SCMS BULLETIN - September 2019

The

Bulletin Saginaw County Medical Society

September 2019 | Volume 78 | No 1

SURPRISE BILLING p. 4-6

REGISTER NOW! 9/17/19 Membership Meeting p. 7

REGISTER NOW! “Has Michigan Gone to Pot?” p. 12-13

www.SaginawCountyMS.com

HEALTH CAN’T WAIT! Prior Authorization Legislation p. 16-17

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The

Bulletin Saginaw County Medical Society

2019-2020 OFFICERS AND DIRECTORS

contents 4-6 7

12-13

President’s Letter Surprise Billing REGISTER NOW & Save the Date!

9/17/19 Membership Meeting “Diversity, Equity and Inclusion Strategies: Caring for Changing Population Demographics”

President Mildred J. Willy MD President-Elect Anthony M. Zacharek MD Past President Julia M. Walter MD

16-17

REGISTER NOW! “Has Michigan Gone to Pot? Current Cannabis Practices & Controversies Conference” HEALTH CAN’T WAIT! Prior Authorization Legislation

11

Welcome SCMS 2019-20 Leaders

Jorge M. Plasencia MD

7

National Physician Suicide Awareness Day

22

Covenant HealthCare

Tiffany K. Kim MD

8

From the Editor

23

Caduceus Meeting

Harvey K. Yee MD

9

16th Annual Jingle Mingle - Save the Date!

24

Elizabeth A. Paulus MD

10

Deepak Chopra MD at the Temple

Bulletin Editor Louis L. Constan, MD

10

28th Annual Heavenrich Endowed Lecture

Retiree Representative Rustico B. Ortiz, MD

14

Barb Smith SR&RN Walk for Hope

Secretary Caroline G.M. Scott MD Treasurer Miriam T. Schteingart MD Board of Directors

Mark G. Greenwell MD

Furhut R. Janssen DO

Resident Representative Mary J. McKuen, MD

15

Welcome New Key Provider CQ Technologies

Julia M. Walter MD

18

Mildred J. Willy MD

MSMS Delegates Elvira M. Dawis MD

Anthony M. Zacharek MD Jorge M. Plasencia MD Christopher J. Allen MD

26

MSMS – Surprise Billing, Upcoming CME Conferences and more!

CMU College of Medicine | CMU Health

27 THRIVE 28

2019 Membership Directory

Ascension St. Mary’s

29

SCHD Medical Director’s Report

20

October Birthdays

30

Advertiser Index

20

Attention Retired Members

32

Key Providers

21

AMA Update

32

Calendar of Events

Miriam T. Schteingart MD MSMS Alternate Delegates Caroline G.M. Scott MD Waheed Akbar MD Mohammad Yahya Khan MD

The Bulletin can be viewed online at www.SaginawCountyMS.com under the Bulletin tab.

ON THE COVER: Health Can’t Wait

Virginia R. Dedicatoria MD Steven J. Vance MD Joseph P. Contino MD Kristine K. Spence DO Karensa L. Franklin MD Scott E. Cheney MD Michael W. Warren MD

EDITOR Louis L. Constan, MD

PUBLISHER Saginaw County Medical Society

EXECUTIVE DIRECTOR Joan M. Cramer

350 St. Andrews Rd., Suite 242, Saginaw, Michigan 48638-5988. Hours: Tuesday, Wednesday, Thursday 8:30 AM - 3:30 PM. Web: SaginawCountyMS.com

DESIGNER Lori Krygier

Telephone: (989) 790-3590. Fax: (989) 790-3640 E-Mail: jmcramer@sbcglobal.net

Peer Review Ethics Committee Waheed Akbar, MD, Chair Caroline G.M. Scott, MD James R. Hines, MD MSMS District 8 Director Thomas J. Veverka, MD Executive Director Joan M. Cramer Administrative Assistant Keri Benkert

All statements or comments in the Bulletin are those of the writers, and not necessarily the opinion of the Saginaw County Medical Society. Contributions are welcome. We publish committee reports, letters to the editor, Alliance reports, public health activities of the members, and some personal items (birthdays, weddings, graduations and like events).

The Editor determines which are accepted. Advertisements are accepted as space is available at our going rates. Members may advertise office information, professional services, skills, and procedures, also at our going rates. We do not accept advertisements from nonmembers, or non-Saginaw hospitals.

The Bulletin is mailed free of charge to SCMS members as part of their membership.

Complimentary copies are sent to various other parties. Others may subscribe at the rate of $50 per year.

The Bulletin | September 2019 3

PRESIDENT’S LETTER

Surprise Billing

By Mildred J. Willy, MD

S

urprise billing is the most important issue facing physicians today. The decisions being made in Washington, DC could have a far greater impact on how we care for our patients than even the Emergency Medical Treatment and Labor Act (EMTALA) did in 1986.

What is “Surprise Billing?”

More than half of Americans have received a surprise medical bill in the past year for a cost they thought was covered by their insurance.

Often, these surprises result from a lack of understanding of complex insurance benefits or increasingly high deductibles. Physicians agree that a federal solution would help take patients out of the middle of billing disputes that can sometimes arise between insurers and providers. But, if it’s not done right, patients’ access to care could be in jeopardy and health insurance companies will be the big winners - leaving patients out in the cold.

Congress is taking significant steps in moving legislation and tackling the issue of Surprise Billing also known

as “out-of-network” billing (OON). At risk to all of us is our livelihood as physicians due to sharp reductions in salaries and reimbursement, and reducing opportunities as to where we can practice and to our patients receiving quality care.

Key Issues If not done correctly, legislation to address surprise bills at the federal level can result in overreach by government authority into physician practices, giving a leg up to insurance companies, hindering patient access to care, and disrupting the entire healthcare system. Implications are broader than what congress is trying to address.

ACEP, the AMA and MSMS advocate for an independent dispute resolution (IDR) sometimes called arbitration. IDR doesn’t tip the scales too far one way or another. Members of congress listen to their constituents, especially patients, so contacting legislators makes a difference. Read more about this in the “out of the middle.org” campaign.

Current landscape. While each proposal that congress is considering takes patients out of the middle of

billing disputes between insurance companies and providers, the challenge is how to determine the reimbursement rates for out-ofnetwork services.

In July, the Energy and Commerce Committee passed out of committee H.R.3630 - No Surprises Act. This legislation caps out-of-network reimbursement at the median innetwork rate. It was initially intended to only do this. Through advocacy, physicians asked for an IDR. The threshold (benchmark) to qualify was set at $1,250/per service, so many bills and services would not qualify and would be set at median in-network rates. The question that also matters is what happens when bills/costs are under the threshhold - how will insurers pay?

Protect People from Surprise Medical Bills Act U.S. Representatives Ruiz and Roe, both physicians, introduced the Bipartisan Protecting People from Surprise Medical Bills Act in June. This includes a baseball-style IDR process for resolving payment disputes between insurers and outcontinued on page 5

More than half of Americans have received a surprise medical bill in the past year for a cost they thought was covered by their insurance.

Often, these surprises result from a lack of understanding of complex insurance benefits or increasingly high deductibles.

4

The Bulletin | September 2019

continued from page 4

of-network physicians where the arbitrator can only choose between the two payments suggested. This would be the preferred method by physicians.

Similarly, on the Senate side, a bill passed by the Health, Education, Labor and Pensions (HELP) Committee last month caps out-of-network services at the median in-network rate for insurers. No IDR. The big concern is that just having these caps would disrupt the healthcare system and over the long term, distort even in-network reimbursement due to its impact on contract negotiations between insurers and providers, and create a downward spiral over time for reimbursement for provider payment, whether in or out-of-network.

Stop Surprise Medical Bills Act in Senate U.S. Senator Bill Cassidy, also a physician, along with others, introduced the STOP Surprise Medical Bills Act which provides a better starting point for patients and providers and includes an IDR. The Chair of HELP Committee, Senator Alexander, has committed to incorporate some kind of IDR in what goes to the Senate floor for a vote.

Regarding deductibles. Cost sharing should be similar for in or out-of-network for emergency services. If a patient gets out-of-network care, there’s no way the insurance company would pay anything. This also means that bill collection will also be more difficult. Congress left on its annual six-week recess and returns September 9, so they can talk with and listen to concerns of the people they represent in their districts.

This is a critical time for advocacy. When congress returns, two other committees, the House Education and Labor Committee and the House Ways and Means Committee, will take up their own Surprise Billing proposals. We should try to shape these proactively.

Amplify this message. Using an IDR does not tilt the scales too far one way or another, and it does not create more work for the patient or administratively for the provider as this can be uploaded online. We would like this to be a 30-day decision, limiting time for insurers to drag out. In New York where this baseball-style arbitration is already being done, the cost of arbitration is about $200-$300, and paid by the party responsible. New York is an example where IDR is used, and premiums and physician charges have not gone up and not that many claims go through IDR due to additional costs.

Three noteworthy facts about IDR: • In New York in 2018, only 849 of 7.5 million cases (0.0113 percent) went to arbitration. This shows that encouraging fair claims and payments from the start disincentivizes entering the process in the first place. Of the 849 cases, final decisions were nearly evenly split.

• Insurance premiums in New York have grown slower than

the rest of the nation. Out-of-network bills have declined 34 percent. This means that IDR is solving surprise bills without significantly raising costs for patients.

• According to a recent Morning Consult poll , more than two-thirds (69 percent) of patients prefer a thirdparty resolution process over allowing the government to set doctors’ rates.

