “we are all in this together” despite different practices and specialties, helped me fan the flame of optimism. There were puzzles, hikes, skiing, and virtual reconnections with friends, near and far. People were generous, and my cul-de-sac became our community. We found Zoom happy hours, and then a vaccine! The Health Department led by Dr. Anthony Chen has worked tirelessly to vaccinate the vulnerable first. And after over a year, I finally got to hug my parents. After relentless darkness, I now see light, and despite despair, we hold onto hope.
SPRING 2021
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E xecutive Director Report
Spring Cleaning “Spring: a lovely reminder of how beautiful change can truly be.” - Anonymous
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Mary Eversole
pring is my favorite time of year. A time of rejuvenation, daffodils, tulips, and sun. There is also the long-standing ritual of spring cleaning with this season. At my grandmother’s house it was like clockwork. Carpets cleaned, windows washed (inside and outside), while the cherry tree bloomed in all its glory in the backyard.
I didn’t know then that the tradition of spring cleaning could be attributed to neural rhythms, Judeo-Christian tradition in biblical times, new year celebrations in Southeast Asian countries, Golden Week in Japan, Nowruz in the Persian new year, and many other spring rituals. Late last fall the Board of Trustees authorized the sale of the PCMS building, its longtime home. We are taking a deep dive into spring cleaning in part to prepare for eventual relocation. In the process we have discovered some fun relics including cancelled checks from 1917, invoices from the 1930s and an extensive library of medical books donated to PCMS over 133 years. While there is no historical value from a preservation perspective it’s been interesting to see what was, especially before the digital age. PCMS members are welcome to have a look at these artifacts. Just give us a ring to set-up a time to come by the office. The Board of Trustees also approved to discontinue publishing the membership directory. Over the last few years, the demand for the directory has decreased and the cost of printing has increased considerably. We are in the process of evaluating a digital directory accessible exclusively for PCMS members. Meanwhile, open the windows, take time to enjoy flowers in bloom and the extra hours of daylight!
Bulletin Submissions If you have a clinical best practice to share with your colleagues, a success story about individual physicians or PAs or a health system, or news about health care innovation taking place in Pierce County that you would like considered for inclusion in an upcoming edition of the PCMS Bulletin, please send your submission to Mary Eversole at mary@pcmswa.org.
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HEAVY HORS D'OEUVRES | LIVE PAINT EVENT
PIERCE COUNTY MEDICAL SOCIETY ANNUAL MEETING 6
Dec. 8, 2021 • 6 pm to 9 pm Silver Cloud Hotel Tacoma @ Point Ruston Waterfront
PIERCE COUNTY MEDICAL SOCIETY
Why bullying happens in health care and how to stop it by Brendan Murphy, News Writer
Poor staffing levels, excessive workloads, subpar management skills, stress and lack of autonomy are some of the factors that contribute to bullying in the workplace—including in medicine—according to a recent AMA report on the problem that pervades health care and how to stop it. AMA policy defines workplace bullying as “repeated, emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating or threatening behavior targeted at a specific individual or a group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten or otherwise harm the target. Individual, organizational and health system factors may contribute to the overall workplace climate or culture that allows unprofessional behavior, such as bullying, to persist.” Why health care’s susceptible to bullies Bullying behaviors are common across workplaces. A report from the Joint Commission indicates that bullying in the health care workplace is more common than sexual harassment and is initiated by both men and women. The hierarchical nature of health care has made it a field that is susceptible to workplace bullying. “Bullying and mistreatment of students and residents are commonplace,” said Audiey C. Kao, MD, PhD, vice president of ethics standards at the AMA. “Few of us have gone through medical education and training who have not either witnessed or been the subject of bullying by individuals in greater power and authority. It’s something that was long overlooked, but it is harmful to the learning environment and needs to be eradicated.” As Dr. Kao highlighted, bullying can be particularly common toward physician trainees. A 14-minute module from the AMA takes a point-by-point approach to explaining intimidation and mistreatment in training, and offers step-by-step advice on how to deal with it. “Resident Intimidation” is one of the AMA GME Competency Education Program offerings, which include dozens of courses that residents can access online, on their own schedule. The modules are available to residency institutions that have subscribed to the AMA’s program.