Concerns. Using a benchmark median in-network rate will create a downward spiral and may limit access to care particularly in rural areas.

What Do Patients Want?

According to the Morning Consult poll, people want lower deductibles. Voters and patients are concerned about the impact of rate setting, especially in smaller communities already facing doctor shortages. And, patients believe insurance companies should pay for surprise medical bills. It is also clear that once patients are out of the middle, they prefer an IDR over government rate setting. Some key findings from the poll include: • More than three-quarters (81 percent) of patients believe the majority of costs associated with surprise medical bills are the responsibility of insurance providers.

• More than half (59 percent) of patients said they wish their insurance company provided plans with lower deductibles, so they could better afford the health care they need.

• More than two-thirds (69 percent) of patients prefer a third-party resolution process over allowing the government to set doctors’ rates.

• Nearly two-thirds (63 percent) of Americans are concerned about the effect government rate setting would have on small communities already facing hospital and doctor shortages.

• When given a choice, 69 percent of Americans prefer a third-party resolution process over allowing the government to set doctors’ rates.

What Can You Do? • Talk with legislators, raise your voice, reach out to your peers and reach out to your community. It is much easier to get appointments in home districts, and legislators want to meet with their constituents on issues that matter to them. It is important to reach out to legislators personally.

• Share the ACEP toolkit, including the IDR fact sheet (see page 6).

• Advocate for the House bill introduced by Ruiz and Roe to be co-sponsored by your legislators.

• Help spread the word about the “out of the middle.org” campaign to your patients.

TAKE ACTION NOW THROUGH MSMS’ ACTION CENTER! The Bulletin | September 2019 5

President’s Letter continued…

SURPRISE BILLING: CONTACT YOUR LAWMAKERS! ADVOCACY 101 Please note: You do NOT need to be a member of ACEP to advocate on this issue. MSMS is also involved, but ACEP is taking the lead due to the nature of the legislation. Surprise billing affects your patients too!

Scheduling the Meeting • Contact the senator or representative’s Washington, DC office and ask to speak with the appointment secretary/ scheduler.

• To find your Representative: Go to www.house.gov/ representatives/find-your-representative and insert your state and zip code.

• To find your Senator: Go to www.senate.gov and use the Find Your Senators drop-down menu in the upper right corner.

• Explain who you are, where you practice, your affiliation with ACEP or MSMS and the reason you want a “District Meeting” with the senator or representative. Be sure to note that you are a constituent. Ask the scheduler how you can arrange a meeting. You may be referred to the district office or the Washington scheduler may help you.

Know Your Lawmaker The first step to successful communication is to know your lawmaker. Before your meeting, you should know: • Your lawmaker’s political party • Legislative committees he or she serves on • Leadership positions he or she holds • Voting record on issues of importance to you • If they are currently co-sponsoring H.R. 3502, “Protecting People from Surprise Medical Bills Act” • Personal facts (such as hometown, previous profession) What to Expect in Your Meeting • Try to identify a personal connection, shared interest or community connection. Don’t underestimate the value of a mutual connection as an icebreaker in your meeting.

• Remember, you are a constituent, a prospective voter, and members of Congress and their staff will welcome you and your valuable input.

• Approach the meeting as a relationship-building exercise, rather than as a meeting to conduct a transaction.

• NEVER discuss individual political contributions or those made by a specific PAC. It is against federal election laws to discuss campaign contributions of any form in a federal office.

6

The Bulletin | September 2019

• Your first goal is to establish your credibility as an informed constituent who is bringing issues to them with a request for support.

• Your second goal is to extend the conversation beyond this initial meeting. Expect to have to follow up and to stay in contact on the issue.

• In some cases, you might be meeting with a District Director instead of the Member of Congress. Do not feel that this means you won’t be taken seriously – that is not the case. Members rely heavily on staff to decide what makes it to their desk and which issues are most important. They will relay your message to the Member and have significant influence.

• Be prepared for unexpected schedule changes which may cut down on the amount of time you have to speak with them.

• If this is your first meeting with your Member of Congress, set your expectations accordingly. Don’t expect quick affirmative decisions to support your position.

During and After Your Meeting • Start by thanking the legislator/staff member for participating in the meeting.

• Introductions: Who you are, your title and place of practice and other relevant information about your activities in the community.

• Provide a clear, concise statement of what policy action you are asking of your legislator.

• Download and print the ACEP IDR fact sheet, and present to them with your business card.

• Explain the benefit of taking the action you seek or the downside of not acting. Emphasize the positive impact their support on this issue will have in their district.

• Use personal stories about your patients and your practice that demonstrate and/or reinforce the need for policy action.

• If you are unsure of any answers, tell them you will get back to them with an answer and do so. Contact the ACEP Washington, DC office for help at jslade@acep.org.

You do not need to be a member of ACEP to contact them – tell them you are a physician member of MSMS. • Invite the Member of Congress to a follow-up tour of your emergency department if applicable.

• Send a thank you note by email (the staff member will likely provide you with their card or they will be available in the office), stay in contact with the office and continue to build your relationship with the lawmaker.

SCMS MEMBERSHIP MEETINGS REGISTER NOW!

Tuesday, September 17, 2019, Membership Meeting

National Physician Suicide Awareness Day Shine a Light. Speak its name.

Tuesday, September 17, 2019 In order to address the issue of physician suicide, the Council of Emergency Medicine Residency Directors (CORD), in collaboration with AAEM, ACEP, ACOEP, EMRA, RSA, RSO and SAEM have come together to annually dedicate September 17th as National Physician Suicide Awareness Day. Vision Zero Physician suicide is a tremendous issue in healthcare today.

While estimates of the actual number of physician suicides vary, literature has shown that the relative risk for suicide being 2.27 times greater among women and 1.41 times higher among men versus the general population. Each physician suicide is a devastating loss affecting everyone - family, friends, colleagues and up to one million patients per year. It is both a very personal loss and a public health crisis. Vision Zero calls on individuals, residency programs, health care organizations and national groups to make a commitment to break down stigma, open the conversation, decrease the fear of consequences, reach out to colleagues, recognize warning signs and learn to approach our colleagues who may be at risk. Let us challenge each other as individuals, communities, institutions and organizations to make changes to reach zero physician suicides. Suicide can be prevented. Be the one to be there. Shed light on this issue and change the culture of medicine to save lives.

Learn more at CORD Wellness Resources

Register now for our Tuesday, September 17, 2019, Membership Meeting at Horizons Conference Center. The social with cash bar starts at 6:30 p.m., followed by dinner, meeting and program at 7 p.m. Joint with the Saginaw Valley Osteopathic Society.

Topic: “Diversity, Equity and Inclusion Strategies: Caring for Changing Population Demographics”

1.25 AMA PRA Category 1 CreditsTM available.

Speaker: Marcia A. Perry, MD – University of Michigan Medical School, Department of Emergency Medicine This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Central Michigan University College of Medicine and the Saginaw County Medical Society. Central Michigan University College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Central Michigan University College of Medicine designates this live activity for a maximum of 1.25 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

REGISTER ONLINE AT www.surveymonkey.com/r/91719ImplicitBias Deadline for reservations 9/11/19 QUESTIONS: SCMS office 790-3590 or keri.benkert@sbcglobal.net

SAVE THE DATE!

Tuesday, October 15, 2019, Membership Meeting Save the date for our Tuesday, October 15, 2019, Membership Meeting at HealthSource Saginaw. The social starts at 6:30 p.m., followed by dinner, meeting and program at 7 p.m.

Meeting notices will be mailed/emailed in late September.

Topic: “Workplace Violence” Speakers: Bradford L. Walters, MD and Howard K. Mell, MD

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www.wolgast.com/blog/topic/medical-office-construction The Bulletin | September 2019 7

FROM THE EDITOR

You Could Ruin Your Day

By Louis L. Constan, MD

A

number of doctor jokes deal with death and dying; I like the one where you warn the Intern to watch the patient closely because if the patient dies, “it could ruin your day.”

death, but to fight mightily against it.

This is a concept that seems to sometimes be lost on the American public.

Let me explain. As I am writing this, and as I am listening to the frenzied news reports of recent tragedies, it seems almost as though the public is We’re taught early on in medical totally unaware of the fact that we live school that death is bad. You ought in a society in which violent death is not let your patient die. In fact, you rather common. The death of 40,000 should do everything humanly, and even Americans last year (1.6 million since superhumanly, possible to make sure that 1968) through gun violence has been your patient does not die. Likewise with largely ignored while the recent 50 or suffering. Do all you can humanly and so deaths has dominated the attention superhumanly do to alleviate suffering. of the nation, as if we are surprised that Thus all those discussions about “morbidity one or two of the 400,000,000 guns in and mortality.” We use those euphemisms American hands might occasionally do because dealing with suffering and death some harm. There is no logic to this way are arguably the most emotionally difficult of thinking. And certainly no compassion things we do as physicians. We’re asked to for all those ignored victims. Doctors can “care” for and about our patients, but that rightly ask what is wrong with a nation means giving something of ourselves to that can ignore the suffering and death them; so when they suffer and die; well, we of multitudes of their countrymen for so die a little and suffer as well. The jokes are long and then freak out over the deaths used to deflect the pain we feel. We press of a few dozen. on because this is our job.

An explanation: I believe this is due The purpose of a Morbidity and to Denial, the same Denial, which, as you Mortality Conference is to review a case may remember, is the first stage of the and look for ways mistakes might have “Five Stages of Grief” we all go through been made in a patient’s care, and to learn when we suffer a loss. Death is a loss, how we all can do a better job of taking and it is difficult to deal with, and so care of the next patient with a similar people just don’t deal with it. They use condition. Because, simply put, our job as euphemisms such as “passing away,” physicians is not to accept suffering and “fatality” and “mortality.” In the case

of gun violence, there is denial on a massive scale. The slaughter is simply too immense to wrap our heads around, so we pretend that somehow, it’s not there. We may even make light of it. “It’s just those gangs, you know.” “It’s those drug dealers.” And when it hits too close to home, when a relative suicides with a gun, no one talks about it. “He died of a long-standing illness.” Denial, denial, denial.

Sure denial is considered a normal stage of grief, but only when it is temporary and is followed by the other stages in short order: Bargaining, anger, depression and acceptance. Americans, on the other hand, and for a variety of reasons, just seem to either ignore (deny) there is a serious gun violence problem, or just accept it as a necessary evil of being an American with our Constitution being what it is.

Doctors, we don’t do that, do we?

Doctors, confronted with the problem of suffering and death analyze the problem clinically as a problem to solve and immediately get to work finding solutions. We fight mightily against it.

America needs to do exactly what doctors have always done when confronted with morbidity and mortality. Americans need to take a hard look at this epidemic and accept continued on page 9

It is high time we as a country stop denying this problem, high time we stop blaming others, high time we stop using euphemisms and get to work fighting mightily against this scourge.

8

The Bulletin | September 2019

SAVE THE DATE!

continued from page 8

it, no matter how uncomfortable that may be (and no matter what one’s political affiliation is) and start taking action. And that action should be scientific action. Not political. There is no room for politics in your exam room; no room for politics in your OR; and no room for politics on this issue where so many lives are at stake.

It is high time we as a country stop denying this problem, high time we stop blaming others, high time we stop using euphemisms and get to work fighting mightily against this scourge.

There are plenty of studies of what works and what doesn’t work to curb gun violence. We need to start doing what works…and continue doing what works. Unless, of course, people stop dying of gun violence. Doctors don’t stop doing research on M and M. No one would expect us to. And we should expect nothing less of our government when it comes to dealing with a national problem as pervasive as gun violence.

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The Bulletin | September 2019 9

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PROGRAM: “The Nature of Reality” TIME: Meet & Greet Doors open at 5:30 p.m., Meet & Greet 6:15-7 p.m., Lecture 7:30 p.m.

LOCATION: The Temple Theatre Shaheen Performing Arts Center TICKET/SPONSORSHIPS: Contact Alexis Alcock at office@templetheatre.com or (989) 754-SHOW Sponsored together by Covenant HealthCare and Ascension St. Mary’s Hospital

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All statements or comments in The Bulletin are those of the writer, and not necessarily the opinion of the Saginaw County Medical Society.

28th Annual Robert M. Heavenrich, MD Endowed Lecture DATE: Thursday, October 17, 2019 SPEAKER: Charles C. Dike, MD, MPH, Associate Professor of Psychiatry, Law and Psychiatry Division, Associate Program Director, Law and Psychiatry Fellowship Program, Yale University School of Medicine PROGRAM: “Social Determinants of Health, Adverse Childhood Experiences and Dangerousness: Opportunities for Intervention” TIME: 6 p.m. cocktail reception with dinner following LOCATION: Horizons Conference Center, 6200 State Street, Saginaw RESERVATIONS: Please RSVP by Friday, October 4, 2019, to Jude Dye at: dyeju@msu.edu, office (517) 355-3308 Presented by MICHIGAN STATE UNIVERSITY COLLEGE OF HUMAN MEDICINE 10 The Bulletin | September 2019

WELCOME SCMS 2019-20 LEADERS The SCMS sincerely thanks the following for their volunteer leadership during the coming year: President

Mildred J. Willy MD | Emergency Medicine President-Elect

Anthony M. Zacharek MD | Surgery – Plastic,

Reconstructive, Hand & Cosmetic Past President

Julia M. Walter MD | Ob/Gyn Secretary

Caroline G.M. Scott MD | Retired – Family Medicine Treasurer

Miriam T. Schteingart MD | Ophthalmology Board of Directors

Jorge M. Plasencia MD | Family Medicine

Tiffany K. Kim MD | Ob/Gyn

Mark G. Greenwell MD | Family Medicine

Harvey K. Yee MD | Radiology

Elizabeth A. Paulus MD | Surgery – Oncology, General

Furhut R. Janssen DO | Psychiatry Bulletin Editor

Louis L. Constan MD | Retired – Family Medicine Retiree Rep.

Rustico B. Ortiz MD | Retired – Internal Medicine Resident Rep.

Mary J. McKuen MD | Ob/Gyn Resident MSMS Delegates

Elvira M. Dawis MD | Pediatrics

Julia M. Walter MD | Ob/Gyn

Mildred J. Willy MD | Emergency Medicine

Anthony M. Zacharek MD | Surgery – Plastic,

Reconstructive, Hand & Cosmetic

Jorge M. Plasencia MD | Family Medicine

Christopher J. Allen MD | Neurology – Pediatric,

Sleep Medicine

Miriam T. Schteingart MD | Ophthalmology MSMS Alternate Delegates

Caroline G.M. Scott MD | Retired – Family Medicine

Waheed Akbar MD | Surgery – Orthopaedic

Mohammad Yahya Khan MD | Pediatrics

Virginia R. Dedicatoria MD | Family Medicine

Steven J. Vance MD | Emergency Medicine

Joseph P. Contino MD | Surgery – General, Breast

Kristine K. Spence DO | Ob/Gyn

Karensa L. Franklin MD | Family Medicine

Scott E. Cheney MD | Radiology

Michael W. Warren MD | Radiology Peer Review Ethics Committee

Waheed Akbar MD | Surgery – Orthopaedic

Caroline G.M. Scott MD | Retired – Family Medicine

James R. Hines MD | Ob/Gyn MSMS District 8 Director

Thomas J. Veverka MD | Surgery – General, Critical Care

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Has Michigan Gone To Pot? Current Cannabis Practices & Controversies Conference Medical Ethics & Pain Management

Saturday, September 28, 2019 Horizons Conference Center 6200 State Street, Saginaw

8:00 am – 12:15 pm

Breakfast 7:00 am – 8:00 am

Course Description As of November 2018, both medical and recreational marijuana are legal in Michigan; however, marijuana remains classified as a Schedule 1 drug by the U.S. Drug Enforcement Administration (DEA) – the same as heroin, LSD, methamphetamines and peyote.

The U.S. Food and Drug Administration (FDA) has not recognized or approved the marijuana plant as medicine. Such discrepancies lead to confusion among physicians, nurse practitioners, nurses, physician assistants, and allied health care professionals as to what they can and can’t prescribe or treat with medical marijuana and for what conditions.

Objectives • Improve the current understanding of cannabis use and prescribing in Michigan under current law • Change how physicians and health care professionals approach marijuana use in pain management, various diseases, toxicity and mental health • Increase understanding of cannabis use disorder and addiction • Increase understanding of the social, medical, ethical and political implications of marijuana, big business and public policy

12 The Bulletin | September 2019

How do the decriminalization and legalization of recreational marijuana play into this landscape? What is the role of medicine, the “big pot/big tobacco” industry and politics?

How addictive is marijuana (medical and recreational)? What is cannabis use disorder? What do evidencebased studies show as well as evidence and data from states like Colorado? What are the dangers and risks of edible cannabis for children?

Find out at this conference!

This course is funded by a grant from the Michigan State Medical Society Foundation.

Has Michigan Gone To Pot?

Current Cannabis Practices & Controversies Conference Target Audience

Forum Speakers 8:00 – 8:45 am Marijuana – Is It a Medicine? * Thersilla Oberbarnscheidt, MD, PhD Addiction Psychiatrist and Neuroscientist Assistant Professor, Western Psychiatric Hospital University of Pittsburg.

8:45 – 9:15 am Pharmacology of Cannabis,Toxicity and Current Michigan Cannabinoids Laws Keenan Bora, MD, Emergency Physician Medical Director, Patient Quality & Safety Envision Physician Services, Midwest Operating Unit, Ann Arbor.

10:00 – 10:45 am Medical Ethics and Cannabis: Decriminalization, Legalization and Socialization ** Robin D. Butler, DM, MB, CNE Fellow Full Professor, School of Business, Northcentral University, Prescott, AZ. Specialist in population health, data science management, and ethical treatment and protocol for underserved and vulnerable populations.

9:15 – 10:00 am Medical Marijuana: A Critical Look at Medicine, Politics, Public Health & Profits Aaron Weiner, PhD, ABPP, Board-certified Psychologist. Director of Addiction Services Linden Oaks Behavioral Health. Naperville, IL.

Physicians, nurses, physician assistants, and all members of the interprofessional healthcare team. Medical and nursing students are welcome.

Disclosure Planners and speakers have disclosed they have no relevant financial relationships with commercial interests.

Accreditation Central Michigan University College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Central Michigan University College of Medicine designates this live activity for a maximum of 4.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

A Certificate of Attendance will be provided to other health care professionals. The American Nurses Credentialing Center (ANCC), Michigan Board of Nursing, American Academy of Nurse Practitioners (AANP) and the National Commission on Certification of Physician Assistants (NCCPA) accept AMA PRA Category 1 Credit™ from organizations accredited by the ACCME. Please check with specific professional licensing boards for acceptance of AMA PRA Category 1 Credit™.