Cultural shift required The reasons to address and eliminate bullying are multifold, chief among them: Bullying behaviors among workers can adversely affect patient care, according to the report. “Patient care is delivered not by a single individual but by a team of individuals,” Dr. Kao said. “If you work in a health care environment where bullying is prevalent or even accepted or not dealt with, you’ll create an unhealthy team dynamic...where individuals are hesitant to raise patient care issues over concerns that they will not be taken seriously because they have been bullied in the past.” Addressing workplace bullying can and must be done at an organizational level, the AMA report says. That means implementing or improving anti-bullying policies that show management’s commitment to a safe and healthy workplace. It also means creating an environment in which all workers feel comfortable speaking up, Dr. Kao said. “When you witness bullying, silence and avoidance is never an effective strategy,” he said. Key management steps The AMA’s report details advice on an effective workplace policy on bullying and tactics to improve organizational culture. In addition, the report says, there are two key steps for management to take: • Make the administration aware that unprofessional behavior is a threat. If the team doesn’t recognize that there is a problem, they won’t have a plan to do something about it, nor recognize the threats to quality care. • Educate the entire staff about why unprofessional or hostile behavior is a problem. If the staff recognizes that the leaders are concerned about bullying, they are more likely to come forward when they feel that bullying has occurred, or better yet, tell their co-worker that their behavior is inappropriate. Reprinted from www.ama-assn.org, Apr 2, 2021
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Legislative Update 2021
105 DAYS mary eversole
This year’s “long” legislative session was like no other. Virtual (for the most part), demonstrations, and a strong focus on pandemic response. The regular session adjourned on April 25, 2021 as scheduled. WSMA’s phenomenal government affairs and policy team drove the policy priorities to benefit PCMS member providers and their patients. Additionally, the final adopted budget did not increase taxes on physicians and provides appropriations that benefits the medical community. It also aims to foster economic recovery over the next two years.
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PIERCE COUNTY MEDICAL SOCIETY
PRIORITY POLICIES NOW LAW*
Audio-only telemedicine, HB 1196: SIGNED Would allow patients to receive covered health care services over the telephone, advancing the goal of ensuring they get the right care, in the right place, at the right time. Due to existing emergency orders, insurers are currently required to cover and pay for audio-only services, but action is needed to ensure that patients can continue to receive appropriate care over the phone on an ongoing basis. HB 1196 generally requires that insurers provide the same coverage and reimbursement for audio-only telemedicine services as they would for care delivered in person or via audio/visual telemedicine.
PPE Reimbursement, SB5169: SIGNED Requires commercial insurance carriers to begin reimbursing for PPE costs during the pandemic. The bill is scheduled to be signed by Gov. Jay Inslee today, April 16. Once signed by the governor, the bill will take effect immediately and Washington will become the first state in the country to require reimbursement for PPE in this way. The WSMA and other supporters of this important legislation believe it is a necessary step to help spread the increased costs of delivering care during the pandemic and ensure everyone is paying their fair share. For the duration of the federal public health emergency, any provider treating patients in state-regulated commercial health plans who has incurred costs for PPE can bill the newly created CPT code 99072 and be reimbursed $6.57 per patient encounter.
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Health equity CME, SB5229: Would direct the boards and commissions of licensed health professions to adopt rules establishing a health equity CME requirement at least once every four years to provide health care professionals with tools to care for patients of diverse identities and backgrounds and to be knowledgeable about cultural sensitivities, patterns of disparities, and implicit bias, all of which can impact patient care and health outcomes.
Medicaid reimbursement, SB5246: Would restore the primary care and pediatric service Medicaid reimbursement rate adjustments vetoed by Gov. Jay Inslee in 2020 due to state budget concerns arising from the pandemic. Restoring the rate adjustments will improve access to care for Washingtonians by expanding physician participation in Medicaid networks at a time when it is desperately needed and long overdue.
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COVID-19 liability protections, SB5271: Would establish a clear method for determining the standard of care for health care providers and facilities caring for COVID-19 patients and reflects the realities of this challenging time. Physicians have faced numerous challenges in delivering care during the pandemic, including shortages of supplies and shifting government directives on when and how services can be delivered.