Register now: cmetracker.net/CMED/Catalog?EventID=24361

For further information contact: CMEDCME@cmich.edu

10:45 – 11:30 am Current Understanding of PTSD, Cannabis Use and Health * Kipling Bohnert, PhD, Assistant Professor Research Investigator, Department of Veterans Affairs The Center for Clinical Management Research A Health Services Research and Development Center of Innovation, Ann Arbor.

Melissa Morse, CME Program Specialist

989-746-7602

Joan Ford, CHCP, CME Administrator

989-746-7555

11:30 am – 12:15 pm Panel Discussion / Question & Answer *Meets State of Michigan licensing requirements for pain and symptom management **Meets State of Michigan licensing requirements for medical ethics

CMU, an AA/EO institution, strongly and actively strives to increase diversity and provide equal opportunity for all individuals, irrespective of gender identity or sexual orientation and including but not limited to minorities, females, veterans and individuals with disabilities. 19-047 MGX 08/19

The Bulletin | September 2019 13

The 17th Annual Walk for Hope 5K walk/run bringing awareness to the importance of mental health and suicide prevention was held on Sunday, August 11, 2019, at Saginaw Valley State University Harvey Randall Wickes Stadium. A record number 2,500+ participated in this year’s Walk. A record amount was raised to fund the Network’s mission to prevent suicide through education and resources, and to support those impacted by suicide.

WHY WE WALK: We walk for loved ones. We walk for friends. We walk for co-workers. We walk for people we support. We walk for our community. We walk for hope.

The Saginaw County Medical Society is a proud sponsor of this year’s Walk for Hope.

Above: Drs. Iris Marteja and Albert Manlapit with Joan Cramer Right, Top to Bottom: Barb Smith and Stacey Urbani of Barb Smith SR&RN Denise Brush shares her story of surviving the loss of her son, Ben Release of butterflies during the closing ceremony

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Summer Legislative Roundtable Discussion on Prior Authorization MSMS and the SCMS hosted a roundtable discussion focusing on prior authorization (PA) in early August at CMU College of Medicine in Saginaw. The objective of the roundtable discussion was to educate lawmakers about the pitfalls associated with PA and step therapy, specifically the negative impact it can have on patient care.

MSMS District 8 Director and SCMS Past President, Dr. Tom Veverka, moderated the roundtable. We were pleased to welcome 94th State Representative, Rodney Wakeman, and Mary Frank of 95th State Representative Vanessa Guerra’s office. Christin Nohner, MSMS Director, State and Federal Government Relations, assisted Dr. Veverka.

We would like to thank the 16 physicians and office staff for attending the roundtable and sharing their frustration with PA and how it detrimentally affects their patients.

Insurance companies continue to escalate the use of PA and step therapy in the name of cost savings, but it’s leading to patient care delays and growing administrative burdens for physician offices. Below are some general stats and talking points to support legislative advocacy efforts.

Impact on Patient Care • These practices can prevent patients from receiving the care their physician has deemed necessary.

• Physician judgment is undermined – why is approval needed if a physician prescribed the treatment and the patient is paying for a health insurance plan that covers it?

• Patient care can be delayed anywhere from a few hours to a few weeks. o In a 2018 American Medical Association (AMA) survey of 1,000 physicians, 91 percent reported care delays associated with PA. • It impacts quality of care as patients who are frustrated with the wait and the confusing process may simply abandon the treatment.

16

The Bulletin | September 2019

o In a 2018 AMA survey, 75 percent of respondents reported that PA can lead to treatment abandonment.

• According to a recent AMA physician survey, nearly a third of respondents reported that PA led to a serious adverse event for their patient.

Administrative Burden • PA and step therapy processes lead to uncompensated work for physicians and staff, which translates into increased overhead costs for practices – many of which are already financially stretched.

• PA cost $2,161 to $3,430 annually per FTE physician1.

• Interactions with insurers cost $82,975 annually per physician2.

Morley CP, Badolato DJ, Hickner J, Epling JW. The impact of prior authorization requirements on primary care physicians’ offices: report of two parallel network studies. J Am Board Fam Med. 2013;26:93-95.

2 Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US physician practices versus Canadians: spending nearly four times as much money interacting with payers. Health Aff. (Millwood). 2011;30:1443-1450.

1

• More than 1 in 3 physicians have staff who work exclusively on PA. • Physicians and their staff spend an average of almost two business days each week completing PA requests.

• These onerous requirements lead to disruptions in practice workflow, resulting in inefficiencies and a reduction in physician time spent providing care to patients.

The Need for Reform • The burden is growing. In a 2018 AMA survey, 88 percent of respondents reported that PA burdens have increased over the last five years.

• Efforts over the years to approach insurance companies about the need to ease the burden have thus far been met with a lackluster response.

• Even national groups, like Blue Cross Blue Shield Association and the America’s Health Insurance Plans, have acknowledged that “the PA process can be burdensome for all involved”; they worked with the AMA and American Hospital Association to put forth a consensus statement to improve the process. continued on page 17

Above clockwise: 94th District State Rep Rodney Wakeman and Mary Frank, representative for 95th District State Rep Vanessa Guerra; Dr. Tom Veverka, Christin Nohner, Sandy Sprague of GLEI and Shannon of Michigan Vascular Center; (back) Jena Colon, Dr. Julia Walter, Jenny Frank, Drs. Kristine Spence and Mark Greenwell, (front) Drs. Sanjay Talati and Miriam Schteingart; Roundtable attendees continued from page 16

• In Michigan, we are not advocating to get rid of these processes, rather we are saying that there must be some reasonable parameters so there is continuity and standardization across health plans.

• We are pursuing reform – both inside and outside the legislative arena – that mirrors widely agreed-upon utilization management principles which include: o Clinical Validity o Continuity of Care o Transparency and Fairness o Timely Access and Administrative Efficiency o Alternatives and Exemptions • We are giving the ability back to the physicians and health care providers to use their extensive training to do what’s best for the patient.

• At the end of the day, health professionals – not insurance companies – should be making the decision around what is most appropriate or medically necessary for their patients.

Legislation Background MSMS – in partnership with the Health Can’t Wait coalition – is leading an effort to reform PA and step therapy in Michigan.

Legislation will be introduced this fall that will seek to streamline and standardize the use of these tools across health insurance plans. Specifically, the bill will address the following areas: • Transparency o Ensure PA requirements are made accessible to the physician/provider/patient

•

• •

• •

• •

o Notification to physician/provider/patient if any changes are made o Insurers must report on statistics related to approval and denials Evidence-based clinical review criteria (e.g. BCBSM rejected a request for CT guided pulmonary biopsy, which was well-established as meeting national specialty society guidelines, because they deemed it “experimental or investigational”).

Expert Reviewer for cases when an adverse determination is made or an appeal is being adjudicated.

Timelines for action on PA requests. o 24-hours for requests deemed “urgent” o 48 hours for requests that are not deemed “urgent” Step therapy protocols can be overridden by the physician if in the best interest of the patient.

MSMS has been building a coalition of provider and patient advocacy groups, collectively called the Health Can’t Wait Coalition.

The first stage of the Health Can’t Wait Campaign officially launched on March 11, 2019.

The official website, healthcantwait.org will, among other things, help us build a repository for physician and patient stories on the impacts of PA, step therapy and other insurance barriers for use in our advocacy.

We are encouraging all physicians to send stories and/ or encourage patients to visit the website.

Health Can’t Wait.

Fix Prior Authorization and Step Therapy.

The Bulletin | September 2019 17

Welcome New Physicians Ascension St. Mary’s and Ascension Medical Group are proud to welcome several new physicians to care locations across Saginaw County.

Elizabeth M. Marshall MD is a primary care physician who joined AMG Frankenmuth Family Physicians on September 3. Dr. Marshall returns to her native Saginaw, having completed medical school and residency at the University of Michigan Medical School. She served as the Chief Resident in the Department of Family Medicine at University of Michigan. Her clinical research interests include women’s health, weight gain in pregnancy and social mediabased research. She is a member of the American Academy of Family Physicians, the Michigan Academy of Family Physicians and the Society of Teachers of Family Medicine.

Dr. Marshall joins fellow Frankenmuth Family Physicians, Janet M. Bach DO, Patrick J. Botz DO and Carmen C. Szilagyi MD at the medical office located at 1027 W. Genesee Street in Frankenmuth. Dr. Marshall is accepting new patients from infants to adults. Appointments can be made by calling (989) 652-5220 or online at GetAscensionCareMichigan.com.

Angel Bermudez MD, Sports Medicine physician, joined Ascension Medical Group Orthopedics on September 3. He will provide a full range of sports injury care services to patients of all ages. With training in Sports Medicine, he has a special interest in the care of athletes including injury prevention and treatment, concussion management and musculoskeletal care.

Dr. Bermudez recently completed his Sports Medicine Fellowship at Henry Ford Health System. His team and sports treatment experience span all levels with extensive professional and collegiate coverage with the Detroit Lions, Detroit Tigers, Detroit Pistons, Wayne State University, University of Detroit Mercy, Lawrence Tech University and regional high schools.

He is board certified in Family Medicine and Sports Medicine.

Dr. Bermudez is a member of the American Medical Society for Sports Medicine and the American College of Sports Medicine.

New patients are being accepted. Consults and referrals can be made by calling (989) 799-1350.

Timothy A. Gates DO PhD, joined Ascension Medical Group Neurosurgery on August 19. As a neurosurgeon, Dr. Gates brings a statewide and regional reputation to Ascension St. Mary’s to care for some of the most complicated spinal cases.

18 The Bulletin | September 2019

His special interests include comprehensive spinal surgery, degenerative disc/cervical disc arthroplasty, minimally invasive spinal surgery and kyphoplasty.

He completed a Fellowship in Comprehensive Spine Surgery at Stanford University Medical Center, and a residency in Neurological Surgery at Michigan State University - Garden City Hospital. He earned his medical degree from Lake Erie College of Osteopathic Medicine, and a Doctor of Philosophy in Neuroscience from Central Michigan University. Dr. Gates is an American College of Osteopathic Surgeons Fellow, a member of the American Osteopathic Association and Michigan Association of Neurological Surgeons.

Dr. Gates is accepting new patients. Appointments can be scheduled at (855) 298-9888. He joins neurosurgeons E. Malcolm Field MD, Joseph Adel MD, Naman Salibi MD, Eric Bialaski DO, Nnenna Mbabuike MD and Thomas O’Hara MD. The office is located in Medical Arts Three, Suite 301, 4677 Towne Centre, in Saginaw.

Physician Recruiter Joins AMG Nikole Montalbano has joined Ascension Medical Group as a physician recruiter. Nikole has been with Ascension for over 15 years, previously serving as a marketing and public relations coordinator. As a recruiter for the midMichigan region, she will recruit qualified physicians and advanced practice providers in accordance with practice and hospital needs. She will conduct initial interviews, and coordinate site visits and tours to determine suitability for placement. Nikole is a graduate of Saginaw Valley State University, and earned accreditation in public relations. She can be contacted at (989) 907-8344.

Rao Gudipati MD to be Honored at the 2019 Cornette Ball Ascension St. Mary’s Foundation proudly announces Rao Gudipati MD as this year’s Spirit of St. Vincent Award honoree. He will be honored during the 25th Annual Cornette Ball on Saturday, November 16 at Horizons Conference Center in Saginaw. The evening will include a cocktail hour, gourmet meal, live music, silent auction and the presentation of the Spirit of St. Vincent Award. Proceeds from the Cornette Ball will support patient care. Tickets and sponsorships are available. For details, contact Tammy Weighman in the Ascension St. Mary’s Foundation office at (989) 907-8875 or tamera.weighman@ascension.org. continued on page 20

Welcome New Physicians Ascension Medical Group and Ascension St. Mary’s are pleased to welcome these new physicians to our employed medical staff.

• Cardiothoracic Surgery Chris Liakonis, DO | (989) 754-3000

• Family Medicine

Chris Liakonis, DO Cardiothoracic Surgery

Roma Srivastava, MD Hematology/Medical Oncology

Elizabeth Marshall, MD Family Medicine

Iftikhar Khan, MD Neurology

Angel Bermudez, MD Orthopedics

Eric Bialaski, DO Neurosurgery

Medley Larkin, DO Gastroenterology

Timothy Gates, DO Neurosurgery

Erika DeGayner, DO Gastroenterology

Nnenna Mbabuike, MD Neurosurgery

Shawn Ingles, DO Gastroenterology

Thomas O’Hara, MD Neurosurgery

Harprabhjit Singh, MD Gastroenterology

Kevin Lawson, MD Orthopedics

Rajeev Tummuru, MD Gastroenterology

Laura Reitz, DPM Podiatrist/Foot and Ankle Surgery

Elizabeth Marshall, MD | (989) 652-5220

• Family Medicine - Sports Medicine Angel Bermudez, MD | (989) 799-1350

• Gastroenterology Medley Larkin, DO Erika DeGayner, DO Shawn Ingles, DO Harprabhjit Singh, MD Rajeev Tummuru, MD The physicians of Ascension Valley Gastroenterology practice throughout the region. | (989) 791-9133.

• Hematology/Medical Oncology Roma Srivastava, MD | (989) 497-3226

• Neurology Iftikhar Khan, MD | (989) 799-2640

• Neurosurgery Eric Bialaski, DO Timothy Gates, DO Nnenna Mbabuike, MD Thomas O’Hara, MD They join neurosurgeons E. Malcolm Field, MD; Joseph Adel, MD; and Naman Salibi, MD. | (855) 298-9888

• Orthopedics Kevin Lawson, MD | (989) 799-1350

• Podiatry Laura Reitz, DPM | (989) 790-6719

The Bulletin | September 2019 19 83293_Ascentions_WelcomePoster.indd 1

5/2/19 7:47 AM

continued from page 18

Field of Hope Gala Presents “One Night in Memphis” The Field Neurosciences Institute (FNI) Board of Directors presents “One Night in Memphis” as this year’s Field of Hope gala entertainment.

The quartet of tribute artists feature the legendary musical talents of Elvis Presley, Carl Perkins, Jerry Lee Lewis and Johnny Cash. The show relives a magical night in late 1956 when they got together and jammed at Sun Records in Memphis. Featuring great hit songs, the show will be energetic and unforgettable. Please join us on Friday, September 27 at the Temple Theatre. Buffet ticket holders will enjoy a wonderful dinner from 5:30-7:30 p.m., with the concert beginning at 8 p.m. For buffet/show tickets, please call FNI at (989) 497-3117. For show tickets only, buy online at http://templetheatre.com or call (877) 754-SHOW. Proceeds from this year’s Field of Hope gala will provide support for a new FNI Fellowship for Intravascular Neurosurgery at Ascension St. Mary’s.

OCTOBER BIRTHDAYS Matthew L. Abrell DPM Mahela S. Ashraf MD Alexander Bejna DO Kaitlyn A. Blanchard MD Judy V. Blebea MD Micah J. Brainerd (Student) Jonathan T. Broadwell MD Ileana M. Daly MD Rodames D. Dedicatoria MD Kirk Dettloff (Student) Onoriode S. Edeh MD Najiha B. Farooqi MD Gerard P. Farrar MD Jade Foldie (Student) James A. Fugazzi MD Marilyn T. Haupt MD Michael L. Hudson (Student) Thomas J. Hyde DMD John B. Johnson MD Bong Jung MD Priscilla Kennedy (Student) Vipin Khetarpal MD Lioudmila Kinachtchouk MD David J. Kramp MD David B. Krebs MD Paul A. LaClair MD Chris Paul Liakonis DO Bei F. Liu MD Namita Natalie Lopes (Student) Anushka N. Magal MD Gurtej S. Mann MD

Alexandra T. Manolis (Student) Iris A. Marteja MD Jack F. Martin MD Ahmed Munir MD Kristi M. Murphy MD Kristin M. Nelsen MD Zenobia E. Ofori-Dankwa MD James M. Parkkonen MD Aws Polina (Student) Ryan A. Powell DO Delicia J. Pruitt MD Ryan M. Prusko (Student) Gerardo Dizon Reyes MD Jenny M. Riepma (Student) Sara L. Rivette MD Jacquelyn A. Robinson MD Rosarita Rullan DO Alaa Shanbour MD Kamran K. Shokoohi MD Allen J. Solomon MD Chai-Yakarn Soontharotoke MD Bala Srinivasan MD Kizhakepat P. Sukumaran MD Sanjay J. Talati MD David M. Thomas (Student) George K. Tong MD Samuel S. Valia MD Happy Special Birthday!

Noel D. Wagner MD Mark A. Zaki MD

ATTENTION RETIRED MEMBERS!

Retired physicians meet for lunch every Wednesday at 12 noon at IHOP, 2255 Tittabawassee Road in Saginaw.

Those attending are responsible for their own lunch, and the informal gathering lasts about an hour.

Join your retired colleagues whenever you like!

If you have any questions, please contact Joan Cramer at the SCMS office at 790-3590 or by email at jmcramer@sbcglobal.net.

20 The Bulletin | September 2019

New BRCA Recommendations: What Primary Care Doctors Must Know The U.S. Preventive Services Task Force (USPSTF) has updated its recommendations on screening for the BRCA1 and BRCA2 genetic mutations that account for 15 percent of ovarian cancer cases, and between five and ten percent of breast cancer cases.

Here are what primary care physicians should know about the new recommendations.

The USPSTF’s recommendation statement, published in JAMA along with the task force’s evidence report, represents a significant change to the group’s 2013 recommendations, and broadens the pool of women for whom primary care physicians should conduct a risk assessment and potentially refer for genetic counseling and testing. READ MORE Kevin B. O’Reilly, News Editor

Read the New AMA Moving Medicine Magazine on Physician Burnout The Summer 2019 issue of AMA Moving Medicine magazine is here! The latest volume explores the many ways physician members are changing the culture and stigma associated with physician burnout. Read AMA Moving Medicine now.

ADVANCED DIAGNOSTIC IMAGING is proud to be part

of mid-Michigan’s well-established medical community. Our highlyexperienced, sub-specialized radiologists are the region’s trusted leaders for professional diagnostic and interventional services.

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3400 North Center Road, Suite 400 • Saginaw, MI 48603 LOCAL TEL: (989) 799-5600 HOURS: Monday–Thursday, 8 am to 5pm

The Bulletin | September 2019

21

between the two organizations that will benefit the region, state, students and residents and communities of the region.