*bills have been passed by the legislature and on the Governor’s Desk for signature at time of publication
BUDGET HIGHLIGHTS
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$59.2 billion state operating budget for two years starting July 1, 2021. ~ $140 million for Medicaid rate increases effective October 1, including 15% increases for primary care and behavioral health services, and 21% for pediatric services. ~ $147 million for Foundational Public Health Services in the 2021-23 budget, and $296 million in the 2023-25 budget. ~ $1.1 billion to respond to the COVID-19 pandemic, including funds for vaccines, testing and public health workforce. ~ $34 million for medical education supports, including $16 million for family medicine residencies and more than $10 million for behavioral health professional loan repayment.
SPRING 2021
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TITLOW PARK | MAIN PICNIC SHELTER 8425 6TH AVENUE | TACOMA FREE TO RESIDENTS & THEIR FAMILIES PCMS MEMBERS: $25 12
PIERCE COUNTY MEDICAL SOCIETY
NON-MEMBERS: $40
The Health Status of Pier ce Count y
Building bridges to better health
A
pril 5-11 was National Public Health Week. It is a great time to celebrate public health employees working every day to keep our communities healthy.
Anthony Chen, MD, MPH
Usually, this work happens quietly in the background without much attention. But the pandemic affected everyone in Pierce County and shone a spotlight on our work to control communicable diseases and respond to emergencies.
time of stress and many unknowns, many feel hopeless. Social isolation is challenging. Constant changes can cause additional stress. When we focus on prevention and wellness, we strengthen our own well-being and help our communities to be healthier.
Public health is essential.
All of us need to take care of ourselves and support others during this time. Ask, listen, and talk openly about stress, anxiety, depression, and use of alcohol and other substances. Offer support and encourage people to get help early.
Our mission is to not just protect but also improve the health of every person and place in Pierce County. We do this by partnering and building bridges. Together, we make sure: • The food you eat is healthy. • The air you breathe indoors and outdoors is clean.
If you or someone you know is experiencing a mental health crisis, call (800) 273-8255 or text 741741.
• You have safe, healthy ways to get around.
If you’re overwhelmed with stress, contact Washington Listens. Call or text (833) 681-0211.
• Mothers are healthy and babies have their best start on life.
Healthy resilient children and youth.
• Children are healthy, ready to learn at school, and prepared to be productive, well-adjusted adults. • You are protected from infectious diseases and are diagnosed and get treated if sick and any outbreaks are controlled. During the pandemic, we have worked hard to inform the public about how to protect themselves against and slow the spread COVID-19; but it is you who have worn the masks, limited your travel and socialization, kept the distance, washed hands, and otherwise help control the infections. We have ensured that doctors’ offices and hospitals can care for those who are sick, that everyone can get tested, and—soon—that everyone can get vaccinated. This year, behavioral health; healthy, resilient children and youth; health equity; and racial justice are equally important priorities for us to keep our community safe and healthy. Community behavioral health and well-being. Behavioral health is key to our overall health. Pierce County statistics on mental health and substance use were worrisome and have undoubtedly worsened during the pandemic. During this
Intervening early to meet the physical, emotional, and behavioral health needs of children and youth is a pathway to improve community health. Healthy, resilient children and youth grow up to be healthy, resilient adults who contribute to our community. We are working with partners to promote healthy people, behaviors, and environments. Health equity and racial justice. All people deserve fair opportunities for jobs, housing, education and health. Health equity means everyone can reach their full health—physical, mental, and social—potential. Not everyone in Pierce County has that opportunity and differences in social, economic, and environmental conditions are to blame. We seek to dismantle racism and create policies, practices, and environments that foster racial justice and equity for all. Learn more Learn more about our services and resources on our website, through our blogs and on social media. Stay up to date as we build bridges to better health.
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PIERCE COUNTY MEDICAL SOCIETY
Washington’s New Physician Assistant Practice Laws to Take Effect in July, 2021 by James Anderson, PA-C
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n March of 2020, Governor Jay Inslee signed HB 2378, a law that brings numerous improvements to PA practice in the state of Washington.