CMU’s College of Medicine, one of six fully accredited medical schools in Michigan, prepares diverse, culturally competent physicians to improve access to high-quality health care, especially in medically underserved populations.

Covenant and CMU College of Medicine Sign 25-Year Primary-Site Affiliation Agreement A new 25-year affiliation agreement between Central Michigan University College of Medicine and Covenant HealthCare will strengthen our collective support of medical student education and research. Covenant and CMU leaders marked this historic agreement with a signing ceremony at the College of Medicine Education Building in Saginaw on Tuesday, July 31.

“Covenant has long recognized the critical role that medical education plays in community health. This agreement provides our long-term commitment of resources and support for the CMU College of Medicine, and is an affirmation that Covenant will serve as the primary site for medical education in the region,” said Covenant President and CEO, Ed Bruff. “Together we will attract the physicians needed in our communities and elevate patient care through collaboration and advanced research.”

Through the agreement, CMU medical students will continue to complete clinical rotations at Covenant facilities under the supervision of physicians who serve as CMU faculty members. It also increases opportunities for clinical research on public and community health issues prominent in the Great Lakes Bay Region. CMU and Covenant increasingly collaborate on education, training, professional development, clinical research, community engagement and public health issues.

“Covenant is a regional leader for health care and an important partner to Central Michigan University for medical education and training,” said Dr. George Kikano, Vice President of Health Affairs and Dean of the CMU College of Medicine.

“By cementing our long-term relationship with Covenant, communities and residents across our region and beyond will benefit from improved access to health care as we fill the critical need for medical professionals.”

CMU President Bob Davies said the agreement marks a significant milestone in the strong and growing relationship 22

The Bulletin | September 2019

Dr. Bishja Joins Covenant Neurology Covenant HealthCare welcomes Mirjon Bishja, MD, as a member of the Covenant Medical Group. Dr. Bishja joins the Covenant Neurology team. Offices are located at 800 Cooper, Suite 11, Saginaw and the team can be reached at 989.583.7090.

Covenant Surgery Offers Advanced Colon & Rectal Procedures Jorge Reguero Hernandez, MD, FACS and Tareq Kamal, MD, FACS are part of the Covenant Surgery team. These highly trained surgeons and medical professionals specialize in the diagnosis, evaluation and treatment of Dr. Reguero these conditions: Hernandez • Advanced colon and rectal polyps • Anal fissures • Anal fistula • Anal sphincter trauma • Appendiceal tumors • Colon cancer • Colovesival and colovaginal fistula Dr. Tareq • Crohn’s disease, stricture, fistula, perforation Kamal • Diverticulitis • Fecal incontinence • Hemorrhoids • Ischemic colitis • Lower-gastrointestinal bleeding • Ostomy complications • Pelvic floor dysfunction • Pelvic tumors • Perirectal abscess • Polyposis syndromes • Pouchitis and ileal pouch complications • Rectal cancer • Rectal prolapse • Rectovaginal fistula • Severe constipation refractory to medical management • Small bowel cancer • Ulcerative colitis continued on page 23

continued from page 22

Caduceus Meeting for Recovering Health Care Professionals

Highlights of advanced procedures offered: • Laparoscopy and robotic surgery for benign and malignant colon disease and rectal cancer • Botox injection to the anal sphincters for anal fissure refractory to medical management • Colonoscopy for colorectal cancer screening and polypectomy • State-of-the-art techniques for rectal prolapse including robotic ventral mesh rectopexy • Cancer and sphincter preservation surgeries • Restorative proctectony/ileal pouch anal anastomosis (J-pouch) for the treatment of ulcerative colitis • Transanal minimally-invasive surgery for rectal tumors (laparoscopic and robotic TAMIS) • Surgery for complex anal fistula: LIFT (ligation of intersphincteric tract) and anal advancement flap • Plus many more

(Behind Pat’s Grocery Store on Midland Road in Freeland)

To contact Covenant Surgery, call 989.790.4855 or visit www.covenanthealthcare.com/cmg/covenantsurgery.

Offices are located in Saginaw at 5415 Cardinal Square Boulevard.

We engage in group discussions where members may want to speak up, ask questions or share thoughts with fellow members.

diabetes Self Management Program

In the United States,

30.3 million

people are living with diabetes – 84 million are living with prediabetes.

Third Thursday of each month at 7 p.m.

Zion Lutheran Church 454 7th Street, Freeland, Michigan Caduceus meetings are available to health care industry professionals, and have adopted many of the principles of 12-Step programs.

Caduceus meetings are “closed” meetings for recovering health care professionals including, but not limited to, nurses, doctors, dentists and pharmacists.

We are the region’s most experienced diabetes management team. Our program is certified by the American Association of Diabetes Educators (AADE) through the Michigan Department Health and Human Service (MDHHS). We are certified to provide education for patients of all ages and diabetes diagnoses, including pregnant women.

Put your trust in the region’s most experienced diabetes management team . . . your PatientCentered Medical Home partner.

We also have a Diabetes Prevention Program to help prevent or delay Type 2 diabetes.

To refer a patient or for more information call 989.583.5193

©2018 Covenant HealthCare. All rights reserved.PK 1/18 10448

The Bulletin | September 2019 23

Bring insurers to the bargaining table

Photo courtesy of MSMS

Regulate Network Adequacy to Stop Surprise Medical Bills Policies aimed at addressing unanticipated out-of-network care - often called surprise billing - should not put patients in the middle of payment negotiations or reward payers whose inadequate, narrow provider networks are a primary driver of the problem. That was the key message from MSMS PresidentElect and American Medical Association (AMA) Trustee S. Bobby Mukkamala MD, at a recent House Ways and Means Health Subcommittee hearing on surprise medical bills.

“The AMA has long been concerned about gaps in out-ofnetwork coverage and is committed to working on solutions to protect patients from the financial impact of ‘surprise’ coverage gaps,” said Dr. Mukkamala, a board-certified otolaryngologist who practices in Flint.

“Congressional action on the issue should protect patients, ensure that payer provider networks are adequate, establish fair payment for physicians and increase transparency,” Dr. Mukkamala said.

“Doctors want to be included in health-plan networks, but they want to do so on the basis of fair contracts,” he added.

“Most health insurance markets are highly concentrated, and 57 percent of physicians work in practices of 10 or fewer physicians. Those factors combine to leave physicians in a weak negotiating position with large commercial health insurers,” Dr. Mukkamala said.

Network adequacy requirements are a key part of the successful approach to surprise billing in New York state. The Empire State’s legislation has led to a dramatic fall in consumer complaints, according to a report “New York’s 2014 Law to Protect Consumers from Surprise Out-of-Network Bills Mostly Working as Intended: Results of a Case Study” - issued by Georgetown University’s Center on Health Insurance Reforms.

Dr. Mukkamala urged Congress to avoid purported fixes that set minimum pay benchmarks based on Medicare rates or payers’ in-network rates. The in-network rates “are negotiated by physicians and plans during the contracting process and fees are discounted in exchange for contracted benefits,” Dr. Mukkamala told the Committee. “Those companies that didn’t sit down to negotiate should not benefit from skipping that step.”

Using discounted rates for out-of-network care would likely lead health plans to “quickly drop physicians from their networks knowing they could use our services for less when we are outside their network,” he added. Pay benchmarks should be based on data from independent sources, Dr. Mukkamala said.

Enrollment Requirements for Prescribers Effective October 1, 2019, providers who prescribe drugs to Medicaid beneficiaries must be actively enrolled in Michigan’s online Medicaid provider enrollment system, the Community Health Automated Medicaid Processing System (CHAMPS).

Claims for drugs prescribed by a provider who is not enrolled in CHAMPS will be denied. This applies to all providers who prescribe drugs, including medical residents.

For further information on emergency overrides, how to tell if a prescriber is not enrolled, and instructions on how to enroll, please reference MSA 19-20 or www.Michigan.gov/ MedicaidProviders.

Proposed Policy, Payment and Quality Provision Changes to the Medicare Physician Fee Schedule for Calendar Year 2020 On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020. READ MORE

Survey: Medical Ethics Due to the new Board of Medicine Renewal requirement of one Medical Ethics CME credit per renewal cycle, MSMS is expanding its offering of on-demand webinars that fulfill this requirement. MSMS’ goal is to provide a variety of webinars that appeal to its membership. Please take a minute to select the top five (5) topics you would like to see offered. READ MORE

continued on page 25

24

The Bulletin | September 2019

A Day of Board of Medicine Requirements continued from page 24

CONTINUING MEDICAL EDUCATION One of the many benefits you receive as a MSMS member is access to DISCOUNTED continuing medical education.

For a full list of upcoming events visit msms.org/eo or call the MSMS registrar at (517) 336-7581.

Friday, November 1, 2019 9 a.m. - 2:45 p.m.

Holiday Inn 3600 Plymouth Road Ann Arbor, MI 48105 Members - $195 Nonmembers - $275 Retired - $105

On-Demand Webinars MSMS has a catalog of on-demand webinars available, allowing you to watch and learn at your convenience. Check out the available series on Human Trafficking, Pain and Symptom Management, Medical Ethics and more HERE. .

ASM 2019: Earn Up to 28.25 AMA PRA Category 1 Credit(s)TM One of the best ways for Michigan physicians to learn the latest in clinical sciences and implement this knowledge into their everyday practice while earning up to 28.25 AMA PRA Category 1 Credit(s)™, is to attend MSMS Foundation’s 154th Annual Scientific Meeting (ASM). The ASM will be held Tuesday through Saturday, October 22-26, at the Sheraton Detroit Novi.

AAFP Credit Pending October 22-26, 2019 Sheraton Detroit Novi The ASM features: • A selection of 25 courses during the five days • Two FREE one-hour plenary sessions • FREE Friday William Beaumont Lecture • Several options for courses on “Pain and Symptom Management” • Many opportunities to network with colleagues and exhibitors

For More Information For questions or additional information, contact Marianne BenHamza at (517) 336-7581 or mbenhamza@msms.org.

Statement of Accreditation: The Michigan State Medical Society (MSMS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. *AMA Credit Designation Statement: The MSMS designates this live activity for a maximum of 28.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

Let MSMS be your resource to earn the new mandated Michigan Board of Medicine CME - all in one day. From 9 a.m. - 2:45 p.m., presentations will address Pain and Symptom Management, Medical Ethics and Human Trafficking, fulfilling these additional requirements.

9 a.m. - 12 p.m. Pain and Symptom Management 12 - 12:45 p.m. Lunch 12:45 - 1:45 p.m. Human Trafficking 1:45 - 2:45 p.m. Medical Ethics For More Information For questions or additional information, contact Beth Elliott at (517) 336-5789 or belliott@msms.org.

Statement of Accreditation: The Michigan State Medical Society (MSMS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA Credit Designation Statement: The MSMS designates this live activity for a maximum of 5 AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

REGISTER ONLINE

23rd Annual Conference on Bioethics – End of Life Care Saturday, November 2, 2019 9 a.m. - 4 p.m.

Holiday Inn 3600 Plymouth Road Ann Arbor, MI 48105 Members - $195 Nonmembers - $275 Retired - $105 For More Information For questions or additional information, contact Beth Elliott at (517) 336-5789 or belliott@msms.org.

REGISTER ONLINE

READ MORE REGISTER ONLINE The Bulletin | September 2019 25

College of

Medicine 2019 Residency Recognition and Awards Celebration

Dr. Haddad to Lead as Internal Medicine Program Director

On June 14, we celebrated residency program completion with 33 new graduates and their families. Health care leaders from local affiliates, members of the Saginaw County Medical Society and many of the College’s volunteer faculty members attended. From this year’s class, seven graduates have elected to stay and practice in the region.

We are pleased to announce that one new graduate Jennifer M. Romeu MD - will be joining CMU Health as a family medicine physician at our Colony clinic location in Saginaw Township. Since the program began in 1947, more than 800 medical students have completed their residencies in Saginaw, with more than an estimated 200 choosing to stay and practice in the Great Lakes Bay Region.

CMU has led resident training in Saginaw since 2012.

We remain focused on recruiting CMU MD program graduates to our GME program and training new doctors for Michigan.

A number of CMU residents received awards for excellence at the event.

We are pleased to announce Nicholas E. Haddad MD as the new Program Director for the Internal Medicine Residency Program for CMU College of Medicine, effective June 10, 2019.

Since returning to Saginaw in 2018, Dr. Haddad has led post-residency and fellowship training as an Associate Professor of Internal Medicine at the College, and is an enthusiastic mentor for residents and students alike. Dr. Haddad is an IM expert, and he has presented nationally and internationally on a variety of infectious diseases topics.

Please welcome Dr. Haddad to his new role. We also extend our sincerest thanks to Sethu K. Reddy MD, Chair, Discipline of Medicine, for serving as Interim Program Director over the last several months.

(l-r) Dianne Gruenberg, Dr. Ghaith Qudah and Dr. Steve Vance with the Dr. Jim Gruenberg Memorial Surgery Resident Award administered by the SCMS Foundation

• Louis E. Zeile Scholarship Award Recipients - Sura S. Khuder MD, Mali Him MD, Zhilwan K. Rahim DO, Alexa M. Shepherd MD and Paul C. Pastolero MD • St. Mary’s of Michigan Resident Award Navya S. Vipparla MD and Ankita A. Kapoor MD • Larry S. Kelly MD Award Jennifer M. Romeu MD • Judith E. Diffenderfer DO Award Karensa L. Franklin MD • Dr. Jim Gruenberg Memorial Surgery Resident Award Ghaith Qudah MD • Society of Teachers in Family Medicine Resident Teacher Award Triptpal S. Sanghera MD 26

The Bulletin | September 2019

CMU Institute for Medical Simulation Receives SSH Accreditation and Donation from Covenant The CMU College of Medicine Institute for Medical Simulation located in two facilities on each campus recently received accreditation in the area of Teaching and Education by the Society for Simulation in Health (SSH). This is a remarkable achievement placing CMU’s medical simulation centers among other leading centers nationally.

The donation of a da Vinci robotic surgical training system from Covenant HealthCare is helping the Covenant HealthCare Simulation Center, located at the College of Medicine in Saginaw, stay on the cutting edge of technology.

SSH’s five-year accreditation puts the CMU College of Medicine among just four colleges and universities in Michigan with SSH-accredited programs, and among the roughly 110 accredited programs in 20 countries. “It is very significant that we are recognized on a national platform,” said Mena Khan MD, Assistant Director of Medical Simulation at the Saginaw simulation center. “This demonstrates that we are educating at the highest level.” Congratulations to Robert A. Sasso MD, Simulation Center Director, and the entire team.

Welcoming the Class of 2023 The CMU College of Medicine welcomed its seventh class on Monday, August 5, for orientation week. The week was filled with information and fun activities for the new students.

On Friday, August 9, the week’s activities culminated with the White Coat Ceremony.

First Do No Harm

By Louis L. Constan, MD

SAVE THE DATE & REGISTER NOW!

4th Annual Psychiatry Update Conference “Psychiatry for the Non-Psychiatrist” Friday, November 1, 2019 | 12-5 p.m.

CMU College of Medicine | Saginaw Campus CMU Health – Psychiatry Department Registration Fees: $50 Physicians | $40 Allied Health Care Professionals $15 Non-CMU Residents/Students ACCREDITATION STATEMENT: Central Michigan University College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Central Michigan University College of Medicine designates this live activity for a maximum of 5.0 AMA PRA Category 5 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For more information and to register, contact Katherine Flores at Katherine.flores@cmich.edu or (989) 746-7785.

It is widely recognized that one-third of the money spent on health care in this country is wasted…and THAT isn’t even the BAD news.

The truly BAD news is that all that unnecessary wasted money, $800,000,000,000 and counting, is actually making us sicker in so, so many ways. We’re just beginning to understand those many ways.

Consider the following quotations from medical practitioners: “Let’s get a test.” “I need to operate.” “Try this pill.”

Such proclamations occur myriad times across the land… and, the unpleasant truth is that, for a wide variety of reasons, it is becoming increasingly clear that patients need a degree of skepticism when listening to such proclamations, because they can be harmful to our health.

An October 2018 article in the “Journal of the American Medical Association, Internal Medicine,” reviewed 140 research articles and 54 individual patient case reports of medical harms caused by unnecessary medical care. The results showed that unnecessary tests, medicines and procedures (defined as services for which the potential harm exceeds the potential benefit) caused a variety of harms: • Physical harm. This, of course, is the first thing we all think of when we think of harm done from medical care, and it was well documented in this study. Shortterm complications of surgery can always occur such as bleeding, infection and death; but also longterm complications, even life-long disability. Less recognized is that short- and long-term physical harm including, of course, death, can also occur from seemingly innocuous pills, even common antibiotics; and medical tests, especially x-ray procedures that use dye contrast injections. This study also identified what they called “down-stream” harms. The original unnecessary medical intervention or test may not have had a complication, but maybe, as a result of something found on that unnecessary intervention, an ADDITIONAL test or procedure was done and THAT test or procedure led to harm. In some documented cases, there were multiple repeat tests or procedures done as a consequence of that one, single unnecessary initial test or procedure. Yikes!

• Psychological harm. Imagine, for a second, what was going through the mind of the above patient who had those multiple unnecessary tests or procedures. Imagine the stress and anxiety of every single one of those tests or continued on page 28

The Bulletin | September 2019 27

continued from page 27

procedures occurring over several months. The stark fear that THIS TIME they’ll find cancer, and then the let-down, but “Oh, we’ll have to do another test.” You can see how it would be enough to cause PTSD. Even under the best of circumstances, our healthcare system can be confusing; even think physically painful, impersonal and scarily expensive. Doctors, the authors of this article point out, tend to discount these issues, but they are always hard on patients psychologically.

• Treatment burden. The frequent doctor visits can lead to being overwhelmed, a loss of control in one’s life. What happens to other responsibilities during all these wasted medical services? One’s life may fall apart…and, as this is unnecessary care, all to no purpose. Simply put, patients get frazzled…and doctors do as well (after all, we now know that our doctors are getting sick from overwork, but that’s a topic for another time).

• Social burden. While getting all the tests and procedures, patients may have to abandon their usual social activities, leading to loss of enjoyment of life. This may overlap with the psychological harm described above and lead to depression.

• Dissatisfaction with health care. Some of the patients started routinely questioning all their doctors. This can be a dangerous situation, when patients become disillusioned with medical care, avoid doctors and delay truly necessary diagnosis and treatment.