One of the key improvements will be the termination of the current requirement for the MD-PA agreements to be approved by the Washington Medical Commission (WMC). The effort to pass this law was spearheaded by the Washington Academy of Physician Assistants (WAPA), and had broad support, including from the Washington State Medical Association (WSMA). An indication of strong support for the bill was the final vote tallies from the state House and Senate bodies: The Washington State Senate approved the bill 49-0, and The House of Representatives approved the bill 96-0. As described by the American Academy of PAs, HB 2378 includes these significant changes:
Changes to PA Practice in Washington June 16, 2021 12-1:00 PM Topics Covered: • Overview of SB 2378 • Upcoming changes as a result of WMC rulemaking • What does this mean for your practice? The goal of these events will be to provide PAs and MDs, related medical agencies, and interested members of the general public and opportunity to learn more about the new rules, in order to properly prepare for the July 1, 2021 kick-off date and subsequent WMC rulemaking changes.
• Removes requirement that practice agreements be approved by the WMC.
Please direct questions about these events to the Director of Quality and Engagement, and check the WMC rule making web page for more information. Rule making hearings and workshops will be announced via rules GovDelivery.
• Removes requirement for WMC approval for anentity to employ or work with a PA.
Reprinted from Washington Medical Commission Physician Assistant News, Update! Vol. 11 Spring 2021
• Removes WMC approval requirement for PAs to practice in remote sites. • Increases the MD/PA ratio from 1:5 to 1:10 with the option to request a higher ratio, with the understanding that a MD may not supervise more PAs than they are adequately able to. • All licensing and regulation of PAs will fall under the allopathic board (WMC) and removes this responsibility from the osteopathic board. Most provisions of the bill take effect July 1, 2021. As this date approaches, MDs and other medically related agencies have expressed interest in better understanding the details of HB 2378, and what it will mean to their daily practices and interactions with PAs. The WMC will be conducting the upcoming event to help PAs, MDs, and other participants in the state medical system prepare for the new rules:
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Liability Insurance Premiums Spike Across the U.S.: AMA Report by Ken Terry
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iability insurance premiums are rising at a rate not seen in nearly 20 years, according to a new report from the American Medical Association (AMA).
While the report is based on premium increases that predated the COVID-19 pandemic, it cites experts who predict that the upward trend in insurance costs will continue. These forecasts come from the actuaries who produce the Medical Liability Monitor’s (MLM) annual survey on liability insurance costs, which provided the data for the AMA study. The research examined premium levels in select geographic areas of the United States from 2011 to 2020. ”In 2019 and 2020, the proportions of premiums that increased year-to-year reached highs not seen since the 2000s,” said the paper, which was written by Jose R. Guardado, PhD. “In 2019, this share almost doubled from 2018, and then it went up again in 2020, when more than 30% of premiums increased from the previous year.” Specifically, the share of insurance premiums that increased in 2019 rose to 26.5% from 13.7% the previous year, the report said. In 2020, the proportion of premiums that grew increased 31.1% over the previous year.
that much, but the largest rate rise in that state (10.8%) was well below the largest increases in most states that had fewer big increases. In Virginia, where only 1.3% of premiums grew by 10% or more, the largest increase was 27.6%. Cost Increases Limited On average, liability insurance premiums across the industry rose by only a few percentage points last year, said Richard Anderson, MD, chairman and CEO of The Doctors’ Company, a large physician-owned liability insurer, in an interview with Medscape Medical News. Moreover, he stressed, this was the first broad-based increase in premium costs after 15 years of consistent rate decreases. But Susan Bailey, MD, president of the AMA, told Medscape Medical News that the rate hikes are coming at a bad time for physicians.