• Financial burden. One patient, of limited income, described paying $36,000 for dietary supplements ordered by his doctor. Few patients are wealthy, and few insurance plans pay the full cost of care. Unnecessary care is already a financial burden, but when it leads to complications, it can be a cascading financial disaster for someone of limited or even moderate means.

What needs to be done about this problem? The article has no answers. But Choosingingwisely.org can help us here, suggesting patients ask the following questions when confronted with a potential medical intervention: • Do I really need this test, treatment or procedure?

• What are the risks?

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The Bulletin | September 2019

• Are there simpler, safer options?

• What happens if I don’t do anything?

• What are the costs?

It would behoove the wise medical practitioner to familiarize himself or herself with these questions, and offer satisfactory answers to all of them BEFORE ordering ANY medical intervention. After all, it is the responsibility of physicians (the Hippocratic Oath says “First do no harm”) to use medical tests, medicines and procedures when and only when those medical services are in the best interests of their patients, and “overusing” medical services are inappropriate.

And, realizing that our community will never attain its goal of economic and physical health without solving the problem of undue patient harms, THRIVE is allotting significant resources to addressing this. More later.

2019 SCMS Private Membership Directory Reminder! The 2019 SCMS Private Membership Directory is available electronically and for download by clicking on the picture of the cover at www.SaginawCountyMS.com under the “Membership” tab.

If you did not receive a hard copy of the new Directory in the spring, please contact the SCMS at keri.benkert@ sbcglobal.net

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Medical Director’s Report Najibah K. Rehman, MD MPH

Big changes are happening in Saginaw County, and I am very excited to be part of this process. I have been in my role for nine months now, split between CMU Health, where I provide outpatient preventive care with administrative time to further strengthen local partnerships, and the Saginaw County Health Department (SCHD). I have become acquainted with wonderful patients, organizations, healthcare leaders and community members to better understand community needs, which has provided me with a guiding path as we enter a new decade in local public health and strategic planning.

I have outlined three priority areas for the next six months at SCHD, which are embedded in the requirements set forth by the Michigan Department of Health and Human Services (MDHHS) for all local public health medical directors: 1. Strengthening of our Communicable Disease (CD) Program.

2. Reviewing and updating all standing orders for SCHD Family Planning, STD, Tuberculosis, Communicable Disease and Immunizations programs.

3. Improving upon communication with local stakeholders by providing information on resources and programs at SCHD, current and longitudinal disease data, and updates on new initiatives/programs.

First, I will focus on our CD program. Every local health department in Michigan is required to investigate ALL reportable diseases to MDHHS, as defined by the CDC and MDHHS.a Within SCHD, one staff member is assigned to investigate HIV/AIDS, Tuberculosis, Syphilis and Gonorrhea/ Chlamydia, respectively. All other communicable diseases are investigated by our passionate and invaluable CD Nurse, Susie Garlick, who has dedicated over 30 years of her career to public health.

Internally, we are reorganizing to meet as a CD team in real time. The further upstream we can get to address a case, the more streamlined our process will be to ensure linkage to care, contact tracing and community/stakeholder communication. To aid in this process, I facilitated a new

partnership with the MDHHS’s Outbreak NetEnhanced (OBNE) Program, funded by the CDC, and led by epidemiology trainees to assist in local investigations for Salmonella, E. coli, Listeria and Shigella. This has freed up significant time for our staff, as one case investigation can take a full day. Additionally, MDHHS investigates linkages between cases. For example, two cases of Salmonella flint were linked to Saginaw County, whereby we were able to provide recommendations and follow-up to ensure that appropriate infection control procedures were executed.

I have met with Infection Control teams at Ascension, Covenant and Aleda Lutz to further strengthen countywide relationships - thanks to everyone for your time and commitment. My next goal is to meet with SVSU and Delta College to discuss their infection control procedures regarding communicable disease prevention and immunizations among students and employees.

Along with colleagues from CMU Infectious Disease and Aleda Lutz Infection Control, we attended the Tri-State Tb Clinical Intensive Workshop hosted by MDHHS in July. It was a great opportunity to learn alongside colleagues, while connecting with others across Michigan and the U.S. We received up-todate guidelines on Tuberculosis treatment and control from world-renowned leaders, and we have brought that information back to Saginaw County. Additionally, Susie and I attended the MDHHS Surveillance for Healthcare-Associated & Resistant Pathogens (SHARP) symposium in May, highlighting emerging antibiotic resistant organisms like Carbapenem-Resistant Enterobacteriaceae, which has been locally relevant after cases were identified at a single institution.b In recent headlines, Candida auris, first identified in 2009 in Japan, has been making its way across the U.S.b We have no known cases in Michigan, but we are always at risk for outbreaks considering the presence of an international airport.

Thank you for providing your assistance and clinical expertise as you all contribute to the public’s health. I look forward to providing future reports, and if you have any questions, concerns or seek guidance, please do not hesitate to contact our CD program at (989) 758-3887 or (989) 758-3880. For specific topic updates or requests, please contact me at (989) 758-3719 or nrehman@saginawcounty.com.

a

2019 REPORTABLE DISEASES IN MICHIGAN—A Guide for Physicians, Health Care Providers and Laboratories: https://www.michigan.gov/documents/mdch/Reportable_Diseases_Michigan_by_Pathogen_478489_7.pdf b

https://www.michigan.gov/documents/mdhhs/3_CP-CRE_Cauris_final_-_WEB_Bay_City_658768_7.pdf

The Bulletin | September 2019 29

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The Bulletin | September 2019

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2019-2020 KEY PROVIDERS

These Area Businesses Support Saginaw County Medical Society Membership Meetings. When you have a need for a service, please consider our Key Providers.

Please mark your calendar for the following meetings and events in 2019. You will receive an email meeting notice and reminder each month for SCMS events. NonSCMS events are listed as a courtesy and you must contact the sponsor directly to register.

SCMS Membership Meetings are held on the third Tuesday of January, April, May, September and October. The SCMS Board meets on the third Tuesday of every month (except July and December) at 5:30 p.m.

Tuesday, September 17, 2019 Horizons Conference Center - SCMS Board meets at 5:30 p.m.

Membership Meeting with Social (cash bar) at 6:30 p.m. followed by dinner and program at 7 p.m. Program: Diversity, Equity and Inclusion Strategies: Caring for Changing Population Demographics. Speaker: Marcia A. Perry, MD – University of Michigan Medical School, Department of Emergency Medicine. RESERVATIONS REQUIRED www.surveymonkey. com/r/91719ImplicitBias. See page 7 for details and to register.

Tuesday-Saturday, October 22-26, 2019 Sheraton Detroit Novi – MSMS Foundation’s 154th Annual Scientific Meeting.

See page 25 for details and to register.

Friday, November 1, 2019 CMU College of Medicine | Saginaw Campus, CMU Health-Psychiatry Department. Fourth Annual Psychiatry Update Conference, “Psychiatry for the Non-Psychiatrist” from 12-5 p.m. See page 27 for details and to register.

Thursday, September 19, 2019 The Temple Theatre – Deepak Chopra presents “The Nature of Reality.”

See page 10 for ticket and sponsorship information.

Friday, November 1, 2019 Holiday Inn, Ann Arbor, Michigan - MSMS presents “A Day of Board of Medicine Requirements.” See page 25 for details and to register.

Friday, September 27, 2019 The Temple Theatre – FNI Field of Hope Gala presents “One Night in Memphis.”

See page 20 for details and ticket information.

Saturday, November 2, 2019 Holiday Inn, Ann Arbor, Michigan – MSMS presents “23rd Annual Conference on Bioethics – End of Life Care.” See page 25 for details and to register.

Saturday, September 28, 2019 Horizons Conference Center – CMU College of Medicine presents “Has Michigan Gone to Pot? Current Cannabis Practices & Controversies Conference.” See pages 12-13 for details and to register.

Saturday, November 16, 2019 Horizons Conference Center - Ascension St. Mary’s Hospital’s “2019 Cornette Ball” honoring Rao Gudipati MD. See page 18 for details and ticket information.

Tuesday, October 15, 2019 HealthSource Saginaw - SCMS Board meets at 5:30 p.m.

Membership Meeting – SPOUSE/SIGNIFICANT OTHER INVITED with Social at 6:30 p.m. followed by dinner and program at 7 p.m. Program: “Workplace Violence.” Speakers: Bradford L. Walters, MD and Howard K. Mell, MD. See page 7 for details.

Tuesday, November 19, 2019 CMU College of Medicine, 1632 Stone Street – SCMS Board meets at 5:30 p.m.

Thursday, October 17, 2019 Horizons Conference Center - 28th Annual Robert M. Heavenrich, MD Endowed Lecture. Charles C. Dike, MD, MPH, Associate Professor of Psychiatry, Law and Psychiatry Division, Associate Program Director, Law and Psychiatry Fellowship Program, Yale University School of Medicine will present “Social Determinants of Health, Adverse Childhood Experiences and Dangerousness: Opportunities for Intervention.” See page 10 for details and to register.

Saturday, November 23, 2019 Saginaw Country Club – 16th Annual Jingle Mingle benefitting the Pregnancy Care Center in Saginaw from 10:30 a.m. to 2:30 p.m. Visit www.

SaginawCountyMS.com and click on Jingle Mingle under the Alliance tab. See page 9 for details.

Joan Cramer/SCMS | Office 790-3590 | Fax 790-3640 | Cell 284-8884 jmcramer@sbcglobal.net www.SaginawCountyMS.com