”It’s important to keep liability premium growth in check, because physician pracIn 2020, premium increases of tices have been incredibly 10% or more were documentstressed during the pan”Liability insurance premiums are rising ed in 14 states. Among these demic: Their patient numat a rate not seen in nearly 20 years...” were Kentucky, where 29.6% bers are down, their reof rate hikes exceeded 10%, imbursements are down, South Carolina (27.8%), Marytheir burnout is up,” she land (18.8%), Nebraska (16.7%), Oregon (16.7%) Montana said. “To add an increased liability premium on top of all (16.7%), Georgia (14.8%), Missouri (14.8%), New Hamp- those negative impacts of COVID-19 — there are some shire (13.3%), Illinois (11.9%), Michigan (11.6%), Texas practices that won’t be able to pay the premiums. Some (9.2%), North Carolina (6.7%), and Virginia (1.3%). practices will be forced to close or to change in some way, and that would be a terrible outcome of the pandemic.” According to the report, the size of the rate hikes was not related to the proportion of increases over 10% in a par- The AMA report found wide geographic variations in the ticular state. South Carolina, for instance, ranked second size of 2020 premiums. For example, general surgeons and in terms of the fraction of premiums that increased by ob/gyns paid premiums of $41,775 and $49,804, respec-
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PIERCE COUNTY MEDICAL SOCIETY
tively, in Los Angeles County, while both specialties had average premiums of $205,380 in Miami-Dade County in Florida — four to five times higher than in Los Angeles. Internists had an even wider divergence in premium costs, paying six times as much in Miami as in Los Angeles. These geographical differences in insurance rates have long existed, Anderson noted, and track almost perfectly with the extent of tort reform in various states. For example, he noted, California has had a very effective tort statute since 1976, while Florida (along with New York and Illinois) lacks such a law.
Some of the state immunity legislation covers not only COVID-19 care but also non-COVID care that was not provided because of the pandemic. For example, some people couldn’t get access to an operating room because the hospital was closed, or elective surgeries couldn’t be done. ”What happens after these immunity laws go away?” Anderson asked. Will there be suits by women who weren’t able to get mammograms and later developed breast cancer? Will people sue doctors because they couldn’t get vaccinated or because they had side effects from being vaccinated?
Taking the Long View Liability insurance cost increases have been worse for Bailey said that the AMA is very concerned about the imphysicians in the past, the report noted. In 2003 and 2004, pending dissolution of the state immunity laws. “The AMA respectively, 77.4% and 82.1% of premiums rose above has pursued federal bipartisan safe harbor legislation protheir prior-year levels. However, rate increases stabilized tecting physicians,” she said. “We feel this is a protection that ought to be across the from 2011 to 2018, the board and should last. No report said. In the latter one knows when the panyear, 80.8% of rates re“Premiums will continue to rise...but the demic will end, and we feel mained the same as in the extent to which they will increase is unclear.” that COVID will be with us previous year. In 2019 and for the time being. We’re 2020, by contrast, that going to be dealing with proportion fell to 68.4% the medical consequences and 60.8%, respectively. of COVID for a long time.” Citing the MLM actuaries, the report attributed the recent rise in liability insurance premiums to deteriorating un- Brian Atchinson, president and CEO of the Medical Profesderwriting results, lower loss reserve margins, and lower sional Liability Association, which represents malpractice insurers, told Medscape Medical News that association returns on investment. members are also concerned about the sunsetting of state The report added, “[The actuaries] expect that...insurers immunity laws. will sustain or even push for higher premiums in the next 12 months.” However, the long-term effect of the pan- ”These [statutes] recognize the unique role healthcare professionals and the institutions where they practice play demic is still unknown, the report stated. in U.S. healthcare. Unfortunately, some states have begun Anderson agreed with these observations. Premiums will ending these protections, putting healthcare providers continue to rise, he said, but the extent to which they will at additional risk,” he said. “This only further affirms the increase is unclear. The number of claims filed against appropriateness of enacting meaningful medical liability physicians dropped last year because the pandemic af- protections for all those providing care throughout the fected the legal system, he noted; but some claims that pandemic.” were not made in 2020 could still be filed this year or next. Regarding the premium increases reported by the AMA, Atchinson said this is something that liability insurers have State Immunity Laws to Sunset Another unknown is how state laws conferring immunity been observing for some time. The rate hikes “may be on healthcare providers for COVID-19 care during the exacerbated by social inflation and a significant increase pandemic will affect claims, he said. Thirty-one states have in large claims and awards,” he noted. “The impact of the such statutes, but virtually all of them will be sunsetted pandemic remains to be seen.” this year, he added. In addition, 19 states never had imReprinted from Medscape - Apr 02, 2021 munity laws.
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